Impact of COVID-19 on mental illness in vaccinated and unvaccinated people: a population-based cohort study in OpenSAFELY (preprint)

Background: COVID-19 is associated with subsequent mental illness in both hospital- and population-based studies. Evidence regarding effects of COVID-19 vaccination on mental health consequences of COVID-19 is limited. Methods: With the approval of NHS England, we used linked electronic health records (OpenSAFELY-TPP) to conduct analyses in a 'pre-vaccination' cohort (17,619,987 people) followed during the wild-type/Alpha variant eras (January 2020-June 2021), and 'vaccinated' and 'unvaccinated' cohorts (13,716,225 and 3,130,581 people respectively) during the Delta variant era (June-December 2021). We estimated adjusted hazard ratios (aHRs) comparing the incidence of mental illness after diagnosis of COVID-19 with the incidence before or without COVID-19. Outcomes: We considered eight outcomes: depression, serious mental illness, general anxiety, post-traumatic stress disorder, eating disorders, addiction, self-harm, and suicide. Incidence of most outcomes was elevated during weeks 1-4 after COVID-19 diagnosis, compared with before or without COVID-19, in each cohort. Vaccination mitigated the adverse effects of COVID-19 on mental health: aHRs (95% CIs) for depression and for serious mental illness during weeks 1-4 after COVID-19 were 1.93 (1.88-1.98) and 1.42 (1.24-1.61) respectively in the pre-vaccination cohort and 1.79 (1.68-1.91) and 2.21 (1.99-2.45) respectively in the unvaccinated cohort, compared with 1.16 (1.12-1.20) and 0.91 (0.84-0.98) respectively in the vaccinated cohort. Elevation in incidence was higher, and persisted for longer, after hospitalised than non-hospitalised COVID-19. Interpretation: Incidence of mental illness is elevated for up to a year following severe COVID-19 in unvaccinated people. Vaccination mitigates the adverse effect of COVID-19 on mental health. Funding: Medical Research Council (MC_PC_20059) and NIHR (COV-LT-0009).

Examining the inter-relationships between social isolation and loneliness and their correlates among older British adults before and during the COVID-19 lockdown: evidence from four British longitudinal studies (preprint)

Background and Objectives: Unprecedented social restrictions during the COVID-19 pandemic have provided a new lens for considering the inter-relationship between social isolation and loneliness in later life. We present these inter-relationships before and during the COVID-19 restrictions and investigate to what extent demographic, socio-economic, and health factors associated with such experiences differed during the pandemic. Research Design and Method: We used data from four British longitudinal population-based studies (1946 MRC NSHD, 1958 NCDS, 1970 BCS, and ELSA). Rates, co-occurrences, and correlates of social isolation and loneliness are presented prior to and during the early stage of the COVID-19 pandemic and the inter-relationships between these experiences are elucidated in both periods. Results: Across the four studies, pre-pandemic proportions reporting social isolation ranged from 15 to 54%, with higher rates in older ages (e.g., 32% of 70-79 and 54% of those over 80). During the pandemic, the percentage of older people reporting both social isolation and loneliness and isolation only slightly increased. The inter-relationship between social isolation and loneliness did not change. Associations between socio-demographic and health characteristics and social isolation and loneliness also remained consistent, with greater burden among those with greater economic precarity (females, non-homeowners, unemployed, illness and greater financial stress). Discussion and Implications: There were already large inequalities in experiences of social isolation and loneliness and the pandemic had a small impact on worsening these inequalities. The concepts of loneliness and social isolation are not transferable and clarity is needed in how they are conceptualised, operationalised, and interpreted.

Living alone and mental health: parallel analyses in longitudinal population surveys and electronic health records prior to and during the COVID-19 pandemic (preprint)

