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Covid-19 and mental health: a transformational opportunity to apply an evidence-based approach to clinical practice and research
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  1. Katharine Smith1,2,
  2. Edoardo Ostinelli1,2,
  3. Andrea Cipriani1,2
  1. 1 Department of Psychiatry, University of Oxford Department of Psychiatry, Oxford, UK
  2. 2 Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
  1. Correspondence to Professor Andrea Cipriani, University of Oxford Department of Psychiatry, Oxford OX3 7JX, UK; andrea.cipriani{at}psych.ox.ac.uk

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Covid-19 was first recognised in December 2019 and is now posing critical challenges for public health, clinical research and medical care worldwide.1 The covid-19 outbreak has rapidly evolved into a fast-moving global pandemic, with world updates produced on a daily basis.2 For busy clinicians, this presents a problem of information overload: while there is a sea of information, finding easily accessible, reliable and up-to-date answers to immediate clinical questions can be difficult and time-consuming. The data available are a broad sweep of official guidance from different organisations (including specialty-based, country-based and worldwide), original research papers, personal/professional experiences and commentaries.

Mental health patients are particularly vulnerable in the context of covid-19, both directly because of their mental health difficulties, but also because of some of the long-term effects of psychotropic medication (such as metabolic syndrome with long-term antipsychotics), comorbid physical health problems and the effects of smoking.3 These factors together mean they are more vulnerable both to covid-19 itself and its complications, as well as to the adverse psychological effects of measures such as self-isolation and disruption to their normal healthcare and lifestyle.4 Moreover, the field of mental health is a particularly challenging area in which to source evidence related to covid-19. Covid-19 is primarily a respiratory disease and so much of the guidance and papers focus on the physical manifestations and their management. Mental health reports to date have generally examined the psychological effects of isolation/quarantine in the general public and psychological impacts on healthcare workers, rather than mental health patients/mental health services themselves. In addition, information specific to mental health is often hidden within more general documents. Some areas relevant to mental health are better covered by other organisations (such as palliative care) rather than those traditionally representing psychiatry. The need for rapid, focused and, above all, clinically relevant guidance is acute. Summaries of mental health guidance, such as those produced in the UK by the Royal College of Psychiatrists, are invaluable.5 However, by including all aspects of care they are lengthy, and it is not easy to find answers to clinical questions quickly.

To tackle this issue, the Oxford Precision Psychiatry Lab (https://oxfordhealthbrc.nihr.ac.uk/our-work/oxppl/, @OxfordPPL) collected from senior clinicians in the local Mental Health Trust a list of specific and focused questions about mental health issues, healthcare provision and covid-19 (https://oxfordhealthbrc.nihr.ac.uk/our-work/oxppl/covid-19-and-mental-health-guidance/).6 We faced a number of challenges in using evidence-based techniques to answer these questions. The possible sources of evidence were numerous and changing daily, and the areas of uncertainty often crossed the interface between psychiatry/mental health and physical and social care. In addition, we wanted to produce summarised information in a timely and user-friendly manner for clinicians in an area which is changing rapidly. The output needed to be collated to answer very specific clinical questions, with links to original sources and accessible to all locally, nationally and internationally. The output also needed to be dynamic and interactive: however systematic the search, in the time available it could not be guaranteed to be 100% comprehensive or error-free. Therefore, a platform which invited contribution and correction by users would be more reliable and useful. Finally, the output needed to be updated frequently, to keep up with a fast-moving field.

First, with the support of the Oxford Health Biomedical Research Centre (https://oxfordhealthbrc.nihr.ac.uk/), we prepared a synthesis of guidance in answer to the specific clinical questions posed by clinicians. A search strategy was agreed and we decided to focus first on English language guidance (covering the UK, USA, Canada, Australia, New Zealand and Singapore) about two topics in relation to covid-19: clozapine management and inpatient issues (including end-of-life care). The summary tables were converted into an open access web page with embedded hyperlinks for ease of use (https://oxfordhealthbrc.nihr.ac.uk/our-work/oxppl/covid-19-and-mental-health-guidance/).6 The rapid timescale of response was important: the initial request was received on 26 March 2020, the final summary tables completed on 30 March 2020, then reviewed by senior clinicians from different subspecialties and professional groups (including medicine, nursing and pharmacy). The web page went live on 01 April 2020 (https://oxfordhealthbrc.nihr.ac.uk/our-work/oxppl/covid-19-and-mental-health-guidance/).6 We welcome any constructive feedback to improve the content/format and are happy to share the information in different translations.

Our second and parallel workstream is a systematic review of the evidence of the impact of covid-19 on mental health patients, and also on clinical mental health staff and delivery of care. A protocol was registered with PROSPERO (CRD42020178819).7 Time is always a challenge, but our aim is to carry out a rigorous systematic review conducted rapidly rather than a rapid review conducted less rigorously.

These are examples of how evidence-based medicine techniques can be applied quickly and successfully in a real-world situation. Evidence-Based Mental Health and the editorial board are happy to collect information about other similar examples and welcome submission of articles about the use and implementation of evidence-based mental health in clinical practice during the covid-19 pandemic.

The covid-19 pandemic and the challenges it presents are unprecedented within most of our lifetimes. The effects of the pandemic, the associated restrictions in social, occupational and healthcare contact are likely to be long-lasting and wide-ranging. Many ways of living and working will not be the same again. So, this moment represents a step change in many areas of our lives, but, as well as loss of freedoms, this also offers the opportunity for positive change. For mental healthcare, both service delivery and clinical research, many of these changes will be transformational. Systems of healthcare frequently get ‘stuck’ in ways of operating. The restrictions associated with covid-19 have forced both clinicians and patients to reappraise care and to focus on what is absolutely essential and evidence-based. New ways of contacting and assessing patients using telemedicine have been rapidly adopted. Healthcare systems, such as the National Health Service, have implemented Information Technology systems to support home working and telephone consultations at a rate which would have seemed impossible in normal circumstances. The current situation has given organisations the urgency to implement these quickly and the impetus to patients to try them positively and proactively. Advantages such as efficiency, rapid access to subspecialty expertise and ease of treating patients in their own homes can be used positively well after the pandemic has gone.8 This change also applies to clinical research where we have an opportunity to think creatively and flexibly about the most efficient and appropriate ways of working, embracing technology to use for example e-consent and videoconferencing more widely.

In order to reappraise effectively our new ways of working, both in the immediate management of issues during the pandemic and also during the longer-term aftermath, we need fast-track implementation of evidence-based medicine techniques in mental health to supply the best evidence to clinicians on specific questions in real time. Digital mental health is definitely the way forward.9 Out of adversity can come new growth, and amidst all the challenges, we should not lose sight of the new advances we can make.10

Acknowledgments

KS, EO and AC are supported by the National Institute for Health Research (NIHR) Oxford cognitive health Clinical Research Facility. AC is also supported by an NIHR Research Professorship (grant RP-2017-08-ST2-006), by the NIHR Oxford and Thames Valley Applied Research Collaboration and by the NIHR Oxford Health Biomedical Research Centre (grant BRC-1215-20005). The views expressed are those of the authors and not necessarily those of the UK National Health Service, the NIHR, or the UK Department of Health. The authors thank Professor Paul Harrison for his comments on the drafted manuscript.

References

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Footnotes

  • Twitter @And_Cipriani

  • Contributors KS and AC drafted the editorial and EO critically revised it.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests AC has received research and consultancy fees from INCiPiT (Italian Network for Paediatric Trials), CARIPLO Foundation and Angelini Pharma, outside the submitted work.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

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