On the path to recovery: traumatic stress research during the COVID-19 pandemic 2021–2023

ABSTRACT

This Special Issue of the European Journal of Psychotraumatology (EJPT) presents 51 articles published between 2021 and 2023 and follows the Special Issue on pandemic-related traumatic stress research published in 2021 (O'Donnell, M. L., & Greene, T. [2021]. Understanding the mental health impacts of COVID-19 through a trauma lens. European Journal of Psychotraumatology, 12(1), 1982502). Research on traumatic stress during the pandemic has cast the spotlight on vulnerable populations and groups, notably front-line healthcare workers; people faced with major losses including the deaths of loved ones; those who personally survived debilitating and often life-threatening viral infection; and students who were isolated and experienced profound delays in their education, relationships, and emerging independence. The papers in this collection underscore the associations between COVID-19 related stressors and a plethora of adverse mental health sequelae, including posttraumatic stress reactions, and draw attention to the ubiquity of grief and moral injury and their wide-ranging and detrimental impact. Currently, there is a paucity of evidence on interventions to enhance resources, self-efficacy, and hope for affected groups and individuals through societal, organisational, and healthcare systems; however early research on the prevention of COVID-related traumatic stress disorders provides a basis for both hope and preparedness for the future.

HIGHLIGHTS

• Stressors and traumatic events occurring due to the COVID-19 pandemic are associated with a wide range of mental health problems, including posttraumatic stress reactions, especially among vulnerable groups (e.g., front-line healthcare workers, individuals who faced major losses such as the deaths of loved ones, those who survived debilitating and often life-threatening infection).

• Loss and moral injury are common and potentially debilitating features of the pandemic.

• Societal, organisational, and healthcare system interventions to enhance resources, efficacy, and hope for affected groups and individuals are still in the early stages, although preliminary research on the prevention of COVID-related traumatic stress disorders is promising.

En este número especial de la Revista Europea de Psicotraumatología (EJPT, por sus siglas en inglés) se presentan 51 artículos publicados entre el 2021 y 2023, y le continúa al número especial sobre las investigaciones acerca del estrés traumático relacionado con la pandemia, publicado en el 2021 (O'Donnell, M. L., & Greene, T. [2021]. Understanding the mental health impacts of COVID-19 through a trauma lens. European Journal of Psychotraumatology, 12(1), 1982502). Las investigaciones sobre el estrés traumático durante la pandemia se han enfocado en las poblaciones y grupos vulnerables, en particular en los trabajadores sanitarios de primera línea; las personas que enfrentaron pérdidas importantes, incluidas las muertes de sus seres queridos; aquellos que sobrevivieron personalmente una infección viral debilitante y, a menudo, potencialmente mortal; y a estudiantes que se encontraban aislados y experimentaron profundos retrasos en su educación, relaciones interpersonales y en su independencia emergente. Los artículos de esta colección subrayan las asociaciones entre los factores estresantes relacionados con COVID-19 y una plétora de secuelas adversas para la salud mental, incluidas las reacciones de estrés postraumático, y llaman la atención sobre la ubicuidad del duelo y el daño moral, su amplio espectro y el impacto perjudicial que representa. Actualmente, existe una escasez en la evidencia relacionada a intervenciones que busquen mejorar los recursos, la autoeficacia y la esperanza de los grupos e individuos afectados a través de sistemas sociales, organizacionales y de salud; sin embargo, las primeras investigaciones sobre la prevención de los trastornos de estrés traumático relacionados con COVID proporcionan una base tanto para la esperanza como para la preparación para el futuro.

KEYWORDS:

• COVID-19
• mental health
• traumatic stress
• stressors
• grief
• moral injury
• healthcare workers
• vulnerable populations

PALABRAS CLAVE:

• COVID-19
• salud mental, estrés traumático
• estresores
• duelo
• daño moral
• trabajadores de la salud
• población vulnerable

With more than 767 million recorded cases of coronavirus and almost seven million deaths worldwide (https://covid19.who.int/) between December 2019 and July 2023, the COVID-19 pandemic’s traumatic impact has been immense and appears to be long-lasting. Research on traumatic stress during the pandemic has documented severe adversity experienced by vulnerable populations and groups, notably front-line healthcare workers, people faced with major losses including the deaths of loved ones, those who personally survived debilitating and often life-threatening viral infection, and students who were isolated and experienced profound delays in their education, relationships, and emerging independence.

To introduce this Special Issue of the European Journal of Psychotraumatology, we will identify key themes in COVID-related research published in the field and in EJPT since the 2021 Special Issue and Editorial (O'Donnell & Greene, 2021) that provided an overview of traumatic stress year of the pandemic. The Special Issue presents articles published subsequently in EJPT between 2021 and 2023 (see Table 1 for an overview), highlighting the impact of the pandemic on vulnerable populations and new research on the prevention of COVID-related traumatic stress disorders that provides a basis for both hope and preparedness for the future.

Table 1. COVID-19 studies in this Special Edition of the European Journal of Psychotraumatology.