Objectives: To describe the mental health gap between those who live alone and those who live with others, and to examine whether the COVID-19 pandemic had an impact on this gap. Design: Ten population based prospective cohort studies, and a retrospective descriptive cohort study based on electronic health records (EHRs). Setting: UK Longitudinal population-based surveys (LPS), and primary and secondary care records within the OpenSAFELY-TPP database. Participants: Participants from the LPS were included if they had information on living status in early 2020, valid data on mental ill-health at the closest pre-pandemic assessment and at least once during the pandemic, and valid data on a key minimum set of covariates. The EHR dataset included 16 million adults registered with primary care practices in England using TPP SystmOne software on 1st February 2020, with at least three months of registration, valid address data, and living in households of <16 people. Main outcome measures: In the LPS, self-reported survey measures of psychological distress and life satisfaction were assessed in the nearest pre-pandemic sweep and three periods during the pandemic: April-June 2020, July-October 2020, and November 2020-March 2021. In the EHR analyses, outcomes were morbidity codes recorded in primary or secondary care between March 2018 and January 2022 reflecting the diagnoses of depression, self-harm, anxiety, obsessive compulsive disorder, eating disorders, and severe mental illnesses. Results: The LPS consisted of 37,544 participants (15.2% living alone) and we found greater psychological distress (SMD: 0.09 (95% CI: 0.04, 0.14) and lower life satisfaction (SMD: -0.22 (95% CI: -0.30, -0.15) in those living alone pre-pandemic, and the gap between the two groups stayed similar after the onset of the pandemic. In the EHR analysis of almost 16 million records (21.4% living alone), codes indicating mental health conditions were more common in those who lived alone compared to those who lived with others (e.g., depression 26 and severe mental illness 58 cases more per 100,000). Recording of mental health conditions fell during the pandemic for common mental health disorders and the gap between the two groups narrowed. Conclusions: Multiple sources of data indicate that those who live alone experience greater levels of common and severe mental illnesses, and lower life satisfaction. During the pandemic this gap in need remained, however, there was a narrowing of the gap in service use, suggesting greater barriers to healthcare access for those who live alone.

Healthcare in England was affected by the COVID-19 pandemic across the pancreatic cancer pathway: a cohort study using OpenSAFELY-TPP (preprint)

Background Healthcare across all sectors, in the UK and globally, was negatively affected by the COVID-19 pandemic. We investigated the effect of the COVID-19 pandemic on the quantity of healthcare services delivered to people with pancreatic cancer. Methods With the approval of NHS England, and drawing from a nationally representative OpenSAFELY-TPP dataset of 24 million patients (over 40% of the English population), we undertook a cohort study of people diagnosed with pancreatic cancer. We queried electronic healthcare records for information on the provision of healthcare services across the pancreatic cancer pathway. To estimate the effect of the COVID-19 pandemic, we predicted the rates of healthcare services if the pandemic had not happened. We used generalised linear models (GLM) and the pre-pandemic data from January 2015 to February 2020 to predict rates in March 2020 to September 2022. The 95% confidence intervals of the predicted values were used to estimate the significance of the difference between the predicted and observed rates. Results The rate of pancreatic cancer and diabetes diagnoses in the cohort was not affected by the pandemic. There were 24,500 people diagnosed with pancreatic cancer from January 2015 to September 2022. The mean age at diagnosis was 72 (SD 11), 48% of people were female, 95% were of White ethnicity and 39% were diagnosed with diabetes. We found a reduction in surgical resections by nearly 25% during the pandemic. In addition, 20%, 10% and 5% fewer people received BMI, HbA1c and liver function tests respectively before they were diagnosed with pancreatic cancer. There was no impact of the pandemic on the number of people making contact with primary care, but the number of contacts increased on average by 1 to 2 per person amongst those who made contact. Abdominal scans decreased by 7% and reporting of jaundice decreased by 20%, but recovered within six months into the pandemic. Emergency department visits, hospital admissions and deaths were not affected. Conclusions The pandemic affected healthcare in England across the pancreatic cancer pathway. Positive lessons could be learnt from services that recovered quickly. The reductions in healthcare experienced by people with cancer have the potential to lead to worse outcomes. Current efforts should focus on addressing the unmet needs of people with cancer.

Home working and its association with social and mental wellbeing at different stages of the COVID-19 pandemic: Evidence from seven UK longitudinal population surveys. (preprint)

Background: Home working rates have increased since the COVID-19 pandemic's onset, but the health implications of this transformation are unclear. We assessed the association between home working and social and mental wellbeing through harmonised analyses of seven UK longitudinal studies. Methods: We estimated associations between home working and measures of psychological distress, low life satisfaction, poor self-rated health, low social contact, and loneliness across three different stages of the COVID-19 pandemic (T1= Apr-Jun 2020 - first lockdown, T2=Jul-Oct 2020 - eased restrictions, T3=Nov 2020-Mar 2021 - second lockdown), in seven population-based cohort studies using modified Poisson regression and meta-analyses to pool results across studies. Findings: Among 34,131 observations spread over three time points, we found higher rates of home working at T1 and T3 compared with T2, reflecting lockdown periods. Home working was not associated with psychological distress at T1 (RR=0.92, 95%CI=0.79-1.08) or T2 (RR=0.99, 95%CI=0.88-1.11), but a detrimental association was found with psychological distress at T3 (RR=1.17, 95%CI=1.05-1.30). Poorer psychological distress associated with home working was observed for those educated to below degree level at T2 and T3. Men working from home reported poorer self-reported health at T2. Interpretation: No clear evidence of an association between home working and mental wellbeing was found, apart from greater risk of psychological distress associated with home working during the second lockdown, but differences across sub-groups may exist. Longer term shifts to home working might not have adverse impacts on population wellbeing in the absence of pandemic restrictions but further monitoring of health inequalities is required.

