Impact of COVID-19 on mental health research: is this the breaking point?

Summary

There are many structural problems facing the UK at present, from a weakened National Health Service to deeply ingrained inequality. These challenges extend through society to clinical practice and have an impact on current mental health research, which was in a perilous state even before the coronavirus pandemic hit. In this editorial, a group of psychiatric researchers who currently sit on the Academic Faculty of the Royal College of Psychiatrists and represent the breadth of research in mental health from across the UK discuss the challenges faced in academic mental health research. They reflect on the need for additional investment in the specialty and ask whether this is a turning point for the future of mental health research.

COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has exposed organisational and societal vulnerabilities to new infectious diseases and highlighted the socioeconomic consequences of lockdown, underpinned by inequalities in access to power and resources. The National Health Service (NHS), social care, public transport, schools, universities and businesses have been tested up to, and beyond, breaking point, resulting in job losses, service failure and poverty. The impact on vulnerable groups, such as those in ethnic minorities, elderly people in care homes and people with intellectual disabilities (also known as learning disabilities in UK health services), was stark in terms of excess mortality. We as a society are still reeling from the shock, and it is unlikely that we will fully understand the full impact of the pandemic for many years.

In this article, we highlight the significant impact that the pandemic has had on mental health research and discuss the consequences of this on clinical practice, professional education and the training of future psychiatrists. Research is a core element of health service design globally and must be viewed as central to providing safe, effective and adaptable mental healthcare, which is increasingly important during times of great international change. Thus, we aim to make the case that mental health research serves a purpose beyond the purely scientific endeavour of intellectual discovery and at present is underfunded when considering the wider burden of mental ill health.

As we emerge from the acute phase of the pandemic, we can start to appraise other critically vulnerable social and institutional structures and practices. We need an improved way of delivering healthcare. Arguably the past 18 months have seen a greater focus on the mental health of individuals and populations than at any time in our history. The public discourse has been dominated by predictions of dire mental health consequences from politicians, journalists and commentators. The cause of any increase in mental health problems is variously ascribed; sometimes to the pandemic itself, sometimes to the unintended consequences of the lockdown, and sometimes to both. What is clear, is that the predicted rise of mental ill health has not yet fully emerged,¹ although the most vulnerable members of our society have been disproportionately affected, particularly those living in poverty, with pre-existing mental or physical health needs and those at both ends of the age spectrum. Furthermore, the full mental health impact of long COVID remains unclear and is likely to be significant.

Training

Although the impact of the pandemic on population mental health remains uncertain, the influence on psychiatric practice, training and research is clearer. The detrimental effects of COVID on the delivery of mental healthcare have been profound, but have been well documented elsewhere. Mental health research, which was already in a precarious position, has been further challenged. Significant gaps remained in our understanding of mental illness prior to the pandemic, during which research progress has slowed. The start of the pandemic saw the redeployment of psychiatry trainees and consultants to COVID-related roles, leading to significant disruption to both mental health services and to individuals’ work and personal lives. As a result, services were often sustained with minimum staffing levels, exacerbated by requirements for short- and long-term self-isolation. To date, clinical activities have not returned to pre-pandemic levels. Trainee progression has also been affected. For trainees in research, many have been left trying to resolve the challenges of insufficient time and funding. Others returned to full-time clinical care during the pandemic, and are now facing major barriers (including filling rota gaps owing to failures of planning rather than the pandemic) when attempting to return to research. This has in large part been because of organisational inertia within the healthcare research structure during much of the pandemic to date.

Academic psychiatry was already in difficulty and these disruptions to training and research are likely to exacerbate chronic problems with careers in psychiatric research. Major universities have been seeking high-performing professors and their associated grant income with little support for a broader range of early-career psychiatrists to obtain research training. The lack of lecturer and senior lecturer posts, and the closure of psychiatry departments in some universities is continuing, which has seen a paucity of early-career academics emerging. Time-limited fellowships have gone some way to ameliorating this, however, this should not be seen as a replacement for substantive research posts. Thus, our ability to meet current and future research priorities is further weakened. Only through research, linked with quality improvement and implementation science working synergistically, can we hope to build a safer, more effective and humane care system, one that is robust to crises and not the immediate target for redeployment or resource cuts at such times.

