'The world was going through what we go through everyday': The experiences of women with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) living with their partners during the COVID-19 lockdown in the United Kingdom.

OBJECTIVES: Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a long-term debilitating illness characterised by profound and persistent fatigue (JAMA: The Journal of the American Medical Association, 313, 2015, 1101). The current study aims to explore the experiences of women with ME/CFS living with their partners during the COVID-19 pandemic in the United Kingdom. DESIGN: The study adopted a qualitative design comprising semi-structured interviews with participants. Interviews were analysed using thematic analysis (TA). METHODS: Participants were women with ME/CFS (n = 21) recruited through ME/CFS support groups in the United Kingdom. All participants were in romantic relationships and lived with their partners. RESULTS: Data were organised into three themes: (1) lockdown disrupting routine, (2) reducing difference and (3) fear of getting COVID-19. People with ME/CFS found that lockdown disrupted their well-established routines. Although routines were disrupted by partners and increased working-from-home practices, participants found having partners at home helpful. People with ME/CFS believed that the changes induced by the pandemic reduced the differences between themselves and the outside world which, prior to lockdown, had felt prominent. They were fearful of getting COVID-19 as they believed this would make their ME/CFS worse. This meant that for people with ME/CFS, the lifting of the lockdown restrictions was an anxiety-provoking time, hence impacting symptoms. People with ME/CFS continued to adhere to government guidelines after national restrictions were eased. CONCLUSIONS: This study outlines the experiences of women with ME/CFS during COVID-19, alongside the long-term impact this has had due to the changes that the pandemic imposed. These findings may have implications for those with long COVID.

Effectiveness of communications in enhancing adherence to public health behavioural interventions: a COVID-19 evidence review.

Health communication has relevance for virtually every aspect of health and well-being, including disease prevention. This review explored the effectiveness of communications in enhancing the adoption of or adherence to behavioural interventions (non-pharmaceutical interventions (NPIs)) related to COVID-19. The review takes the UK as a case study and focuses on self-reported behaviours (e.g. social distancing). It also reviews the psychosocial determinants of adherence. Searches were conducted using PubMed, Scopus, CINAL, ASSIA and iCite databases. Eleven thousand five hundred records were identified and 13 were included in the final sample. Included studies suggest that NPI adoption or adherence was generally high, and communication had significant impacts, with key themes including clarity and consistency, trust and control. Based on the evidence in this review, features of effective communication in the context of NPI adoption or adherence are (i) information should be conveyed clearly and conflicting (mixed) messages should be avoided; (ii) information should be conveyed by trusted sources (e.g. health authorities) and (iii) communication should strike a balance between being authoritative but avoiding language seen as controlling (e.g. 'you must'). Future research should prioritize quantitative, experimental and longitudinal study designs, that focus specifically on communication as an intervention, and which measure behaviour. This article is part of the theme issue 'The effectiveness of non-pharmaceutical interventions on the COVID-19 pandemic: the evidence'.

Public decisions about COVID-19 vaccines: A UK-based qualitative study.

OBJECTIVE: To explore UK public decisions around whether or not to get COVID-19 vaccines, and the facilitators and barriers behind participants' decisions. DESIGN: This qualitative study consisted of six online focus groups conducted between 15th March and 22nd April 2021. Data were analysed using a framework approach. SETTING: Focus groups took place via online videoconferencing (Zoom). PARTICIPANTS: Participants (n = 29) were a diverse group (by ethnicity, age and gender) UK residents aged 18 years and older. RESULTS: We used the World Health Organization's vaccine hesitancy continuum model to look for, and explore, three main types of decisions related to COVID-19 vaccines: vaccine acceptance, vaccine refusal and vaccine hesitancy (or vaccine delay). Two reasons for vaccine delay were identified: delay due to a perceived need for more information and delay until vaccine was "required" in the future. Nine themes were identified: three main facilitators (Vaccination as a social norm; Vaccination as a necessity; Trust in science) and six main barriers (Preference for "natural immunity"; Concerns over possible side effects; Perceived lack of information; Distrust in government;; Conspiracy theories; "Covid echo chambers") to vaccine uptake. CONCLUSION: In order to address vaccine uptake and vaccine hesitancy, it is useful to understand the reasons behind people's decisions to accept or refuse an offer of a vaccine, and to listen to them and engage with, rather than dismiss, these reasons. Those working in public health or health communication around vaccines, including COVID-19 vaccines, in and beyond the UK, might benefit from incorporating the facilitators and barriers found in this study.

