Covid-19 – five lessons, five years on

By early March 2020, it was fairly obvious to most people in Britain that the coronavirus pandemic that had begun in China was going to seriously disrupt our lives. Apocalyptic images from northern Italy had begun to appear on our TV screens in January – our youngest son, returning from a school skiing trip in February, was dumfounded that, on his return, nobody at the UK border had shown the slightest interest in his health.

My university had issued advice about enhanced hygiene rules and social distancing, and it was uncertain to what extent it would be possible for us to continue our teaching and research. Over dinner with my wife, Sam, I thought aloud about studies I had conducted on the social determinants of mental health, and whether it might be useful to monitor the impact of the coming pandemic on the wellbeing of ordinary people.

At some point over the next few days, I shared this idea with my long-term friends and collaborators Mark Shevlin, Jamie Murphy, and Orla McBride at Ulster University – all experienced researchers in psychiatric epidemiology. I was rather hesitant, even sceptical about whether what I envisaged would be possible; after all, we had no money. The reaction from Ulster, however, was decisive: we had to make the effort. We began lobbying anyone who we thought might have the resources to help us. This was the beginning of what we came to call the Covid-19 Psychological Research Consortium.

The following weeks were a blur of activity, in which planning the research had to compete with many other challenges in our personal and professional lives - the exfiltration of my son from Cardiff University, nearly five hours away by car, was a particularly memorable occasion - and after the suspension of all face-to-face meetings at the University of Sheffield on Friday 13 March, the clinical psychology course team had to move our upcoming interviews online with only a few days' notice. The last social event I enjoyed for months was seeing Shakespeare's King John at Stratford-on-Avon on 14 March; there were many empty seats in the theatre, which closed immediately after the performance.

We were fortunate that senior staff at both universities recognised the value of our idea and quickly provided start-up funds. Another factor in our favour was our established relationship with the Qualtrics survey company, whose staff in Dublin, led by Sinead O'Brien, energetically helped us to set up our survey questionnaire and find a sample. 

Other long-term friends and collaborators joined the team (Kate Bennett, a qualitative researcher at Liverpool; Liam Mason, a former PhD student and clinical neuropsychologist at University College London), along with volunteers who responded to a mass email at Sheffield (Jilly-Gibson Miller, a health psychologist; Liat Levita, an expert in adolescent mental health; Todd Hartman, a political scientist). 

Crucially, they all passed what my friend Tony Morrison at Manchester University calls the 'pub test'. That said, I did not get to see any of them in an actual pub until we had our first face-to-face meeting two years later.

For me, this was an exciting time, and it soon became obvious that our project had many implications for psychology as a profession. Here, I will outline those lessons that seem most important as I look back.

Lesson #1: In an emergency, psychological research can be set up surprisingly quickly

Readers who are experienced researchers will be aware of the numerous barriers that ensure that the pathway from a good idea to data collection can be long and torturous. Many of these hurdles have evolved to protect the integrity of research or the rights and well-being of our participants and, when planning clinical projects, we typically expect a period of between six months and a year between initial conception and data collection. However, these kinds of delays are untenable during a crisis.

In fact, exactly two weeks passed between my conversation with my wife and the collection of our first data point, which was on 23 March 2020, by coincidence the day that the UK Government announced the first lockdown. Within a week, Qualtrics had secured for us a quota sample of 2025 adults, stratified by age, sex, and household income, who turned out to be a good match for the UK population on many other variables (e.g., ethnicity, voting history) (McBride et al., 2021).

Aside from the propitious factors already mentioned, many others came together to make this possible. For example, the University of Sheffield Research Ethics Committee agreed to be on standby so that the time between application and approval was less than two hours. We were not given a free pass; amendments were required and the application was resubmitted and underwent further review within this time. 

