 Welcome to the next ECB COVID webinar series. I'm Luke Lavin, the Director General of the Research Department here at the ECB. And it's my great pleasure to introduce to you Professor Kirsten Krünen. Kirsten is a psychologist. She's the Professor of Psychiatric Epidemiology at Harvard University School of Public Health, where she leads, among others, the Trauma Epidemiology and Population Mental Health Research Group. And she oversees a number of training programs in this area. Today, she will be talking to us about the mental health effects of COVID-19 and the lockdowns associated with that. And she will end with some advice based on her experience on how one can manage one's own mental health. This topic is of great current interest to the ECB for two obvious reasons. The first, as you know, is that the ECB produces regularly forecasts of the economy. And assessing the impact of the pandemic on the economy has become an integral part of our work since its outbreak. An important part of this assessment concerns the possible scarring effects of the crisis on workers and consumers. And these scarring effects can manifest themselves in a variety of ways, but the impact on health and mental health in particular is one important channel. Second, and closer to home, we care about this topic because the crisis is impacting the well-being of our staff and their families in profound ways. As an institution, we should recognize and address mental health issues by offering the needed support. Research is showing that these needs have altered and come more to the fore during the recent crisis. So we look forward to learning today from Kerstin what insights the latest research and clinical experience on mental health has to offer. On behalf of the entire ECB and executive board, it's a great pleasure to have you with us today. The floor is yours. Thank you so much, Luke. And I'm really honored to be here and honored to be asked. And I look forward to your questions. Let's get started. And again, thank you for being here. So the COVID-19 pandemic and population mental health, what do we know and what can we do? So as I mentioned, I've been studying trauma epidemiology, which is the effects of traumatic experiences like disasters, war, violence, mental and physical health for my whole career. So although being in a global pandemic is, you know what, none of us have ever been in a global pandemic before because the last one was 100 years ago, we actually know a lot about the effects. And we actually know a lot about the potential effects and the effects now as more and more data are coming out. So I will talk about what we know about trauma generally and then try to bring in some of the more recent research on COVID. So seven major points in this talk. First one is this may or may not surprise books on this call, but trauma exposure either as a victim of trauma or a witness is actually quite common even in the pandemic time and so-called normal times or COVID times. And I think just to remind people, you can think about all the news reports. I only know the news in the US, but it seems like daily or at least weekly, we're hearing about some mass traumatic event globally, whether it's terrorist attacks, disasters, war, the US, there's a lot about shootings, police shootings and mass shootings. And if you think about it, if you start to wonder if these events are common, I just wanted to share a typical measure that we use to ask people about traumatic life events. So this is a, this is called the life events checklists, really available online. And we might, in a study, we might bring up these questions and ask people how they experience them and have someone they know experience them. And when you look at the list, and if you think about yourself or people in your life, you can start seeing that these things are quite common. There's quite a range of experiences that are traumatic. And when we do epidemiology, which is when we study trauma and mental health populations in communities, they're not in patients in a clinic, but in people in their homes where they live, we find that when we ask people that all the countries, in all the survey at the time the survey was done, we, over 50%, no matter what country we asked it in, 50% of the people had experienced one traumatic event. And usually it was a larger percentage of the country. We just look at the US, it's, you know, Emily is the vast majority of Americans experienced at least one trauma. Most have experienced more than one trauma. So let's just say these kinds of events are common. And again, they have been studied for the last, but for a long time, but epidemiology for the last 20 years or so. And the COVID-19 epidemic has many characteristics of other traumas that we've studied. So, and how do we define a trauma? So I gave you some examples of events, but a traumatic event is an experience that causes physical, emotional, and psychological distress or harm. And it's an event that's perceived as an experience as a threat to one's safety or the stability of one's world. Now this is a definition from way before COVID. This paper is from 10 or 15 years ago. But I think reading this actually, it seems to very much apply in our current experience. And what are some of the things that we're experiencing that we know are problematic for mental health? So novelty, people experience that's new, it's like a good way, it's stressful, it's a threat to things that are unending and unpredictable, which the last year has been, at least my experience. And when people feel a lack of control, though that combination of stressors is really difficult for mental health. On top of that, we have all these consequences of COVID or of the shut businesses closing, shortages on, in the US there were certain shortages, less so now, impact on jobs in the economy, fears of infections, impact of quarantine, and then the constant sort of media barrage we all experience. On top of that, we have these other factors which we know are toxic to mental health. Social isolation due to the necessary public health measures, stigma of people who've had COVID or around getting COVID and massive bereavement as again, been widely covered. So given that, two of the things we might, two of the mental health consequences that we know are most common after a traumatic event and the kinds of the subsequent stressors bereavement are post-traumatic stress disorder and depression. I'm gonna talk briefly about those. So what is post-traumatic stress disorder? So if you think about PTSD, you may have stereotypes for movies or things like that, but really it's when one experiences a, an experience that is threatening as unpredictable, especially if you feel like it's life threatening or threatened sort of the safety and stability of family members. You can say that's a traumatic experience and your kind of human self-preservation system goes on permanent alert as the