The Effects of Traffic Air Pollution in and around Schools on Executive Function and Academic Performance in Children: A Rapid Review.

This review summarises the extant literature investigating the relation between traffic-related air pollution levels in and around schools and executive functioning in primary-school-aged children. An electronic search was conducted using Web of Science, Scopus, and Education Literature Datasets databases (February 2020). Review articles were also searched, and forwards and backwards searches of identified studies were performed. Included papers were assessed for quality. We included 9 separate studies (published in 13 papers). Findings suggest that indoor and outdoor particulate matter with a diameter of 2.5 µm or less (PM2.5) negatively influences executive function and academic achievement and that indoor and outdoor nitrogen dioxide (NO2) adversely affects working memory. Evidence for the effects of particulate matter with a diameter of 10 µm or less (PM10) is limited but suggests potential wide-ranging negative effects on attention, reasoning, and academic test scores. Air pollution in and around schools influences executive function and appears to impede the developmental trajectory of working memory. Further research is required to establish the extent of these effects, reproducibility, consequences for future attainment, and place within the wider context of cognitive development.

Public perceptions of non-adherence to pandemic protection measures by self and others: A study of COVID-19 in the United Kingdom.

BACKGROUND: Novel viral pandemics present significant challenges to global public health. Non-pharmaceutical interventions (e.g. social distancing) are an important means through which to control the transmission of such viruses. One of the key factors determining the effectiveness of such measures is the level of public adherence to them. Research to date has focused on quantitative exploration of adherence and non-adherence, with a relative lack of qualitative exploration of the reasons for non-adherence. OBJECTIVE: To explore participants' perceptions of non-adherence to COVID-19 policy measures by self and others in the UK, focusing on perceived reasons for non-adherence. METHODS: Qualitative study comprising 12 focus groups conducted via video-conferencing between 25th September and 13th November 2020. Participants were 51 UK residents aged 18 and above, reflecting a range of ages, genders and race/ethnicities. Data were analysed using a thematic approach. RESULTS: Participants reported seeing an increase in non-adherence in others over the course of the pandemic. Reports of non-adherence in self were lower than reports of non-adherence in others. Analysis revealed six main themes related to participants' reported reasons for non-adherence in self and others: (1) 'Alert fatigue' (where people find it difficult to follow, or switch off from, information about frequently changing rules or advice) (2) Inconsistent rules (3) Lack of trust in government (4) Learned Helplessness (5) Resistance and rebelliousness (6)The impact of vaccines on risk perception. Participants perceived a number of systemic failures (e.g. unclear policy, untrustworthy policymakers) to strongly contribute to two forms non-adherence-violations and errors. CONCLUSION: Findings suggest that latent and systemic failures-in the form of policy decisions that are commonly experienced as too changeable, inconsistent and confusing, and policy makers that are commonly perceived as untrustworthy-may play a significant role in creating the conditions that enable or encourage non-adherence.

Public attitudes towards COVID-19 contact tracing apps: A UK-based focus group study.

