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Sleep problems and fatigue ‘directly linked to COVID-19’

Mental illness as a direct result of COVID infection is less certain, say researchers



The link between COVID-19 with sleep problems and fatigue has been confirmed by a new study into the impact of the virus – although doubt exists over whether infection is directly responsible for mental illness. 

People who tested positive for COVID were found to have an increased risk of such issues, with a six-fold increase in the likelihood of reporting fatigue to a GP, and a three-fold increase in the risk of sleep problems. 

There was also an 83 per cent increase in mental illness following a positive PCR test, although this was also recorded as being 71 per cent among those without COVID. 

The researchers on the study, led by the University of Manchester, say this does cast doubt as to whether COVID directly causes mental illness, as this finding also includes other mental health risk factors like pandemic-related anxieties, and whether people with mental illness may be more likely to seek a test. 

The findings were compiled through analysis of electronic primary care health records of 226,521 people from across the UK. 

Dr Matthias Pierce, who led the work at The University of Manchester, said: “When we began this research project we wanted to investigate whether we could find any evidence in primary health care records that COVID-19 was linked to an increased risk of mental health illness, sleep and fatigue problems.

“While fatigue is clearly a consequence of COVID-19 the risk of experiencing sleep problems is also very high. However, we are sceptical regarding the extent that COVID-19 is directly causing people to become mentally ill, or whether those with a predisposition to mental illness are more likely to get tested.”

“This study shows a clear association between COVID-19 infection and fatigue and sleep problems,” says Professor Trudie Chalder, a cognitive behavioural psychotherapy specialist at King’s College London’s Institute of Psychiatry, Psychology and Neuroscience (IoPPN).

The next research steps will be to explore mechanisms of such associations and targeted interventions.”

Professor Roger Webb, who co-leads the Mental Health research programme at the National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC), which funded the study, added: “Our findings align with those generated by investigations conducted in other countries in revealing elevated risks of mental illness, self-harm, fatigue, and disrupted sleep patterns among people testing positive for infection during the pandemic. 

“Establishing the mechanisms that have caused these outcomes to occur is the next major challenge for researchers in our field.”


Pre-school play ‘lowers risk of mental health problems later’

The findings give the first clear evidence that ‘peer play ability’ has a protective effect on mental health



Children who learn to play well with others at pre-school age tend to enjoy better mental health as they get older, new research has revealed. 

The findings provide the first clear evidence that ‘peer play ability’, the capacity to play successfully with other children, has a protective effect on mental health.

Researchers at the University of Cambridge analysed data from almost 1,700 children, collected when they were aged three and seven, and found those with better peer play ability at age three consistently showed fewer signs of poor mental health four years later. 

They tended to have lower hyperactivity, parents and teachers reported fewer conduct and emotional problems, and they were less likely to get into fights or disagreements with other children.

Importantly, this connection generally held true even when the researchers focused on sub-groups of children who were particularly at risk of mental health problems. 

It also applied when they considered other risk factors for mental health – such as poverty levels, or cases in which the mother had experienced serious psychological distress during or immediately after pregnancy.

The findings suggest that giving young children who might be vulnerable to mental health issues access to well-supported opportunities to play with peers – for example, at playgroups run by early years specialists – could be a way to significantly benefit their long-term mental health.

Dr Jenny Gibson, from the Play in Education, Development and Learning (PEDAL) Centre at the Faculty of Education, University of Cambridge, said: “We think this connection exists because through playing with others, children acquire the skills to build strong friendships as they get older and start school.

“Even if they are at risk of poor mental health, those friendship networks will often get them through.”

Vicky Yiran Zhao, a PhD Student in PEDAL and first author on the study, added: “What matters is the quality, rather than the quantity, of peer play.

“Games with peers that encourage children to collaborate, for example, or activities that promote sharing, will have positive knock-on benefits.”

The new findings build on further recent research which has helped to show the power of play in children’s mental health.

The researchers used data from 1,676 children in the Growing up in Australia study, which is tracking the development of children born in Australia between March 2003 and February 2004. 

It includes a record, provided by parents and carers, of how well the children played in different situations at age three. This covered different types of peer play, including simple games; imaginative pretend play; goal-directed activities (such as building a tower from blocks); and collaborative games like hide-and-seek.

These four peer play indicators were used to create a measure of ‘peer play ability’ – the underlying ability of a child to engage with peers in a playful way.

The researchers calculated the strength of the relationship between that measure and reported symptoms of possible mental health problems – hyperactivity, and conduct, emotional and peer problems – at age seven.