danger might return at any moment. And we think of PTSD as a disorder of fear and we know that fear is evolutionarily useful. We learn to be afraid of things from childhood of things that will harm us and actually becoming afraid really helps us survive. We learn to be afraid of, in this case, it's a snake, but you're afraid of fire, touch fire, keep yourself safe. And we think of PTSD as dysregulated fear. And really what we think about PTSD is the kind of fear response or the response one has to threat is normal. But in PTSD, that kind of response persists over time and doesn't diminish over time, even when the threat has passed. So kind of a classic example of this might be that when I was early in my training, I worked at a veterans hospital in the US where war veterans are treated. And I had someone I was assessing and he reported every time he heard a car backfire, he would hit the deck. It would be like he's re-experiencing being in a battlefield. And he would talk about walking down the street or going into a restaurant and always needing to have his back against the wall so he could see the entries and exits so that he could get out. And so kind of living in that hyper-vigilant, that sort of fear state. And those are some of the classic symptoms of PTSD. And just to give a flavor of this, this is a screen we use for PTSD. It's called the primary care screen for PTSD. If you are positive on these, it doesn't mean you have PTSD as a full disorder, but it's used to screen people who need further evaluation. And the questions on this screen are, have you had nightmares or thoughts about the event when you don't want to? Does it, do you try hard not to think about it or go out of your way to avoid situations? Are you constantly on guard? Watchful or easily startled? Do you feel numb or detached from people? Activities for your surroundings or feel guilty about and unable to stop blaming yourself or others for the events or problems they may cause? And if you screen, if you have three or more guesses on this, then it's recommended that you get more evaluation. But this is more to give a sense of like what we might see with PTSD. And also, I just wanted to make sure I mentioned that depression is also a very common experience people are having right now. And I'll present so much of my research, the research I'll present will be on PTSD, depression and anxiety. So depression, people may be more familiar with, but it's feeling down or in the US we say blue, low mood for two weeks or more where it's persistent. You might feel hopeless. You might feel bad about yourself. And in some people, depression can be feel angry or easily irritated or on edge. Often it also is accompanied by problem sleeping, eating too much or too little. And we see that depression is also very related to traumatic events. So this is just some data from disaster studies which shows that the more traumatic events someone's experienced, the more likely they are to have depression. So one of the questions I often get asked is, what's normal to experience right now? Because we are going through a global pandemic. Everyone's stress level is incredibly high. I know for example, I've been working, I've been virtual since I guess last March and will be for their foreseeable future, which means my son has been home at school. So we've been schooling and working in the same apartment. So just sort of daily life is a lot more stressful. And when things are, when the bad things happen, especially traumatic events, it's normal to feel distressed. And so we wanna make sure we distinguish between distress, this reaction to something bad happening that's temporary. If you lose someone you love, you feel grief that can look a lot like depression versus a sort of persistent problem that interferes with functioning. And these are just some data. I could have shown probably there's probably hundreds, there are many thousands of studies like this now. But we've done studies where, for example, we enroll people after they've experienced a serious traumatic event. So in this case, this is a study from Israel that my colleague Eric Shalev did and he recruits people from emergency room. So after the emergency room, they recruit people and they follow them over time to look at the mental health impact. And the things that bring them to the emergency room in Israel tend to be some sort of war or a terrorist attack type situation or accidents tends to be in this sample. And what we see is that right in the short weeks after the event, everyone kind of looks similar. If you look, everyone's sort of PTSD symptoms look elevated. But in most people actually over time, those symptoms diminish naturally. This isn't a treatment study, it's just a naturalistic observational study. But in a chunk of people, and usually it's around 20%, no matter what sample we look at, these symptoms persist over time. They don't seem to just remit naturally. And those are people that when that happens, it's when you wanna be concerned and consider intervention and treatment. And to tie this back to COVID, so what are we seeing with COVID? So we are seeing some of these similar patterns. So these are European data. And from Denmark, France and the Netherlands and the UK, it's on the bottom. And basically these are various cohort studies that were existing, most existing before and then following different groups of people, population based during COVID for, and the lines or worries in the bottom in the UK study is anxiety. And basically all found this peak in worrier anxiety early on that went down a bit over time and then has sort of stabilized, but stabilized at a pretty high level to have 20% with high anxiety and then UK data is high and higher than we would expect during sort of non-COVID times. And so we are seeing that people did sort of have, there was sort of a blip of higher stress and which went down a bit, but it has persisted, which is concerning. And we see this in the US too. So we've looked at, colleagues of mine have looked at, for example, depression symptoms in the US before and during the COVID-19 pandemic. And what they found is two things that are concerning. One is that there's more cases of severe depression. So you can see where it says it's threefold increase. This is, you look at moderately severe, severe. These are people who probably make criteria for a major depressive disorder. But you also just see this increase in mild and moderate depression, just general increase in depression across the population. And this is using comparing to pre-pandemic data. And this as you can see, you just look at the score on something at PHQ, which is also a depression screen, it's nine items with different severity levels. But if you just look at scores on this, you see this general increase, general move towards higher scores in the population. This is just to say, maybe it probably doesn't surprise anyone, but people just