Lessons learned about stress and the heart after major earthquakes

Placing engineering in the earthquake response and the survival chain

Earthquakes injure millions and simultaneously disrupt the infrastructure to protect them. This perspective argues that the current post-disaster investigation paradigm is insufficient to protect communities' health effectively. We propose the Earthquake Survival Chain as a framework to change the current engineering focus on infrastructure to health. This framework highlights four converging research opportunities to advance understanding of earthquake injuries, search and rescue, patient mobilizations, and medical treatment. We offer an interdisciplinary research agenda in engineering and health sciences, including artificial intelligence and virtual reality, to protect health and life from earthquakes.

Exposure to earthquakes and development of ischemic heart disease

BACKGROUND

The evidence regarding the effect of earthquake exposure on the development of cardiovascular diseases is limited. This study evaluated the association between the 2016 Gyeongju earthquake, which had a magnitude of 5.8, and over 600 subsequent aftershocks occurring within a year in Korea, with the development of ischemic heart disease (IHD) among residents of Gyeongju.

METHODS

Ten years (2010-2019) of medical records from a randomly selected cohort of residents (n = 540,858) in Gyeongju and 3 control cities were acquired from the national health insurance service. Employing difference-in-difference and meta-analyses, the risks of IHD development of Gyeongju residents before (reference: Sep 2014 to Aug 2015; period 1: Sep 2015 to Aug 2016) and after (period 2: Sep 2016 to Aug 2017; period 3: Sep 2017 to Aug 2018; period 4: Sep 2018 to Aug 2019) the earthquake were estimated.

RESULTS

The monthly average incidence of IHD in Gyeongju was 39.5 persons (per 1,000,000) for reference period and 38.4 persons for period 1. However, the number increased to 58.5 persons in period 2, and 49.8 persons in period 3, following the earthquake. The relative risk (RR) [with a 95% confidence interval] of developing IHD among Gyeongju residents increased by 1.58 times (1.43, 1.73) in period 2, 1.33 times (1.21, 1.46) in period 3, and 1.15 times (1.04, 1.27) in period 4, in comparison to both the control cities and the pre-earthquake reference period. The increase in RR was particularly noticeable among women, adults aged 25-44, and individuals with lower incomes.

CONCLUSIONS

The major earthquake in Korea was associated with an increase in the development of IHD among local residents. Individuals exposed to earthquakes may benefit from cardiovascular health surveillance.

Impact of Earthquake on Cardiovascular Health: What Should Cardiovascular Healthcare Providers Anticipate After the Devastating Earthquakes in Turkey and Syria?

Natural disasters like earthquakes have direct and indirect association with major adverse cardiac events. They can impact cardiovascular health by multiple mechanisms not to mention their impact on cardiovascular care and services. Besides the humanitarian tragedy that calls attention globally, we as part of cardiovascular community are concerned with the short and long outcomes of those who survived the recent Turkey and Syria earthquake tragedy. Therefore, in this review, we aimed to draw attention of cardiovascular healthcare providers to the anticipated cardiovascular issues that may arise in survivors on short- and long-term postearthquakes to ensure proper screening and earlier management of this population. With the anticipated increase in natural disasters in future considering climate changes, geological factors, and human activities, the cardiovascular healthcare providers as part of medical community should be aware of the high rate of cardiovascular disease burden that can occur among survivors of earthquakes and other natural disasters, so, they should act accordingly in terms of preparedness measures, adequate response planning starting from services re-allocation to personnel training and enhancing access to medical and cardiac care in both acute and chronic contexts, not to mention screening and risk-stratifying the patients to optimize their management.

Seismic activity and development of mood disorders: Findings from the 2016 Kyungju earthquake

BACKGROUND

An earthquake with a moment magnitude of 5.8 occurred in Kyungju on 12 September 2016. Although the earthquake was the largest seismic activity in Korean history, there were no direct casualties from the event. This study evaluated whether a moderate-level earthquake is related to acute development of mood disorders in earthquake-exposed residents.

MATERIAL AND METHODS

The healthcare information of residents (n = 865,263) living in Kyungju and control cities (Gimpo, Jeonju, Gimhae, and Pohang) over a 10-year period (from 2010 to 2019) was gathered from the national health insurance database. Difference-in-difference analysis was used to compare the daily incidence of mood disorders (manic episode; bipolar affective disorder; depressive episode; recurrent depressive disorder) 20 weeks before (reference: -20 to -11 weeks, period 1: -10 to -1 weeks) and after (period 2: 0-9 weeks, period 3: 10-19 weeks) the earthquake. Subregional analyses based on the distance to the epicenter and stratification analyses by sex, age, and income were conducted.