Impact of the COVID-19 Pandemic on Community and Student Populations
1. Ajdukovic et al. (2021). Mental health status and risk factors during Covid-19 pandemic in the Croatia’s adult population	9.8% of the population was at risk of adjustment disorder, 7.7% of depression disorder, 7.8% of anxiety disorder, and 7.2% were experiencing high levels of stress.
2. Birkeland et al. (2021). No buffer effect of perceived social support for people exposed to violence during the COVID-19 pandemic: a cross-sectional community study	Even though high levels of perceived social support can protect against psychological distress in the face of pandemic worry in the community this study’s findings indicate that this resource is not as useful for individuals exposed to current violence.
3. Chen et al. (2022). Depression and PTSD in the aftermath of strict COVID-19 lockdowns: a cross-sectional and longitudinal network analysis	In a community sample in China assessed in April, June, August, and October 2020 both cross-sectional and longitudinal networks showed the most central depressive symptoms to be sadness and depressed mood, and the most central PTSD symptoms changed from irritability and hypervigilance at the first wave to difficulty concentrating and avoidance of potential reminders at later waves, with irritability/anger as the most influential bridge longitudinally. And feeling blue and intrusive thoughts as gateways to the emergence of other symptoms.
4. Cipolletta et al. (2022). Narratives of the worst experiences associated with peritraumatic distress during the COVID-19 pandemic: a mixed method study in the USA and Italy	Themes of the worst COVID-19 experiences were anxiety, threat, loss, anger, stress and constriction. Threat was the most prevalent theme and correlated with being quarantined, being infected and a loved one receiving the diagnosis. US participants’ descriptions of their worst experiences related more to life-threat and loss, while Italians reported more threat to the world, stress, social isolation, and feeling trapped.
5. Dragan et al. (2021). Adjustment disorder, traumatic stress, depression and anxiety in Poland during an early phase of the COVID-19 pandemic	COVID-19 pandemic was highly stressful for 75% of a representative sample of adults in Poland. Increased symptoms of adjustment disorder were reported by 49%, and this was associated with female gender and not having a full-time job. Screening also indicated that generalised anxiety (44%) and depression (26%) were prevalent as well.
6. Essadek et al. (2022). Assessment of mental health of university students faced with different lockdowns during the coronavirus pandemic, a repeated cross-sectional study	A repeated cross-sectional study of a university student population in France found decreases in the scores for depression, anxiety, and distress symptoms between the first lockdown and the lifting of the lockdown. But an increase in symptoms of depression, anxiety, and suicidal ideation between the first and second lockdown
7. Friesen et al. (2022). COVID-19-related distress is associated with analogue PTSD symptoms after exposure to an analogue stressor	An analogue experimental study with university students viewing films showed that COVID-19-related distress but not rumination was associated with post-film intrusion and rumination load, with the effects mediated by associative learning, consistent with the hypothesis that that stress enhances both associative learning and PTSD symptoms.
8. Gibert et al. (2021). Stress induced by the COVID-19 health situation in a cohort of 111 subjects present in the Bataclan concert hall during the November 2015 terrorist attacks in Paris	Among adults exposed 4.5 years previously to mass terrorist violence, COVID-19 stress was correlated with PTSD symptom severity and inversely correlated with self-reported mindfulness and social support.
9. Hong et al. (2023). The role of mindfulness and dysexecutive functioning in the association between depression and COVID-19-related stress: cross-sectional and longitudinal analyses	Among young adults in China during the COVID pandemic, mindfulness was inversely related to depressive symptoms and to dysexecutive function, suggesting that mindfulness practices and reducing dysexecutive function may be important in preventing or reducing problems with depression in crises such as the COVID-19 pandemic.
10. Lotzin et al. (2022). Dealing with the COVID-19 pandemic in Europe: five lessons from the European Society for Traumatic Stress Studies	Based on emerging research from five European countries a panel of experts conclude that mental health symptoms are increasing but there is no increase in severe mental health disorders, and the pandemic has affected the mental health of entire countries as well as individuals based on the stressors experienced and on the systemic healthcare responses and innovations.
11. Lotzin et al. (2021). Risk and protective factors, stressors, and symptoms of adjustment disorder during the COVID-19 pandemic – First results of the ESTSS COVID-19 pan-European ADJUST study	He European Society of Traumatic Stress Studies (ESTSS) longitudinal ADJUST Study with N = 15,563 adults recruited in eleven countries (Austria, Croatia, Georgia, Germany, Greece, Italy, Lithuania, the Netherlands, Poland, Portugal, and Sweden) from June to November 2020 found a prevalence of self-reported probable adjustment disorder of 18.2% with risk factors including female gender, older age, being at risk for severe COVID-19 illness, poorer general health status, current or previous trauma exposure, a current or previous mental health disorder, and longer exposure to COVID-19 news, and protective factors including higher income, being retired, and having more face-to-face contact with loved ones or friends. Pandemic-related stressors associated with higher levels of symptoms of adjustment disorder included fear of infection, governmental crisis management, restricted social contact, work-related problems, restricted activity, and difficult housing conditions.
12. Miragall et al. (2021). The impact of strict and forced confinement due to the COVID-19 pandemic on positive functioning variables, emotional distress, and posttraumatic growth in a Spanish sample	Among adults in Spain surveyed in the first two weeks and the 5th week of COVID-19 lockdown, women, youths, individuals without a partner, with lower monetary incomes, or diagnosed with a mental disorder or chronic illness reported poorer functioning and greater emotional distress that worsened later in the lockdown despite evidence of posttraumatic growth in the later phase by some individuals.
13. Raymond et al. (2022). A longitudinal investigation of psychological distress in children during COVID-19: the role of socio-emotional vulnerability	Parent child dyads assessed before the pandemic were re-assessed in June 2020 (T1), September 2020 (T2), December 2020 (T3), and March 2021 (T4), and high levels of socio-emotional vulnerability to psychopathology was found to lead to a higher risk of suffering from anxiety and PTS, but not depressive symptoms, in the first year of the pandemic.
14. Richardson et al. (2022). Well-being of Canadian Veterans during the COVID-19 pandemic: cross-sectional results from the COVID-19 Veteran well-being study	In a survey of Canadian military veterans 55.9% reported worse mental health functioning compared to before the pandemic, with an estimated prevalence of probably PTSD, major depressive disorder, generalised anxiety disorder, alcohol use disorder, and suicidal ideation, 34.2%, 35.3%, 26.8%, 13.0%, and 22.0%, respectively. Between one-third and one-half attributed their symptoms as either directly related to or exacerbated by the pandemic. Approximately 18% of respondents reported using telehealth for mental health services during the pandemic, and among those, 72.8% indicated a choice to use telehealth even after the pandemic.
15. Shiffman et al. (2023). Postpartum post-traumatic stress symptoms during the COVID-19 period: exposure and fear as mediating factors	Assessments with women 10 weeks and 6 months after a liveborn, term birth during the first lockdown in Israel showed that stressful pandemic-related events did not increase the risk of developing PTSS, but COVID-19 related fears were associated with PTSS. Women who had medical complications during pregnancy, but not delivery, were at lower risk of developing subsequent PTSS, perhaps due to their ongoing contact with medical facilities despite the pandemic.
16. Yang, Fu et al. (2021). Network analysis of COVID-19-related PTSD symptoms in China: the similarities and differences between the general population and PTSD sub-population	A network analysis of data from a population survey of 2500 adults in China found that COVID- related PTSD symptoms have similar interrelationships as have been reported for other PTSD symptoms and self-destructive/reckless behaviours are a core symptom of COVID-19 related PTSD.