Across the entire dataset, children with a higher peer play ability score at age three consistently showed fewer signs of mental health difficulties at age seven. 

For every unit increase in peer play ability at age three, children’s measured score for hyperactivity problems at age seven fell by 8.4 per cent, conduct problems by 8 per cent, emotional problems by 9.8 per cent and peer problems by 14 per cent. 

The effect was evident even among the at-risk groups. In particular, among the 270 children in the ‘low persistence’ category, those who were better at playing with peers at age three consistently had lower hyperactivity, and fewer emotional and peer problems, at age seven. 

The researchers suggest that assessing children’s access to peer play at an early age could be used to screen for those potentially at risk of future mental health problems. 

They also argue that giving the families of at-risk children access to environments which promote high-quality peer play, such as playgroups or small-group care with professional child minders, could be an easily deliverable and low-cost way to reduce the chances of mental health problems later.

“The standard offer at the moment is to put the parents on a parenting course,” Gibson said.

“We could be focusing much more on giving children better opportunities to meet and play with their peers. 

“There are already fantastic initiatives up and down the country, run by professionals who provide exactly that service to a very high standard. 

“Our findings show how crucial their work is, especially given that the other risk factors jeopardising children’s mental health could often be down to circumstances beyond their parents’ control.”

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A silent epidemic: traumatic brain injury in the community

Professor Nick Alderman, clinical director at Elysium Healthcare, looks at neurobehavioural support



In the UK there are an estimated 1.3 million individuals enduring the long-term effects of traumatic brain injury (TBI) living within the community. Often, symptoms of neurobehavioural disability, a legacy of TBI, can go undiagnosed and unsupported, inhibiting how successfully they can live within the community and putting a huge strain on their relationships and family life.

Professor Nick Alderman is clinical director, neurobehavioural rehabilitation services and head of psychology at Elysium Neurological Services. He is acknowledged internationally as one of the foremost experts in neurobehavioural rehabilitation, having more than three decades experience in this field. In June 2021, Professor Alderman, and his research colleagues at Swansea University, published a study which looked at the prevalence and predictors of neurobehavioural disability amongst survivors with TBI in the community. 

In this EveryExpert article, we talk with Professor Alderman – also part of NR Times’ expert panel – about how the Swansea Neurobehavioural Outcome Scale (SASNOS) can be used in a community setting and the necessity to raise awareness about the silent epidemic of TBI survivors across the UK.


Hi Nick, thanks for talking with us today. Could you start by explaining more about how the lives of individuals, who are enduring the long-term effects of TBI, are impacted in a community setting?

Nick: “Neurobehavioural disabilities can be very complex. There is a large range of symptoms that are due to a variety of factors that people can inherit as a result of a traumatic brain injury.  For example, there’s the organic damage to the brain itself. When the damage is to the frontal part of the brain this can have a significant impact on a person’s life within the community, because this is the part of the brain that’s responsible for controlling behaviour and picking up feedback. A function of the frontal lobe is also to enable us to adapt our behaviour to new and novel situations. 

“So, when people have frontal lobe damage as a result of a TBI, not only are they more likely to have challenging behaviour, they can often have real difficulties in coping with novel situations. This produces a sort of dilemma as in situations, like a formal conversation or structured exchange, where people are well rehearsed in the behaviour, because before injury the behaviour was just habitual, there are no obvious problems. The person can seem to be functioning ok. This is why individuals can perform well in formal assessments but outside of the assessment they actually struggle in many aspects of life.

“As soon as you put someone into a new or novel situation where they’ve got to think on their feet, you see problems with planning and organisation. This can easily result in frustration, and because they may also have difficulties inhibiting behaviour as another legacy of TBI, they may express this by shouting or being aggressive, which can be frightening and intimidating to other people. 

“So that’s the organic damage, but of course there’s damage to function as well, particularly to cognitive function, memory, attention and planning skills.” 

So neurobehavioural disabilities is about a lot more than just challenging behaviour or aggression?

Nick: “Yes, exactly. It’s about all different sorts of impact on people that have a very subtle, but in many cases, a very catastrophic effect on their day-to-day lives. One common example is that individuals can often have difficulties with the ability to attend to multiple events. For instance, let’s take myself as I’m speaking here now. I’m having to think about what I’m saying, what I’m about to say, I’m looking at you to see if you’re paying attention to gather some feedback. So I’m having to process lots of things at the same time and that has an impact on my behaviour. 

