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      Multidisciplinary research priorities for the COVID-19 pandemic – Authors' reply

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          Abstract

          We are encouraged and stimulated by the responses to our Position Paper on COVID-19 mental health science. Some key messages are consistent: the mental health effects of COVID-19 are likely to be profound, long lasting, and will touch all sectors of society. Moreover, there was consensus that only by harnessing a truly multidisciplinary response will we be able to mitigate the mental health risks effectively. How best to respond will be a challenge that requires most of us to think and work differently, and for our scientific, research, and practice communities to come together to create novel solutions. These responses complement the priorities outlined in our Position Paper and will stimulate further research using diverse methods, including more perspectives from the social sciences and focusing on additional vulnerable populations—eg, young people with complex forensic mental health needs, 1 and babies. 2 In terms of public discourse around the COVID-19 pandemic, the message in the UK and North America is that we are all in this together, but such statements are not supported by statistics. COVID-19 affects groups of people differentially; mortality rates are socially patterned, with deaths being more common among people older than 70 years, members of black, Asian, and minority ethnic communities, and those who are most socially disadvantaged. When describing the outcomes of COVID-19, as Damian Barr wrote on Twitter, it is more accurate to say that although we are all navigating the same coronavirus storm, we are in different types of boats: some people are in super-yachts and others have only a single oar. Those in the most affected boats are also more likely to be exposed to a clustering of socially structured disadvantage across generations resulting in increased morbidity and mortality from COVID-19. It is crucial, therefore, that research into the mental health effects of social and welfare policies and structural inequality is prioritised. 3 To address health paradoxes, history suggests we need to seek innovations to our existing approaches. 4 Mental health science must embrace the full range of scales at which initiatives can be targeted (ie, societal, community, and individual targets). We must consider mechanisms of change at all levels, irrespective of whether these are public health interventions, individual approaches, or global initiatives. We need to find new ways to bring research communities together, because mental health science is best served when we join forces, complementing each other. Diversity will be our strength, and it is only through working together across disciplines that we will tackle the global challenge of COVID-19. A few points have been raised that, although included in our Position Paper, are important to emphasise. First, co-design should be integral to everything done as part of the mental health science response; those affected by COVID-19 and those with mental health problems must have a voice. For example, young people should be included as equal partners in the design and implementation of mental health science solutions. Such collaboration will enrich the research process and could lead to inclusion of novel aspects of positive mental health, such as resilience, courage, and compassion. 5 Second, research into the COVID-19 pandemic should ensure that black, Asian, and minority ethnic communities are represented, both as participants in co-design and on study management groups. Indeed, we welcome the call for a race equality impact assessment being applied to all forthcoming research studies. 6 Research into the link between ethnicity and COVID-19 outcome is urgent, 7 and mental health aspects need to be included here. To effectively identify the effect of the virus and interventions on different communities, such representation must be sufficiently granular and recognise the intersectionality of risks. Third, in the rush to understand the effect of COVID-19 on mental health and wellbeing, it is more important than ever that the highest standards of ethical research practice are maintained. Such standards include respecting confidentiality, recognising potential harms, and focusing on issues around acceptability (of potential interventions) and trustworthiness (in terms of data collection and data sharing). 5 Townsend and colleagues 8 have published some useful guidance; for example, they recommend mood measurements, mood mitigation techniques as standard, and they stress the importance of doing research that has clear benefits, while keeping risks low. Fourth, the mental health science response must be truly multidisciplinary in implementation. In the Position Paper, we highlighted a wide range of disciplines, and the original author group was drawn from diverse disciplinary backgrounds. However, many further professions need to be included; for example, nursing is central to the COVID-19 research response. 9 Just under 40 000 mental health nurses make up the largest component of the UK National Health Service psychiatric workforce, and it is essential that mental health nurse researchers are included to ensure that any research is responsive to their concerns and priorities. Fifth, we recognise that feeling distressed or anxious is understandable for many going through such unprecedented times. 10 Therefore, it is important that any mental health response is commensurate and tailored. Clearly, for those who are vulnerable, it is important to be vigilant to mitigate the risks to mental health difficulties. We also need to consider longer term preventive approaches more broadly, so that we are more responsive to the chronic outcomes of the current pandemic as well as being better prepared for future public health crises. The Position Paper was pitched as a call for action; we are grateful for these responses, which help increase breadth and inclusion in the mental health research response to COVID-19. This work is not only an important reminder to funding agencies but also an even stronger incentive to advance the mobilisation and coordination of the whole community of mental health scholars. It has already provided a welcome platform for starting dialogue with researchers, research funders, and the wider mental health science community, and a continued conversation is necessary. It is now a responsibility to include the voices of all those whose mental health is affected by this pandemic and ensure that research findings are translated into practice.

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          Most cited references10

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          Is ethnicity linked to incidence or outcomes of covid-19?

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            Key ethical questions for research during the COVID-19 pandemic

