Addressing mental health needs during the Covid-19 pandemic and beyond

Challenge

The outbreak of the COVID-19 pandemic began in December 2019, forcing countries to take unprecedented social distancing measures aimed at containing the disease’s spread (Ransing et al. 2020). The effects of the viral pandemic have led to increased morbidity and mortality, while the precautionary measures taken have led to financial losses and a stifled economy. The pandemic has also triggered mental health conditions (Adhanom Ghebreyesus 2020; Ransing et al. 2020; OECD 2020). It has become clear that the COVID-19 crisis is accompanied by mental health consequences, which are likely to be even greater than what was witnessed in previous disasters, and will continue after the pandemic ends (Fiorillo and Gorwood 2020; Raker, Zacher and Lowe 2020). Some research predicts that the COVID-19 outbreak may lead to a second pandemic of mental health crises (Choi et al. 2020).

Even before the COVID-19 outbreak, statistics on mental health have been alarming. Depression and anxiety alone cause a global economy loss of more than 1 trillion USD per year (UN 2020). In low- and middle-income countries, between 76% and 85% of the people diagnosed with mental health conditions do not receive treatment (OECD 2020a; WHO 2019). Moreover, there is less than 1 mental health professional for every 10,000 people globally (UN 2020).

Given the unprecedented, frontline-role that the individual members of the population are playing in mitigating the progression of the epidemic throughout a country, through their personal behaviors, lifestyle decisions, and adherence to advice from health policymakers, the importance of addressing psychological distress in the population cannot be overemphasized (OECD 2020b, 2020c). The COVID-19 crisis has affected individuals’ mental health in different ways (OECD 2020b, 2020c; UN 2020; UN Population Fund 2020), resulting in loneliness, fear, trauma, unemployment, stress, 20% increased alcohol consumption in Canada (UN 2020), and 60% increased domestic abuse in Europe (UN 2020). The pandemic has also caused a social stigma for COVID-19 patients, their families, healthcare workers (HCWs), and certain ethnic groups. This can result in people not getting tested and treated (UNICEF 2020).

In many pandemic situations, frontline HCWs find themselves overwhelmed, with limited resources and inadequate support (Valle 2016; WHO 2015). This exposes them to numerous stressors; when not properly attended, these stressors cause repercussions on the quality of care provided (UN 2020). The psychological impact of COVID-19 on frontline HCWs is serious and can have long term effects (Lai et al. 2020). Recent reports have described that HCWs are facing elevated levels of stress, anxiety, depression (Du et al. 2020), severe insomnia, obsessive-compulsive symptoms, somatization (Zhang, Wang et al. 2020), vicarious traumatization (Li et al 2020), and increased risk of developing other mental health problems (Greenberg et al. 2020). The impact has even led the most vulnerable HCWs to commit suicide (Montemurro 2020).

The response to pandemics and crises often focuses on disease surveillance, vaccine and drug requirements, and the economic impact. Psychosocial resources and mental health interventions (Dong and Bouey 2020; Jung and Jun 2020; Ransing et al. 2020) are typically absent or limited, particularly if the mental health system has been poor prior to the crisis (Pan American Health Organization 2009; WHO 2015; Valle 2016). Currently, there is a clear global consensus that mental health care and psychosocial support are an essential part of the global health system (WHO 2013; UN 2015; Cratsley and Mackey 2018) and during disasters (WHO 2015). However, there is still an urgent need to invest in mental health prevention and care before, during, and after the pandemic. If the size of the problem is not addressed, this will lead to an even more drastic increase in the number of people suffering and will have long-term social and economic costs to society (UN 2020).

Proposal

The COVID-19 pandemic provides the G20 leaders with an opportunity to act unanimously in addressing this unfolding mental health crisis. It is vital to include stakeholders from various public and private sectors in the development and implementation of policies (McDaid 2005). Their engagement in the process ensures that plans and recommendations taken can be implemented and are aligned with the resources and local context (McDaid 2005). Moreover, non-government organizations (NGOs) play an important role in providing tangible examples of effective services that would help facilitate policy development and implementation (McDaid 2005).

This policy brief focuses on the following aspects related to responding to mental health needs during the COVID-19 pandemic:

1. Recognize the need for embedding mental health in Emergency Preparedness Response
A lesson learned from the COVID-19 pandemic and previous crises is that we need to invest more in emergency preparedness, now and for the future. The health systems need to focus on prevention and early detection, as well as be well-prepared and equipped to respond efficiently and promptly without jeopardizing the quality of care provided and adding a drastic increase on cost. Building strong, resilient health systems is important for effective responsiveness, but that cannot be achieved without the inclusion of mental health (Adhanom Ghebreyesus 2020).