17. Yang, Xu et al. (2022). Event centrality and post-traumatic stress symptoms among college students during the COVID-19 pandemic: the roles of attention to negative information, catastrophizing, and rumination	A survey of college students in China found that the event centrality of COVID pandemic-related experiences and was associated with PTSD symptoms with mediation by cognitive factors including negative beliefs, catastrophizing and rumination.
18. Zhang and Chen (2021). Scientific evidence on mental health in key regions under the COVID-19 pandemic – meta-analytical evidence from Africa, Asia, China, Eastern Europe, Latin America, South Asia, Southeast Asia, and Spain	A meta-analysis of 388 studies with 1,067,021 participants found that populations in Africa and South Asia reported worse overall mental health symptoms, followed by Latin America, compared to China, Europe, and Southeast Asia.
19. Zhang and Chen (2021). Meta-analytic evidence of depression and anxiety in Eastern Europe during the COVID-19 pandemic	A meta-analysis of 18 studies found evidence of high prevalence rates of clinically significant symptoms during the COVID-19 pandemic in Eastern Europe.
20. Zrnic Novakovic et al. (2022). You can't do anything about it, but you can make the best of it: a qualitative analysis of pandemic-related experiences in six European countries	Qualitative analysis of a survey of adults in six European countries identified pandemic-related stressors (Restrictions and changes in daily life, Emotional distress, and Work and finances), positive consequences (Reflection and growth, Opportunity for meaningful/ enjoyable activities, and Benefits on interpersonal level), and coping approaches (Beneficial behavioural adjustment, Beneficial cognitive-emotional strategies, and Social support).
Impact of the COVID-19 Pandemic on Refugees
21. Akhtar et al. (2021). A longitudinal study of mental health before and during the COVID-19 pandemic in Syrian refugees	Refugees from Syria living in a camp in Jordan who received a psychological intervention were assessed either before or after the pandemic, and those assessed during the pandemic had less severe PTSD symptoms but additional worries due to the risk of infection or infecting others.
22. Liddell, Murphy et al. (2021). Factors associated with COVID-19 vaccine hesitancy amongst refugees in Australia	In a sample of refugees in Australia, predictors of vaccine hesitancy were younger age, information and trust barriers, lower logistical barriers, and attitudes relating to low control and risk posed by COVID-19.
23. Liddell, O’Donnell et al. (2021). The association between COVID-19 related stressors and mental health in refugees living in Australia	In a sample of refugees in Australia, the strongest predictor of all mental health outcomes was COVID-19 serving as a reminder of difficult past events. Refugees’ most prevalent stressors related to worries of being infected by COVID-19 or the risk COVID-19 posed to others, which predicted health anxiety and PTSD. Social-related difficulties predicted depression and disability symptoms. Accessing and trusting information from authorities not prevalent stressors; and were not associated with mental health problems, nor was accessing basic supplies and financial support. Fears relating to the future such as concerns about visa application processes predicted health anxiety and disability.
Mental Health Sequelae of COVID-19 Infection and Hospitalization
24. Bonazza et al. (2022). Recovering from COVID-19: psychological sequelae and post-traumatic growth six months after discharge	A high prevalence of anxiety and depressive symptoms was confirmed among COVID-19 survivors 6 months after hospitalisation. Anxiety and depressive symptoms and PTSD were associated with a previous diagnosis of a mood disorder and having received psychological consultation. Post-traumatic growth was associated with younger age and having received psychological consultation.
25. Greene et al. (2022). Anticipating PTSD in severe COVID survivors: the case for screen-and-treat	Based on research from previous pandemics, studies of critical care survivors, and COVID-19 data, it is estimated that up to 30% of survivors of severe COVID will develop PTSD, which often is undetected across primary and secondary care settings. Psychological needs of survivors must not be overshadowed by a focus on physical recovery.
26. Ju et al. (2022). Hospitalization, interpersonal and personal factors of social anxiety among COVID-19 survivors at the six-month follow-up after hospital treatment: the minority stress model	A survey of adults in China six months after COVID-related hospitalisation found that social/interpersonal and personal factors had a stronger association with social anxiety than hospitalisation factors and highlight the importance of internalised stigma as a risk.
27. Loehde & Novakovic (2021). Acute and Transient Psychotic Disorder induced by fear of coronavirus infection	This case study describes the emergence of clinically significant psychotic symptoms related to fear of COVID infection that remitted with antipsychotic medication but recurred 4 months later and were again successfully treated within 48 hours of treatment initiation with antipsychotics.
28. Xiao et al. (2022). Depression, anxiety and post-traumatic growth among COVID-19 survivors six-month after discharge	A survey of adults in China six months after COVID-related hospitalisation found that post-hospitalisation and psychosocial factors had relatively stronger associations with depression, anxiety and PTG than pre-hospitalisation and hospitalisation factors. Promoting social support and social inclusion may be useful strategies to improve the mental health of COVID-19 survivors.
Research on the Impact of the COVID-19 Pandemic on Front-Line Healthcare Workers
29. Bapolisi et al. (2022). Psychopathological states among Congolese health workers during the first wave of COVID-19 pandemic: links with emotion regulation and social support	Depression and acute stress disorder were highly prevalent among Congolese healthcare workers during the first wave of the COVID-19 health pandemic. Hostility, self-blame, rumination, and social support were associated with these mental health disorders.
30. Berkhout et al. (2022). Shared sources and mechanisms of healthcare worker distress in COVID-19: a comparative qualitative study in Canada and the UK	This international comparative qualitative study showed that, despite differences in the political, social, health service, and pandemic-related context, the sources and mechanisms of distress experienced by healthcare workers in Canada and the UK were remarkably similar.
31. Clemens et al. (2021). The mediating role of COVID-19-related burden in the association between adverse childhood experiences and emotional exhaustion: results of the egePan – VOICE study	In German health-care professionals, ACEs were associated with a higher burnout (emotional exhaustion), mediated by COVID-19-associated problems including increased smoking, drinking and use of antidepressants/ tranquilisers, feeling unprotected, feeling being burdened by COVID-19 problems and greater exhaustion and sleep problems.
32. D'Alessandro-Lowe et al. (2023). Characterizing the mental health and functioning of Canadian respiratory therapists during the COVID-19 pandemic	Moral distress and symptoms of depression, anxiety, stress and PTSD were prevalent among Canadian Respiratory Therapists and were associated with functional impacts.
33. Laurent et al. (2022). Risk and protective factors for the possible development of post-traumatic stress disorder among intensive care professionals in France during the first peak of the COVID-19 epidemic	More than 20% of healthcare professionals surveyed at the first peak of the pandemic and again 3 months later had potential PTSD with mostly intrusion symptoms and risk factors including other life events during the crisis, having a high level of psychological distress, a high level of perceived stress related to the workload and human resources issues, the emotional burden related to the patient and family, and stressors specific to COVID-19 during the first peak of the crisis. The workers preferred to use support from colleagues, relatives and/or a psychologist, and very few used the telephone hotlines.
34. Patel et al. (2023). Associations between trauma and substance use among healthcare workers and public safety personnel during the SARS-CoV-2 (COVID-19) pandemic: the mediating roles of dissociation and emotion dysregulation	Among healthcare workers, dissociation fully mediated the relation between PTSD and alcohol-related problems and emotion dysregulation partially mediated the relation between PTSD and substance-related problems. Among public service workers, emotion dysregulation rather than dissociation fully mediated the relation between PTSD and alcohol-related problems.