The ESRC launched a rapid funding stream which, in June, awarded us the resources we needed to continue the project. With more secure funding, we were able to recruit a brilliant postdoctoral researcher, Sarah Butter, who was supported by my inexhaustible PhD student, Anton Martinez, who took time out from his PhD to help keep the project going.

Data collection for a third wave began in August and for a fourth wave in December. Eventually, by 24 March 2023, three years and a day after we began, we started our ninth wave of data collection. At each wave we replaced participants who dropped out with 'top-up' samples so that, in total, 7209 people took part.

Moreover, as news of our work became known to former friends and collaborators elsewhere, we were approached by researchers in Ireland (Phil Hyland in Maynooth), Spain (Carmen Valiente at Computense University), Italy (Marco Bertamini in Padova), and other countries, asking if they could run parallel surveys with our instruments. Some of these initiatives came to fruition, so that it was sometimes possible to pool data or conduct international comparisons. 

We became more inventive in our approaches, embedding cognitive tests in our surveys (Lloyd et al., 2021) and inviting selected participants to have qualitative interviews online (Derrer-Merk et al., 2024). The major challenge for the research team throughout this process was to clean, analyse and report the data from each wave while selecting instruments for the wave that was to follow. Even today, we are sitting on a mountain of data that remains unanalysed and which we are happy to share with anyone who has hypotheses they would like to test (McBride et al., 2020); data from the first six waves can be freely accessed).

Looking back, it would have been better to have begun data collection in the week before lockdown, but this is easy to say with hindsight. The main lesson from these experiences is that, given the right expertise and sufficient boldness of purpose, it is possible to launch a population mental health surveillance project surprisingly quickly in such a way that, as we will see, valuable data can be collected about how ordinary people are affected by a crisis.

Lesson #2: Mental health professionals and researchers must not make exaggerated and unfounded claims about the likely impact of a crisis

The crisis brought major challenges to professionals of all kinds: epidemiologists who needed to develop models to predict the likely course of the pandemic; biomedical researchers who needed to develop novel vaccines at breakneck speed; health service providers who needed to find ways of managing the sudden surge in people with serious illness; and economists who needed to work out the likely fiscal impacts of the social measures required to prevent contagion. In such circumstances, almost everyone wants to be useful, and many mental health professionals and organisations highlighted the importance of addressing the mental health consequences of the pandemic.

However, much of the rhetoric that developed in this process was far from helpful. A widespread trope, which seems to have originated with a press release from the Royal College of Psychiatrists on 15 May, was that Britain and other nations would shortly be confronted with a 'tsunami' of pandemic-related psychological distress. For example, the Daily Telegraph (14 May 2020) reported that 'Health experts warn of Covid-19 mental health crisis'; the BBC News (18 May 2020) that 'Psychiatrists fear "tsunami" of mental illness after lockdowns'; and the Daily Express (19 August 2020) that 'NHS fears "tsunami" of patients as mental health cases soar'.

This narrative created catastrophic expectations about the likely impact of the pandemic and (although this is difficult to prove empirically) likely contributed to the stress experienced by millions of ordinary people. It was also unrealistic – it should have been obvious to all mental health professionals that not everyone responds to a crisis in the same way.

After all, previous research had shown that social cohesion is protective against stress (Jetten et al., 2017), that collective traumas such as natural disasters are very often less damaging than interpersonal traumas such as assaults (Benjet et al., 2016), and that some people respond positively to traumatic experiences of any kind by re-evaluating their lives in a process of post-traumatic growth (Tedeschi & Calhoun, 2004). Moreover, some of the adjustments in the pandemic were experienced as positive by many people. My commute to work reduced from 2 hours to 15 seconds, and many parents told us that they, like ourselves, enjoyed seeing more of their adolescent children.

Misinformation about the mental health impacts of the pandemic continued to be disseminated throughout the crisis, and insufficient efforts were made to counter it. An egregious example was the claim often repeated by some less ethical journalists that the pandemic was the cause of a wave of suicides, especially in adolescents. In fact, we found no evidence of an increase in suicidal ideation during the crisis (Hyland et al., 2022) and, in Britain, there was little evidence of excessive suicides (Appleby et al., 2021).