1.1 Address mental health and psychosocial concerns in COVID-19 national emergency responses. During a crisis such as the COVID-19 pandemic, government institutions across different sectors should assess the impact of the precautionary measures and decisions not only at the financial and social levels but also at the level of the mental health and well-being of the population and specific vulnerable groups (UN 2020). These measures (such as stay-at-home emergency measures) should be well planned not only to protect the physical health of people from any pandemic-related adversities but also to minimize any harm on their mental health (UN 2020). This enhances people’s coping skills and adaptivity, eases lockdown restrictions, reduces suffering, and speeds up recovery, opening the way to rebuilding of communities (UN 2020). However, in the case of lockdown restrictions, mental health services should be made more accessible through remote support and technology-based treatments and interventions.

1.2. Ensure that mental health care services are available and uninterrupted for COVID-19 patients and people with severe mental health conditions and psychosocial disabilities. It is reported that the mental health needs of COVID-19 patients, quarantined family members, and medical personnel have been poorly handled (Duan and Zhu 2020). As part of the mental health response during pandemics, governments should ensure that Departments of Mental Health or other authoritative organizations are able to assume a leadership position in the psychosocial management of disaster-like situations and plan psychological intervention activities (de Girolamo et al. 2020; Duan and Zhu 2020). This necessitates efficient utilization of mental health resources and requires departments in health facilities to coordinate and communicate with each other about the best way to assess mental health needs of patients, provide relevant treatment, and ensure follow-up and evaluations (Duan and Zhu 2020).

High priority should also be given to protecting and promoting the human rights of people with severe mental, neurological, or substance use disorders and psychosocial disabilities (Adhanom Ghebreyesus 2020; WHO 2020a). In-person treatment must be defined as an essential service to be continued throughout the pandemic; no one should be left untreated. Continuation or suspension of in-person treatment should be decided on a case-by-case basis, depending on the severity of the mental conditions, or the importance of the healthcare needed, such as prenatal and maternal mental healthcare (WHO 2020a).

Training healthcare teams consisting of counsellors, nurses, or social workers can play a major role in mental health response. This will require strengthening personnel training, optimizing organizational and management policies, and constantly reviewing experiences in practice (Duan and Zhu 2020).

1.3. Enhance remote support for mental health care during pandemics. Remote support is needed in pandemic situations while people are forced to stay in their homes and HCWs have to be on the frontline. Many mental health centers and hospitals had to give their beds to COVID-19 patients to help in this crisis, causing increased scarcity in mental health services (UN 2020). In Madrid city, the number of beds available for people needing emergency mental health services was reduced by 75% (UN 2020). Therefore, governments and other community actors need to invest more in remote technology-based interventions, innovations in mental health care and sharing of resources to ensure adequate coverage and equal access (UN 2020). Mental health e-treatments and tele-interventions have been proven to be as effective as in-person treatment (UN 2020). Remote psychosocial support and hotlines should especially be available to vulnerable groups such as older adults experiencing loneliness, those with pre-existing health conditions (Raker, Zacher and Lowe 2020); women confined at home facing domestic violence (Adhanom Ghebreyesus 2020; OECD 2020a, 2020b; UN 2020 Population Fund); and youth who are exceedingly affected by a higher level of mental health distress that is aggravated by social isolation, disrupted education, and future uncertainty (OECD 2020c; UN 2020).

1.4. Ensure updates about COVID-19 are released regularly and made accessible to all people, in ways that support mental health, psychosocial well-being, and prevent social stigma. The COVID-19 pandemic has provoked social stigma that affected COVID patients, their families, HCWs, and certain ethnic groups. Although it is understandable for people to be confused, anxious and afraid due to an unknown disease like this, fueling stigma can hinder social cohesion and the ability to confine the spread of the virus. Stigma can result in people hiding their illness and not getting screened, treated, and quarantined (UNICEF 2020).

One of the causes of heightened stigma, anxiety and psychiatric distress during COVID-19 has been insufficient knowledge about how the coronavirus is transmitted, treated and how infection is controlled (Shanafelt, Ripp and Trockel 2020; UNICEF 2020).

Governments, key players, and various media channels have a critical role in avoiding this stigma and its associated issues which hamper response efforts (Druss 2020; UN 2020; UNICEF 2020)). Communication is key; proper simple words should be used, misconceptions should be corrected, and messages should be released to show support for both people infected and those on the frontlines (Fleming 2020; Ransing et 2020; UNICEF 2020). Successful examples for mental health initiatives targeting youth and older adults, include Germany, Ireland, Portugal, and the United Kingdom. These initiatives involve dissemination of information, access to educational material, mental health advice, and combatting stigma via videos, webinars, social media, and trainings (OECD 2020c).

2. Establishing an integrated National Emergency Mental Health Plan that considers the actions needed for every phase of a pandemic (before, during and after).
There are a number of principles that need to be considered when developing this plan. Global solidarity and partnership are required, bringing together expertise of different countries, sharing innovations, and ensuring accessibility to new technologies and resources (Pan American Health Organization 2009).

