COVID-19 and Mental Health (CMH) Initiative

Mental health and substance use impacts of COVID-19
Lay Summary of Knowledge Synthesis Project


Illustration of the ultrastructure of the COVID-19 virus

The COVID-19 pandemic has resulted in increased mental health challenges and substance-related harms for many Canadians. In April 2020, the Government of Canada announced a $115-million investment in Canada’s rapid research response to COVID-19, including funding for a CIHR COVID-19 and Mental Health (CMH) Initiative.

The CMH Initiative is providing urgent knowledge and evidence to support decision-making throughout the mental health and substance use responses to the pandemic through a series of funding opportunities including the Operating Grant: Knowledge Synthesis: COVID-19 in Mental Health and Substance Use. Research funded through this competition rapidly synthesized current evidence on mental health service needs, delivery and guidelines, practice and related issues, placed in the COVID-19 context.

This report summarizes the results of an in-depth analysis of the final reports submitted by knowledge synthesis grantees in November 2020. The analysis was conducted by the CIHR Institute of Neurosciences, Mental Health and Addiction (CIHR-INMHA) team, who reviewed and discussed the syntheses in order to highlight and group key findings, identify cross-cutting themes, and guide knowledge mobilization activities. Projects are grouped thematically for ease of reference; however, some projects are applicable to more than one population.

Not all 45 funded projects are featured in this document, as its purpose is to identify and summarize common themes. A searchable repository of the funded knowledge syntheses, as well as other projects funded through this initiative can be found online.

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Children, Youth, and Families

School-aged children and youth report worsening mental health during COVID-19

More research is needed to guide decision-making with respect to school closures/reopening, including the potential impact on the mental health of children and youth with pre-existing mental health concerns, special needs, or other vulnerabilities. More research is also needed to evaluate COVID-19-specific mental health interventions targeting students.

Children with a disability or chronic illness are more negatively impacted

Children who have pre-existing physical health and/or mental health conditions (e.g. Autism Spectrum Disorder, eating disorders, chronic pain) have generally been more negatively affected by the pandemic than children without such conditions. Children with other difficulties (e.g. with social relationships, academic success, development or illness) have also been negatively impacted as a result of the pandemic.

Having a solid and diversified social net and support, and maintaining structure and routine, may contribute to improved outcomes. A reduction in social demands as a result of the pandemic has been beneficial for some families by reducing stress and increasing family time.

Caregivers require additional support

Individuals who are caregivers for others require additional support, especially during the COVID-19 pandemic. Caregivers report depression, anxiety, poor sleep, stress, fear, and symptoms of post-traumatic stress disorder. There is some evidence to suggest that women caregivers report worse outcomes, including increased depression.

Parents of autistic children have experienced an increase in demands and family-related stressors and have a critical need for social support. There is limited evidence for programs to support caregiver mental health, representing an urgent need for new knowledge. There is some evidence of a protective effect of social connection and close social relationships via online communications or communities (e.g. Facebook groups).

Caregivers of individuals with eating disorders require additional support and education (e.g. guided parental self-help cognitive behavioural therapy, transition to at-home monitoring).

More evidence is needed to guide virtual mental health services for children, adolescents and emerging adults

There is a need for evidence-based practice guidelines to guide professionals in providing the most effective virtual mental health services for children and youth. It is important that guidelines are developmentally appropriate, evidence-based, establish criteria for when in-person visits are recommended, meet ethical standards of care, and address accessibility, consent procedures, safety planning, and internet privacy.

Populations that may have a need for mental health services include but are not necessarily limited to: youth with new onset/existing chronic pain and their families; children, adolescents and emerging adults living with an eating disorder; and youth with pre-existing chronic disease or mental illness.

It is important to consider virtual adaptations for school-based suicide risk assessments for children and youth, particularly those who may be at disproportionate risk. Schools are a key suicide prevention and intervention site, and school-closures may therefore negatively impact youth. There is a need for more diverse research to guide recommendations for conducting suicide risk-assessments through virtual means.