An important lesson for future crises, therefore, is that public health bodies should work with psychologists to plan the careful dissemination of calming, realistic and helpful advice from the very earliest moment possible.

Lesson #3: Peer review can impede the distribution of important findings during an international crisis, but cannot be dispensed with

We were not the only researchers to realise the importance of psychological research to understand the impact of the pandemic. Globally and often haphazardly, researchers of all stripes attempted to adapt their research to address an unprecedented event. There were two consequences of this.

First, the peer-review process proved to be a major barrier to the dissemination of research findings. For example, we completed our preliminary analysis of our data from our first wave (Shevlin et al., 2020) by the end of the first week of April, two weeks after the first lockdown, but it was badly held up in the review process. 

Hence, although we probably were one of the earliest research groups to obtain data from a representative sample our initial findings were not published until 19 October. Meanwhile, a large number of poor-quality studies, usually with highly unrepresentative convenience samples and often promoting the tsunami of mental-ill health narrative, either bypassed the peer-review process or had an easy ride in less scrupulous outlets (Nieto et al., 2020).

In future crises, leading mental health journals would make a positive contribution to public mental health simply by adjusting their procedures to ensure that findings are subjected to accelerated review. One approach might be for journals to set up standing review panels for crisis-related research, with pre-determined criteria that could be applied very quickly (for example, automatic rejection of studies using convenience samples).

Lesson #4: Not everyone responds to an international crisis in the same way… looking at population means is misleading

Our initial research report suggested that, during the first week of lockdown, there was a modest increase in the average level of depression and anxiety in the population (Shevlin et al., 2020). This tentative interpretation was based on comparing our findings with those from previous British surveys which had used the same instruments because, as already noted, we did not have longitudinal data from before the pandemic. However, it was broadly consistent with the findings from other research groups (e.g. Fancourt et al., 2021).

As we collected data from further waves of our survey, we were able to report more detailed analyses using latent growth curve analyses, clearly identifying that different segments of the population were responding to events in different ways. In an analysis of data from the first three waves (Shevlin et al., 2021), we found five trajectories, two consisting of people who were resilient and unaffected (56.6 per cent) and those with chronic and likely pre-existing mental health problems (6.3 per cent). 

More interesting were two classes that deteriorated (11.6 per cent and 6.8 per cent, the main difference being whether or not they started with relatively high levels of depression and anxiety) and an adaptive class that started with a high level of symptoms but improved dramatically (8.6 per cent). A follow-up at wave 5 after one year showed that these trajectories largely stabilised and remained unchanged after the first three months (Shevlin et al., 2023).

There were identifiable psychological factors that distinguished between these groups. For example, compared to the resilient group, all the other groups started the pandemic with higher levels of loneliness, death anxiety, and intolerance of uncertainty. We also explored demographic and potential causal factors using a variety of methods. 

For example, in our initial report, we found that anxiety about the pandemic was higher in older participants, but depression and anxiety were higher in those who were younger (Shevlin et al., 2020). Using network analysis, we found that a major stimulus for psychological distress was the economic uncertainty created by the crisis (Zavlis et al., 2021), which we later confirmed in a more conventional analysis showing a strong relationship between distress during the pandemic and financial hardship (Shevlin et al., 2022).

Meanwhile, our Spanish colleagues explored factors that promoted post-traumatic growth during the pandemic (Vazquez et al., 2021), finding that a 'primal belief' that the world is a positive place was associated with a positive response to the crisis, whereas suspiciousness towards others and intolerance of uncertainty were associated with trauma symptoms. Echoing these findings, I took part in a delightfully uplifting (at least for me) edition of Radio 4's Woman's Hour in which listeners phoned in to talk about their positive experiences during the pandemic.