generally are feeling worse. And this is the data that are coming out more recently show that this is persisting. And as the longer the COVID persists, the longer we're in this situation, the more likely we'll see these adverse outcomes. And what might we see a year or so from now? So these are data from Sierra Leone, which may not be a great comparison in some ways, but this is a year post the Ebola epidemic after it had been resolved. And basically what you see in that population is a year later is really high in the prevalence of anxiety and depression. So, and about almost half of the population studied had anxiety and depression or PTSD or both. So works experience some clinically significant disorders. That's just to say, it's the long-term projections are concerning. But the effect of, the effect of whether it's COVID or trauma generally is socially patterned. And I wanna talk about that a bit. So it's not, it doesn't affect everyone equally, just like COVID doesn't affect everyone equally. The stress part of COVID doesn't either. So what are some things we know? So from research that's been done, again, trauma epidemiology, we know that there are differences by sex and race and ethnicity, this again, this is US data. So we know that women tend to have higher, for example, with PTSD and depression, higher risk of men than men. And that in the US there's big racial and ethnic differences. There tends to be some evidence that black Americans have higher rates of PTSD than white Americans. And when we look at what explains these differences, it tends to be due to differences in trauma exposure, particularly exposure to violence, again, during normal times. And we see some of these patterns playing out in terms of mental health and COVID. So these are, I'm just gonna give some snapshots from different places around the world. There's just an overwhelming amount of data coming out. But for example, in China, they've observed sex differences in problems of PTSD. This is really early on, but you can definitely see that in women compared to men, you see these higher problems of PTSD and PTSD symptoms. These are just different symptoms of PTSD. We also see just as people of lower SES in the US have been disproportionately infected by COVID, we definitely see greater mental health impacts on a by income level. For example, these data are from England. So you can see that you see this baseline. So pre-COVID, this increase in anxiety, high anxiety related to COVID, but then you also see that it's really differential by income level. And again, you see this similarly in Hong Kong in some ways, one of the things that struck me, I do a lot of global research, which is not really what I'm gonna present today, but what's been striking is some of the patterns you see globally, which is often, you see in these very different places, you see common patterns. So these are data from Hong Kong and you can see that this is depression related to assets or financial assets and stress. And you can basically see that people with lower assets, with lower resources have higher depression and particularly if people have high stress and low assets, they really have the highest rates of depression. And then this is the European data from the cohorts I mentioned earlier and you can see the data by the countries. And this looked at loneliness. So that is something that I've learned more about. It hadn't been a focus of my work before the pandemic, but there actually is a whole body of work and people here are aware that high levels of loneliness are associated with earlier mortality, increased risk of chronic disease and sort of a lot of bad health outcomes. And so of course, during this time with the shutdowns and everything people have been studying loneliness, and loneliness is also very socially patterned. What's interesting in the data that are coming out that you see here from the European countries is we don't see these really big sex differences or even maybe so much education differences or typical socioeconomic status differences. The big differences that seem to be pretty consistent are that younger people are feeling more lonely than older people. And I'll show some other data that also show that this sort of seemed to be some worse mental health impact in younger people. And then also we see higher loneliness among people with previous mental illness, which might be expected. And so just to mention this age effect. So I've been working in a, I work in these large cohorts at Harvard and we nested a COVID study within the cohort that we're studying and we follow the people over time. So we did monthly questionnaires. We're ending, we're doing our last questionnaire this April. Anyway, I wanted to present data from two cohorts, just this is unpublished, but you can see the one that says NHS2 that's on my, I guess it'd be on your left too, my left. This is a study of healthcare workers that started in 1989, women who are nurses and fall over their life to look at environmental factors in women's health. And on the right are data from the kids of the nurses. So it's called the growing up today studies, the adult children of the nurses. And what we're consistently finding is that the younger people, whether they're healthcare workers or not, their mental health looks worse. So this is on PCSD scores. You can sort of see this marked difference, but no matter what the outcome is, it does seem to be that this younger cohort looks worse. And we're not seeing a big effect of being an active healthcare worker in our cohorts. Happy to talk more about that. And then another thing that really affects mental health in relation to trauma is, as I mentioned, a number of stressors. So you can see here that the number of stressors varies by post-traumatic stress symptoms status. And the people who there's just to be association between having more stressors and higher PTSD symptoms, which again, might not be surprising. So the thing that may be more surprising here is that trauma and PTSD and depression are inextricably linked to physical health. And although this talk is focused on mental health, it did not wanna leave out that mental health affects our physical health and vice versa. And so I'm gonna present some research on this that I've done over the last, I guess 10 years now. And the cohort I'm just gonna focus on for the next few slides is called the nurses health study too. And I know there's probably some researchers on this call, so I wanted to provide a little context. So this cohort was started in 1989 to look at lifestyle and environmental factors in women's health. And so we have studied the effects of mental health on physical health within this cohort. And we've looked at the effect of mental health on PTSD, on health behaviors, on some more biological indicators like inflammation and also on disease. So some of the things we find, and I don't know if people have observed