In some cases, there may be a need for in-person care to supplement virtual services. Guidelines are needed for clinicians and caregivers regarding when in-person medical evaluation is necessary. This is especially relevant to young people with eating disorders, and children and youth at increased risk of suicide. Special consideration must also be paid to the mental health and substance use needs of marginalized young people (e.g. those experiencing homelessness, those involved in child welfare system).

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General Population

Epidemics and pandemics impact suicide, and suicidal behaviour and thoughts

Public health emergencies such as the COVID-19 pandemic have an impact on suicide and suicidal behaviour and thoughts.

There are several factors that should be closely monitored: Disconnection, social isolation and loneliness; real or perceived barriers to health care (including mental health care); pre-existing mental illness, substance use problems and/or suicidal ideation (including marginalized groups); individuals in vulnerable roles and those with high levels of exposure to the illness; and exposure to widespread negative media coverage.

Public health emergencies may also impact suicide rates in high-risk populations or professional groups, including: Older adults, people who are or become unemployed or under-employed, people with pre-existing mental health and/or substance use problems, and frontline health and social care staff.

There is an urgent need for more research on suicide in the context of the COVID-19 pandemic, in order to inform suicide prevention policies and clinical practice.

It is important to ensure equity in digital mental health care

Some groups are at higher risk of negative mental health outcomes and also lack access to care in their own language, or that is appropriate for their culture. Many groups are at-risk due to persistent socioeconomic inequalities, including poverty, stigma and discrimination.

People with lived and living experience (PWLE) should be included in consultations to plan for mental health care.

It is essential that mental health care, including digital/virtual care, is accessible. This includes ensuring that care is offered in multiple languages, through various platforms (e.g. video, text messaging, landlines), and in various formats (e.g. not just written text, large font, etc.).

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Healthcare Workers

The COVID-19 pandemic is impacting the mental health of women in health care

In Canada, 80 percent of our health workforce is composed of women (Porter et al. 2017).

Women in health care, particularly those that are younger, mid-career, single, and women who are caregivers to young children are experiencing increased stress and burnout as a result of COVID-19 and related public health measures.

There is limited information regarding interventions to support the wellbeing of women healthcare workers during a pandemic. Organization-led activities for stress reduction are poorly utilized. Women healthcare workers may prefer self-coping strategies such as rest, exercise, and practices such as yoga and meditation, but there is limited evidence to support the efficacy of these practices. Regular exercise is a protective factor for depression and anxiety.

There is an urgent need for research studies to identify strategies that women healthcare workers can use to effectively manage their mental health.

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Indigenous Peoples and Communities

COVID-19 has exacerbated existing inequities in Indigenous communities

Multiple and intersecting social inequities are the primary cause of most health issues (physical and mental) in Indigenous communities. Mental health and substance use issues that are experienced by Indigenous Peoples during the pandemic are not novel – these issues existed already and are now being exacerbated by the pandemic.

The pandemic has forced a rapid shift to telehealth services, however there is very little evidence available to guide this transition. Accessing services may be particularly difficult for remote communities.

Virtual gatherings may help respond to the needs of some underserved indigenous populations, but are not a replacement for face-to-face ceremonies

There are many challenges and opportunities associated with virtual sharing circles and ceremonies as a way to address the needs of underserved Indigenous people.

Although many practices can be adapted to the virtual space, participants may not have access to technology or the internet, or possess the technological literacy required to participate. In addition, virtual mental health services may not be satisfying to all Indigenous participants. It is therefore important to develop ways to deliver in-person Indigenous-led services and ceremonies safely (e.g. outdoors).

The pandemic is negatively affecting the mental health of indigenous children in rural and remote communities

Indigenous children are at much higher risk of emotional and mental health issues than their non-Indigenous peers. This population is uniquely vulnerable, is heavily impacted by COVID-19 restrictions, and lacks access to health supports.