BACKGROUND: During the 2020 COVID-19 pandemic, one of the key components of many countries' strategies to reduce the spread of the virus is contact tracing. OBJECTIVE: To explore public attitudes to a COVID-19 contact tracing app in the United Kingdom. SETTING: Online video-conferencing. PARTICIPANTS: 27 participants, UK residents aged 18 years and older. METHODS: Qualitative study consisting of six focus groups carried out between 1st-12th May, 2020 (39-50 days into the UK 'lockdown'). RESULTS: Participants were divided as to whether or not they felt they would use the app. Analysis revealed five themes: (1) lack of information and misconceptions surrounding COVID-19 contact tracing apps; (2) concerns over privacy; (3) concerns over stigma; (4)concerns over uptake; and (5) contact tracing as the 'greater good'. Concerns over privacy, uptake and stigma were particularly significant amongst those stated they will not be using the app, and the view that the app is for the 'greater good' was particularly significant amongst those who stated they will be using the app. One of the most common misconceptions about the app was that it could allow users to specifically identify and map COVID-19 cases amongst their contacts and in their vicinity. CONCLUSIONS: Our participants were torn over whether digital contact tracing is a good idea or not, and views were heavily influenced by moral reasoning. PATIENT OR PUBLIC CONTRIBUTION: No patients were involved in this study. The public were not involved in the development of the research questions, research design or outcome measures. A pilot focus group with participants not included in the present paper was used to help test and refine the focus group questions. Summary results were disseminated via email to participants prior to publication for feedback and comment.

Public perceptions and experiences of social distancing and social isolation during the COVID-19 pandemic: a UK-based focus group study.

OBJECTIVE: This study explored UK public perceptions and experiences of social distancing and social isolation related to the COVID-19 pandemic. DESIGN: This qualitative study comprised five focus groups, carried out online during the early stages of the UK's stay at home order ('lockdown'), and analysed using a thematic approach. SETTING: Focus groups took place via online videoconferencing. PARTICIPANTS: Participants (n=27) were all UK residents aged 18 years and older, representing a range of gender, ethnic, age and occupational backgrounds. RESULTS: Qualitative analysis revealed four main themes: (1) loss-participants' loss of (in-person) social interaction, loss of income and loss of structure and routine led to psychological and emotional 'losses' such as loss of motivation, loss of meaning and loss of self-worth; (2) criticisms of government communication-participants reported a lack of trust in government and a lack of clarity in the guidelines around social distancing and isolation; (3) adherence-participants reported high self-adherence to social distancing guidelines but reported seeing or hearing of non-adherence in others; (4) uncertainty around social reintegration and the future-some participants felt they would have lingering concerns over social contact while others were eager to return to high levels of social activity.Most participants, and particularly those in low-paid or precarious employment, reported feeling that the social distancing and isolation associated with COVID-19 policy has had negative impacts on their mental health and well-being during the early stages of the UK's 'lockdown'. CONCLUSIONS: A rapid response is necessary in terms of public health programming to mitigate the mental health impacts of COVID-19 social distancing and isolation. Social distancing and isolation 'exit strategies' must account for the fact that, although some individuals will voluntarily or habitually continue to socially distance, others will seek high levels of social engagement as soon as possible.

The relationship between the cortisol awakening response and cortisol reactivity to a laboratory stressor.

OBJECTIVES: The cortisol awakening response (CAR) and cortisol reactivity to an acute laboratory stressor both involve steep increases in cortisol secretion and are associated with preparing the body to deal with stressors ahead. Alterations in both have been linked to negative clinical and health outcomes. However, these two aspects of our biological stress response have rarely been directly compared, and the extant research focuses on state, rather than trait CAR. Given the similar roles of the CAR and cortisol reactivity, and their relationships to psychopathology, it is important to understand whether trait CAR and cortisol reactivity to acute stressors are related and whether a blunted CAR may be predictive of blunted cortisol reactivity across an acute laboratory stress task. DESIGN: Cross-sectional. Participants completed the Trier Social Stress Test (TSST) the week after daily assessment of the CAR. METHODS: Salivary cortisol secretion across the TSST was compared to the CAR, sampled across five weekdays at waking (S1) and 30 min past waking, for 54 female participants. RESULTS: A smaller CAR, lower peak cortisol, and blunted CAR increase were all significantly related to a steep rise and flattened slope of recovery in cortisol secretion following the TSST. Additionally, lower S1 was predictive of a blunted rise in cortisol secretion from baseline to immediately post-task. CONCLUSION: There was a significant relationship between trait CAR and cortisol secretion across the TSST. The results provided mixed support for hypotheses. A blunted CAR was associated with impaired recovery in cortisol secretion following the TSST, but, surprisingly, a rapid rise in cortisol peaking immediately following the stress task. Statement of contribution What is already known on this subject? The CAR and cortisol reactivity to an acute laboratory stress task both are thought to marshal the body's resources to deal with stress. Both the CAR and cortisol reactivity have been related to psychosocial states and clinical and health outcomes in past research. State CAR has been linked to cortisol reactivity to stressors, and a greater CAR is thought to help an individual deal with stressors in the day ahead. What does this study add? The current study predicts trait CAR sampled across multiple days from the rise and recovery in cortisol secretion across an acute stress test. Comparison of trait CAR and cortisol reactivity may clarify both their relationship to each other and to clinical and health outcomes.