“For individuals with brain injury, often their ability to monitor, in that sense, is much more restricted. So in social situations where an individual with TBI is engaging in conversation with another person, and somebody else joins that conversation, perhaps the conversation changes direction, the individual with TBI can struggle to respond appropriately. 

“Somebody with these sorts of difficulties can’t pick up on the fact that the conversation has changed, because they’re so intent on monitoring their own output in terms of their verbal behaviour. As a consequence, their behaviour therefore becomes socially inappropriate because they’re not adjusting it to the new set of circumstances. It can often be labelled as rude or ignorant, when they’re not deliberately being so. The behaviour is a product of the cognitive problems they have.”

And these are considered quite basic social interactions – conversations, exchanges etc. So if an individual can’t manage this it can be quite limiting on what they’re able to do in everyday life. 

Nick: “Absolutely, and this issue is often missed in formal assessments – because of the reasons explained earlier. People will think of things like aggression because that’s easy to conceptualise and much easier to measure. But when it comes to the social niceties it’s much more difficult to establish their impact. 

“For clinicians working face to face with individuals with brain injuries, we have long been cognisant of these issues but there weren’t really any good instruments out there to measure neurobehavioural disability in the round. That’s why we developed the SASNOS and why it’s important from a rehabilitation point of view. We need global measures to give us this all round assessment, otherwise they’re biased. If clinicians are only measuring aggression, for example, they’re not measuring these other very subtle symptoms that are often the bigger problem. 

“The other thing is, which led to the development of the SASNOS, was the fact that nearly all of the measures that were being used had been modified from psychiatry so they hadn’t been specifically developed for brain injury. There’s obviously an assumption on the part of people who think that the psychiatry of aggression is going to be the same as the psychiatry of brain injury, and they’re not. The drivers are completely different.” 

So let’s talk about your recent paper, looking at the use of the SASNOS in the community. What was the reasoning behind the study? 

Nick: “The main motivation was to try and illustrate the prevalence of neurobehavioural disability holistically, not just with aggression, but with the whole range of symptoms that individuals experience. The SASNOS has been used extensively in patient settings. We’ve successfully been able to compare the prevalence and severity of neurobehavioural disability for people in specialist neurobehavioral units such as the Avalon Centre. 

“But, we know from the research, that most people who have these sorts of difficulties are out in the community and they don’t get access to the appropriate support. There are 1.3 million people, it is estimated, that are living in the community with the long-term effects of an acquired brain injury, including traumatic brain injury. The research shows that these difficulties are chronic, they don’t go away and they don’t tend to get better. They are more disabling in terms of community reintegration than physical disabilities. They are the reasons why marriages and families break up, why people have hit out at home and ended up in prison or on the streets, or in long term psychiatric care. 

“So the motivation to look at the community group is very much from that point of view. In the paper we show that the difficulties weren’t as severe as you would find in patients who’d been admitted to specialist neurobehavioural programmes, because they’re a particular sample. But the difficulties were still quite severe, even for violence and aggression. Particularly with interpersonal relationship problems and problems with cognitive function.” 

Was there anything particular about the community sample in your study? 

Nick: “Well the main point to stress here is that these individuals looked for all intents and purposes like they are fully recovered. However TBI is a silent epidemic, individuals seem to be functioning normally and, if you look at someone, there doesn’t seem to be anything wrong with them. But actually the reality is very different.

“It’s only when people are put in situations where their ability to direct frustration gets tested, or they are put into a very unique situation and they don’t have the capacity to cope. They’ve lost the ability to plan and change behaviours. If they’re in novel or new situations their difficulties really come to the fore.”  

Could we talk a little more about contextualizing and self-awareness i.e. the individual has an awareness that they have this disability or that they’ve been impacted in this way. Does this self-awareness help them to manage behaviour and responses?

Nick: “You’d think it would, but it doesn’t always. Some people are very insightful about what has happened but this can lead to an increase in depression because they are very aware that their situation has changed. Others have less awareness and insight. For example, if you ask relatives or someone that knows the individual well, and talk to them about their difficulties, there’s often a disconnect.

“Relatives can describe numerous difficulties and then we talk to the person with TBI and they might say “I don’t have any problems and I don’t know why I’m here today”. It can be a barrier for rehab because if people don’t recognise that they are experiencing difficulties, they won’t necessarily want to seek out rehabilitation. 

“An advantage of the SASNOS is that it has two versions. One version that people that know the person with TBI can complete, and another version that the person themselves can complete. So clinicians and researchers can look at that paradox.” 