Examining Children and Adolescent Mental Health Trajectories during the COVID-19 Pandemic: Findings from a year of the Co-SPACE Study (preprint)

A major concern throughout the COVID-19 pandemic has been the impact on young people’s mental health. The objective of this study was to map children and adolescents’ mental health trajectories over thirteen months of the pandemic and examine whether family, peer, and individual-level factors were associated with different trajectories. The current study focuses on a convenience sub-sample from the Co-SPACE study of 3,322 children and adolescents (aged 4-16 years) for whom parents completed a baseline survey and at least one follow-up survey between March 2020 and May 2021. We used growth mixture models to examine distinct trajectories in emotional, conduct, and hyperactivity/inattention difficulties using the Strengths and Difficulties Questionnaire and multinomial logistic regression models to estimate factors associated with individual trajectory membership. The general trend in participating young people’s mental health appeared to follow changes in national guidelines. For distinct trends, a 5-trajectory model best explained the changes in emotional problems whilst 4-trajectory models best explained variation in hyperactivity/inattention and conduct problems. While most young people followed low stable (62%-85%) or moderate stable (28%) symptom trajectories, 14-31% experienced very high, high stable or increasing mental health difficulties. Young people following high stable trajectories were more likely to have special educational needs and/or neurodevelopmental disorders, parents who reported higher levels of stress and parent-child conflict and were less likely to have at least one close friend. Most participating young people experienced low stable symptoms but nearly one third experienced high stable or increasing mental health difficulties. Young people with complex needs and parents with higher psychological distress were particularly vulnerable to high stable mental health difficulties while those with positive peer relationships were less vulnerable. This study offers insight into potential factors that can be addressed using targeted interventions to improve the wellbeing of parents and young people in the event of future lockdowns and school closures.

Mental health outcomes following COVID-19 infection: Evidence from 11 UK longitudinal population studies (preprint)

Background Evidence on associations between COVID-19 illness and mental health is mixed. We examined longitudinal associations between COVID-19 and mental health while considering: 1) pre-pandemic mental health, 2) time since infection; 3) subgroup differences; and 4) confirmation of infection via self-reported test, and serology data. Methods Using data from 11 UK longitudinal studies, involving 54,442 participants, with 2 to 8 repeated measures of mental health and COVID-19 between April 2020 and April 2021, we standardised continuous mental health scales within each study across time. We investigated associations between COVID-19 (self-report, test-confirmed, serology-confirmed) and mental health using multilevel generalised estimating equations. We examined whether associations varied by age, sex, ethnicity, education and pre-pandemic mental health. Effect-sizes were pooled in random-effects meta-analyses. Outcomes Pooled estimates of the standardized difference in outcome between those with and without self-reported COVID-19 suggested associations with subsequent psychological distress (0.10 [95%CI: 0.06; 0.13], I 2 =42.8%), depression (0.08 [0.05; 0.10], I 2 =20.8%), anxiety (0.08 [0.05; 0.10], I 2 =0%), and lower life satisfaction (−0.06 [-0.08; -0.04], I 2 =29.2%). Associations did not vary by time since infection until 3+ months and were present in all age groups, with some evidence of stronger effects in those aged 50+. Self-reported COVID-19, whether suspected or test-confirmed and irrespective of serology status, was associated with poorer mental health. Interpretation Self-reporting COVID-19 was longitudinally associated with deterioration in mental health and life satisfaction. Our findings have important implications for mental health service provision, given the substantial prevalence of COVID-19 in the UK and worldwide. Funding MRC and NIHR

Association of COVID-19 employment disruption with mental and social wellbeing: evidence from nine UK longitudinal studies (preprint)