Chronic stress exposure, diurnal cortisol slope, and implications for mood and fatigue: Moderation by multilocus HPA-Axis genetic variation.

Chronic stress exposure has been shown to alter hypothalamic-pituitary-adrenal (HPA) axis functioning, which may mediate its effects on psychopathology and negative health outcomes. The nature of the chronic stress-HPA axis dysregulation is unclear and individuals likely vary in the extent to and manner in which indices of HPA axis regulation, such as diurnal cortisol slope, are influenced by chronic stress. We examined whether HPA-axis-linked genetic variation moderates the association between chronic stress and diurnal cortisol slope, and potential implications for mood and fatigue (possible manifestations of negative clinical outcomes). 211 adolescents (M age 15.89, 54.5% female) completed chronic stress interviews and provided DNA samples. Participants then provided saliva samples at waking and 12 h post-waking for two consecutive weekdays. HPA-axis genetic variation was calculated using a multilocus genetic profile score (MGPS) approach, using ten SNPs from CRHR1, NR3C1, NR3C2, and FKBP5 to generate an additive score of HPA-axis-linked genetic risk. Neither chronic stress nor MGPS directly predicted diurnal slope, but MGPS moderated the association between chronic stress and diurnal slope, with stress predicting a high waking cortisol followed by steep slope among youth with low but not high MGPS scores. MGPS also interacted with chronic stress to predict both negative affect and fatigue, and moderated the indirect effect of chronic stress on mood and fatigue via diurnal slope. Results suggest that diurnal cortisol regulation may be one mechanism by which genetic risk intensifies the association between chronic stress and negative outcomes.

Childhood adversity moderates the influence of proximal episodic stress on the cortisol awakening response and depressive symptoms in adolescents.

Childhood adversity (CA) is known to predict sensitization to proximal stressors. Researchers have suggested that disruptions in hypothalamus-pituitary-adrenal axis functioning may be a biological mechanism. If so, CA may predict altered associations between proximal life stress and markers of cortisol secretion. We examined whether CA moderates associations between recent episodic stress and (a) the cortisol awakening response (CAR), and (b) depressive symptoms, in 241 adolescents aged 14-17 years (cortisol n = 196). Salivary cortisol was sampled at 0, 30, and 60 min postawakening for 2 days. The CAR was calculated as the area under the curve with respect to increase and waking cortisol. CA and episodic stress were assessed using contextual-threat-method-coded objective interviews. CA significantly interacted with episodic stress to predict both the CAR and depression. Among those with low CA, episodic stress predicted increased CAR but did not predict depression. For adolescents with high CA, episodic stress predicted lower CAR and higher depression. These interactions were found only for independent (uncontrollable, fateful) events, and not for dependent (self-generated) stress. Increased allostatic load resulting from CA exposure may interfere with adolescents' ability to optimally regulate their CAR in relation to recent stress, contributing to increased depression risk.

Behavioral excesses in depression: a learning theory hypothesis.

This paper reviews two learning theory-based models of experiential contributions to depression: response contingent positive reinforcement and learned helplessness. The authors argue that these models connect to a phenomenon that may explain why symptoms of behavioral excess (e.g. rumination) often occur in depression that is otherwise marked by symptoms of behavioral deficit (e.g. anhedonia). Specifically, the authors illustrate that that concept of schedule strain (or low rates of response contingent reinforcement giving rise to low frequencies of behavior) unites these models. Depression is more likely, or more severe, when schedule strain conditions occur in situations containing reinforcers important to the individual and/or when they simultaneously occur in a number of situations. Conditions of schedule strain are known to give rise to adjunctive behaviors: apparently irrelevant, easy behaviors that deliver immediate reinforcement. This paper suggests that, for some depressed individuals, behavioral excess symptoms like rumination and overeating might serve adjunctive functions. Implications of this hypothesis are discussed.