If the individual who has TBI doesn’t have that insight into their situation, they’re not going to come forward for help, so do you have to rely on the families to come forward?

Nick: “Yes often we do, the families are usually the torch bearers or flag bearers for trying to get their relatives into a rehabilitation programme. Or it’s because their behaviour is such that they’ve got into trouble with the law, and may need residential neurobehavioural support. 

“An individual can suffer a TBI and make a good physical recovery whilst they are in hospital, because they’re in an environment that’s structured and supported. They get to know the environment and can make progress. However when they get discharged, often without a follow up, they’re just left to get on with it and that’s where the difficulties begin to show.

“That’s why it’s quite unusual for us to see patients within months of injury, it’s usually years before the full social impact of the injury is felt. So this is why the SASNOS is important, it makes these hidden disabilities, that have such a catastrophic impact on daily life, apparent and visible which gives them substance. And it can be done much more quickly, hopefully reducing the negative impact on the individual and their family.”

Thanks for your time today Nick, as we conclude our conversation is there anything else you’d like to add?  

Nick: “Well I’d just like to reiterate the importance of continuing to try and educate people and raise awareness of the issues for individuals with TBI who are living within the community. I often refer to the startling statistic that there are 1.3 million people living with TBI in the UK, many of whom are living without adequate support. As a silent epidemic, they are hidden from sight, until their difficulties become so great they need help from residential services. 

“The figure of 1.3 million people just refers to TBI but if you add to that the number of people with other forms of acquired brain injury, that’s a sizable portion of the population. And if this article can contribute to that growing movement of raising awareness and education, that would be a very positive contribution.”

  • For more about Elysium Neurological Services, visit here

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Research links loneliness and mental health distress

Disabled and young people were found to be particularly at risk, a new study reveals



New research has identified direct links between chronic loneliness and mental health distress, according to new findings released today. 

Research analysed mental health wellbeing and the impacts of loneliness over a sustained period, with results showing that chronic loneliness played a significant role in the onset and continuation of mental health distress.

The analysis also shows that mental health distress can play a significant role in the onset and continuation of chronic loneliness. Chronic loneliness is defined as people reporting they ‘often’ or ‘always’ feel lonely.

It suggests that targeted early intervention may play a more significant role in combating the effects of loneliness on mental health in the short term. Recent research also highlighted loneliness and social isolation as a direct risk factor in dementia.

The independent research from the National Centre for Social Research was compiled from data encompassing over 35,000 people aged 16 and over from 2013/14 to 2019/20. 

As part of the study, researchers looked at what types of people were vulnerable to loneliness, whether risk factors for loneliness had changed, the relationship between mental wellbeing and loneliness, and what factors alleviated loneliness in the short term.

The new findings show that, in addition to the link between loneliness and mental health distress, specific groups of people are more vulnerable to the effects of loneliness:

  • Young people between 16-34 were found to be particularly at risk, with research showing they were at five times greater risk of chronic loneliness than those aged 65 or older. Drivers of loneliness in young people were identified as negative social experiences, such as bullying from peers and siblings and arguments with parents
  • People with a disability or long standing health condition were 2.9 times more likely to experience chronic loneliness, and were less likely to move out of loneliness than those without a disability
  • Those in the LGBTQ community were also disproportionately affected, with people who identified as gay or lesbian 1.4 times more likely to be lonely, and people who identified as bisexual 2.5 times more likely to be lonely
  • Those in the lowest income quintile were 50 per cent more likely to experience chronic loneliness when compared with the wealthiest quintile.

Dr Sokratis Dinos, director of Health at the National Centre for Social Research (NatCen), said: “This research highlights the significant relationship between loneliness and mental health. 

“People experiencing chronic loneliness were shown in our study to be nearly four times more likely than people without chronic loneliness to be in mental distress.

“Poor mental health can lead to difficulties connecting with others, social withdrawal and loneliness, while loneliness can equally contribute to poor mental health. 

“Our research highlights the benefit of targeted support for people at different life stages, and community based activities for people with shared interests to improve outcomes.”

The Government has pledged to bring together ministers from across departments in renewed efforts to tackle the issue of loneliness.

Minister for Mental Health, Gillian Keegan, said: “Loneliness is a growing issue – and this research emphasises the continued need to ensure those feeling lonely can access the resources they need.”

During the pandemic, the Government allocated loneliness as a specific target category in the Government’s £750million charity funding package. It continues to encourage people to ‘lift someone out of loneliness’ as part of the Better Health: Every Mind Matters campaign, emphasising the benefits of social connection this Loneliness Awareness Week.

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