RESULTS

The weekly average incidence rate (/100,000 persons) of mood disorders in Kyungju residents increased from 27.0 (-20 to -11 weeks) and 28.3 (-10 to -1 weeks) persons before the earthquake, to 38.1 persons (0 to 9 weeks) after the earthquake. A significant increase in the risk of developing mood disorders was observed in Kyungju residents during the 0 to 9 weeks after the earthquake when compared to the control cities [relative risk (95 % confidence intervals): vs. Gimpo, 1.40 (1.05, 1.88); vs. Jeonju, 1.45 (1.14, 1.84); vs. Gimhae, 1.48 (1.14, 1.93)]. The increase was more prominent in women, low-income individuals, and those living closer to the epicenter.

CONCLUSION

Moderate-level earthquakes without direct casualties may cause mood disorders in residents living in affected areas. Mental health aid programs should be provided to earthquake victims even if the earthquake has caused limited life and property loss.

The connection between heart rate variability (HRV), neurological health, and cognition: A literature review

The heart and brain have bi-directional influences on each other, including autonomic regulation and hemodynamic connections. Heart rate variability (HRV) measures variation in beat-to-beat intervals. New findings about disorganized sinus rhythm (erratic rhythm, quantified as heart rate fragmentation, HRF) are discussed and suggest overestimation of autonomic activities in HRV changes, especially during aging or cardiovascular events. When excluding HRF, HRV is regulated via the central autonomic network (CAN). HRV acts as a proxy of autonomic activity and is associated with executive functions, decision-making, and emotional regulation in our health and wellbeing. Abnormal changes of HRV (e.g., decreased vagal functioning) are observed in various neurological conditions including mild cognitive impairments, dementia, mild traumatic brain injury, migraine, COVID-19, stroke, epilepsy, and psychological conditions (e.g., anxiety, stress, and schizophrenia). Efforts are needed to improve the dynamic and intriguing heart-brain interactions.

Sudden gamer death: non-violent death cases linked to playing video games

BACKGROUND AND AIMS

Internet gaming disorder (IGD) is an emerging problem. Rarely, media reports about people, who have died during playing video games, but thus far no systematic, scientific study is available about the topic. We investigated such cases, looking for common characteristics, connection between gaming and death, and the possible reasons leading to death.

METHODS

Cases were collected through internet search with general keywords, with ones specific to identified cases, and by working along cross references.

RESULTS

24 cases were found: one from 1982, the others between 2002 and 2021. Twenty-three of the victims were male, age ranged from 11 to 40 years. More than half of the cases originated from Southeast Asia, and 12 deaths happened in internet cafes. Gamers played action-rich multiplayer games. In 18 cases the gaming session before death was extremely long (around a day or even several days) with minimal rest. The cause of death was pulmonary embolism in 5 cases, cerebral hemorrhage in 2 cases, most of the rest was presumably due to fatal cardiac arrhythmia.

DISCUSSION

Long sedentary position and dehydration may precipitate thromboembolism, acute blood pressure elevation during gaming may promote cerebral hemorrhage, and several factors (including acute and chronic sleep deprivation, exhaustion, stress) can lead to acute autonomic dysfunction and fatal arrhythmia.

CONCLUSION

Incidence of non-violent death cases linked to playing video games is presumably very low. It mostly occurs in young males and it is often characterized by extremely long gaming time.

Projecting the Impacts of a Changing Climate: Tropical Cyclones and Flooding

PURPOSE OF REVIEW

There is clear evidence that the earth's climate is changing, largely from anthropogenic causes. Flooding and tropical cyclones have clear impacts on human health in the United States at present, and projections of their health impacts in the future will help inform climate policy, yet to date there have been few quantitative climate health impact projections.

RECENT FINDINGS

Despite a wealth of studies characterizing health impacts of floods and tropical cyclones, many are better suited for qualitative, rather than quantitative, projections of climate change health impacts. However, a growing number have features that will facilitate their use in quantitative projections, features we highlight here. Further, while it can be difficult to project how exposures to flood and tropical cyclone hazards will change in the future, climate science continues to advance in its capabilities to capture changes in these exposures, including capturing regional variation. Developments in climate epidemiology and climate science are opening new possibilities in projecting the health impacts of floods and tropical cyclones under a changing climate.