Cortisol secretion in depressed, and at-risk adults.

Distinct patterns of cortisol secretion have been associated with depression in past research, but it remains unclear whether individuals at-risk for depression may also have similar patterns of cortisol secretion. This is the first study to date of both naturalistic diurnal cortisol secretion and cortisol reactivity to a psychosocial laboratory stressor in depressed and at-risk adults. Cortisol secretion patterns were compared for 57 currently depressed, at-risk (based on trait-level positive and negative affect), and control participants over 5 days and in response to a laboratory stressor. After controlling for potentially confounding biobehavioral variables, the depressed group had a larger cortisol awakening response (CAR) and higher average diurnal cortisol compared to control participants. Individuals at-risk for depression also had significantly higher waking cortisol levels than control participants. Results for the psychosocial laboratory stressor did not show the predicted elevations in cortisol for depressed and at-risk participants compared to controls. The at-risk group recovered more quickly when compared to the depressed group both in levels of cortisol and concurrent measures of negative affect. The at-risk and depressed participants were similar on the diurnal cortisol measures, but differed on response to the laboratory social stressor, suggesting divergence in cortisol secretion patterns between currently depressed and temperamentally at-risk individuals. Further investigation of HPA functioning of individuals at-risk for depression may clarify the stress processes involved in risk for depression onset.

The stress sensitization hypothesis: understanding the course of bipolar disorder.

BACKGROUND: The influence of psychosocial stress on the course of bipolar disorder has been increasingly recognized. The authors tested hypotheses about both stress and early adversity "sensitization" on the course of bipolar disorder over a one-year period. METHODS: The participants were 58 adults (29 male and 29 female) with a diagnosis of bipolar I disorder. They were evaluated every three months for one year. Stressful life events and the presence of early adversity were assessed by structured interview. RESULTS: There was no significant interaction between stress and episode number in the prediction of bipolar recurrence. The interaction of early adversity severity and stressful life events significantly predicted recurrence in a manner consistent with the sensitization hypothesis. Participants with early adversity reported lower levels of stress prior to recurrence than those without early adversity. Individuals with early adversity also had a significantly younger age of bipolar onset. LIMITATIONS: The sample size was small and the number of past episodes was determined retrospectively, mainly through self-report. CONCLUSIONS: Severe early adversity may result in a greater effect of stress on bipolar recurrence and earlier onset of bipolar disorder, suggesting the need for further studies of stress mechanisms in bipolar disorder and of treatments designed to intervene early among those at risk.

Anomalous prefrontal-subcortical activation in familial pediatric bipolar disorder: a functional magnetic resonance imaging investigation.

BACKGROUND: The neurobiological features of pediatric bipolar disorder (BD) are largely unknown. Children and adolescents with BD may be important to study with functional neuroimaging techniques because of their unique status of early-onset BD and high familial loading for the disorder. Neuroimaging studies of adults with BD have implicated the dorsolateral prefrontal cortex (DLPFC) and anterior cingulate cortex (ACC) in the development of this disorder. OBJECTIVES: To study children and adolescents with BD via functional magnetic resonance imaging using cognitive and affective tasks and to examine possible abnormalities in the DLPFC and ACC, as well as selected subcortical areas, in pediatric familial BD. DESIGN: We evaluated 12 male subjects aged 9 to 18 years with BD who had at least 1 parent with BD as well as 10 age- and IQ-matched healthy male controls. Stimulants were discontinued for at least 24 hours; other medications were continued. Subjects underwent functional magnetic resonance imaging at 3 T while performing a 2-back visuospatial working memory task and an affective task involving the visualization of positively, neutrally, or negatively valenced pictures. SETTING: An academic referral setting, drawing from the Bay Area of San Francisco, Calif. RESULTS: Compared with controls, for the visuospatial working memory task, subjects with BD had greater activation in several areas including the bilateral ACC, left putamen, left thalamus, left DLPFC, and right inferior frontal gyrus. Controls had greater activation in the cerebellar vermis. In viewing negatively valenced pictures, subjects with BD had greater activation in the bilateral DLPFC, inferior frontal gyrus, and right insula. Controls had greater activation in the right posterior cingulate gyrus. For positively valenced pictures, subjects with BD had greater activation in the bilateral caudate and thalamus, left middle/superior frontal gyrus, and left ACC, whereas controls had no areas of greater activation. CONCLUSIONS: Children and adolescents with BD may have underlying abnormalities in the regulation of prefrontal-subcortical circuits. Further functional magnetic resonance imaging studies of attention and mood with greater sample sizes are needed.