Background: The COVID-19 pandemic has led to major economic disruptions. In March 2020, the UK implemented the Coronavirus Job Retention Scheme, known as furlough, to minimize the impact of job losses. We investigate associations between change in employment status and mental and social wellbeing during the early stages of the pandemic. Methods: Data from 25,670 respondents, aged 16 to 66, from nine UK longitudinal studies were analysed. Changes in employment (including being furloughed) were defined by comparing employment status pre-pandemic and during the first lockdown. Mental and social wellbeing outcomes included psychological distress, life satisfaction, self-rated health, social contact, and loneliness. Study-specific modified Poisson regression estimates, adjusting for socio-demographic characteristics and pre-pandemic outcome measures, were pooled using meta-analysis. Results: Compared to those who remained working, furloughed workers were at greater risk of psychological distress (adjusted risk ratio, ARR=1.12; 95% CI: 0.97, 1.29), low life satisfaction (ARR=1.14; 95% CI: 1.07, 1.22), loneliness (ARR=1.12; 95% CI: 1.01, 1.23), and fair/poor self-rated health (ARR=1.26; 95% CI: 1.05, 1.50), but risk ratios appear less pronounced compared to those no longer employed (e.g., psychological distress, ARR=1.39; 95% CI: 1.21, 1.59) or stable unemployed (e.g., psychological distress, ARR=1.33; 95% CI: 1.09, 1.62). Conclusions: During the early stages of the pandemic those furloughed had increased risk for poor mental and social wellbeing. However, their excess risk was lower in magnitude than those who became or remained unemployed, suggesting that furlough partly mitigated poorer outcomes.

The UK COVID-19 furlough scheme and associations with smoking, alcohol consumption and vaping: evidence from 8 UK longitudinal population surveys. (preprint)

BackgroundDisruptions to employment status can impact smoking and alcohol consumption. During the COVID-19 pandemic, the UK implemented a furlough scheme to prevent job loss. We examine how furlough was associated with participants smoking, vaping and alcohol consumption behaviours in the early stages of the pandemic. MethodsData were from 27,841 participants in eight UK adult longitudinal surveys. Participants self-reported employment status and current smoking, current vaping and drinking alcohol (>4 days/week or 5+ drinks per typical occasion) both before and during the pandemic (April-July 2020). Risk ratios were estimated within each study using modified Poisson regression, adjusting for a range of potential confounders, including pre-pandemic behaviour. Findings were synthesised using random effects meta-analysis. Sub-group analyses were used to identify whether associations differed by gender, age or education. ResultsCompared to stable employment, neither furlough, no longer being employed, nor stable unemployment were associated with smoking, vaping or drinking, following adjustment for pre-pandemic characteristics. However, some sex differences in these associations were observed, with stable unemployment associated with smoking for women (ARR=1.35; 95% CI: 1.00-1.82; I2: 47%) but not men (0.84; 95% CI: 0.67-1.05; I2: 0%). No longer being employed was associated with vaping among women (ARR=2.74; 95% CI: 1.59-4.72; I2: 0%) but not men (ARR=1.25; 95% CI: 0.83-1.87; I2: 0%). There was little indication of associations with drinking differing by age, gender or education. ConclusionsWe found no clear evidence of furlough or unemployment having adverse impacts on smoking, vaping or drinking behaviours during the early stages of the COVID-19 pandemic in the UK, with differences in risk compared to those who remained employed largely explained by pre-pandemic characteristics.

Psychological Distress Before and During the COVID-19 Pandemic: Sociodemographic Inequalities in 11 UK Longitudinal Studies (preprint)

Background: How population mental health has evolved across the COVID-19 pandemic under varied lockdown measures is poorly understood, with impacts on health inequalities unclear. We investigated changes in mental health and sociodemographic inequalities from before and across the first year of the pandemic in 11 longitudinal studies. Methods: Data from 11 UK longitudinal population-based studies with pre-pandemic measures of psychological distress were analysed and estimates pooled. Trends in the prevalence of poor mental health were assessed across the pandemic at three time periods: initial lockdown (TP1, Mar-June 20); easing of restrictions (TP2, July-Oct 20); and a subsequent lockdown (TP3, Nov 20-Mar 21). Multi-level regression was used to examine changes in psychological distress compared to pre-pandemic; with stratified analyses by sex, ethnicity, education, age, and UK country. Results: Across the 11 studies (n=54,609), mental health had deteriorated from pre-pandemic scores across all three pandemic time periods (TP1 Standardised Mean Difference (SMD): 0.13 (95% CI: 0.03, 0.23); TP2 SMD: 0.18 (0.09, 0.27); TP3 SMD: 0.20 (0.09, 0.31)). Changes in psychological distress across the pandemic were higher in females (TP3 SMD: 0.23 (0.11, 0.35)) than males (TP3 SMD: 0.16 (0.06, 0.26)), and slightly lower in below-degree level educated persons at some time periods (TP3 SMD: 0.18 (0.06, 0.30)) compared to those who held degrees (TP3 SMD: 0.26 (0.14, 0.38)). Increased distress was most prominent amongst adults aged 35-44 years (TP3 SMD: 0.49 (0.15, 0.84)). We did not find evidence of changes in distress differing by ethnicity or UK country. Conclusions: The substantial deterioration in mental health seen in the UK during the first lockdown did not reverse when lockdown lifted, and a sustained worsening is observed across the pandemic. Mental health declines have not been equal across the population, with females, those with higher degrees, and younger adults more affected.