35. Qureshi et al. (2022). Factors influencing the mental health of an ethnically diverse healthcare workforce during COVID-19: a qualitative study in the United Kingdom	Qualitative analysis of results of focus groups with healthcare workers in the United Kingdom between December 2020 and July 2021 identified mental health concerns including anxiety (due to inconsistent protocols and policy); fear (of infection); trauma (due to increased exposure to severe illness and death); guilt (of potentially infecting loved ones); and stress (due to longer working hours and increased workload).
36. Tekin et al. (2022). Experiences and views of frontline healthcare workers’ family members in the UK during the COVID-19 pandemic: a qualitative study	Qualitative analysis of interviews with Close family members and friends of United Kingdom healthcare workers showed a high level of motivation to support the worker but also evidence that increased domestic responsibilities and emotional burden due to anxiety about their loved ones’ work, the fact that sacrifices made by family members were not noticed by society, anxiety they about their family's physical health, the impact of hearing about traumatic experiences, and the failure of healthcare organisations to meet the needs of the workers all negatively affected the workers’ significant others.
37. Yeung et al. (2022). Finding the positives from the COVID-19 pandemic: factors associated with posttraumatic growth among nurses in Hong Kong	A survey of nurses in Hong Kong six months into the COVID-19 pandemic found that part-time work, religious affiliation, COVID-related worries, psychological distress, and satisfaction with workplace protections were associated with posttraumatic growth.
38. Yeung et al. (2023). ‘Caring for the helpers': factors associated with professional quality of life among Hong Kong nurses during the fifth wave of the COVID-19 pandemic	A survey of nurses in Hong Kong two years into the COVID-19 pandemic found that stressors from clinical work environments, insufficient emotional support, and less positive reframing were associated with lower compassion satisfaction; higher secondary traumatic stress (STS) and burnout. COVID-19-related worries /uncertainties and emotional processing were associated with higher STS, whereas insufficient organisational support for communication with the healthcare system was associated with higher burnout.
Traumatic Grief and Moral Injury
39. Djelantik et al. (2021). Traumatic grief research and care in the aftermath of the COVID-19 pandemic	This editorial discusses important themes regarding prolonged grief disorder in the aftermath of the COVID-19 pandemic, to gather and present useful information for clinicians and researchers.
40. Eisma and Tamminga (2022). COVID-19, natural, and unnatural bereavement: comprehensive comparisons of loss circumstances and grief severity	COVID-19 deaths (vs. natural deaths) were more often unexpected and characterised by an inability to say goodbye appropriately. People bereaved due to COVID-19 also were more often infected and quarantined. COVID-19 deaths (vs. other deaths) more often involved intensive care admission and altered funeral arrangements. COVID-19 deaths yielded higher grief levels than natural deaths (but not unnatural deaths).
41. Hanauer et al. (2023). ‘Feeling disconnected’ – risk factors for PGD and themes in grief counselling during the COVID-19 pandemic. A mixed-method study	A survey of German grief counsellors identified risk factors for prolonged grief disorder including lack of social support, limited possibilities to accompany a dying loved one, absence of traditional grief rituals, and societal impacts of the pandemic generally and on bereavement support and health care, and a potential protective factor, the chance for personal growth.
42. Hegarty et al. (2022). ‘It hurts your heart': frontline healthcare worker experiences of moral injury during the COVID-19 pandemic	Frontline healthcare workers in Great Britain described being routinely exposed to ethical conflicts that created by exacerbations of pre-existing systemic issues including inadequate staffing and resourcing, and a range of mental health symptoms primarily related to perceptions of institutional betrayal as well as feeling unable to fulfil their duty of care towards patients.
43. Plouffe et al. (2021). Impacts of morally distressing experiences on the mental health of Canadian health care workers during the COVID-19 pandemic	Among Canadian healthcare workers during the pandemic, resource adequacy, positive work life, and ethical work environment negatively predicted severity of moral distress, whereas COVID-19 risk perception positively predicted severity of moral distress. Moral distress predicted symptoms of depression, anxiety, PTSD, and burnout.
44. Rodrigues et al. (2023). ‘Against everything that got you into the job': experiences of potentially morally injurious events among Canadian public safety personnel	Qualitative analyses of interviews with Canadian public service personnel found that potentially morally injuring events in the course of their work compromise their ability to act in accordance with the principles that motivate them in their work, and, in combination with traumatic experiences and routine stress, are associated with adverse psychological, professional and personal outcomes.
45. Zerach & Levi-Belz (2021). Moral injury and mental health outcomes among Israeli health and social care workers during the COVID-19 pandemic: a latent class analysis approach	Latent class analysis of data from a survey of health and social care workers in Israel one year into the pandemic identified approximately 20% who reported high exposure to morally injuring events, and 30% who reported exposure to moral injury due to betrayal by others, with elevated levels of depressive, anxiety, posttraumatic, and moral injury symptoms and self-criticism and low levels of self-compassion characterizing them.
Interventions for Pandemic-Affected Workers and Populations
46. Caille et al. (2023). EMDR for symptoms of depression, stress and burnout in health care workers exposed to COVID-19 (HARD): A study protocol for a trial within a cohort study	This protocol describes a ‘trial within a cohort’ (TwiC) design consisting of a cohort study with an embedded pragmatic randomized trial testing the effectiveness of EMDR in reducing depression, burnout and PTSD in health care workers exposed to COVID-19.
47. Dai et al. (2022). The mechanism of governments’ and individuals’ influence on protective behaviours during the second wave of COVID-19: a multiple mediation model	A community survey in Beijing showed that during COVID-19 resurgence, people perceived government intervention as directly and indirectly influencing protective behaviours through individual factors, such as perceived efficacy and positive emotions, and that posttraumatic growth could mediate the indirect pathway to protective behaviours.
48. Dyer et al. (2022). Psychological support for healthcare workers during the COVID-19 pandemic: a mixed methods study involving support providers	While delivering supports was generally a positive experience for healthcare providers, adaptation to the demands of this role was dependent upon important factors (e.g., clinical experience) that need to be considered in planning psychological supports for healthcare staff.
49. Fino et al. (2021). Helping patients connect remotely with their loved ones modulates distress in healthcare workers: a tend-and-befriend hypothesis for COVID-19 front liners	A survey in June 2020, of healthcare workers (nurses = 146; physicians = 63) engaged in the COVID-19 frontline in Italy showed that nurses assisting patient-family videocalls reported significantly lower levels of distress and a better quality of wakefulness compared to those who did not, whereas physicians reported higher levels of distress during such virtual communications.
50. Reitsma et al. (2021). Online treatment of persistent complex bereavement disorder, posttraumatic stress disorder, and depression symptoms in people who lost loved ones during the COVID-19 pandemic: study protocol for a randomized controlled trial and a controlled trial	This study protocol describes a two-phase test of online cognitive behaviour therapy to reduce symptoms of PTSD, depression, and persistent complicated bereavement disorder with adults who lost a loved one during the COVID-19 pandemic.
51. Trottier et al. (2021). Development of RESTORE: an online intervention to improve mental health symptoms associated with COVID-19-related traumatic and extreme stressors	Preliminary data with frontline healthcare workers are presented for RESTORE (Recovering from Extreme Stressors Through Online Resources and E-health), a cognitive behavioural guided on-line programme designed to also be used with recovered severely ill COVID + patients, and close others of COVID + patients who have recovered or died are at risk for clinical levels of mental health symptoms in the context of the COVID-19 pandemic.

