"We must be very cautious before celebrating the use of digital tools as a major advance in mental health."

"Overall, I think we have learned about changes in behavior and in the use of mental health devices by users ."

A year ago, you and I would probably have talked on the phone and wouldn't have used, or even considered using, a video conference. Now, however, it has become a common tool. This shift also affects mental health. Overnight, mental health services, which were severely impacted by lockdowns in Spain, Italy, and many other countries, were forced to use these kinds of digital tools.

Many studies have been published describing and even emphasizing digital tools.

I don't want to underestimate their importance, but I think we need to balance the evaluation of digital tools because it's not clear whether the assessment of a person's emotional state or the involvement of the personal relationship is the same as in a virtual setting.

New technologies have been useful for specific times, and in cases of great physical distance, this makes sense. If you're in Australia and the nearest mental health center is thousands of kilometers away, there's clearly an advantage to using digital tools to shorten that distance. But if you live in Milan, 500 meters from a device, the story changes because distance becomes irrelevant.

My question to the professionals is this: do you prefer to see people face to face or on a screen?

There are many examples and situations that should make us cautious. For example, a recent Cochrane review evaluated the effectiveness of video conferencing in preventing depression among older people living in care homes. The conclusion was that there is no evidence to support the claim that video conferencing prevents depression in this population group. This likely means that older people living in these facilities require and desire physical contact with their family and friends.

There are other issues, for example, let's take the case of a woman who is depressed because she suffers domestic violence and receives a virtual visit from her healthcare provider. It's not the same to see this person in a health center, where she can speak freely, as it is to see her when she is at home, living with her abuser. So, how can we be sure that she speaks with complete freedom? Or in a case of substance abuse, how can we be sure that there will be enough privacy to speak freely about such a sensitive topic?

Therefore, regarding the use of digital tools, a careful evaluation should be conducted before emphasizing their use. We must be very cautious before celebrating their widespread use as a major breakthrough.

User satisfaction with telecare during COVID-19

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On the other hand, I would like to highlight the research study "Psychiatric hospitalization rates in Italy before and during COVID-19: did they change? An analysis of register data , " in which we show that four months after the lockdown in Italy there was a 50% drop in hospitalizations. The explanation for this drop is very interesting, even beyond the topic of COVID-19, and allows us to learn about various phenomena.

One possible explanation is that, overnight, the threshold of tolerance changed. In ordinary circumstances, when a patient exhibited disruptive behavior and exceeded a certain tolerance threshold, the family felt they could no longer manage the situation and requested hospital admission to normalize the situation. During the lockdown, when hospital admission became very difficult or even impossible, there was a sudden shift in families' tolerance thresholds. Thus, behaviors that were not normally acceptable became acceptable due to the exceptional circumstances.

Another explanation is that, due to the lockdown, substance and alcohol use became more difficult. And we already know that these addictions are triggers for mental health problems, so many situations were avoided because the addictions were more under control.

"We must look at the pandemic from different perspectives, not just the traditional one. Naturally, there are negative consequences, but this pandemic has also provided other people with the opportunity to change their lives, to re-evaluate their values; this is what has been defined as post-traumatic growth ."

It is true that in these few months, more than 80 studies have been published on the prevalence of depression, anxiety, and other disorders in the general population due to COVID-19. All of these studies have been conducted through online surveys, usually distributed via email, inviting anyone who wanted to participate to answer the questionnaires. Therefore, these studies should be considered with caution for several reasons:

• It has been shown that the percentage of people who respond to online questionnaires is very small, in some cases only 5% or 10% of the entire sample invited to participate. This suggests a significant bias, because if only 5% of those invited respond, this 5% may consist of people in an altered emotional state, who are ill or suffering. In this situation, they are more motivated to respond.
• On the other hand, if you answer a questionnaire saying that you feel very stressed and anxious today because of the pandemic, we don't know what your situation was a year ago. It's very important to understand that without longitudinal knowledge of a person's emotional state, we lack data.