Stigma around mental health is a barrier to accepting support among Indigenous children. Positive messaging resources that promote mental wellness among children and youth may promote mental health and prevent suicide. These educational resources must be culturally safe, strength-based, bound in traditional knowledge, community-oriented, realistic and accessible.

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Individuals with a Chronic Disease or Chronic Pain, and Patients on Waitlists

Virtual interventions can be effective in improving mental health for individuals with chronic disease and chronic pain

Digital mental health interventions (particularly internet-based cognitive behavioural therapy) are effective to improve anxiety, depression, distress and post-traumatic stress symptoms as well as quality of life in adults living with many chronic diseases.

Internet-based and telemedicine treatments can also be effective to reduce pain and depressive symptoms in individuals living with chronic pain.

For both children and adult populations, more evidence is needed to support the effectiveness of certain types of digital mental health interventions (e.g. online forums, telephone support, virtual reality), as well as self-guided smart phone apps, websites, online chats and forums, and text messages.

Virtual peer-support may be beneficial to patients on waitlists for procedures.

Patients on waitlists for procedures delayed by COVID-19 have unique challenges and needs

Patients on waitlists for medical procedures delayed by the COVID-19 experience anxiety, depression, low quality of life, feel angry and frustrated, and have reduced trust in the healthcare system.

Caregivers of wait-listed individuals may have similar levels of depression and greater anxiety than patients themselves.

Teaching coping skills to wait-listed patients through in-person or online classes does not always reduce anxiety or depression, or improve quality of life, and may not be easy to implement.

Patients may prefer help from peers (support groups, peer mentors) and periodic communication about: reason for delay, their position on the wait list, in what order patients would be selected for procedures, and possible procedure date.

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Individuals with a Pre-Existing Mental Illness

Virtual interventions may be effective for treating schizophrenia

Social restrictions during the COVID-19 pandemic have reduced access to in-person clinical services. Almost all clinical services for individuals with schizophrenia are delivered in-person, and it is unclear which interventions have evidence for delivery through virtual options.

Virtual cognitive behavioural therapy (CBT) and cognitive remediation have demonstrated preliminary efficacy to treat schizophrenia but require the most training for appropriate implementation.

More evidence is needed regarding which psychosocial interventions are most effective through virtual care for schizophrenia-spectrum disorders.

There are benefits to remote cognitive assessment in severe mental illness, but more research is needed

The COVID-19 pandemic has highlighted the urgent need to identify best practices for remote cognitive assessment of individuals living with severe mental illness to ensure they can properly receive psychological interventions delivered through digital technologies.

Wider geographical reach and automation of procedures appear to be important benefits; however, privacy and the need for more validation of assessment tools are major factors to consider in the future use, development and implementation of these solutions.

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Older Adults

Infection control measures negatively impact the mental health of older Canadians

Pandemic-response measures have negatively impacted aging Canadians both in long-term care (LTC) settings as well as those living in the community. Older adults are more likely to experience social isolation and loneliness if they are widowed, female, of low socio-economic status, live alone, or live with a chronic condition.

Social connection is important

Maintaining social connections and addressing loneliness are important factors for mental wellness in older populations. Social connection contributes to improved mood, emotions and cognition, and reduces anxiety, depression and other negative outcomes, including responsive behaviours in individuals with dementia.

Virtual therapy is effective

There are benefits to internet cognitive behavioural therapy, telephone cognitive behavioural therapy or telephone psychotherapy, however, access to technology, technological literacy, and a sustained LTC workforce may prevent this population from accessing and/or benefitting from these interventions.