this with themselves during COVID is that our mental health actually affects our health behaviors. So one of the things that, sorry people can hear me dog in the background, but one of the things that we've seen in the cohort is we can look at, for example, physical activity before and after someone develops a mental health problem. So in this case, we can look at women's physical activity as it goes along the cohort. And then once they experience trauma and develop PTSD, we can look at how that changes. And we see after women develop PTSD, they, we see this dramatic reduction in their physical activity, on average. We also see a little more complex viewing with people and I appreciate this, this increase in television viewing. And so after women develop PTSD or the women with more, after women experience trauma, the ones who develop more PTSD seem to have increases, more greater increases in their television viewing. Which again, less exercise, more TV viewing, more sedentary behavior. And we also see these effects on body mass index, partly probably as a consequence. So we see that women with PTSD seem to have a little bit higher body mass index, but what's really more market is as we trace it out over time is they seem to have a greater increase in body mass index over time. And this translates out into differences and a bunch of biological indicators, which I can ask people to ask questions about. But here I'm just showing inflammation. So we see that women with chronic PTSD have higher inflammation. CRP is a marker that's usually used to calculate cardiac risk. And it's higher in women with PTSD. These are women who are free of heart disease at the time of this measure was taken, but they do show this increased risk of heart disease. And this does translate out. So we see that women with PTSD have higher incidence. In this case, this figure I'm showing is diabetes. So the line, this is the pink, pink line that's six to seven symptoms are women with the highest PTSD symptoms have increased risk of developing diabetes over the life of the cohort. And that's compared to women with less PTSD or women who have experienced trauma, don't have symptoms or no trauma. And we see this also, we have shown this with cardiovascular disease, even rheumatoid arthritis and a whole range of adverse health outcomes. And most recently we've been looking at accelerated aging. So I don't know, a part of me, I feel like sometimes this past year I've aged 10 years in a year, but there is this sort of popular idea of stress aging you and we actually do find that in the research we do. So we find that women who have PTSD and depression show biological markers that indicate accelerated aging, but that also we see it in something that's sort of more tangible, which is cognition. So this just shows, again, this isn't published yet, stuff we're still analyzing, but you see that, you see in these two domains that are very influenced by age, cycle motor speed and attention and learning and working memory. The orange dot is the sort of decrements in these cognitive abilities with age. So they tended to climb at age and you see this really dramatic difference at lower levels, lower scores on these in women with particularly women who have trauma, PTSD and depression. And most strikingly, this translates out to increased risk of early mortality. So we think a lot about the effects of, obviously we've seen this higher rate of mortality with COVID, but the mental health effects can also have effect on mortality. I think there's been a number of big articles on this and this is just from our cohort that we see this increased risk of early mortality related to depression and PTSD. And it's sort of striking because these are all women who at some point were healthcare workers. So there's not a general population. It's actually a population where almost 100% of them see a GP once a year. They're in the health system. So these aren't people who don't have healthcare on average. And so one of the things people are wondering, and I don't have data to show this, but these are data on that are kind of explore the idea that in addition to the COVID, the deaths we've been reported related to COVID, there's increase in deaths related to other diseases during COVID, which can be for all kinds of reasons, including in the US healthcare shutdowns. And we've seen this sort of in this, but looks like a higher level with C-rebrovascular diseases, Alzheimer's dementia, diabetes, and hypertension. And we also may see them related to mental health. There has been some reports of increase, for example, overdose deaths, which are probably mental health related. And then just briefly, other mental health effects of COVID. I talk more about these sort of what we're all experiencing from the stress and trauma, but we may see there are reports of mental health consequences of getting sick with COVID and people who've had the disease. And for example, we went back and we looked at the data on people who've experienced SARS. There is pretty good evidence that people experience some long-term mental health consequences. And some of them may be from actually having the disease itself. It could be a biological effect. It could be the sort of trauma of having the disease. And people are, they actually couldn't find great data, but there have been a number of articles on this that survivors of COVID are at high risk themselves for post-traumatic stress disorder. A friend of mine who had COVID, who was in ICU, not in a ventilator, she definitely reports some sort of PTSD related to, she got allergies recently, and if sort of she has any sense of not be able to breathe or something, she gets this very panicky feeling. So there can also be those effects. And then finally, before I get to the, what can we do? The other piece we might see is that the adverse effects of trauma may be seen across generations. So we've done studies, talked about the nurses health study. We've actually looked at trauma and PTSD and the moms and the kids. And what we found is that mothers with PTSD are exposed, children and moms with PTSD are exposed to more trauma themselves. And children and moms with PTSD maybe not surprisingly are more likely to have PTSD themselves. But what's more striking is there's, I'm giving example from our studies, but there's all other work out there that shows that, for example, women who experience abuse as children, they're offspring are at risk for a number of adverse health outcomes. In this case, for example, children or mothers who are abused are more likely to initiate smoking early and maintain high levels of consumption. And we've also shown these effects on BMI where children of women who are abused have higher BMI's and these more rapid risk weight trajectories in their young adulthood. So there does also just seem to be these transgenerational effects, which we may see. And in this last little bit, I'll just