Purpose The COVID-19 pandemic has many potential impacts on people with mental health conditions and on mental health care, including direct consequences of infection, effects of infection control measures and subsequent societal changes. We aimed to map early impacts of the pandemic on people with pre-existing mental health conditions and services they use, and to identify individual and service-level strategies adopted to manage these. Methods We searched for relevant material in the public domain published before 30 April 2020, including papers in scientific and professional journals, published first person accounts, media articles, and publications by governments, charities and professional associations. Search languages were English, French, German, Italian, Spanish, and Mandarin Chinese. Relevant content was retrieved and summarised via a rapid qualitative framework synthesis approach. Results We found 872 eligible sources from 28 countries. Most documented observations and experiences rather than reporting research data. We found many reports of deteriorations in symptoms, and of impacts of loneliness and social isolation and of lack of access to services and resources, but sometimes also of resilience, effective self-management and peer support. Immediate service challenges related to controlling infection, especially in inpatient and residential settings, and establishing remote working, especially in the community. We summarise reports of swiftly implemented adaptations and innovations, but also of pressing ethical challenges and concerns for the future. Conclusion Our analysis captures the range of stakeholder perspectives and experiences publicly reported in the early stages of the COVID-19 pandemic in several countries. We identify potential foci for service planning and research.

Highlights Antidepressant gender disparity less in type 2 diabetes than general population No evidence of ethnic disparity in antidepressant prescribing in type 2 diabetes No evidence of disparity in antidepressant prescribing for insulin users Considerable evidence gaps for antidepressant prescribing in type 2 diabetes

Background: Depression is a common and chronic comorbidity affecting approximately one in four people with type 2 diabetes (T2DM), and often lasting several years. Past systematic reviews have been unable to identify evidence for longterm (12+ months) antidepressant treatment outcomes in comorbid depression and type 2 diabetes. These reviews are >10years old, included only randomised controlled trials or had limited search strategies. We aimed to systematically review observational studies for long-term outcomes of antidepressant treatment in adults with comorbid depression and T2DM, including broader, up-to-date searches. Methods and findings: This review was pre-registered on PROSPERO (CRD42020182788). We searched seven databases using terms related to depression, T2DM and antidepressant medication. From 14,389 reports retrieved, 63 were screened at full text stage and 0 met inclusion criteria. The reasons for exclusion at full text stage were: Studies did not meet inclusion criteria for antidepressant treatment (n = 50); studies did not meet inclusion criteria for T2DM (n = 36); studies did not meet inclusion criteria for depression (n = 29); studies did not include follow-up time (n = 25); studies did not meet inclusion criteria for observational study (n = 14); studies did not include any measurable outcomes (n = 5); studies did not include a suitable comparison (n = 3). Conclusions: We found no evidence concerning long-term outcomes of antidepressant treatment in individuals with comorbid depression and T2DM. Insufficient ascertainment of antidepressant prescription, case identification, and short follow-up times are the primary reasons for this. Research is urgently required to determine long-term outcomes associated with antidepressant treatment in this patient group

Background Individuals with physical comorbidities and polypharmacy may be at higher risk of depression relapse, however, they are not included in the ‘high risk of relapse’ group for whom longer antidepressant treatment durations are recommended. Aims In individuals with comorbid depression and type 2 diabetes (T2DM), we aimed to investigate the association and interaction between depression relapse and (a) polypharmacy, (b) previous duration of antidepressant treatment. Method This was a cohort study using primary care data from the UK Clinical Practice Research Datalink (CPRD) from years 2000 to 2018. We used Cox regression models with penalised B-splines to describe the association between restarting antidepressants and our two exposures. Results We identified 48 001 individuals with comorbid depression and T2DM, who started and discontinued antidepressant treatment during follow-up. Within 1 year of antidepressant discontinuation, 35% of participants restarted treatment indicating depression relapse. As polypharmacy increased, the rate of restarting antidepressants increased until a maximum of 18 concurrent medications, where individuals were more than twice as likely to restart antidepressants (hazard ratio (HR) = 2.15, 95% CI 1.32–3.51). As the duration of previous antidepressant treatment increased, the rate of restarting antidepressants increased – individuals with a previous duration of ≥25 months were more than twice as likely to restart antidepressants than those who previously discontinued in <7 months (HR = 2.36, 95% CI 2.25–2.48). We found no interaction between polypharmacy and previous antidepressant duration. Conclusions Polypharmacy and longer durations of previous antidepressant treatment may be associated with depression relapse following the discontinuation of antidepressant treatment.

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