There are strategies to promote mental health, but they may be difficult to implement due to resource challenges and infection prevention measures

There are some strategies that may promote mental health, particularly in LTC populations, for example: Managing pain, implementing structured bedtime routines, creating opportunities for creative expression, and maintaining religious or cultural practices. That said, many strategies to improve social connection may not be feasible within the COVID-19 context, where infection prevention and staffing are primary concerns. More research is needed on social connections in older populations, both within the context of infectious disease outbreaks and beyond.

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People Who Use Drugs

Substance use and related harms are likely increasing during the pandemic

Substance use is likely increasing during the pandemic and is associated with increased psychological distress due to the pandemic. Not all segments of the population are experiencing these increases.

Challenges related to sudden substance withdrawals and opioid overdoses are likely increasing due to the pandemic, and treatment and supports (including access to services) are being impacted.

The pandemic is resulting in shifts in access to legal and illegal substances.

There is a gap in knowledge with respect to ethical decision making for people who use drugs during medical access disruptions

People who use drugs (PWUD) have been disproportionately impacted by the COVID-19 pandemic because of their social, psychological, and biological vulnerability. Public health mandated restrictions and resulting emergency changes to health and human services have impacted PWUD.

There is a lack of ethically guided decision-making resources to support PWUD in the context of medical access disruptions. Diverse communities of PWUD must be engaged in research, and in developing relevant and sustainable drug policies and public health guidelines.

Digital health solutions for addiction are effective, but more sex- and gender-based research is needed

Digital health services for addiction are effective for adults, but more research is required on their effectiveness for females or women, due to a lack of sex- or gender-based analysis in empirical investigations of digital health resources.

Providers of substance use treatment should consider which apps and web-based tools for substance use concerns may be considered gender- and trauma-informed when determining which digital health resources may benefit clients.

Safe supply models face many barriers and should be tailored to the needs of PWUD

There is a disconnect between academic literature and what PWUD believe to be important. It is therefore essential that PWUD are more heavily involved in research design and implementation.

Safe supply models need to be tailored to the needs of PWUD, local capacities, and the political or social landscapes of the geographic region. Emergency preparedness is necessary to ensure these services are resilient to interruptions caused by mass events such as pandemics.

There are several barriers to effective safe supply, spanning the user-level, prescriber-level, programmatic level, policy-level, and societal-level.

The most frequently reported barriers include restrictive laws, policies and funding. PWUD report additional barriers including access to substances of choice, concerns about child apprehension, and a lack of cultural competency within safe supply and/or opioid agonist treatment programs. Finally, prescribers report barriers including regional differences in service delivery, colleague support, and a lack of, or disagreement between, clinical guidance documents.

A better definition of “safe supply” is needed.

Treatment for substance use issues differs in the context of major social disruptions

Treatment uptake in response to a drug shortage only occurs if services are widely available. In contexts without widespread service coverage, shortages may potentiate riskier injecting behaviours; “big events” such as pandemics may increase the risk of a range of harmful outcomes for PWUD.

Disrupting opioid substitution therapy can cause severe consequences for PWUD such as relapse, withdrawal and restart of risky injection behaviours.

Flexibility and service continuity is essential for reducing negative impacts on PWUD, including for example: telemedicine, centralized systems to facilitate transfers between treatment settings, adapting treatment plans, maintaining usual service hours as much as possible, and flexible models such as mobile units and outreach services.

Standardized but flexible disaster preparedness guidelines are needed to allow adequate and efficient health system response to disruptions.

Trauma-informed care is important during and after the pandemic. Lockdowns and stay-at-home measures may exacerbate mental health and substance use issues.

Within the population of PWUD, women, Indigenous Peoples, visible minorities, and people experiencing homelessness or mental illness may be at particular risk of harm.

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Public Safety Personnel

There are benefits and barriers to digital health for military, veterans, and public safety personnel (PSP)

In trauma-affected populations, digital health tools have many benefits, including increased access and reduced stigma. Digital health can be as effective as in-person delivery of psychotherapeutic interventions for clinically and significantly reducing symptoms of post-traumatic stress disorder, major depressive disorder, and anxiety disorders among military, veterans, and PSP.