share data that's, I think this will be out soon, but again, also not published, is because of some of the concerns of the longer-term effects of mental health effects of COVID on offspring. Some colleagues and I joined together and we did a global study of health and well-being, of pregnant and postpartum women during COVID-19 pandemic. So I'll briefly present just some of those results as it's one of the global studies that was involved in. So there's about 7,500 participants and they were recruited by social media in a number of countries and the survey was translated into local languages. And this is a group, this isn't a population representative group, they tend to be sort of a better off group. Most are partnered, most had some education from college, about quarter where healthcare are essential workers. And they're a little bit older than typical recent moms, they are 31. And this is our distribution globally. So most, the largest sample, not surprisingly, it's from the US and then from Mexico and South Africa with sort of decent samples from some other places in the world. And what we found was that these women, perian postpartum women during COVID had higher prevalence of anxiety, depression and PTSD, both than you'd see in similar sample women pre-COVID but also then was reported in the general population during COVID. And some of the factors that were associated with poor mental health during COVID were things that might be familiar to folks. So this study we did, we sent people filled out measures online, but they also had write-in. So I think the women's sharing their experiences kind of resonates with a lot of people. So for example, one of the things women reported was that, we found that was that women who checked social media more often had worse mental health. And this is just association, we can't say that. Social media causes the mental health problems, it can be that people are feeling worse, tend to check social media, but we did find this really strong relationship between checking social media many, many times a day and higher rates of depression, anxiety and PTSD. And, but similarly, we found the same thing for news sources. So it just didn't seem to be like doing one thing. It wasn't like social media was bad, news was good. It's sort of any engagement with news, texting, et cetera around COVID was associated with worse mental health. And again, we don't know in what direction, but the association was pretty consistent. And especially if you're checking a lot of different kinds of media, that was associated particularly with higher mental health problems. The other thing that was kind of striking in these was just that even things like interacting with friends and family around COVID was associated with, for example, higher loneliness. So this is something that's been found consistently in different studies during this time is that this relationship between sort of different kinds of media exposure and worse mental health symptoms. It's really hard to tease apart the direction, but it does relate to what we can do, which I'll talk about later. The other thing we found, which again may not be surprising now is that there's COVID itself, but it was really the COVID related stressors, childcare, healthcare and economic that these women said were important to their mental health. And we have these writings and I won't because of time read them all, but I'm sharing the slides, but women talked about the stress related to having to cancel doctors appointments, feeling depressed because of unemployment and family struggling experiences around the birth and changes to their birth plan. A lot of fears around children and their current children and what if they get sick and can't take care of their children or their baby, feeling isolated and lonely, which was striking again, because this is normally a time when you're pregnant or you're having a baby that you want people around you and having friends and family members that died. And this was back in the late May, June. This was now almost a year ago. And just like I kind of reported related to other events, other disasters we've studied, number of COVID stressors were reported was related to worse levels of depression when women with more stressors had more anxiety, more PTSD and more loneliness. We also found that there were changes in lifestyle factors were associated with worse psychological distress. So when we looked at this, whether the relationship between changes in diet, for example, or fitness or sleep, there was this definitely strong association where people who were feeling worse also experienced, also reported worsening of diets, exercising less and sleeping much worse. And this quote from this woman kind of summarized that. I felt like summarized our data a lot. COVID-19 is the least of my problem. What worries me is depression, being pregnant and not having a job, which is that I would like COVID-19 to kill me, but I have a good immune system, so I recovered quickly, helped me, I need treatment for depression, good job. So with that, I realized that was kind of a dismal picture. I'll just finish with what can be done and then move to questions. So I don't know if people will remember this because this is sort of all, but kind of early on the pandemic, Google came out with do the five and these were the five things. You can tell it's bit dated now because of the mask wearing is on there, but we and some colleagues had this idea of like can we have a do the five for mental health? And so actually someone on a webinar I did came up with the actual five, but I'm gonna use that to just suggest some things we can do. So one is to recognize the problem. And I think that is actually happening. I think the fact that you are having this webinar and that I hear more and more people recognizing that they are at both a population level and individual of this huge issue. And for example, in the US, this was like June 40% of US adults were struggling with mental health or substance abuse. And I also, when I was doing some research for this talk found a lot of discussions online about some papers online talking about the economic consequences related to mental health and COVID and that there would seem to be a lot of active attention to that. These are data pre COVID, this is from 2015, which was estimating the direct and indirect costs related to mental health problems as a percentage of GDP. And one of the things the paper pointed out, which Luke pointed out in the introduction is that the challenges with mental health unlike other chronic physical disease is that it affects people at their most prime age. It tends to hit in young adulthood and really can be disabling during the times of life that people should be working and being most productive, getting their education. And so it can really hit the economy. So when they were talking about these costs, the cost of mental health