Review on Disasters and Lower Limb Venous Disease

As per the World Health Organization, a disaster is defined as “an event that occurs in most cases suddenly and unexpectedly, causing severe disturbances to people or objects affected by it, resulting in the loss of life and harm to the health of the population.” A number of health issues are often reported following disasters, such as physical and psychological trauma, infections, malnutrition, and cardiovascular events. Among these, venous thromboembolism is deemed serious and thus should be taken into consideration. Indeed, its risk has been demonstrated to increase following earthquakes, floods, burns, and intoxications. The recent coronavirus pandemic summarizes some of the main triggering factors involved in acute and chronic venous disease development in a disaster setting: inflammation, infection, lockdown-induced reduced mobility, potential malnutrition, and overweight.

Proper venous risk assessment and guideline application have been determined to be essential in disaster management, particularly in the current time in which sheltering could lead to a potential exacerbation of the pandemic, which can only increase the risk for venous thrombotic diseases.

Global scientific teamwork is needed to make the recommendations as evidence-based and as homogeneous as possible among continents.

In this present review, we focus on how earthquakes impact venous thromboembolism, including an analysis of other disaster-related conditions, such as burns and intoxication. (This is a review article based on the informative seminar of the 40th Annual Meeting of Japanese Society of Phlebology.)

Clinical Features of Patients With Heart Failure After the 2016 Kumamoto Earthquakes

OBJECTIVE

Acute and chronic stress after severe earthquakes can contribute to cardiovascular events, including heart failure (HF). On April 14, 2016, magnitude 7 earthquakes occurred in the Aso region in the western part of Japan. This study aimed to investigate the clinical characteristics of HF in this area after these earthquakes.

METHODS

We investigated the clinical characteristics and 1-y mortality rate of patients with HF. Nutritional status was evaluated with the Geriatric Nutritional Risk Index (GNRI) and the Prognostic Nutritional Index (PNI).

RESULTS

Among a total of 58 cardiovascular events, HF was the most frequently observed (n = 28). The mean age of individuals with HF was 85.5 y. The total incidence of HF was significantly higher compared with the average of the prior 2 y. Disaster influence on mental health was suggested by patient history in 20 patients (71%). The 1-y mortality rate among patients with HF was 50%. Among those who died, 93% had malnutrition status (GNRI <92 and /or PNI ≤38).

CONCLUSIONS

Our results demonstrated the poor prognosis of patients with HF following the disaster. The prevalence of malnutrition was high in those patients. Careful follow-up is necessary, especially for older people with frailty.

The relationship between acute stress and neurophysiological and behavioral measures of food-related inhibitory control: An event-related potential (ERP) study

Stress influences many health-related behaviors including diet and nutrition intake, often resulting in increased calorie intake, fewer healthy eating behaviors, and poorer nutrition. Food intake is modulated by inhibitory control and has important implications for our physical, mental, and emotional health. Yet, little is known about the relationship between stress and food-related inhibitory control. We tested the influence of a short-term experimental stressor on behavioral and event-related potential (ERP; N2 and P3 components) measures of food-related inhibitory control. Ninety-seven healthy participants were randomly assigned to complete the Trier Social Stress Test (TSST) (n = 48, 27 females [52.9%]) or a neutral control condition (n = 49, 35 females [70%]) immediately followed by food-specific go/no-go and neutral go/no-go tasks while electroencephalogram (EEG) data were recorded. Stress levels were successfully manipulated, with heightened self-report and physiological measures (heart rate and systolic blood pressure) of the stress response in individuals who completed the TSST compared to control. As expected, the high calorie food-specific go/no-go task elicited larger N2 amplitude than the neutral task. N2 component amplitude was also significantly larger following the TSST relative to the control task. There were no significant between-group or task differences for P3 amplitude or behavioral measures. Findings suggest heightened N2 amplitude following psychological stress that is not specific to food or inhibition processes and may reflect heightened arousal following stress. Future research in individuals with overweight/obesity or experiencing chronic stress will further clarify the role of stress in food-related inhibitory control.