There's a wonderful study by my colleague Dr. Andreas Reif, head of the Department of Psychiatry at University Hospital Frankfurt, which will be published soon and is very relevant. He started a longitudinal study in 2017 to assess resilience in a sample of 15,000 people. They were collecting data every three months. When the lockdown hit, they realized it was a fantastic opportunity to compare the situation before and after the lockdown, so they started collecting data from these thousands of people every week for two months.

Well, 84% of these people showed no worsening compared to their previous situation . A small percentage, 8%, worsened but recovered to their normal situation within a few weeks, and another small percentage, 8%, did register a high level of depression and emotional distress. This longitudinal study invites us to take a different perspective, examining different patterns within the population.

Continuing with what I mentioned earlier, I would like to mention the study The article "Pandemic-Driven Posttraumatic Growth for Organizations and Individuals ," published this November, studies this posttraumatic growth, defined as the psychological change experienced as a result of a highly stressful situation, in the context of COVID-19. Some studies have suggested that it is experienced by people who live through traumatic situations such as natural disasters, traffic accidents, or serious illnesses, and it is clear that, for many people, the pandemic has been a traumatic experience. This article outlines the main dimensions of this growth.

By this I mean that our perspective must be broad and encompass all the dimensions it can have in mental health."

How the pandemic is affecting us

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"One area that, in my opinion, has been neglected and is of great importance concerns the expression of emotion. We have known for a long time that there are families, especially those with a child with a psychotic disorder, in which the parents have blocked and hidden their emotions. There are cases of hypercritical, highly intrusive parents, with little capacity to provide warmth and emotional affection, and who easily become embroiled in arguments and conflicts. These studies have shown a linear relationship between the amount of time spent face-to-face, for example, between parents and the child with psychosis, and the risk of relapse. In other words, if the parents spend eight hours face-to-face with the child, there is a greater risk of relapse. If the time shared is three hours, the risk is reduced. Because of the lockdown, from one day to the next, there was this incredible increase in the time these families spent together. We should study how many relapses have occurred as a result. It is an important area for future research."

"For months, the public has been overwhelmed with information about effectiveness: the effectiveness of preventative measures, diagnostic tools, treatments for infected individuals, vaccines… The public previously knew almost nothing about these concepts; now they know everything. The concept of effectiveness has become a common word that everyone understands. Perhaps we should take advantage of this."

Deborah Glik, a health communication researcher at the UCLA Fielding School of Public Health, has spent years studying risk communication . It's a very important topic because it encompasses many cognitive, perceptual, and communication dimensions. Mental health services should lead the way in risk communication; they should be able to guide the government on how to effectively communicate with the public.

It's important to understand that people don't change their behavior based on the risk itself, but rather on their individual perception of that risk. This perception can be accurate or completely distorted, leading to an exaggerated perception of risk or a belief that it doesn't affect them. A common thought, for example, is: "It can't happen to me, it can happen to others," or "So I don't need to take precautions; others do because the risk is for them, not me." These behaviors directly harm other people, so it's extremely important that people perceive risks appropriately.

Who better than mental health professionals to convey to the authorities the importance of taking these perceptions into account?

"BESTCOPE ( The behavioural, mental health(care) and broader (psycho)social impacts of the covid-19 pandemic: a european multimodal project ) is a project we submitted last spring to apply for European research funding of 20 million euros. It is a project driven by a consortium of 12 European institutions with expertise in the areas of mental health, epidemiology, biostatistics, public health, health economics, dissemination, and communication."

The objective was to assess and compare the impact of stressful events related to the COVID-19 pandemic on the full spectrum of the mental health system in different EU countries and on other psychosocial indicators, and the costs of the pandemic on such services; to carry out a longitudinal and cross-sectional assessment to identify which variables at the individual and system level influence the burden of stressors and mental health, or the use of mental health services, as a consequence of pandemic control decisions; to identify predictors of psychosocial well-being, protective and risk factors in health workers, in samples of the general and vulnerable populations, such as children, adolescents, infected persons, persons with physical or mental disorders; and to provide health authorities and policymakers with evidence-based guidelines and recommendations to improve preparedness and response to the current epidemic, potential future epidemics, or other major disasters.

The funds were awarded to four projects, and ours is the fifth to be selected, pending a possible increase in European funding. If that happens, we will be able to proceed.