problems aren't just treatment, it's the cost of consumers not spending, it's the cost of people not being productive working. And so I think that's something going forward that people will need to think about. The other thing is expanding the safety net. Often people don't connect the, hopefully this group would, but the economy with mental health and actually efforts that can expand the safety net whether it's in an institution providing benefits for people that will help reduce their stress or at a national level really can be in mental health interventions. And there is a lot of data on this. This is one paper that we did that just kind of shows this clearly. So we looked at home foreclosures during the 2008 Great Recession and Mental Health and found that home foreclosures prospectively predicted new mental health events in people who hadn't had them before. So your home was foreclosed, you're at greater risk of having depressive episode, anxiety disorder, even if you had never otherwise been mentally healthy before because we were able to study it over time. So, and there's a lot of data on this that when the economy is negatively impacted, it negatively impacts people's mental health. So all these are just some different things that have been happening in the US. I think you're involved in does a better job with this, but that these actually policy level interventions will help protect people's mental health. And then the other thing is thinking about who's most at risk. I think one of the challenges during the pandemic is that there's so many groups at risk. I showed data with people with mental health problems. There does seem to be younger people at risk, people who are isolated, families who especially children, healthcare workers, et cetera. So it really does argue that you need interventions that go beyond just individual, just given the number of at-risk groups. And so in terms of getting a little practical on what can people do. So one of the things that actually there is some good science behind, and it could be a whole nother talk, which maybe you'll have someone come, is that actually altruism improves our own mental health. So when you do something that benefits somebody else, it actually not only benefits them, actually impacts your brain in a way that will make you feel better. So one thing that people can do, if you can figure out a way to help others, these are examples early on in the pandemic from my neighborhood where people were making masks for healthcare workers. But if there's things you can do, and sometimes even small things, they actually can also be good for you. And I think we often forget that, especially now when we've been doing this for a year and we're all a bit burned out. And some of that could be participating in science and surveys, and some people have found that to be helpful, but anything you can do that you feel like is helping someone else, even if it's not related to COVID, related to something else going on in their life, will actually make you feel better. And then also about cultivating resilience, which again could be a whole talk in itself. So I took this from the world WHO so that there'd be some reference to it, but it's some of the things when people ask me what can one do is it's often sounds so basic and it's stuff that's easy to say and maybe harder to do. So I think we can't underestimate the importance of maintaining all the lifestyle things that we normally do for our health. They will also affect our physical health. For example, like trying to stay on a schedule even if your whole life is virtual, trying to eat at regular times, go to bed at regular times, and really trying to get exercise, which I know varies as what you can do depending on where you live in the lockdowns. And another thing is really limiting your media exposure if you find that agitates you. So for myself, I can tell you what I do, what people need for their job varies. So I have found that getting my news from reading is much less stressful than getting it from the TV or even the radio anymore. So I have really limited that. I've actually deleted my Twitter app and my Facebook app from my phone so that I'm not checking it all the time. And those kinds of things, they sound kind of maybe silly or simple, but actually can sort of just help increase your daily wellbeing. And there's tons of resources out there. These are ours we put out there, but there are a number. I wished I had found some in languages that might be more relevant people here in German, but I don't think I would be able to understand if they were great resources, but there are a ton of publicly available resources now. So reach out for that. And then lastly is to try to cultivate empathy. So this is something one of my post-docs made early on, which was be kind to everyone you meet, be kind for everyone you meet, is fighting a hard battle, which is just trying to really have a lot of empathy for yourself, those around you, especially for yourself, your parent, and those around you and to kind of manage that your expectations for yourself and those around you because we aren't in normal times. And I find myself every day as sort of someone who's been a very kind of high-powered professional and a parent that I'm almost every day, I feel like I have to kind of lower my standards for myself, I kid and be a little more, be more relaxed about what I expect. Often from myself is the hardest, the biggest challenge. And something that I actually found really lovely that people did in my neighborhood was they've been taking rocks and painting them and putting them out places and I have a dog. So when I walk the dog, I'll be waiting for the dog, do her business and see these things around the neighborhood. So there's been, people have been trying to have these expressions of empathy in the community where I live, which does kind of pick my spirits up some days. And so I want to stop there. This is the student Lee who came up with this acronym. And I want to stop there and just again, have time for your questions and just also acknowledge that the memory of the, I think it's three million people have died of COVID and their family and friends who are grieving. This is Bob, Samuel and Karen Brown who are two of my family members who died in March from COVID. And I'm sure that people, those call have lost people too. So thank you. Happy to answer questions. I'm going to exit my slides. I did send a copy of my slides and if anyone wants them, they're available. Thank you. So thank you so much, Karistan. You're welcome. And also for putting on these links we will of course distribute and I think this was heavy stuff for us. We are not, I mean, like you as a professional in this area, many of us on the call are not confronted with this type of materials on a daily basis in a different line of business. But so I think some on the call might take some time to process and just