A massive natural disaster, the Great East Japan Earthquake, and the incidence of dialysis due to end-stage kidney disease

Background

Disaster-related stress can increase blood pressure and the incidence of cardiovascular diseases. However, the role of massive disasters in the development of end-stage kidney disease (ESKD) remains unknown. We investigated the incidence and different causes of dialysis initiation in patients with chronic kidney disease in a city affected by the Great East Japan Earthquake.

Methods

This was a single-center, retrospective observational study. All patients who initiated or were treated with dialysis at Kesennuma City Hospital between 2007 and 2020 were enrolled. The year of dialysis initiation was retrospectively determined based on the initiation date. The causative renal diseases that led to the need for dialysis initiation were divided into four groups: diabetic nephropathy, hypertensive renal disease, glomerulonephritis, and others.

Results

Age at dialysis initiation differed significantly among the four groups (p = 0.0262). There was a significant difference in the numbers of the four groups before and after the Great East Japan Earthquake (p = 0.0193). The age of hypertensive renal disease patients was significantly higher than those of patients with diabetic nephropathy (p = 0.0070) and glomerulonephritis (p = 0.0386) after the disaster. The increasing number of dialysis initiations after the Great East Japan Earthquake appeared to be associated with changes in hypertensive renal diseases; the number peaked after 10 years.

Conclusions

There was an increase in the number of dialysis initiations, especially caused by hypertensive renal diseases, for up to 10 years after the Great East Japan Earthquake.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40620-021-01140-9.

Identifying and Describing Impact of Disasters on Non-Communicable Diseases: A Systematic Review

BACKGROUND

Patients with non-communicable diseases are vulnerable to disasters. This is a systematic review describing the impact of disasters on non-communicable diseases.

METHODS

A systematic review was conducted using PRISMA standards. Relevant articles published from 1997 to 2019 collected by searching the Scopus, PubMed, Science Direct, databases. We specifically examined reports describing NCDs and including the key words "non-communicable disease and Disasters". NCDs included cardiovascular, respiratory, diabetes, cancer and mental health diseases.

RESULTS

Of the 663 studies identified, only 48 articles met all the eligibility criteria. Most studies have shown the impact of all natural disasters on non-communicable diseases (39.8% n=19). The largest study was the effect of earthquakes on non-communicable diseases (29.2% n=14). For the NCDs targeted by this research, most of the included studies were a combination of four diseases: cardiovascular disease, respiratory disease, diabetes and cancer (44% n=21). Followed by cardiovascular disease (14.6% n=7), chronic respiratory disease (12.5% n=6), diabetes and cancer (6.2% n=3) and mental health (12.5% n=6).

CONCLUSION

The incidence of disasters affects the management of treatment and care for patients with NCDs. Specific measures include a multi-part approach to ensuring that patients with non-communicable diseases have access to life-saving services during and after disasters. The approach of the health system should be expanded from traditional approaches to disasters and requires comprehensive planning of health care by policy makers and health professionals to develop effective strategies to enable patients to access medical, therapeutic and diagnostic services in natural disasters.

Public health impact of daily life triggers of sudden cardiac death: A systematic review and comparative risk assessment

BACKGROUND

Sudden cardiac death (SCD) may be triggered by daily circumstances and activities such as stressful psycho-emotional events, physical exertion or substance misuse. We calculated population attributable fractions (PAFs) to estimate the public health relevance of daily life triggers of SCD and to compare their population impacts.

METHODS

We searched PubMed, Scopus and the Web of Science citation databases to retrieve studies of triggers of SCD and cardiac arrest that would enable a computation of PAFs. When more studies investigated the same trigger, a meta-analytical pooled risk random-effect estimate was used.

RESULTS

Of the retrieved studies, eight provided data enabling computation of PAFs. The prevalence of exposure within population for SCD triggers in the control periods ranged from 1.06% for influenza infection to 8.73% for recent use of cannabis. Triggers ordered from the highest to the lowest risk increase were: physical exertion, recent cocaine use, episodic alcohol consumption, recent amphetamine use, episodic coffee consumption, psycho-emotional stress within the previous month, influenza infection, and recent cannabis use. The relative risk increase ranged from 1.10 to 4.98. By accounting for both the magnitude of the risk increase and the prevalence in the population, the present estimates of PAF assign 14.5% (95% confidence interval [CI] 4.9-28.5) of all SCDs to episodic alcohol consumption, 9.4% (95% CI 1.2-29.3) to physical exertion, 6.9% (95% CI 0.3-25.0) to cocaine, 6% (95% CI 1.2-14.6) to episodic coffee consumption, 3% (95% CI 0.4-6.8) to psycho-emotional stress in the previous month, 1.7% (95% CI -0.9 to 12.9) to amphetamines, 0.9% (95% CI -4.9 to 12.5) to cannabis, and 0.3% (95% CI 0.2-0.4) to influenza infections.

