A recent position paper on the connections between mental health care and COVID-19 was met with immediate criticism for failing to include authors or perspectives from the Global South, or low- and middle-income countries. In response, the journal editors published an editorial taking responsibility for the omission and the lack of representation in the paper. Further, the editors claim that it is time for a new approach to global mental health that does not assume that expertise is concentrated in high-income countries and needs to be “scaled up” worldwide.
“It is a concern that ‘global mental health’ contains assumptions about knowledge and expertise that are inimical to the very populations it purportedly sets out to help. Without sufficient forethought, global mental health may become a globalized iteration of psychiatry’s potential to reinforce existing power structures and hierarchies,” the editors write.
The editors describe key concepts “at this end—and new beginning—of global mental health,” including calls for equity and justice, an acknowledgment of “the failings of high-income states . . . the resourcefulness of low-income and middle-income countries,” and also, “the diverse experiences of populations within those settings.”
They go on to outline two processes that are transforming global mental health:
“First, the recognition that expertise comes from individuals and communities in specific social, cultural, and economic environments, rather than the world being a blank slate on which supposedly value-neutral, technocratic solutions can be imposed.”
“Second, the development of a model of the world that goes beyond simple—and implicitly hierarchical—classification of countries by income. This model looks instead for mutual learning between communities at a more complex level.”
Global mental health implications of the COVID-19 pandemic, with its considerable variation in impact and presentation according to context, have proven challenging to characterize. In a letter to the journal in April, titled “COVID-19 gives the lie to global health expertise,” Sarah Dalglish of the Johns Hopkins School of Public Health, wrote:
“Global health will never be the same after COVID-19—it cannot be. The pandemic has given the lie to the notion that expertise is concentrated in, or at least best channeled by, legacy powers and historically rich states. We must move quickly, for our own security, beyond the rhetoric of equality to the reality of a more democratic, more multipolar, more networked, and more distributed understanding and operation of global health. Conversations about how to do so, although just beginning, are long overdue.”
The recent position paper released in The Lancet Psychiatry, led by Carmen Moreno, professor and researcher in psychology at the University of Seville, endeavored to capture the complexities and bidirectional forces at play impacting patterns associated with COVID-19 and psychological wellbeing.
Moreno and colleagues summarized potential consequences for mental health initiatives implemented by mental healthcare facilities and professionals to address rapid emergent needs, and areas in need of continued attention. The authors delineated areas of impact affecting the general public, people who have or had COVID-19, people with preexisting mental disorders, and health care workers. They go on address response efforts from public health and community outreach initiatives, those established in mental healthcare settings, and those that have been implemented to support special populations such as workers deemed essential in the context of the pandemic.
The position paper concluded by describing adaptations to the mental health care status quo that have been driven by COVID-19.
“In this Position Paper, an international group of mental health experts, including service users and carer leaders, reflects on the mental health challenges posed by COVID-19 and how best to address potential changes in services. We describe the mental health needs, potential systems adaptations, and outcome measures that can help to turn a crisis into an opportunity for improvement.”
The heterogeneity of the effects of COVID-19, according to context, cannot be overstated. For example, racial and ethnic minority communities have seen disproportionately high rates of COVID-19 incidence and mortality. Economic implications of disease containment procedures (e.g., business closures to prevent spread) will continue to exert devastating impacts on marginalized communities and “exacerbate healthcare disparities.”
There are also many ways in which, in individual facilities and communities, disease containment measures have led to innovations in access to care (e.g., increased virtual offerings and provision of home-based treatment). There is tremendous variability in the expression of impact based on resources and contextual capacity to respond.
Moreno and colleagues report that most of the research regarding shifts in mental health and associated supports in the context of COVID-19 is from survey studies —results of which are “heterogeneous, probably because of differences in methods used, study locations, and the timing of the studies in terms of the course of the pandemic.” Longitudinal research is needed.
Survey research has, however, offered some valuable insights. According to Moreno and team, surveys of the general public have indicated increases in characteristics of stress, anxiety, and depression stemming from various disease containment-related psychosocial stressors. Behavioral manifestations of these upticks have been observed in patterns such as panic buying, phobic anxiety, and indications of binge-watching television.
According to the authors, anger and risky at-home behaviors (e.g., online gambling and increases in alcohol sales in addition to at-home alcohol consumption) have also been noted. The pandemic may be fueling preexisting mental health challenges for many, and social media doesn’t appear to be helping.
The containment measures have also offered opportunities for distance from abundant stressors, and inaccessible systems present before the pandemic. The authors cite preexisting occupational issues that may be potentially circumvented during the epidemic, such as challenging commutes, in-person interpersonal problems at work, and bullying.
One particular issue capturing substantial public interest in the US has been the effects of the pandemic on children’s’ lives. As the school year steadily approaches, discussions of what school could look like and what should be prioritized in support of students have proven polarizing.
Moreno and team highlight past studies conducted in historical instances of quarantine, finding that children and teens in mandatory isolation may be at higher risk for the development of acute stress and adjustment disorders than their peers. Loneliness may be experienced as painful and amount to additional longer-term concerns. Yet, given the prolonged nature of containment measures and their sprawling reach, it isn’t easy to gauge if past research can be generalized in application to present circumstances.