Services

The economic impact of the pandemic meant research to improve integrated and high-quality care was again undermined. In addition, despite some NHS trusts supporting trainees and consultants to include research as a core part of their job plans, such good practice is sadly far from universal. The problem of lack of protected research time existed prior to COVID, while during the pandemic and its aftermath, more psychiatrists are unable to pursue research, despite the pressing need for data to support service evaluation and quality improvement as well as intervention trials. Many sessions for research that were removed at the height of the pandemic have yet to be restored. Frequently, short-term contracts for university staff were not extended despite the continuing, if not increased demands for their work, especially in teaching and supervision. This was seen under the guise of managing short-term finances and as a necessary response to the crisis.

Mental health research has long been underfunded, but since the start of the pandemic, calls have been cancelled and funds have been withdrawn.² Many ongoing grants have not been extended despite COVID-19-related delays, and a £120 million cut in funding by UK Research and Innovation has been implemented. The Medical Research Council commented on ‘mental health’ only twice in their review of medical research funding during the pandemic.³ Research commissioners have diverted funds to COVID, funding a small number of large grants at relatively few institutions for short periods of time, in the hope that research can be completed in less time than is necessary.

The rapid vaccination development programme has produced a model of academic advancement that is not easily transferable to the need for better interventions in mental healthcare, nor for developing a future cohort of researchers working in mental health and related interdisciplinary areas of scholarship. Furthermore, the focus on COVID-19 has led to a large volume of papers published, many of which are poor quality, with several high-profile retractions.⁴ Mental health funding for COVID-19 research has been limited given the vast scope of the problem and the need to rigorously pursue synergistic efforts across disciplines to adequately capture and mitigate the impact on mental health. In parallel, the World Health Organization has noted profound disruption to clinical mental health services during the pandemic across the globe, which will itself impede clinically focused research opportunities.⁵

Academic Psychiatry

The ongoing pressures of COVID-19 along with the low priority of mental health research in the UK are likely to have a further impact on the long-term viability of UK academic psychiatry. We have reached a point where reversal of these long-term trends will be difficult and full attention to reinvigorating mental health research must be given to prevent its further deterioration. Reduced time and funding for research will further worsen career progression and the pre-existing failure to recruit sufficiently diverse researchers will continue to highlight structural problems within much of the current mental health research output.

It is essential that mental health should be allocated an equitable system of research funding, training and practice that reflects a reasonable work–life balance and does not promote inequalities. Potential for discrimination and racism in universities is well recognised and requires positive systems-wide actions. More provision should be made to allow clinical psychiatrists to also be involved with research – this could be through protected research time, which may help to address recruitment difficulties to many consultant psychiatry posts. Our experience with NHS trusts who do include research as part of advertised job proposals is that such trusts are likely to attract more job candidates as well as being more likely to retain staff in the long term. Similarly, there is evidence that research-active trusts have better clinical outcomes. It is clear that there are systemic changes that need to be made to ensure the future of high-quality research as we move beyond the acute phase of the pandemic.

The Academic Faculty of the Royal College of Psychiatrists call upon our fellow researchers, practitioners and policymakers to address parity in resources and to recognise the centrality of mental healthcare and thus mental health research to the global post pandemic recovery.

Opportunities arising because of increasing global connectivity could be harnessed to develop and implement mental health research more meaningfully, particularly as a large burden of mental health matters sit in low- and middle-income countries. The pandemic could be a lever for positive change to bring research communities across continents and disciplines together. With these changes, we might be able to bring academic psychiatry successes back in line with other world-class research from the UK.

Integrating clinical work and academic practice will require a change to existing structures, where the NHS and universities operate to divergent priorities, interests and business models. Without a progressive, integrated approach, in response to evident weaknesses unearthed by COVID-19, we might be mourning academic psychiatry as the specialty that no one knew they needed until it was gone.