*4.4. Conclusions*

This longitudinal study aimed to access the longer-term effects of COVID-19 on mental health and wellbeing, with a particular interest in those who have experienced ACE relative to those who have not. This study shows on a group level, before any stratification, that there is a statistically significant increase in Depression, Stress, and Anxiety, and reduction in psychological well-being over time. However, when stratified by those who report ACE and those who do not, the effect of increased psychological distress is not present for the non-ACE group, though significantly reduced psychological wellbeing remains. For those who report ACE, there is significantly higher levels of psychological distress over time as well as reduced psychological wellbeing, with increased ACE relating to increased psychological distress. This study further shows that Psychological Flexibility has a strong negative relationship to psychological distress and mediated the relationship between ACE and psychological wellbeing.

Before COVID-19, the mental health services in Ireland were underfunded, and only 6% of the overall health budget was dedicated to mental health, half of what other countries such as the United Kingdom and New Zealand contribute. With such limited resources, it is of utmost importance to support those most vulnerable to the enduring effects of COVID-19. Therefore, in line with the findings of this study, those with ACEs should be considered within this category and their needs responded to accordingly.

As supported by our findings, examples of this could be through evidence-based interventions in the community and clinic that utilize Psychological Flexibility as a core concept, such as ACT, Mindfulness, or positive psychology-based interventions. Servicelevel additional measures could be adopted from other countries, i.e., Scotland National Health Service, such as improved screening [72]; and introducing a national trauma training programme in all settings (schools, prisons, police force, hospitals, etc.). Emanuel and colleagues [73] note that it is now the ethical responsibility of those in government to uphold the principle of reciprocity, whereby society should now return the goodwill shown by individuals during the COVID-19 pandemic in following public health guidelines by providing adequate medical, social and psychological support as needed during and after the initial phases of the pandemic.

**Author Contributions:** Conceptualization, A.B. (Angela Browne), L.M., A.C. and T.B.; Data curation, A.B. (Anna Berry), L.K.T., L.M., A.C. and T.B.; Formal analysis, A.B. (Angela Browne), O.S., A.C. and T.B.; Funding acquisition, T.B.; Investigation, A.B. (Angela Browne), O.S., A.B. (Anna Berry), L.K.T., M.S., L.M., A.C. and T.B.; Methodology, A.B., O.S., A.C. and T.B.; Project administration, A.B. (Angela Browne), A.C. and T.B.; Supervision, A.C. and T.B.; Validation, E.M., L.K.T., M.S., L.M., A.C. and T.B.; Visualization, A.B. (Angela Browne), M.S. and T.B.; Writing—original draft, A.B. (Angela Browne); Writing—review & editing, A.B. (Angela Browne), O.S., A.B. (Anna Berry), E.M., L.K.T., M.S., L.M., A.C. and T.B. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was, in part, funded by the Health Research Board and Irish Research Council, under grant number COV19-2020-044. This grant funded the APC.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Research Ethics Committee of University College Dublin.

**Informed Consent Statement:** Informed consent was obtained from all participants involved in the study.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author.

**Conflicts of Interest:** The authors declare no conflict of interest.