Risk factors for long COVID: analyses of 10 longitudinal studies and electronic health records in the UK (preprint)

The impact of long COVID is increasingly recognised, but risk factors are poorly characterised. We analysed questionnaire data on symptom duration from 10 longitudinal study (LS) samples and electronic healthcare records (EHR) to investigate sociodemographic and health risk factors associated with long COVID, as part of the UK National Core Study for Longitudinal Health and Wellbeing. Methods Analysis was conducted on 6,899 adults self-reporting COVID-19 from 45,096 participants of the UK LS, and on 3,327 cases assigned a long COVID code in primary care EHR out of 1,199,812 adults diagnosed with acute COVID-19. In LS, we derived two outcomes: symptoms lasting 4+ weeks and symptoms lasting 12+ weeks. Associations of potential risk factors (age, sex, ethnicity, socioeconomic factors, smoking, general and mental health, overweight/obesity, diabetes, hypertension, hypercholesterolaemia, and asthma) with these two outcomes were assessed, using logistic regression, with meta-analyses of findings presented alongside equivalent results from EHR analyses. Results Functionally limiting long COVID for 12+ weeks affected between 1.2% (age 20), and 4.8% (age 63) of people reporting COVID-19 in LS. The proportion reporting symptoms overall for 12+ weeks ranged from 7.8 (mean age 28) to 17% (mean age 58) and for 4+ weeks 4.2% (age 20) to 33.1% (age 56). Age was associated with a linear increase in long COVID between age 20-70. Being female (LS: OR=1.49; 95%CI:1.24-1.79; EHR: OR=1.51 [1.41-1.61]), poor pre-pandemic mental health (LS: OR=1.46 [1.17-1.83]; EHR: OR=1.57 [1.47-1.68]) and poor general health (LS: OR=1.62 [1.25-2.09]; EHR: OR=1.26; [1.18-1.35]) were associated with higher risk of long COVID. Individuals with asthma also had higher risk (LS: OR=1.32 [1.07-1.62]; EHR: OR=1.56 [1.46-1.67]), as did those categorised as overweight or obese (LS: OR=1.25 [1.01-1.55]; EHR: OR=1.31 [1.21-1.42]) though associations for symptoms lasting 12+ weeks were less pronounced. Non-white ethnic minority groups had lower 4+ week symptom risk (LS: OR=0.32 [0.22-0.47]), a finding consistent in EHR. Associations were not observed for other risk factors. Few participants in the studies had been admitted to hospital (0.8-5.2%). Conclusions Long COVID is clearly distributed differentially according to several sociodemographic and pre-existing health factors. Establishing which of these risk factors are causal and predisposing is necessary to further inform strategies for preventing and treating long COVID.

Inequalities in healthcare disruptions during the Covid-19 pandemic: Evidence from 12 UK population-based longitudinal studies (preprint)

Background: Health systems worldwide have faced major disruptions due to COVID-19 which could exacerbate health inequalities. The UK National Health Service (NHS) provides free healthcare and prioritises equity of delivery, but the pandemic may be hindering the achievement of these goals. We investigated associations between multiple social characteristics (sex, age, occupational social class, education and ethnicity) and self-reported healthcare disruptions in over 65,000 participants across twelve UK longitudinal studies. Methods: Participants reported disruptions from March 2020 up to late January 2021. Associations between social characteristics and three types of self-reported healthcare disruption (medication access, procedures, appointments) and a composite of any of these were assessed in logistic regression models, adjusting for age, sex and ethnicity where relevant. Random-effects meta-analysis was conducted to obtain pooled estimates. Results: Prevalence of disruption varied across studies; between 6.4% (TwinsUK) and 31.8 % (Understanding Society) of study participants reported any disruption. Females (Odd Ratio (OR): 1.27 [95%CI: 1.15,1.40]; I2=53%), older persons (e.g. OR: 1.39 [1.13,1.72]; I2=77% for 65-75y vs 45-54y), and Ethnic minorities (excluding White minorities) (OR: 1.19 [1.05,1.35]; I2=0% vs White) were more likely to report healthcare disruptions. Those in a more disadvantaged social class (e.g. OR: 1.17 [1.08, 1.27]; I2=0% for manual/routine vs managerial/professional) were also more likely to report healthcare disruptions, but no clear differences were observed by education levels. Conclusion: The COVID-19 pandemic has led to unequal healthcare disruptions, which, if unaddressed, could contribute to the maintenance or widening of existing health inequalities.