CONCLUSIONS

In addition to episodic alcohol consumption, a trigger with the greatest public health importance for SCD, episodic physical exertion, cocaine use and coffee consumption also show a considerable population impact.

Establishing the Status of Patients With Non-Communicable Diseases in Disaster: A Systematic Review

OBJECTIVE

People with NCDs are particularly vulnerable to disasters. This research systematically reviewed reports describing studies on the status of patients with NCDs before, during and after disasters.

METHOD

Relevant articles published from 1997 to 2019 were collected by searching the Scopus, PubMed, and Science Direct databases. We specifically examined reports describing NCDs and including the key words 'Non-Communicable Disease and Disasters.' NCDs include cardiovascular, respiratory, diabetes and cancer diseases.

RESULTS

The review identified 42 relevant articles. Most of the included studies were found to have described the conditions of patients with NCDs after disasters - 14 (13.3%), during disasters - 11 (26.2%), before disasters - 6 (14.3%), within all stages of disasters: before, during and after - 6 (14.3%), only during and after disasters - 4 (9.5%), and includes before and during disasters - 1 (2.4%).

CONCLUSION

NCDs pose major health issues in disasters. Development of strong counter measures against the interruption of treatment, as well as surveillance systems to ascertain medical needs for NCDs are necessary as preparation for future disasters.

Philemon and Baucis deaths: A case of two siblings and state of the art

The simultaneous discovery of two corpses at the same scene obliges the forensic pathologist to consider many circumstances. First, the hypothesis of homicide/crime has to be investigated. However, when the circumstances, autopsy, histological data and toxicological and biochemical analyses suggest a natural cause of death, Philemon and Baucis syndrome should be considered. While a few cases of Philemon and Baucis deaths involving couples of spouses have been reported in the literature, only one paper describes the simultaneous deaths of two siblings. The case presented here concerns the death of two siblings who were found in an advanced stage of decomposition in their apartment, which had been allocated to them by social services. The victims were known to be living in conditions of social and economic deprivation and to be suffering from psychiatric disorders. The first suspected cause of death was malnutrition. However, this was excluded by complete autopsy, histological studies and, especially, biochemical investigations, which excluded starvation ketoacidosis. Moreover, no evidence of trauma or poisoning was found in either of the bodies. Despite the advanced stage of decomposition, one of the bodies presented with histological signs of myocardial sclerosis, left ventricular hypertrophy and contraction band necrosis, suggesting that the mechanism of death involved a fatal arrhythmia. The circumstances and the post-mortem findings were highly suggestive of Philemon and Baucis syndrome.

Using Logistic Regression to Identify Leading Factors to Prepare for an Earthquake Emergency during Daytime and Nighttime: The Case of Mass Earthquake Drills

Historical data have demonstrated that earthquakes can happen any time of the day and night. Drills may help communities to better prepare for such emergencies. A cross-sectional survey was conducted from 4 October to 20 November 2017, in Mexico City. The sample size was 2400. The addressed research questions were “what factors predict the likelihood that respondents would report that they agree on conducting mass evacuation drills: (a) any time of the day and (b) any time at night?” The logistic regression technique was employed to identify the factors leading to the outcome. In relation to (a), five variables were significantly associated with the outcome, i.e., age, frequency of drills, warning time, knowledge on what to do, and “perception vulnerability city”. Regarding (b), five variables were also significantly associated with the outcome variable, i.e., age, level of education, frequency of drills, negative emotions, and fear of house/building collapsing. More generally, several drills should be conducted any time of the day and night; further, 50% of them should be announced and 50% unannounced. Furthermore, the time of earthquake drills should be randomly selected. In this way, we may just match the spatial–temporal dimension of an earthquake emergency. It is hoped that the findings will lead to better preparedness of the residents of the capital city during an earthquake occurrence.