Bipolar offspring: a window into bipolar disorder evolution.

Children of parents with bipolar disorder (bipolar offspring) represent a rich cohort for study with potential for illumination of prodromal forms of bipolar disorder. Due to their high-risk nature, bipolar offspring may present phenomenological, temperamental, and biological clues to early presentations of bipolar disorder. This article reviews the evidence for establishing bipolar offspring as a high-risk cohort, the studies which point to possible prodromal states in bipolar offspring, biological findings in bipolar offspring which may be indicators of even higher risk for bipolar disorder, initial attempts at early intervention in prodromal pediatric bipolar disorder, and implications for future research.

Decreased N-acetylaspartate in children with familial bipolar disorder.

BACKGROUND: Relatively low levels of brain N-acetylaspartate, as measured by magnetic resonance spectroscopy, may indicate decreased neuronal density or viability. Dorsolateral prefrontal levels of N-acetylaspartate have been reported to be decreased in adults with bipolar disorder. We used proton magnetic resonance spectroscopy to investigate dorsolateral prefrontal N-acetylaspartate levels in children with familial bipolar disorder. METHODS: Subjects were 15 children and adolescents with bipolar disorder, who each had at least one parent with bipolar disorder, and 11 healthy controls. Mean age was 12.6 years for subjects and controls. Subjects were allowed to continue current medications. Proton magnetic resonance spectroscopy at 3-Tesla was used to study 8 cm(3) voxels placed in left and right dorsolateral prefrontal cortex. RESULTS: Bipolar subjects had lower N-acetylaspartate/Creatine ratios only in the right dorsolateral prefrontal cortex (p <.02). No differences in myoinositol or choline levels were found. CONCLUSIONS: Children and adolescents with bipolar disorder may have decreased dorsolateral prefrontal N-acetylaspartate, similar to adults with BD, indicating a common neuropathophysiology. Longitudinal studies of at-risk children before the onset and during the early course of bipolar disorder are needed to determine the role of prefrontal N-acetylaspartate as a possible risk marker and/or indication of early bipolar illness progression.

Characterization of children of bipolar parents by parent report CBCL.

In past research the Child Behavior Checklist (CBCL) has differentiated among various diagnostic categories for children and adolescents. However, research has not been conducted on whether the CBCL differentiates among diagnostic categories for children at high risk for development of psychopathology. This study compares four diagnostic groups [bipolar disorder (BD), attention/deficit-hyperactivity disorder (ADHD), Depressed/Anxious and No Diagnosis] within a cohort of 58 children of bipolar parents to determine whether their CBCL scores will replicate the scores of children not at high risk for bipolar disorder. The cohort of children of bipolar parents received elevated scores on the CBCL scales in comparison with non-clinical populations. In addition, the CBCL distinguished between children of bipolar parents with and without clinical disorders. Finally the BD group differed from the ADHD group only on the Aggressive Behaviors, Withdrawn and Anxious/Depressed subscales of the CBCL. Therefore the CBCL did not discriminate between the BD and ADHD groups as it had in previous studies of children with BD and unspecified family history. It is possible that this discrepancy is due to a group of children of bipolar parents with ADHD who are currently prodromal for bipolar disorder and therefore received higher scores on the CBCL based on prodromal symptomatology. A longitudinal follow-up of this cohort is necessary to ascertain whether this is the case.