The UK Coronavirus Job Retention Scheme and changes in diet, physical activity and sleep during the COVID-19 pandemic: Evidence from eight longitudinal studies (preprint)

BackgroundIn March 2020 the UK implemented the Coronavirus Job Retention Scheme (furlough) to minimize job losses. Our aim was to investigate associations between furlough and diet, physical activity, and sleep during the early stages of the COVID-19 pandemic. MethodsWe analysed data from 25,092 participants aged 16 to 66 years from eight UK longitudinal studies. Changes in employment (including being furloughed) were defined by comparing employment status pre- and during the first lockdown. Health behaviours included fruit and vegetable consumption, physical activity, and sleeping patterns. Study-specific estimates obtained using modified Poisson regression, adjusting for socio-demographic characteristics and pre-pandemic health and health behaviours, were statistically pooled using random effects meta-analysis. Associations were also stratified by sex, age, and education. ResultsAcross studies, between 8 and 25% of participants were furloughed. Compared to those who remained working, furloughed workers were slightly less likely to be physically inactive (RR:0.85, [0.75-0.97], I2=59%) and did not differ in diet and sleep behaviours, although findings for sleep were heterogenous (I2=85%). In stratified analyses, furlough was associated with low fruit and vegetable consumption among males (RR=1.11; 95%CI: 1.01-1.22; I2: 0%) but not females (RR=0.84; 95%CI: 0.68-1.04; I2: 65%). Considering change in these health behaviours, furloughed workers were more likely than those who remained working to report increased fruit and vegetable consumption, exercise, and hours of sleep. ConclusionsThose furloughed exhibited broadly similar levels of health behaviours to those who remained in employment during the initial stages of the pandemic. There was little evidence to suggest that such social protection policies if used in the post-pandemic recovery period and during future economic crises would have adverse impacts on population health behaviours.

Pre-pandemic mental health and disruptions to healthcare, economic, and housing outcomes during COVID –19: evidence from 12 UK longitudinal studies (preprint)

Background The COVID-19 pandemic and associated virus suppression measures have disrupted lives and livelihoods and people already experiencing mental ill-health may have been especially vulnerable. Aim To quantify mental health inequalities in disruptions to healthcare, economic activity and housing. Method 59,482 participants in 12 UK longitudinal adult population studies with data collected prior to and during the COVID-19 pandemic. Within each study we estimated the association between psychological distress assessed pre-pandemic and disruptions since the start of the pandemic to three domains: healthcare (medication access, procedures, or appointments); economic activity (employment, income, or working hours); and housing (change of address or household composition). Meta-analyses were used to pool estimates across studies. Results Across the analysed datasets, one to two-thirds of participants experienced at least one disruption, with 2.3-33.2% experiencing disruptions in two or more domains. One standard deviation higher pre-pandemic psychological distress was associated with: (i) increased odds of any healthcare disruptions (OR=1.30; [95% CI:1.20–1.40]) with fully adjusted ORs ranging from 1.24 [1.09–1.41] for disruption to procedures and 1.33 [1.20– 1.49] for disruptions to prescriptions or medication access; (ii) loss of employment (OR=1.13 [1.06–1.21]) and income (OR=1.12 [1.06 –1.19]) and reductions in working hours/furlough (OR=1.05 [1.00–1.09]); (iii) no associations with housing disruptions (OR=1.00 [0.97–1.03]); and (iv) increased likelihood of experiencing a disruption in at least two domains (OR=1.25 [1.18–1.32]) or in one domain (OR=1.11 [1.07–1.16]) relative to no disruption. Conclusion People experiencing psychological distress pre-pandemic have been more likely to experience healthcare and economic disruptions, and clusters of disruptions across multiple domains during the pandemic. Failing to address these disruptions risks further widening the existing inequalities in mental health.

Mental health in relation to changes in sleep, exercise, alcohol and diet during the COVID-19 pandemic: examination of five UK cohort studies (preprint)