1. Impact of the pandemic on community populations, students, veterans and refugees

While the mental health impact of the COVID-19 pandemic on healthcare workers has been a focal point of investigation, other at-risk populations including students (Ali et al., 2021; Bountress et al., 2022; Essadek et al., 2022; Pat-Horenczyk et al., 2021), refugees (Akhtar et al., 2021; Liddell, Murphy, et al., 2021; Liddell, O'Donnell, et al., 2021), persons exposed to violence (Birkeland et al., 2021; Gibert et al., 2021) or past childhood adversity (Clemens et al., 2021), and military personnel (Richardson et al., 2022) have also been a nidus for research on mental health outcomes. A multitude of studies and reviews have highlighted the ubiquitous negative mental health effects of the pandemic (Nochaiwong et al., 2021; Zhao et al., 2021) and lockdowns (Chen et al., 2022), including PTSD (Bonati et al., 2022; (Laurent et al., 2022) Yuan, et al., 2021), adjustment disorders (Ajdukovic et al., 2021; Dragan et al., 2021; Liddell, O'Donnell, et al., 2021; Lotzin et al., 2021; Shiffman et al., 2023), substance use disorders (Patel et al., 2023), and even transient psychoses (Loehde & Novakovic, 2021).

The research provides comparative data and estimates of risk in country populations and samples, other than healthcare workers (Cheung et al., 2022; Kwong et al., 2021) (e.g., in infected individuals and in survivors of COVID-19 post-hospitalisation) (Rogers et al., 2020). In hospitalised survivors of COVID-19, for example, one study found that more than one-third of patients met the diagnostic criteria of probable PTSD 1-month post-discharge (Ju et al., 2021), while another found that the prevalence of PTSD was similarly high at 6 months (Bonazza et al., 2022). Post-hospitalisation services and social support that promote social inclusion were found to have a stronger association with lower levels of anxiety and depressive symptoms and higher levels of posttraumatic growth than pre- or intra-hospitalisation factors with another sample of adults in China who had been discharged from COVID-related hospitalisation 6 months previously (Xiao et al., 2022). Therefore, healthcare providers need to anticipate and carefully assess for possible PTSD in severe COVID-19 survivors to proactively identify, follow-up, and treat survivors following hospital admission, and for doing so in collaboration with multidisciplinary clinics (Greene et al., 2022).

Yet findings on these mental health trajectories in the aftermath of SARS-CoV-2, across populations, are inconsistent. For example, an umbrella review of systematic reviews undertaken by the World Health Organization (WHO) (2022) concluded from longitudinal studies of the general population that there was an approximately 25% increase in depression and anxiety disorders in the first year of the pandemic, with ‘the greatest increases … in places highly affected by COVID-19’ (p. 1). However, other systematic reviews of longitudinal data have pointed to a relatively small magnitude of increase, limited only to the early phase of the pandemic, with high variability in the prevalence of mental health symptoms and mental disorders across samples and over time (Prati & Mancini, 2021; Robinson et al., 2022; Salanti et al., 2022; Sun et al., 2023; Xiao et al., 2022). A recent systematic review that examined the dose-response of mental health problems in the first year of the pandemic found that depression and anxiety symptoms increased substantially in the general population during the first two months of the pandemic, with the increase in these symptoms positively associated with stringency/containment measures and cumulative reported cases/deaths (Salanti et al., 2022). In contrast, mental health trajectories varied greatly across studies after the first two months of the pandemic. Methodological variation (e.g., sampling, mental health measures, and availability of baseline pre-pandemic assessments), country-level differences in pandemic severity, study timing in relation to the evolution of COVID-19 and circulating variants, and individual-level and contextual factors, all may be contributing to the high heterogeneity in prevalence estimates.

Multiple (and cumulative) trauma exposures – both pandemic-related and non-pandemic – were also ubiquitous in the first year of the pandemic, with data pointing to the identifiable risk and protective factors for PTSD in trauma-exposed individuals (Ajdukovic et al., 2021; Chen et al., 2022; Yang et al., 2021, 2022). A systematic review and meta-analysis that assessed the prevalence of anxiety, depression, posttraumatic symptoms, stress, and sleep problems in the early pandemic period reported that posttraumatic stress symptoms were the most prevalent presentation in COVID-19 infected individuals, though the rates of all mental health problems among COVID-19 infected individuals were uniformly high (Dragioti et al., 2022). In the ADJUST study by Lotzin and colleagues (2022) published in this Special Issue, the estimated prevalence of PTSD among trauma-exposed general population adults recruited from 11 countries was 17.7%, more than twice the base rate of PTSD in the non-COVID era. Using a new assessment to identify pandemic-specific stressors, Lotzin et al. (2022) found that non-modifiable risk (e.g., younger age, female sex) and modifiable risk (e.g., poor health status) and protective (e.g., social contact) factors were associated with PTSD, underlining the importance of brief early targeted interventions for both full and subclinical PTSD. While this cross-sectional study could not support causal inferences on vulnerability and protective factors, it highlights touchpoints for future mental health pandemic preparedness with respect to screening and early intervention (Lotzin et al., 2021).

Many countries around the world instituted successive lockdowns of varying stringency over the first two years of the pandemic. A systematic review of college students, covering studies predominantly from China, and no studies from low- and middle- income countries, found that college students were more anxious, depressed, stressed and fatigued than before the pandemic. Factors such as low family socioeconomic status, living in rural areas, knowing someone who was infected with COVID-19, and being a family member or friend to a healthcare worker, were strongly associated with poorer mental health outcomes (Elharake et al., 2023). In a survey early in the pandemic of more than 19,000 French university students, conducted over three successive stages (lockdown, the lifting of lockdown, and second lockdown), successive lockdowns worsened mental health, especially among PhD students; in contrast, there was a significant reduction in depression, anxiety, and psychological distress when the lockdown was lifted (Essadek et al., 2022). Once again, these findings underline the importance of identifying risk groups for early preventative efforts.

Early in the pandemic, COVID-19 infection had features consistent with high magnitude, prolonged traumatic stressors capable of giving rise to PTSD. The notion that the pandemic itself might constitute a mass traumatic event triggered much discussion and debate in the literature. Severe and enduring stress prior to a discrete trauma could predispose individuals to maladaptive processing during and after trauma exposure, and result in the development of PTSD symptoms, considering that fear conditioning (also referred to as associative fear learning) is a prime neural process underlying the development of PTSD. Friesen and colleagues (2022) tested the associations of pandemic stress, associative learning and memory, and PTSD symptoms in an analogue trauma experimental paradigm with university students. The authors found that ‘the relationship between COVID-19-related distress and intrusion load was partly (for valence) and fully (for arousal and fear) mediated by associative learning’. While their findings are preliminary and cannot be extrapolated to real-life traumas, they suggest that in a subgroup of individuals who have high levels of distress there may be aberrant processing of the traumatic stressors occurring in the pandemic, which could increase the risk for PTSD.