questions but I have a lot of questions already but I think it was good to put sort of also some references where people then can go to if they have ideas later on today. Yeah. All the slides have references on the bottom. So, you know, people can or you know and also honestly reach out to me too. That's fine. I'm happy to have that. So one question I get which is related to this question is in your multi-step process, you started to recognize the problem. But what if this is a type of trauma that people are really experiencing for the first time and you have sort of don't really have the self-awareness or you just don't know what you are experiencing because it's the first time or you don't know where to go. How, what kind of pointers do you have for some problems? Well, I think that that's a really good question. I think that, so when you might start asking yourself if there is a problem, so do you even know there's a problem or around you maybe someone else sees it is, so some of the really markers are is there a change in your functioning? I'll say what that means. Like, is it, are you someone who in normal times or even when you've had a difficult time before, you know, still was able to get out of bed and do your work and concentrate? Are you having trouble concentrating at work? Are you losing your temper more? Are you, is it interfering where you're, you know, my kid, my kid, who resides me all the time, he's 14, but you know, are people pointing out? Like, you don't seem yourself. Do you, are people pointing that out? And if those, then you might start thinking like, oh wow, this is really getting to me. More than it's just, you know, it's just a difficult time. So I think those are some of the things is, is it, you don't have to sit there and ask yourself like the symptom checklist, but is it interfering with how I live my life? The other thing that I know I ask myself is, can you still do the things, do you still get joy from things that you used to get joy from? So now it's hard cause a lot of things we can't do, but you know, when you can do something, if it's something like I play the piano, and if I can make myself sit there, I still enjoy it. But you know, if I start losing that, if I start losing like the interest in things that normally I would enjoy, then that is a definite marker for sure. And then in terms of, yeah, and I can think more about in terms of where to go, I think that is, that is a challenge for me, given that people, this group is in a different country. But the one thing I would say is, don't keep it to yourself. So try to, if you think you're feeling like that you could ask somebody, if you have a friend, if you don't have a partner, you know, or someone who lives with you, a friend, and be like, hey, have you noticed? I feel like I'm not feeling like myself. Try to have that conversation. I know it's hard, but. Thank you. You spoke about post-traumatic stress, which of course by definition is something that happens after. Right. I think trauma. So one question I received is, is the worst yet to come? In a sense, yeah, it was pretty heavy what you already presented, but indeed many of the studies you summarized are about traumatic experiences and the people reporting, but this post-traumatic stress. Yeah. Yes, I think that is what a sort of, what is the typical, basically I guess the question is, how much time after trauma experience do you develop some of this post-traumatic? Right. So we usually, well, I know, and this is a very unique situation because it is still going on. And I think that usually if you're gonna develop a problem like depression or PTSD after trauma, it happens fairly soon. Let's say in the first three to six months, I mean, there's some reports that you kind of can have like this delayed, but generally it usually happens. People usually feel bad shortly after something's happened and then it gets better for most people over time and then some people it doesn't get better or it doesn't completely resolve. I think that in terms of these effects, I think one of the challenges has been the unpredictability and the longer this goes on, the more it impacts our lives and disrupts our lives. And so there will be some fallout and what that exactly will be. I think some of this is also influenced by more macro factors like do governments buffer people? Are people, especially in the US, are people losing their homes, things like that? That will obviously make it worse if there is interventions that help protect people's livelihoods and economic lives and my view that will make it better. But it's hard. I would hope we would have been in a different place at this point, right? And I know you're in a different place than we are in the US, so that's... Yeah, there are all these differences that you alluded to, but it seemed indeed that one of the surprising kind of common insights is that around the world, there's sort of common drivers, right, that you pointed to. Well, one thing, there's another question that you did not mention was vaccination. So that's sort of on the positive side. Is there any work already showing that this can be really... This can help with sort of reducing uncertainty and this is like really... I've seen a little bit, yes, right. And I didn't have any good figures on this, but there is in some of the different groups I'm involved in or not, the people have been doing these mental health surveys throughout and then now they're tracking if people are like with vaccinations and they do see a positive association between... Well, people themselves often seem to report at least initially, we'll see a persistent feeling better, one's vaccinated and just feeling less anxious and also more hopeful. And I think that they do see these big effects, we just have this news about the J&J, Johnson Jackson, Johnson vaccine in the US has been paused. And I predict that the mental health like has gone down forever. And so I do see that. And I guess the question is whether it will persist over time. And I think for many people, these kinds of positive developments, they'll experience this improvement in their mental health. There will be some portion of people who will be more persistent, but I do think that for most people, once you relieve some of the stressors and things, mental health tends to improve. So... So I had warned you that there are a couple of researches. Yeah. So there are like a set of questions related to sort of what to make out of this survey response. So now how much can we trust that, especially people who experience a trauma, truthfully report in this service, how do you deal with that as a researcher? I'm sure this is a combination of you. That's a great question. And more generally how to kind of distinguish between self-perception and something that is more objective. Yes, those are a great question. So actually people, this is something that really interests me. I like these