            In these times of rapid change, with high levels of uncertainty, anxiety, social isolation, and financial pressure, mental health worldwide is likely to be at risk. Researchers are rightly ensuring that mental health research is included in the response to the coronavirus disease 2019 (COVID-19) pandemic. 1 Here, we reflect on ethical issues to consider when conducting research on self-harm, suicide, and the broader impacts of COVID-19 in the midst of a global pandemic, and provide some recommendations to consider when researching these topics. In non-pandemic times, research suggests that participating in self-harm and suicide studies is unlikely to cause substantial distress, even in the most vulnerable, 2 and that any detrimental effects are short lived and outweighed by altruism. 3 However, we do not know whether this holds in the context of a global pandemic. Researchers around the globe have paused their work for several reasons. First, to avoid unnecessary burden on people who might be in distress during the pandemic. Second, because the context of the current research environment means that results will require cautious interpretation. Third, to ensure that continued recruitment of people to studies on self-harm and suicide when a global crisis is occurring is reasonable and safe; transferring face-to-face research online must be very carefully considered. Finally, because the supports and services that participants would be signposted to throughout a study might not able to provide support in the usual ways and formats. Mental health research, including self-harm and suicide, is a vital part of the response to the pandemic, but we are concerned about the ethical robustness of some studies already recruiting. We have seen studies that do not provide sufficient information to enable fully informed consent, do not measure mood before or after participation, do not provide any signposting other than to potentially anxiety-provoking messages about COVID-19, and do not attempt any kind of mood mitigation or debrief to help to stabilise anyone that does become distressed after participation. We would recommend that researchers be mindful that general research into the impacts of COVID-19, even if this does not evaluate mental health, self-harm, or suicide, should be viewed as a highly sensitive topic, with similar attention to safeguards needed to protect the wellbeing of participants. We recommend that all studies into COVID-19, self-harm, and suicide measure mood before and after participation; a simple visual analogue scale has been used to good effect in several studies. 4 These mood measurements can also be used to decide whether a study can ethically continue, with a stop-study criterion set and applied if participants report very decreased mood after participation. Researchers should provide signposting and check that the services signposted to are operational and able to provide support (and in what format). Finally, providing mood mitigation to all participants is an important method to boost mood, particularly when participants have been asked to consider anxiety-provoking questions about COVID-19 and answer sensitive questions about self-harm or suicide. A number of methods including exam howlers, 5 cute animal pictures, 4 interactive websites, 6 and so-called doodle pages 7 have been shown to work for young people. The ethics of voucher lotteries and other incentives for participants in studies on suicide and self-harm have been questioned by lived experience authors. 8 Valuing the time of participants who contribute to these studies and respecting the challenges of taking part in research on difficult topics is important at a time of financial difficulty for many, particularly when there is little access to supports. For new work evaluating COVID-19 and mental health impacts, patient and public involvement must be central to prioritising and designing research studies. Indeed, the MQ COVID-19 and mental health initiative 1 includes people with lived experience in the 18 members of their leadership team. This would be strengthened if people with lived experience were among the core leadership team (currently comprised of six senior academics). More than ever, it is crucial that patient and public involvement is embedded into research and that lived experience advisors are supported effectively—both emotionally and financially. Sarah Knowles (University of York) has recently curated materials for researchers to facilitate effective co-creation and patient and public involvement in the digital world. 9 For all research to be considered ethical, the benefits must be high and the risk minimised. The research community must be very clear about who will benefit from the research, how it can be implemented to inform policy and practice, and in what time frame. Clearly, ethics committees across the globe have a vital role to play in weighing these issues and in the context of a growing plethora of online studies. Given social distancing and lockdowns, an effective digital response is crucial. Clinical mental health services globally are having to mobilise staff digitally and remotely to meet current need. The research community also needs to respond effectively to the COVID-19 pandemic, but we must ensure that what we are doing is ethical. © 2020 Sakkmesterke/Science Photo Library 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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              Receding horizons of health: biocultural approaches to public health paradoxes.

              Worldwide challenges to health reflect a "paradox of success," whereby both the strengths and the weaknesses of current approaches in public health, epidemiology, and biomedicine have determined the nature of the health problems we now face. In detail, we analyze and illustrate five constituent paradoxes that fuel continued health risk even in the face of success, including: (1) unmasking, (2) local biology, (3) socialization, (4) emerging and reemerging disease, and (5) savage inequity. We trace the pathways behind the paradoxes and their effects on health, and demonstrate that biocultural dynamics are involved in each. Furthermore, we track the roots of health paradox to changes that divert or disrupt pathways for production of health. These analyses contribute to an emerging literature of research and praxis on integrative biocultural models of health.
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                Author and article information

                Contributors
                Journal
                Lancet Psychiatry
                Lancet Psychiatry
                The Lancet. Psychiatry
                Elsevier Ltd.
                2215-0366
                2215-0374
                18 June 2020
                July 2020
                18 June 2020
                : 7
                : 7
                : e44-e45
                Affiliations
                [a ]Suicidal Behaviour Research Laboratory, Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 0XH, UK
                [b ]Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
                [c ]National Institute for Health Research Biomedical Research Centre at the Maudsley, Maudsley Hospital, London, UK
                [d ]Anthropology Faculty, Emory University, Atlanta, GA, USA
                [e ]UK Dementia Research Institute, London, UK
                [f ]Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
                [g ]Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
                [h ]University of Exeter Medical School, University of Exeter, Exeter, UK
                [i ]Black Dog Institute, Sydney, NSW, Australia
                [j ]Department of Psychological Science, Department of Medicine, and Program in Public Health, University of California, Irvine, CA, USA
                [k ]Department of Psychiatry, University of Cambridge, Cambridge, UK
                [l ]Swansea University Medical School, Swansea University, Swansea, UK
                [m ]The McPin Foundation, London, UK
                [n ]Independent, Cambridge, UK
                [o ]South London and Maudsley NHS Foundation Trust, London, UK
                [p ]Department of Occupational Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
                [q ]Katherine Cowan Consulting, St Leonards-on-Sea, UK
                [r ]Department of Research and Development, Cambridgeshire & Peterborough NHS Foundation Trust, Cambridge, UK
                [s ]Department of Psychology, Uppsala University, Uppsala, Sweden
                [t ]Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
                Article
                S2215-0366(20)30247-9
                10.1016/S2215-0366(20)30247-9
                7302786
                32563319
                9aa26993-833f-48c1-ba99-1bc8d0bed232
                © 2020 Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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