Identifying peritraumatic distress in relation to COVID-19 experiences and pinpointing the most traumatogenic experiences for clinically significant symptoms can aid early detection, while contextualising individual experiences through personal narrative exploration can inform more personalised interventions for those who need them (Cipolletta et al., 2022). To this end, based on mixed methods analyses of results a 2-country survey (Italy and USA) detailed in this Special Issue, Cipolletta et al. (2022) document a clear relationship between COVID-19 related experiences of life-threat, anxiety and resource deprivation and levels of peritraumatic distress that reached the threshold of clinical significance. Cross-country differences that were evident (Americans endorsing more life-threat and losses compared to Italians reporting more threat to the world, stress, social isolation, and feelings of being trapped), were explained in part by differences in the stringency of lockdown and containment measures. These findings call attention to appropriately orienting interventions to address different nations’ unique needs.

In addition to PTSD, depression and anxiety disorders have consistently been identified as common morbidities in the general population during the pandemic (Xiong et al., 2020; Zhao et al, 2021; (Cipolletta et al., 2022; Zhang et al., 2022; Zhang & Chen, 2021)). Network analysis allows for the interrogation of the structure of these morbidities and their symptom level interactions. During COVID-19, longitudinal evaluation of the development and maintenance of PTSD and depression symptoms using network modelling can afford temporal insights into putative prevention and intervention targets (Chen et al., 2022). In a study reported in this Special Issue that applied both cross-sessional and longitudinal network analysis to data from a participant sample from the Greater Wuhan Area, sadness and depressed mood were the most central depressive symptoms, while for PTSD irritability and hypervigilance evolved to difficulty concentrating and avoidance of reminders over time (Chen et al., 2022). The mechanisms underpinning the maintenance of symptoms of PTSD are many and, as noted above. may include post-traumatic cognitions. Data from college students published in this Special Issue suggest that event centrality (i.e., perceiving the COVID-19 pandemic as a central event to understanding oneself and the world) predicted posttraumatic stress symptoms and this was mediated through cognitive processes, such as rumination, catastrophizing and attention to negative information (Yang et al., 2022). These findings suggest that evidence-based therapies for PTSD that facilitate the reappraisal of negative cognitions warrant use in clinical practice and research evaluation in the context of this and future pandemics.

As the largess of data has shown, individuals, populations and countries have been differentially affected by COVID-19 (Bapolisi et al., 2022; Berkhout et al., 2022; Zhang et al., 2022; Zhang & Chen, 2021), and ‘evidence-based mapping of risk and protective factors’ has been ‘important to inform governance of the pandemic’ (Lotzin et al., 2022). Nimble pivoting to tele-mental health services and rollout of e-health interventions, the higher demand for mental health services, the normalisation of mental distress and the reduction in stigma, and enhanced help-seeking, all have had unexpectedly positive and far-reaching effects (BinDhim et al., 2021). The authors propose leveraging these positive effects in tandem with employing a public mental health-based stepped-care model (Dai et al., 2022) that is stress- and trauma- informed. Even in the post-pandemic COVID era, these are prudent recommendations with wide applicability for future pandemics, that we as a global community will inevitably face.

2. Impact of the COVID-19 pandemic on front-line healthcare workers

During the pandemic, frontline health workers including nurses and physicians (Ford et al., 2022), but also professionals and paraprofessionals from a wide variety of allied health fields such as respiratory therapists (D'Alessandro-Lowe et al., 2023), public safety personnel (Rodrigues et al., 2023), and social care workers (Zerach & Levi-Belz, 2021) were exposed to extreme hazards (e.g., viral transmission, insufficient PPE) and workplace stressors (e.g., medical crises, patients and families separated and in distress, deaths of patients and co-workers, moral dilemmas) (Adams et al., 2023; Berkhout et al., 2022; Laurent et al., 2022). It is important to remember that no one-size-fits-all in the experiences, adaptations, and difficulties experienced by front-line workers based on differences in the pandemic-related stressors that confronted workers of different occupational backgrounds and responsibilities, in their stress-related reactions, and their life contexts (Tekin et al., 2022) (Patel et al., 2023; Qureshi et al., 2022).

Stressors confronting healthcare workers extend into their personal lives, including fear and guilt regarding the safety of loved ones (Hegarty et al., 2022; Laurent et al., 2022; Plouffe et al., 2021; Qureshi et al., 2022; Wilson et al., 2022; Yeung et al., 2023), isolation in lengthy periods of self-quarantine (Fino et al., 2021), and stigma and violence from community members (Assefa et al., 2021; McCall et al., 2023). Despite preventive recommendations from the World Health Organization as early as March 2020, front-line workers caring for patients infected with the coronavirus experienced multiple potentially traumatic stressors including exposure to the virus without consistent or sufficient access to adequate personal protective equipment and personal viral testing, and feeling entrapped in life threatening conditions by external coercion and a sense of obligation to do whatever was necessary to save the lives or ameliorate the suffering of their patients while not abandoning or betraying the trust of co-workers (D'Alessandro-Lowe et al., 2023; McGlinchey et al., 2021). These stressors were amplified in settings that lacked economic and medical resources: frontline workers in low and middle-income countries were more likely to view occupational health/safety and infection prevention /control programmes as inadequate than workers in high-income countries (Bapolisi et al., 2022; Harrigan et al., 2022; Zhang & Chen, 2021).

The stressors and risks confronting front-line healthcare personnel during the pandemic often were psychologically traumatic due to the threats to their lives, the lives of their co-workers and patients, and the health and lives of their families (Laurent et al., 2022). In addition, as described in a paper in this Special Issue, front-line healthcare workers were faced with the extreme physical and emotional suffering of patients and the distress and grief of patients’ family members when separated from or only able to minimally comfort or protect their dying loved-ones, and traumatic losses and deaths of co-workers (Berkhout et al., 2022), in addition to the fear and distress experienced by their families (Tekin et al., 2022). As a result, workers were at risk for severe secondary traumatic stress, vicarious trauma, compassion fatigue, and traumatic grief (Adeyemo et al., 2022; Hegarty et al., 2022; Maftei & Holman, 2021; Plouffe et al., 2021; Yeung et al., 2023; Zerach & Levi-Belz, 2021).