Facilitators of digital health interventions for these populations include convenience of access (particularly for rural/remote clients), comfort in participating from home (including less stress and stigma), and reduced travel time and missed work.

Barriers to digital health use in these populations are similar to other populations and include privacy concerns and technology issues. Additionally, PSP are generally more hesitant to seek help for mental health concerns compared to the general population, and structural workplace challenges can also interfere with accessing care. Connectivity can cause inequalities in access to care (e.g. access to high quality internet).

More research is needed to support the mental health of first responders and other PSP

There is an urgent need for evidence-based solutions to manage the mental health burden of first responders and other PSP during and following the pandemic.

There is evidence that firefighters and PSP prefer to seek peer support when managing their mental health. Mindfulness, training focused on mental health, and cognitive behavioural therapy may be effective strategies to incorporate into a mental health management program for this population. Although internet-based cognitive behavioural therapy (iCBT) has demonstrated effectiveness, it is not widely available or accessed within this community.

Mental health care should be embedded in all future emergency response planning.

There is a critical need for high-quality studies to identify effective mental health management strategies for firefighters, other first responders, and all PSP.

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Vulnerable or At-Risk Populations

The pandemic is exacerbating problems that already exist

The COVID-19 pandemic is intensifying existing issues including homelessness and domestic violence. Research highlights the intersection of racialized and at-risk populations, who face disproportionate negative impacts as a result of the pandemic.

Maintaining access to care is essential for individuals in situations of social precarity

When planning services for the most vulnerable populations, maintaining access to care is essential. This includes ensuring that appropriate technology, training and supervision are available. Providers must be careful not to inadvertently perpetuate access inequities (e.g. pivoting to virtual care without a concurrent plan around addressing resource-related barriers to access).

Harm reduction activities that are vital to maintain during the COVID-19 pandemic include overdose monitoring and prevention, safe supply initiatives, and HIV/STI prevention.

Sex and gender diversity must factor into the adaptation of services during the pandemic to prevent further health inequities, especially for women and 2SLGBTQ+ people who are dealing with substance use.

Youth who experience homelessness are more likely than the general population to have pre-existing mental health and substance use challenges, struggles with financial hardship, and employment uncertainty. Challenges faced by this population have been exacerbated by the COVID-19 pandemic.

The COVID-19 pandemic has caused an increase in intimate partner/domestic and gender-based violence

Disasters are associated with a rise in intimate partner violence (IPV), along with lasting parallel issues such as post-traumatic stress disorder (PTSD), trauma, and mental health issues. Policy responses to pandemics, such as isolation and lockdowns, exacerbate issues. Substance use (SU) and IPV are related and intensive interventions may reduce SU or IPV, but rarely both. Related mental health issues such as depression and trauma require ongoing service support.

The COVID-19 pandemic has exacerbated gender-based violence against women and girls. Social determinants of health factors place racialized women and girls at an increased disadvantage during the pandemic. Racialized members of society bear a disproportionate burden of stress, illness and health inequities; these have been always present but have become further amplified in the context of the ongoing COVID-19 pandemic.

Virtual care may be effective for some individuals

Virtual care interventions for individuals at risk of domestic and sexual violence are most effective when used to supplement or facilitate, rather than replace, in-person professional trauma-focused care.

There are several barriers and challenges to virtual delivery of care for this population including: privacy and confidentiality, client safety, technological barriers and the loss of human connection in virtual settings that is vital in healing trauma.

There is strong evidence to support online psychological therapies for reducing psychological symptoms such as depression, anxiety and PTSD among individuals exposed to domestic violence or sexual assault. These online therapies can be safely used to support individuals and families in violent or abusive situations.

There is an urgent need to address inequities in digital access to care and treatment.

