Mental health and the COVID-19 pandemic: looking back and moving forward

Abstract COVID-19 continues to exert unprecedented challenges for society and it is now well recognised that mental health is a key healthcare issue related to the pandemic. The current edition of the Irish Journal of Psychological Medicine focusses on the impact of COVID-19 on mental illness by combining historical review papers, current perspectives and original research. It is important that psychiatrists leading mental health services in Ireland continue to advocate for mental health supports for healthcare workers and their patients, while aiming to deliver services flexibly. As the pandemic evolves, it remains to be seen whether the necessary funding to deliver effective mental healthcare will be allocated to psychiatric services. Ongoing service evaluation and research is needed as the myriad impacts of the pandemic continue to evolve. In a time of severe budgetary constraints, ensuring optimum use of scare resources becomes an imperative.


Introduction
The COVID-19 pandemic continues to present the greatest global health challenge in modern history. While emerging data is improving our understanding of the virus and its impact on health, societal cohesion and world economies, the situation globally continues to evolve. As such, findings and learnings that emerge at one point of the pandemic can appear to have relatively limited utility at another point. Arguably, never in living memory has there been a global phenomenon impacting population mental health in such a dynamic fashion. The challenge for mental health science is to capture and report these dynamic trends in a timely manner to inform and support psychiatrists implementing evidence-based care in this uniquely challenging environment. A parallel requirement is that such services are adequately resourced to meet the needs of both service user and provider.
This COVID-19-themed issue of the Irish Journal of Psychological Medicine aims to provide a more nuanced understanding of the multifaceted mental health impact of the pandemic to date. In so doing, we sincerely hope that this issue will provide colleagues with a timely and useful resource in these uncertain times.

Mental health effects of COVID-19
A number of commentators in the popular media have noted that one potential silver-lining of this pandemic has been a mainstreaming of mental health within the broader considerations of the health impact of the pandemic. It is has been noted that mental health needs have never been as central to public discourse as during recent media discussions about the impact of the various restrictions implemented due to the pandemic. The assumption that this increased consideration of mental health will indeed represent a true and meaningful shift in public policy towards psychiatric services and, by extension, increased funding, is yet to be borne out. Indeed, there remains a very real risk that this discourse will merely serve to enhance the already considerable societal focus on psychological well-being and continue to marginalise the moderate to severe end of the mental illness spectrum. It is particularly noteworthy that certain high-risk groups with pre-existing mental illness might remain most vulnerable to the potentially deleterious psychological impact of the pandemic, notwithstanding that many patients within these groups may display significant resilience. An ambiguous focus on mental health, which fails to take account of the urgent needs of overextended and under-resourced psychiatric services, represents a clear and pressing concern. Within this exceptional set of circumstances, the compelling need for effective advocacy emanating from psychiatrists to constructively inform and shape public discourse has been brought sharply into focus.
As predicted at the outset of the first wave of the pandemic, psychiatric morbidity is peaking later than the physical health consequences of the pandemic (Gunnell et al. 2020), and current trends suggest that this peak will indeed endure for longer than the impact on physical health. Emerging data from services nationwide indicates increasing referrals to psychiatric services following the initial pandemic lockdown, and ongoing evaluation of referrals to psychiatric services is now needed.
A further strategy which can help to determine the effects of the current pandemic is a reflection on historical events and the retrospective lessons that may be learned from them. Two historical papers in this issue focus on previous pandemics and other global events to evaluate how mental illness was impacted at the time. The multifaceted impact of COVID-19 on population mental health may not be realised for some time and it is important to start planning now for ongoing consequences such as the potential severe economic consequences in the months and years ahead.

Self-care
Another somewhat double-edged silver-lining of the pandemic is the increased acknowledgement of the psychological burden associated with frontline healthcare service provision (Behrman et al. 2020;Faderani et al. 2020). Pre-pandemic data indicated a high-level of stress and burnout among doctors in Ireland (McNicholas et al. 2020;Humphries et al. 2020). Calls have been consistently made since the outset of the pandemic to enshrine the well-being of healthcare staff as a central tenet of the overall model of healthcare service response (Unadkat and Farquhar, 2020). This pro-active approach was advocated not only because protecting staff was recognised as the right thing to do but also to buffer against the predictable psychological consequences of providing healthcare within extremely challenging and rapidly-changing circumstances (Maunder et al. 2008).
This Special Issue highlights some of the array of tools which have been proposed as helpful to clinicians to offset stress and enhance resilience. To this end, there are considerations of mindfulness and story-telling which are proffered as possible means to pause and reflect and indeed the somewhat unique (for this journal) inclusion of poetry and prose represents an attempt to support and highlight the importance of enacting such strategies. Undoubtedly, however, research into what are described as psychological preparedness tools for healthcare workers is at a nascent stage and considerable further research is required prior to widespread implementation.
It is unsurprising, therefore, that while comprehensive Pandemic Preparedness Tools (Adelaja et al. 2020) all incorporate specific elements designed to support the psychological well-being of healthcare staff, it appears reasonable to assert that additional support structures or tools have not been the experience of clinicians working throughout the pandemic. Indeed, a recent survey by the British Medical Association reported that 40% of the 6650 respondents indicated a worsening in their mental health status compared to pre-pandemic (Rimmer, 2020), with 10% describing their mental health as much worse. This is broadly in keeping with data from previous pandemics which suggest that, of those who experience negative psychological sequelae, the majority of healthcare staff will experience transient psychological distress rather than diagnosable moderate-severe conditions (Greenberg et al. 2020;Maunder et al. 2003Maunder et al. , 2006Maunder et al. , 2008. These figures remain concerning however, and while Irish data does not exist, if the medical population in Ireland experiences similar trends to our international colleagues, the overall prevalence rates and service need for doctors as psychiatric patients will rise significantly. As psychiatrists, we have a particular duty to highlight these risks; effective advocacy within this context is paramount. Moreover, this underscores a recognised pressing but under-considered need to develop doctor specific psychiatry services within the psychiatric service framework in Ireland. This model, already piloted in England and extended in the context of the pandemic, has seen an exponential rise in referrals over the latter stages of the pandemic (Conference Proceedings for Occupational Health and Burnout among Healthcare Workers: https:// www.ucd.ie/medicine/capsych/summerschool2020/).

Research priorities
As outlined above, the constantly evolving nature of the pandemic presents an unprecedented challenge to researchers aiming to identify strategies for addressing the mental health issues arising in the current pandemic. Risk factors for mental illness may coalesce in different ways at different time points of the pandemic waves. By extension, the particulars of service need and delivery will also shift against this backdrop and it is important that psychiatric services remain flexible in service delivery at this time. Despite these challenges, it is crucial to prioritise an integrated approach to psychiatric translational research in Ireland which can inform service innovation and development. The efforts of colleagues to continue to innovate and examine outcomes despite the aforementioned complexities and myriad pressures is indeed laudable and worthwhile as our efforts to transform and remodel services can have real impact for our service users.

Conclusion
As with the first edition dedicated to COVID-19, we sincerely hope that this themed issue provides a useful resource to colleagues as we continue to grapple with unprecedented demands. There is currently no road map to inform how the situation will evolve and what will be the ultimate extent of service need. Once again, we are most grateful to all contributors who, despite unparalleled service pressures, have taken the time to reflect and share perspectives on their experiences, innovations and clinical practice. This issue highlights the extraordinary demands on psychiatric services and the likely enduring nature of this need in the years to come as longer-term impacts of the pandemic, particularly potential economic contraction, exert their toll on population mental illness. Effective advocacy for our patients, ourselves and our colleagues remains paramount.

Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.