Not surprisingly, therefore, studies, including in this Special Issue (Greene et al., 2021; Patel et al., 2023), have documented how healthcare workers, especially those on the front-line caring for patients with severe coronavirus infections, have reported a plethora of psychological problems (e.g., anxiety, depression, somatisation, obsession/compulsions, insomnia) (Greene et al., 2021), primary and secondary traumatic stress symptoms (Greene et al., 2021; Hegarty et al., 2022), burnout (Alkhamees et al., 2023; Long et al., 2023; Rossi et al., 2023), and severe impairment and danger due to addiction and suicidality (Patel et al., 2023; Ryan et al., 2023; Uvais, 2021). Almost half of a sample of front-line healthcare workers assessed by structured interview during the pandemic met criteria for PTSD, and nearly 40% for major depressive disorder, with pandemic-related traumatic stressors appearing directly related to depression and to exacerbate the effects of pre-pandemic trauma exposure when PTSD occurred (Wild et al., 2022). A longitudinal study of health and social care personnel between November 2020 and August 2021 found that one in seven (13–16%) reported severe and unremitting symptoms of psychological distress and physical pain across peaks and periods of relative respite in the pandemic (Jordan et al., 2023). In a paper published in this Special Issue, focus groups with healthcare workers, physicians, nurses, midwives, and allied health professionals of under-represented ethnocultural backgrounds in that same mid-pandemic time period identified fear of infection, traumatic grief due to exposure to patients’ suffering and deaths, guilt due to potentially infecting loved ones, and extreme work hours and workloads as critical contributors to mental health problems (Qureshi et al., 2022). Although the intensity and inescapability of these potentially traumatic conditions has greatly diminished as the prevalence and severity of coronavirus infection has waned, the long-term impact of months of exposure to multiple extreme stressors on front-line healthcare workers’ mental and physical health (Melnyk et al., 2023), and occupational burnout (Rossi et al., 2023) warrant careful surveillance.

Healthcare workers who have experienced significant adversity in their childhood also may be at particularly high risk for burnout and behavioural and mental health problems (Clemens et al., 2021), but it is essential that childhood (or adult) victimisation not become a source of stigma for these crucial personnel in addition to the stigma they already often face due to their courageous willingness to care for COVID-infected patients (Bapolisi et al., 2022). Difficulties with dissociation may be an important indicator of risk for healthcare workers, considering its role as a mediator between PTSD symptoms and alcohol-related problems (Laurent et al., 2022).

3. Moral Injury

Moral injury has emerged as a defining dilemma for front-line healthcare personnel in the pandemic (Dale et al., 2021; Mantri et al., 2020; Williamson et al., 2020; Wilson et al., 2022) and is also covered in a special issue of this journal (https://www.tandfonline.com/doi/full/10.1080/20008066.2023.2196899). Front-line workers and professionals often faced extreme moral dilemmas during the pandemic, for example being unable to uphold core personal and professional values when having to make triage decisions that denied lifesaving care to some patients or having to deny loved ones access to dying patients (Adeyemo et al., 2022). A series of papers published in this Journal highlighted the complex forms of moral injury experienced by front-line healthcare personnel, and its potentially debilitating impact. A combination of qualitative interviews and a psychometric assessment with the Moral Injury Events Scale at a six-month follow-up with 30 front-line healthcare workers identified a combination of personal (i.e., ‘feeling unable to fulfill their duty of care towards patients’) and systemic (i.e., institutional betrayal related to a worsening of pre-existing ‘inadequate staffing and resourcing’) facets of debilitating moral injury (Hegarty et al., 2022).

Qualitative interviews with public safety personnel, including paramedics and crisis hotline responders, similarly faced potentially morally injurious events in the line of duty that ‘compromise their ability to act by the principles that motivate them in their work’ and are associated with ‘adverse psychological, professional, and personal outcomes’ (Rodrigues et al., 2023) (p. 2205332). As early as three weeks after the initial pandemic lockdown, almost half of a self-selected sample of physicians working on both COVID-specific and general medical units who were surveyed in Romania reported having experienced potentially morally injurious events (Maftei & Holman, 2021). A year later, a survey of Israeli health and social care workers identified sub-groups who reported either very high levels of both personal moral injury and institutional betrayal (one in five of the respondents) or institutional betrayal (one in three of the respondents) – with these workers also reporting high levels of anxiety, guilt, and PTSD symptoms and self-criticism and low levels of self-compassion (Yeung et al., 2023; Zerach & Levi-Belz, 2021)

4. Emotional support and posttraumatic growth

Not all studies have documented negative mental health outcomes related to the pandemic. A survey of college students reported that mental health and alcohol use problems were either not significantly different compared to pre-pandemic report, and in some instances were better than what students reported when assessed a year earlier (Bountress et al., 2022). These positive effects are also highlighted in a paper in this Special Issue by a team of leading researchers and leaders from the European Society for Traumatic Stress Studies (ESTSS) who identified five lessons learned from research on mental health problems during the COVID-19 pandemic in the Central, Eastern, Nordic, Southern, and Western subregions of Europe, represented by five member countries (Georgia, Germany, Portugal, Sweden, UK) (Lotzin et al., 2022).

During the pandemic, a paper published in this Special Issue provided evidence that healthcare personnel can experience posttraumatic growth (Yeung et al., 2022). Reliable social support in the workplace and in their personal lives (Effendy et al., 2023) appears instrumental in fostering this positive transformation. Several online emotional support programmes from healthcare workers and trainees have been evaluated during the pandemic, showing evidence of effectiveness in reducing distress and promoting positive emotions and support seeking (Harkanen et al., 2023). However, another study found that frontline healthcare workers preferred support from colleagues, family, or psychologists in person to virtual services such as hotlines. Psychotherapists who provided support to frontline healthcare staff identified five themes that guided their work in a qualitative focus group study published in this Special Issue: encouraging flexible adaptability, supporting a sense of serving the community in crisis, finding value in the work, developing new roles, and seeing a way forward (Dyer et al., 2022).

However, it is important to remember that, despite their value, self-care and professional support interventions for healthcare workers, although widely deployed globally during the pandemic, were not alone sufficient because they do not address ‘wider structural and employment factors (e.g. system resourcing and organisation) that determine the working conditions’ (Byrne et al., 2023) (p. 104863). A study published in this Special Issue found that people surveyed in China during the second wave of the COVID-19 pandemic viewed governmental and organisational intervention as essential to providing the resources promoting posttraumatic growth in the pandemic, and crucial to facilitating a sense of hope and efficacy in workers and the community (Dai et al., 2022).

5. Grief and bereavement

Traumatic grief and complicated bereavement have affected not only front-line workers but persons from every walk of life during the pandemic (Eisma & Tamminga, 2022). Along with the sense of threat that occurred at the height(s) of the pandemic, loss was described as a central theme in the worst experiences reported by adults in the US and in Italy (Cipolletta et al., 2022). Grief counsellors in Germany described several key stressors in the pandemic that were associated with traumatic bereavement, including separation from a dying loved one, the absence of traditional rituals for grieving, a lack of social support, and the larger context of global crisis and limited resources for bereavement support (Hanauer et al., 2023). A survey published in this Special Issue of adults in China bereaved due to the pandemic found that almost 70% reported high levels of both prolonged grief and PTSD symptoms, especially those who lost a child or primary partner due to COVID (Chen & Tang, 2021). The epidemic level of traumatic bereavement caused by the pandemic led to a paper in this Special Issue that formulation of key themes that are essential for policy, practice, and research going forward: 1. a unified conceptual framework and diagnosis for what constitutes prolonged grief disorder is needed; 2. validated screening tools and therapeutic interventions are needed for early detection and prevention of chronic grief disorders; 3. approaches to pharmacotherapy also are needed to prevent or treat prolonged grief disorders; 4. developmentally attuned approaches to helping bereaved older adults and 5. children and adolescents are needed; 6. a systematic understanding of both grief and prolonged grief disorder are needed to guide all of these crucial initiatives (Djelantik et al., 2021).