BackgroundResponses to the COVID-19 pandemic have included lockdowns and social distancing with considerable disruptions to peoples lives. These changes may have particularly impacted on those with mental health problems, leading to a worsening of inequalities in the behaviours which influence health. MethodsWe used data from four national longitudinal British cohort studies (N=10,666). Respondents reported mental health (psychological distress and anxiety/depression symptoms) and health behaviours (alcohol, diet, physical activity, and sleep) before and during the pandemic. Associations between pre-pandemic mental ill-health and pandemic mental ill-health and health behaviours were examined using logistic regression; pooled effects were estimated using meta-analysis. ResultsWorse mental health was related to adverse health behaviours; effect sizes were largest for sleep, exercise and diet, and weaker for alcohol. The associations between poor mental health and adverse health behaviours were larger during the May lockdown than pre-pandemic. In September, when restrictions had eased, inequalities had largely reverted to pre-pandemic levels. A notable exception was for sleep, where differences by mental health status remained high. Risk differences for adverse sleep for those with the highest level of prior mental ill-health compared to those with the lowest, were 21.2% (95% CI: 16.2, 26.2) before lockdown, 25.5% (20.0, 30.3) in May, and 28.2% (21.2, 35.2) in September. ConclusionsTaken together, our findings suggest that mental health is an increasingly important factor in health behaviour inequality in the COVID era. The promotion of mental health may thus be an important component of improving post-COVID population health.

Examining changes in parent-reported child and adolescent mental health throughout the UK’s first COVID-19 national lockdown. (preprint)

Background The COVID-19 pandemic has significantly changed the lives of children and adolescents, forcing them into periods of prolonged social isolation and time away from school. Understanding the psychological consequences of the UK’s lockdown for children and adolescents, the associated risk factors, and how trajectories may vary for children and adolescents in different circumstances is essential so that the most vulnerable children and adolescents can be identified and appropriate support can be implemented. Methods Parents and carers (n = 2988) in the U.K. with children and adolescents aged between 4 and 16 years completed an online survey about their child’s mental health. Growth curve analysis was used to examine the changes in conduct problems, hyperactivity/inattention and emotional symptoms between the end of March/beginning of April and July using data from four monthly assessments. Additionally, growth mixture modelling identified mental health trajectories for conduct problems, hyperactivity/inattention and emotional symptoms separately and subsequent regression models were used to estimate predictors of mental health trajectory membership. Results Overall levels of hyperactivity and conduct problems increased over time whereas emotional symptoms remained relatively stable, though declined somewhat between June and July. Change over time varied according to child age, the presence of siblings, and with Special Educational Needs (SEN)/ Neurodevelopmental Disorders (ND). Subsequent growth mixture modelling identified three, four and five trajectories for hyperactivity/inattention, conduct problems and emotional symptoms, respectively. Though many children maintained “stable3low” symptoms, others experienced elevated symptoms by July. These children were more likely to have a parent/carer with higher levels of psychological distress, to have SEN/ND, or to be younger in age. Conclusions The findings support previous literature and highlight that certain risk factors were associated with poorer mental health trajectories for children and adolescents during the pandemic.

How did the mental health of children and adolescents change during early lockdown during the COVID-19 pandemic in the UK? (preprint)

BackgroundThe COVID-19 pandemic has caused extensive disruption to the lives of children and young people. Understanding the psychological effects on children and young people, in the context of known risk factors, is crucial to mitigate the effects of the pandemic. This study set out to explore how mental health symptoms in children and adolescents changed over a month of full lockdown in the UK in response to the pandemic.MethodsUK-based parents and carers (n = 2,673) of school-aged children and young people aged between 4 and 16 years completed an online survey about their child’s mental health at two time points between March and May 2020, during early lockdown. The survey examined changes in emotional symptoms, conduct problems and hyperactivity/inattention.ResultsThe findings highlighted particular deteriorations in mental health symptoms among pre-adolescent children, which translated to a 10% increase in those meeting possible/probable caseness criteria for emotional symptoms, a 20% increase in hyperactivity/inattention, and a 35% increase in conduct problems. In contrast, changes among adolescents were smaller (4% and 8% increase for hyperactivity/inattention and conduct problems respectively) with a small reduction in emotional symptoms (reflecting a 3% reduction in caseness). Overall, there were few differences in change in symptoms or caseness over time according to demographic characteristics, but children and young people in low income households and those with special educational needs and/or neurodevelopmental disorders, exhibited elevated symptoms (and caseness) at both time points. ConclusionsThe findings highlight important areas of concern in terms of the potential impact of lockdown on children and young people’s adjustment. Developing an understanding of who has been most severely affected by the pandemic, and in what ways, is crucial in order to target effective support where it is most needed.