According to the authors, isolation and traumatic aspects of care in the context of treatment for COVID-19 can have psychological consequences for those who are or have been infected and their families. Although many healthcare systems have gone to great lengths to provide psychosocial support to patients in acute distress undergoing care for COVID-19, high rates of post-traumatic symptoms have been noted post-hospitalization. Preliminary evidence points to potential cognitive and emotional components of the disease following severe infection, but much remains to be determined.
The position paper presents research to indicate that people with preexisting mental health challenges are at increased risk of COVID-19 infection and infection severity. Isolation and vulnerability to emotional struggles stemming from disease containment measures that may disrupt routine and regular medical support are issues for many. Downsizing inpatient units to reduce the potential for exposure may disrupt care for those with preexisting psychiatric conditions.
“Risk factors for infection with SARS-CoV-2 and a severe course of COVID-19 include severe mental illness, alcohol or drug misuse, and homelessness, all of which are associated with other risk factors such as comorbid physical conditions. People with mental disorders are at increased risk of infections in general (and thereby potentially at increased risk of COVID-19), and are more likely to develop severe organ dysfunction and to die in ICUs than people without mental disorders.”
The authors also explore the implications of COVID-19 for individuals on the frontlines, specifically healthcare workers. They reference one recent study of healthcare workers in 34 hospitals in Wuhan, suggesting that approximately half of those surveyed indicated symptoms of depression and anxiety, just over one third reported insomnia and most indicated distress. Mental health consequences for providers may be significant, particularly in the absence of space to process complex emotions and amid limited governmental guidance.
Although not addressed in this position paper, school personnel—navigating options to best support children in the midst of ambiguity regarding how and where to make schoolwork—are also balancing substantial pressures, the consequences of which should not go overlooked. Many essential workers are struggling to reconcile occupational demands and significant physiological and psychological stressors precipitated by the spread of COVID-19.
Moreno and team describe some of the ethical concerns that have emerged in the field of mental health service delivery, such as social justice issues reflected in the exaggeration of disparities that already existed (e.g., discontinuation of mental health programs already spread thin, reduced user access to support they had previously relied on, inequality in access to healthcare). They also note some indications of dwindling initiatives promoting co-production (a collaborative system of mental health service delivery driven by user priorities) despite their traction pre-pandemic.
Big picture, public health responses implemented in many countries include broad dissemination of guidance related to how to access mental health support, as well as revisions to access, insurance, and privacy terms to facilitate ease in care. Policies surrounding psychotropic prescription have also shifted in many countries. The authors indicate research is needed to investigate the effects of these abrupt changes.
In many places, “telehealth was rapidly adopted, with remote video or phone conferencing, online blended or coached therapies, and self-help therapies provided through apps.”
The authors note some evidence of short-term positive impact, yet the long-term effects and sustainability of such telehealth approaches require further investigation. Moreno et al. also outline some of the ways in which virtual supports fail to reach some of the highest-need individuals and groups, and may be insufficient in the context of severe distress.
Some examples of initiatives to combat the detrimental psychological effects of COVID-19 containment measures in countries impacted have included food delivery programs, “voluntary-sector user-run and carer-run services [organizing] emergency funds for struggling people, virtual mutual support meetings, community conversations, and online resources.”
Moreno and colleagues’ position paper calls for initiatives to empower service user knowledge and involvement:
“The role of service users in guiding person-centered approaches in mental health services is well established […] in Australia, Canada, New Zealand, the UK, and the USA, is rapidly becoming more common in Scandinavia, and is developing slowly in some Asian and Latin American countries. The need for rapid decision making should not be used to justify the circumvention of co-production protocols, and in countries where such involvement is not the norm, the COVID-19 pandemic and the renewed discussion of racial inequalities and inequalities in the availability of adequate and adapted healthcare access should be viewed as an opportunity to build user-involvement support and infrastructure.”
This position paper illustrates the potential for COVID-19 to drive shifts in mental healthcare that could ultimately increase access to supports and reduce disparities in access. However, it also reveals risks inherent in sacrificing quality and human connection in service delivery in favor of efficiency.
The expansion of some of the flexible, user-led initiatives that have surfaced during the emergence of COVID-19 may serve to ensure care better aligned with local needs than top-down efforts. However, in the absence of substantial, widespread measures to mitigate the devastating economic and social implications of disease containment measures, mental health interventions may be experienced as cheap and superficial.
Despite substantial variability in what COVID-19 has meant across states and countries, Moreno and team provide an overview of the risks and opportunities presented by these circumstances:
“Low-quality mental health care based on affordability without assessment of quality or monitoring of needs and efficiency will only contribute to increasing inequalities and worsening mental health globally. Now more than ever, we need to put in place service provision that targets health needs and reduces disparities, both globally and within individual countries. Despite substantial cross-national differences in social and mental health systems, we believe that such an approach is feasible with some location-specific adaptations. It could even turn the COVID-19 pandemic into an opportunity to improve mental health care for everyone.”
Moreno, C., Wykes, T., Galderisi, S., Nordentoft, M., Crossley, N., Jones, N., . . . Arango, C. (2020). How mental health care should change as a consequence of the COVID-19 pandemic. The Lancet Psychiatry. DOI:10.1016/s2215-0366(20)30307-2 (Link)
Dalglish, S. L. (2020). COVID-19 gives the lie to global health expertise. The Lancet, 395(10231), 1189. (Link)
Lancet Psychiatry Editors. (2020). The end, and the beginning, of global mental health. Lancet Psychiatry, 7, 538-46. (Link)