research questions because I am a researcher, but... So we have actually... So we've dug into this in some particular areas. As people can imagine, getting objective indicators of trauma is hard. If you look at that list, so many of the events are private. You don't have an objective. So the two areas where we have more objective things are in combat and war, because a group I was involved in looked at people's self-reports of combat exposure in trauma and war. And their actual military historical records and did what they report actually happened at that time during most of the reports. And we can say that we actually found surprisingly high concordance. And even if we use just objective indicators, it predicted people's mental health pretty well. So there does seem to be... And then the other is it's a little more complicated is with reports of one's own child abuse. So there are studies that have... That have like child protective services records. So like where there was documented abuse versus people's self-report. And then looked at the different impacts. What I can say is that documented abuse does predict adverse mental health. But the two... It's actually a very... The two don't always correspond and it get why it is kind of complicated. So I think we know from objective trauma, the objective measures of trauma that those do affect mental health negatively. But it's a more complicated picture between self-report. And then the perception is... Yeah, exactly how we've tried to disentangle. In some ways it might be... One of the things we've learned, it's actually a complicated picture because it's really not like... For example, if you look at something like life threat, where's your life threatened? It's really not the objective aspects that seem to predict mental health. Like how injured you were in things. It actually is whether you've perceived your life to be threatened. And so that's just to say that is actually true, that the perception is incredibly powerful. Okay, clear. And also you talk to a very clear when you said, well, this is an association and this is causality now. So, of course, this is the play you're on. And especially with the COVID mental health stuff coming out, the problem is that, I'm sure, is that it's phenomenal that all this research, whether it's on vaccinations or on mental health and COVID is being reported quickly. The negative is it's being reported quickly and you have tons of stuff out there without the caveats. So it is all association. Yeah, yeah, yeah. Okay, and then there's a whole range of questions, of course, about what we can do. I mean, we all believe that change starts with ourselves and both as individual and as an organization. So, for instance, one group of people we often talk about, we have trainees, these are students, they spend one year with us and now they spend an awful year with us because they were locked down in an apartment, they didn't even come to work physically and often are by themselves. But of course, there are a variety of demographic groups among our staff members affected. So, maybe sort of final question, what can we do either as individuals or as an organization to support our colleagues? You spoke about that a bit, but... Yeah, yeah, now those are good questions. About your experience also at the central bank and knowing what kind of individuals... Right, I know and I have trainees and students too and actually my students like yours, they call themselves the Catastrophe Cohort, actually that's their name for themselves now. So, what can you do? I mean, as an individual, I have to say as, and I'm sure there's a lot of parents, what I said about the expectations, modifying my expectations like literally multiple times a day, I have to do that. I mean, I'm sure the researchers, I'm a professor at Harvard, I'm no slacker, but I have to just, and so that is actually like a practice, so that's a practice, that's not like, oh, I lowered my expectations, it's like every day I've lowered my expectations. And then the other piece is I didn't go into this very much, but our brains are hardwired for threat and fear and negative information. This gets at the media because that's what helped us survive and evolve and pass on our genes essentially. So, we actually have to consciously focus on positive things. So, whatever you do that, it's always to say, oh, meditate or whatever, but it's just, I think every day, trying to figure out something that makes you feel whatever positive, like, could be like having glass of wine on my porch or like anything that we have to think about, focus on something positive. So, that's as individuals, that's like two things, really cultivate that, however, and that's individual. And then as an organization, I think it's very challenging because everyone in the organization is probably overstretched. So, there's not a lot of resources, but I think that having things like this, recognizing it and managers and supervisors in the organization can listen to what people need, whether it's, so people who work in my group allow them to need a lot of flexibility, for example, on schedules, because for example, they have had, now we're going out, childcare has been closed. So, they've had to split little kids at home, split their schedules. So, trying to listen to what people need and then respond, and some of that will be on individual managers and then some, the more that can be done in an organizational level, it's easier because it's not dependent on having a good manager or someone who's gonna listen. Because there's, I know that's true with the students, like, my students, at least I talk to them a lot, but some of the students and trainees are just out there and then other colleagues I've done have done a better job than me of having informal times where they've set up, like some of the groups I know they set up lunch times and on Webex or on Zoom, and it's not an agenda, but it's just like people can just meet and finding ways for people to connect, particularly for the students, because I have the same thing where I have trainees who are now in apartments where they don't know anybody and can't see anybody and that's really hard. Some of them actually moved to countries to come to the US and then are now stuck and can't go home. So, it's a hard, yeah. Well, this is fascinating stuff, we've been run out of time. Yes. Thanks for all the, we had over 100 colleagues on the call. Oh wow, that's great, thank you. So many questions I could not ask you, but thanks really for doing this. It gave us a lot of food for thought. Some of the things that you pointed out at the end, I do know many of the colleagues are doing, we should definitely more. So thank you for offering all these suggestions. Oh, you're welcome and thank you, and I wish we had more time, but thank you and everyone take care and yeah, and I hope things improve. I hope to see you under better circumstances.