Inequality in access to health and care services during lockdown - Findings from the COVID-19 survey in five UK national longitudinal studies (preprint)

Background: Access to health services and adequate care is influenced by sex, ethnicity, socio-economic position (SEP) and burden of co-morbidities. However, it is unknown whether the COVID-19 pandemic further deepened these already existing health inequalities. Methods: Participants were from five longitudinal age-homogenous British cohorts (born in 2001, 1990, 1970, 1958 and 1946). A web and telephone-based survey provided data on cancelled surgical or medical appointments, and the number of care hours received during the UK COVID-19 national lockdown. Using binary or ordered logistic regression, we evaluated whether these outcomes differed by sex, ethnicity, SEP and having a chronic illness. Adjustment was made for study-design, non-response weights, psychological distress, presence of children or adolescents in the household, keyworker status, and whether participants had received a shielding letter. Meta-analyses were performed across the cohorts and meta-regression evaluated the effect of age as a moderator. Findings: 14891 participants were included. Females (OR 1.40, 95% confidence interval [1.27,1.55]) and those with a chronic illness (OR 1.84 [1.65-2.05]) experienced significantly more cancellations during lockdown (all p<0.0001). Ethnic minorities and those with a chronic illness required a higher number of care hours during the lockdown (both OR approx. 2.00, all p<0.002). Age was not independently associated with either outcome in meta-regression. SEP was not associated with cancellation or care hours. Interpretation: The UK government's lockdown approach during the COVID-19 pandemic appears to have deepened existing health inequalities, impacting predominantly females, ethnic-minorities and those with chronic illnesses. Public health authorities need to implement urgent policies to ensure equitable access to health and care for all in preparation for a second wave.

Changes in the behavioural determinants of health during the coronavirus (COVID-19) pandemic: gender, socioeconomic and ethnic inequalities in 5 British cohort studies (preprint)

BackgroundThe coronavirus (COVID-19) pandemic and consequent physical distancing measures are expected to have far-reaching consequences on population health, particularly in already disadvantaged groups. These consequences include changes in health impacting behaviours (such as exercise, sleep, diet and alcohol use) which are arguably important drivers of health inequalities. We sought to add to the rapidly developing empirical evidence base investigating the impacts of the pandemic on such behavioural outcomes. MethodsUsing data from five nationally representative British cohort studies (born 2001, 1990, 1970, 1958, and 1946), we investigated sleep, physical activity (exercise), diet, and alcohol intake (N=14,297). Using measures of each behaviour reported before and during lockdown, we investigated change in each behaviour, and whether such changes differed by age/cohort, gender, ethnicity, and socioeconomic position (SEP; childhood social class, education attainment, and adult reporting of financial difficulties). Binary or ordered logistic regression models were used, adjusting for prior measures of each health behaviour and accounting for study design and non-response weights. Meta-analyses were used to pool cohort-specific estimates and formally test for heterogeneity across cohorts. ResultsChanges in these outcomes occurred in in both directions ie, shifts from the middle part of the distribution to both declines and increases in sleep, exercise, and alcohol use. For all outcomes, older cohorts were less likely to report changes in behaviours compared with younger cohorts. In the youngest cohort (born 2001), the following shifts were more evident: increases in exercise, fruit and vegetable intake, sleep, and less frequent alcohol consumption. After adjustment for prior behaviour levels, during lockdown females were less likely to sleep within the typical range (6-9 hours) yet exercised more frequently; lower SEP was associated with lower odds of sleeping within the typical range (6-9 hours), lower exercise participation, and lower consumption of fruit and vegetables; and ethnic minorities were less likely than White participants to sleep within the typical range (6-9 hours), exercise less frequently, yet reported less frequent alcohol consumption. ConclusionsOur findings highlight the multiple changes to behavioural outcomes that may have occurred due to COVID-19 lockdown, and the differential impacts across generation, gender, SEP and ethnicity. Such changes require further monitoring given their possible implications to population health and the widening of health inequalities.

Demographic and health factors associated with pandemic anxiety in the context of COVID-19 (preprint)

Objectives The mental health consequences of COVID-19 are predicted to have a disproportionate impact on certain groups. We aimed to develop a brief measure, the Pandemic Anxiety Scale, to capture the specific aspects of the pandemic that are provoking anxiety, and explore how these vary by health and demographic factors. DesignData were from a convenience sample of parents (N=4,793) and adolescents (N=698) recruited in the first 6 weeks of lockdown. MethodsFactor analytic and IRT methods were used to validate the new measure in both parent and adolescent samples. Associations between scores on the new measure and age, gender, household income, and physical health status were explored using structural equation modelling (SEM). Results Two factors were identified in both samples: disease-anxiety (e.g. catching, transmitting the virus) and consequence anxiety (e.g. impact on economic prospects), and unique associations with health and demographic factors were observed. Conclusions Anxieties due to the COVID-19 are multifaceted, and the PAS is a short, reliable and valid measure of these concerns. These anxieties are differentially associated with demographic, social and health factors, which should be considered when developing strategies to mitigate the mental health impact of the pandemic.