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Cross-Cutting Theme: Virtual Care

Digital mental health interventions are effective therapies

Digital mental health interventions (e.g. internet/telephone psychotherapy) are effective therapies for mood, anxiety, and post-traumatic stress disorders across populations. There is very strong evidence in support of internet-based cognitive behavioural therapy (iCBT). Group-based, clinician-led virtual care is feasible and effective.

Virtual care solutions are effective to treat chronic pain in youth, and to treat chronic pain and depressive symptoms in adults.

Digital health resources for treating addiction are effective, but gender-specific data is limited and barriers to care must be carefully considered.

There is some evidence to support technology-based social connections (e.g. Facebook groups, peer-support networks) for caregivers of autistic people, older adults in long-term care facilities and for patients on waitlists for medical procedures and their families.

Access to virtual care is an important consideration

It is essential to ensure that virtual care is accessible. Consideration should be given to language, platform (e.g. video, text messaging, landlines), and format (e.g. not just written text, large font, etc.).

Perceptions and acceptance of the use of digital health influence uptake. This is influenced by cultural norms, experience, skill level and comfort with technology.

Providers must be careful not to inadvertently perpetuate access inequities (e.g. pivoting to virtual care without a concurrent plan around addressing resource-related barriers to access).

In rural and remote areas, access to technology and access to the internet may be limited.

Technological literacy is an important consideration for many individuals.

In some cases, virtual care may supplement, but should not replace in-person care

Clinical practice guidelines have been developed to guide virtual care for individuals with eating disorders, however it may be necessary for some patients to have access to certain in-person services.

Virtual care interventions for individuals at risk of domestic and sexual violence are most effective when used to supplement or facilitate, rather than replace, in-person, professional trauma-focused care.

It may not be possible to adapt Indigenous practices to virtual formats.

Individuals with severe mental illness (e.g. schizophrenia) and those at risk of suicide may benefit from certain virtual interventions but may also require in-person care.

There are a number of knowledge gaps with respect to virtual care

The effectiveness of some types of digital mental health interventions is unknown, including online forums, teleconsultation, virtual reality, smart phone apps, online chats and forums, and text messages.

More knowledge is needed to support the use of digital mental health interventions in children and youth. There is a need for standardized practice guidelines for providing virtual mental health services to children, adolescents and emerging adults.

More research is required on the efficacy of digital health resources for women in Canada with substance use concerns. There is also a need for more sex- and gender-based analysis of digital health resources.

More research is needed to address inequities in digital access to care and treatment.

There are several barriers to virtual care

Barriers to virtual care that have been identified include but are not necessarily limited to:

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Cross-Cutting Theme: The Impact of the COVID-19 Pandemic on Women’s Mental Health

The COVID-19 pandemic is having a disproportionate impact on caregivers – most of whom are women – and women in healthcare

Women in health care, particularly those that are younger and mid-career, are experiencing increased stress and burnout as a result of COVID-19 and related public health measures. In Canada, 80 percent of the health workforce is composed of women (Porter et al. 2017).

Individuals who are caregivers for others require additional support, especially during the COVID-19 pandemic. Caregivers report depression, anxiety, poor sleep, stress, fear, and symptoms of post-traumatic stress disorder.

Women caregivers, including parents, report worse outcomes, including increased depression.

Disasters are associated with a rise in violence against women

Disasters such as the COVID-19 pandemic are associated with a rise in intimate partner violence, along with lasting parallel issues such as post-traumatic stress disorder, trauma, and mental health concerns.

The COVID-19 pandemic has exacerbated gender-based violence against women and girls. Public health responses to pandemics, such as isolation protocols and lockdowns, exacerbate these issues.

Social determinants of health factors place some women and girls at an increased disadvantage

People who use drugs, women, Indigenous Peoples, visible minorities, and people experiencing homelessness or mental illness are more likely to be at risk of harm.

Living alone, being widowed, female and lower socio-economic status and living with a chronic condition or impairment are important risk factors for negative outcomes.

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