Children are a particularly vulnerable population in crises such as the COVID-19 pandemic, due to their normative immaturity (the other side of the coin of their remarkable psychosocial resilience and neurobiological plasticity) and the ever-changing developmental challenges they face in formal and informal learning, developing security and acceptance in family and peer relationships, and forming a sense of self (Schmidt et al., 2021). The pandemic confronted children with a flood of potential and actual losses, including due to lockdowns, quarantines, school and activity closures, separations from primary caregivers, extended family, and friends, and the ever-present threat of illness or death for themselves and significant others. A study published in this Special Issue also highlights the importance of identifying children who have pre-existing socio-emotional vulnerability when a major crisis such as the pandemic occurs, showing that those children were at highest risk for posttraumatic and anxiety symptoms when assessed at four intervals in the first year of the COVID-19 pandemic (Raymond et al., 2022).

6. Interventions

The isolation of patients has been exacerbating distress in relatives but also in frontline healthcare workers. Patient-family video calls were found to have mixed effects on healthcare workers (Fino et al., 2021). Tending to patients’ emotional needs by facilitating patient-family video calls with families mitigates distress in COVID-19 front-line nurses. Physicians, however, reported higher levels of distress during such virtual communications. This raises the question of how much can we ask of frontline providers in serving as facilitators or surrogate sources of support for patients as well as providing formal healthcare. Online CBT is being investigated as an approach to helping people recover from persistent complex bereavement disorder, PTSD, and depression in the wake of the pandemic (Reitsma et al., 2021).

Interventions to support and care for the frontline providers who care for, and all too often have had to grieve for, patients with COVID-related (and often many other) illness(es) also are crucial (Trottier et al., 2021). However, careful planning is needed to ensure a match between the care provided to the frontline workers and other at-risk personnel and their needs and preferences (Dyer et al., 2022). Informal support from known and trusted persons may be preferred to impersonal crisis-focused or online interventions (Laurent et al., 2022). Online support may be a valuable complement to in-person interventions due to its wide reach and capacity to incorporate sophisticated interventions (Reitsma et al., 2021). With the wide availability and reduced time and other costs (e.g., transportation) of telehealth, this modality may be preferred to on-site services (Richardson et al., 2022). To reduce distress in healthcare workers during the COVID-19 pandemic we need to examine what could be effective interventions under these specific circumstances (Caille et al., 2023). Should long-term mindfulness practices be stimulated to maintain mental health and prevent burnout under COVID-19 stress (Hong et al., 2023)?

7. Future COVID-19 research

More than 3.5 years since COVID-19 was first detected, the Director-General of the WHO declared early in May this year that COVID-19 was no longer a global health emergency. He warned of the deep scars that the disease will continue to leave on our world. This is especially true of the often-invisible mental health scars that, for many, will take years and even generations to heal. Based on the ensemble of papers described above, many of which were published in EJPT, what are the overarching lessons learned that could be taken forward for research and practice, and policy (preparedness and prevention) for future pandemics?

For research, longitudinal data that are enriched by deep phenotyping of mental health outcomes, including long COVID, are needed. Together with observational studies, large-scale, international efforts to investigate the effectiveness, safety, and usability of low intensity, high impact, sustainable, and culturally sensitive interventions for high-risk groups, that are accessible and scalable will improve preparedness for future pandemics. A recent scientometric analysis on the key thematic trends in mental health research in the post-lockdown period, up until 31 December 2022, recommended, based on existing literature, that a research priority focus should be on the ‘developmental trajectories of children and adolescents to determine the long-term consequences of the pandemic and post-lockdown period on education, relationships, and mental health’ (Cataldo et al., 2023, p. 15). This includes early interventions in youth with risk factors for developing mental illness, as well as research on COVID-19 related fears and other psychopathology in the peri- and postpartum (Shiffman et al., 2023), and investigation of interventions to support mothers during this period. In addition, what is needed is a systematic evaluation of strategies across the lifespan to strengthen and optimise mental health services to withstand the increased demand for mental health care in the post-emergency COVID era and inform supportive policies that initiated in healthcare and workplace settings, including volunteer-led initiatives. This is arguably critical in low- and middle- income countries where the high disease burden is compounded by health worker shortages, and less access to psychological support. A study on Congolese health workers in this Special Issue (Bapolisi et al., 2022) underscores the need to incorporate emotion regulation and social support strategies in psychological interventions aimed at mitigating high rates of psychopathology among healthcare workers.

Through the pandemic vaccine hesitancy was fuelled by misinformation, disinformation, and distortion of information. Early on there was impetus to understand the roots of hesitancy and low vaccine uptake, with determinants such as demographic factors (e.g., age, gender, ethnicity), along with individual beliefs (e.g., perceived susceptibility to and severity of COVID-19) and perceived risks of vaccination all found to play a role. To this end, vaccine education, consistent, accurate and unified messaging at all levels, and transparency on the part of government and healthcare officials, are key to enhanced vaccine uptake going forward. More targeted efforts are likely required in marginalised populations, such as refugees and immigrants (Liddell, O'Donnell, et al., 2021), where barriers to uptake can be effectively addressed by establishing trusted relationships within the community, providing culturally sensitive education, and firming up the evidence base on interventions that show promise (Daniels et al., 2022).

For clinical practice improvements to occur, there will need to be ongoing research that identifies the clinical challenges and potential approaches to early prevention and ongoing treatment that are most beneficial to affected populations, acceptable and feasible for clinicians, and cost-effective for funders and policymakers. One of the positive spin-offs of research to date is the assimilated discourse on burnout, compassion fatigue, moral injury, and racial trauma in psychotherapeutic and counselling settings that has been spurred by both the adversities and the opportunities posed by the pandemic. As stated by Cattie et al (2022, p. 283), ‘the healing of COVID-era activities has illuminated a few: acknowledging challenges in health care and supporting individuals; being honest about what depletes us and what sustains us; connecting across settings, disciplines, and typical divides; and building broad engagement as a critical resource for changing our spaces’.

In conclusion, the strides made in the traumatic stress field in response to this global crisis should fuel more innovative and impactful research, clinical, and policy initiatives.

Disclosure statement

No potential conflict of interest was reported by the author(s).