Lesson #5: The psychological impact of an international crisis extends far beyond mental health

From the outset, we realised that we should collect a broad range of data to track a wide range of pandemic impacts. There is no space here to list all of these dimensions of the pandemic. An important one was health behaviours, particularly social distancing, which was less observed by young males living in cities, and people with low incomes and educational attainment, and which we found that, at a psychological level, was positively predicted by reflective motivation (making plans to enact the behaviour and the supporting belief that the behaviour is a good thing to do; see Gibson Miller et al., 2020; Gibson-Miller et al., 2024).

However, some psychological facets of the pandemic were less obvious. In the beginning, the news media were full of reports of shortages caused by 'panic buying' with, for some reason, the availability of toilet rolls being singled out as particularly affected. A rapid review of the literature revealed that very little previous research existed on this subject and so we developed and tested a model informed by animal foraging theory, asking over 3,000 participants in the UK and Ireland whether they had deliberately over-purchased a range of common domestic and food items (Bentall et al., 2021). 

The main finding was that fears about over-purchasing had been exaggerated, with only about a quarter of citizens reporting buying more than they normally would. When it occurred, it happened across a wide range of product categories and the significant predictors were those we had anticipated from foraging theory. Specifically, household income, the presence of children at home, psychological distress, threat sensitivity (right-wing authoritarianism; RWA) and mistrust of others (paranoia) were positively associated with over-purchasing whereas analytic reasoning skills had an inhibitory effect.

In another analysis, we investigated whether the pandemic had an effect on political attitudes (Hartman et al., 2020). Previous research had suggested that the trait of right-wing authoritarianism has situational effects so that people high in RWA only express authoritarian behaviour when they are under some kind of threat or challenge to the social order (Stenner, 2005; Stenner & Haidt, 2018). 

The pandemic therefore provided an unexpected opportunity to test whether the existential effect of the virus would have a similar effect. Again using our samples from the UK and Ireland, we found that RWA interacted with social anxiety such that, as anxiety about the pandemic increased, so too did the effect of RWA on nationalist beliefs and hostility to migrants.

Other analyses focused on attitudes towards vaccines, with vaccine hesitancy being predicted by a wide range of psychological variables (Murphy et al., 2021). Of particular importance were conspiracy theories about the origins of the virus, which were therefore a major but (in my view) insufficiently challenged threat to public mental health (Hartman et al., 2021). Interestingly a recent analysis has shown that this effect varied as the pandemic progressed, so that conspiracy mentality had its greatest influence on vaccine refusal at the end of 2020, just as the vaccines became available (Adinugroho et al., 2024). Most likely this was the point at which most people first faced a realistic choice about whether to accept them or not.

The overarching lesson

I've tried to draw out the most obvious lessons, looking back from a distance of more than four years. I am sure that other researchers will think of others that are just as important. However, I would like to point to one final lesson that is perhaps the most vital of all.

Collectively, the psychology profession learned a great many things in the Covid crisis. However, so far as I am aware, no systematic effort has been made to draw these lessons together in a way that would help prepare us for the next international crisis (pandemic, war) which will surely come. The British Psychological Society could provide an immense service to the world by convening those of us who lived and worked through the pandemic to summarise our findings and draw up an action plan for the future. 

Such a plan would include the rapid assembly of a national psychological task force, the launch of a predesigned and sufficiently funded national mental health surveillance project, a public mental health dissemination strategy focusing on collective strategies (for example, building social networks) rather than individual interventions and targeting specific groups (young adults with children at home, those at most economic risk), and strategies to address the scourge of misinformation which, in the era of the internet, can spread rapidly and cause immense harm.

Richard Bentall PhD FBA, is Professor of Clinical Psychology at the University of Sheffield. 

'Writing this article has been an interesting and emotionally stirring process. My Covid colleagues who I shared it with have all commented the same. Those times were an experience that changed us all.'

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