GPER-Deficient Rats Exhibit Lower Serum Corticosterone Level and Increased Anxiety-Like Behavior

Ample evidence suggests that estrogens have strong influences on the occurrence of stress-related mood disorders, but the underlying mechanisms remain poorly understood. Through multiple approaches, we demonstrate that the G protein-coupled estrogen receptor (GPER) is widely distributed along the HPA axis and in brain structures critically involved in mood control. Genetic ablation of GPER in the rat resulted in significantly lower basal serum corticosterone level but enhanced ACTH release in response to acute restraint stress, especially in the female. GPER^−/− rats of either sex displayed increased anxiety-like behaviors and deficits in learning and memory. Additionally, GPER deficiency led to aggravation of anxiety-like behaviors following single-prolonged stress (SPS). SPS caused significant decreases in serum corticosterone in WT but not in GPER-deficient rats. The results highlight an important role of GPER at multiple sites in regulation of the HPA axis and mood.

Related Factors Associated With Earthquake Inpatient Mortality

OBJECTIVES

To date, we have only limited evidence of the determinants of earthquake inpatient mortality-related factors. This study is among the first to explore related factors of inpatient deaths using data from multiple hospitals and multiple earthquakes.

METHODS

We included and retrospectively analyzed data on 32,976 earthquake inpatients in the West China Earthquake Patients Database. Of these, we analyzed the records of 284 patients who died during hospitalization. We collected 12 dichotomous variables with reference to previous reports: patients' age (both ≤ 15 years and ≥ 65 years), gender, prehospital treatment, intensive care unit (ICU) admission, the presence of severe traumatic brain injury (TBI), trunk injury, severe poly-trauma, crush syndrome, multiple-system organ failure (MSOF), infection, and cardiac/respiratory disease. We performed multivariate logistic regression analysis to explore independent related factors of mortality.

RESULTS

Ultimately, we identified severe TBI, MSOF, old age (≥ 65 years), ICU admission, crush syndrome, and cardiac/respiratory disease as independent mortality-related factors. Severe TBI was the greatest risk factor of inpatient death (ods ratio [OR], 31.913, 95% confidence interval [CI], 20.484-49.720), followed by MSOF (OR 30.905, 95% CI, 21.733-43.947).

CONCLUSION

To reduce earthquake inpatient mortalities, the related factors analyzed in this study should be prioritized in future inpatient earthquake response strategies.

Study Protocol for the COVID-19 Pandemic Adjustment Survey (CPAS): A Longitudinal Study of Australian Parents of a Child 0-18 Years

BACKGROUND

The COVID-19 pandemic presents significant risks to the mental health and wellbeing of Australian families. Employment and economic uncertainty, chronic stress, anxiety, and social isolation are likely to have negative impacts on parent mental health, couple and family relationships, as well as child health and development.

OBJECTIVE

This study aims to: (1) provide timely information on the mental health impacts of the emerging COVID-19 crisis in a close to representative sample of Australian parents and children (0-18 years), (2) identify adults and families most at risk of poor mental health outcomes, and (3) identify factors to target through clinical and public health intervention to reduce risk. Specifically, this study will investigate the extent to which the COVID-19 pandemic is associated with increased risk for parents' mental health, lower well-being, loneliness, and alcohol use; parent-parent and parent-child relationships (both verbal and physical); and child and adolescent mental health problems.

METHODS

The study aims to recruit a close to representative sample of at least 2,000 adults aged 18 years and over living in Australia who are parents of a child 0-4 years (early childhood, N = 400), 5-12 years (primary school N = 800), and 13-18 years (secondary school, N = 800). The design will be a longitudinal cohort study using an online recruitment methodology. Participants will be invited to complete an online baseline self-report survey (20 min) followed by a series of shorter online surveys (10 min) scheduled every 2 weeks for the duration of the COVID-19 pandemic (i.e., estimated to be 14 surveys over 6 months).

RESULTS

The study will employ post stratification weights to address differences between the final sample and the national population in geographic communities across Australia. Associations will be analyzed using multilevel modeling with time-variant and time-invariant predictors of change in trajectory over the testing period.

CONCLUSIONS

This study will provide timely information on the mental health impacts of the COVID-19 crisis on parents and children in Australia; identify communities, parents, families, and children most at risk of poor outcomes; and identify potential factors to address in clinical and public health interventions to reduce risk.