2.1. Conduct a thorough evaluation of the current mental health resources and capabilities available, as well as an assessment of the mental health needs, as an initial phase of planning. Based on this evaluation, resources can be mobilized and re-evaluated, focusing on building human resource capacity to deliver high-quality mental, health, and social care (UN 2020). This can be built across not only the health sector but also social and educational sectors, especially in low-and middle-income countries with limited budgets (UN 2020). Psychiatric organizations should work closely with scientific agencies and various government sectors to evaluate mental health needs and expand on clinical and educational interventions (Kaufman et al. 2020).

2.2. Consolidate and enhance financial support for development of mental health programs during crises. Despite the increase in mental health conditions in general and specifically during crisis (National Center for Chronic Disease Prevention and Health Population 2012), this sector has received little attention from policy makers, stakeholders, and researchers. Countries spend only 2% of their health budgets on mental health on average; and less than 1% of all development assistance for health goes to mental health (Gilbert et al. 2015). Unfortunately, we lack replicable, scalable, and applicable frameworks to help plan, develop, and deliver mental health care during pandemics. It is time for governments and other actors to invest in current mental health momentum by developing and funding national strategies and community-based services (UN 2020).

2.3. Combine organizations’ efforts by working collectively and building coalitions to develop mental health interventions. The plan should call on different NGOs, as well as both private and government psychiatric organizations to develop mental health interventions and effective coping strategies. Organizations in key roles need to jointly prepare and provide resources and expertise that are required to address the high flood in psychosocial needs during pandemics/disasters (Kaufman et al. 2020; Newnham et al. 2016).

The focus should be on strengthening community psychosocial support mechanisms that already exist (UN 2020). This includes helping isolated people stay connected, reduce loneliness (especially in older adults), support frontline HCWs, aid people who have lost their incomes, assist people in adopting alternative solutions, and ensure people can grieve safely with respect to cultural traditions (Pan American Health Organization 2009; UN 2020). This should rely on local expertise and experiences of those who are well trained to respond during emergencies and provide psychological first aid support (Newnham et al. 2016; Valle 2016). For example, members of the community (teachers, police force, fire personnel) can be trained and involved in psychological first aid to improve emotional distress among people (WHO 2020b).

In cases of emergency, investing in programs and interventions that promote psychosocial wellbeing is a wise decision (UN 2020). It is also important to ensure that these services and interventions are effective, affordable, and adaptable to ethnic and cultural characteristics (Pan American Health Organization 2009).

2.4. Inclusion of mental health care as part of a universal health coverage. Populations suffering from poor mental health and elevated psychosocial distress will show reduced adherence to physical health interventions as well as to public health measures and guidance (Adhanom Ghebreyesus 2020). Thus, it is critical to ensure that mental health care is no longer excluded from healthcare benefit packages and insurance plans (UN 2020). The COVID-19 outbreak has placed a huge burden on all types of health facilities, including mental health centers, psychiatric hospitals, and clinics (Shanafelt, Ripp and Trockel 2020). Resources are scarce and constrained in crisis situations, which limits the capabilities of health professionals to address the mental health needs of the people, in general, and the vulnerable groups, in specific. Therefore, it is critical for governments to strengthen mental healthcare systems by putting in place contingency plans that can secure continuity of vital services and treatment (Druss 2020). This will also require building capacities and partnerships with public health organizations (Druss 2020).

3. Instate mental health support mechanisms for healthcare teams working to provide care during the COVID-19 pandemic.
There is no doubt that HCWs are a specific concern during the COVID-19 outbreak, and at times of crises generally, as they are at the focal center of the health response. Their occupation already exposes them to significant stress and anxiety while providing them with minimal, if any, mental health support (Heilbron 2020). Research on previous pandemics has shown that HCWs were highly likely to develop post- traumatic stress disorder, depression, and substance abuse. Preliminary results published from China and Italy during the COVID-19 epidemic further confirm this (Adams and Walls 2020; Brooks et al. 2020). In a survey conducted in Italy, HCWs were found to suffer from post-traumatic stress disorder (49%), severe depression (24.7%), and anxiety (19.8%) (Lai et al. 2020; Rossi et al. 2020). These figures exacerbate the already high prevalence of mental health problems in this profession, in addition to physicians’ suicidality rates being the highest than in any other profession (Angres et al. 2003; Kalmoe et al. 2019). Numerous studies have reported a vast list of concerns that HCWs face, such as fear of getting infected and transmitting the virus to their co-workers and families (Crew et al. 2020), lack of adequate support (Lai et al. 2020), shortage of medical equipment and personal protection equipment (Ayanian 2020), expanding workload caring for COVID-19 patients and shortage of staff (Ayanian 2020), changing instructions and information (Heilbron 2020), lack of sleep and work-related burnout (Pfefferbaum and North 2020), limited support at home (Heilbron 2020), stigma (Nezlek et al. 2012; Heilbron 2020; Troyer, Kohn and Hong 2020), and difficult access to mental health services (Ayanian 2020). Therefore, anticipating the needs of the heath workforce and protecting them should be a crucial aspect of the public health response to the COVID-19 outbreak (Lai et al. 2020). Focusing on enhancing their mental health will affect the quality of their work, hence improving the lives of their patients and the care given (Heilbron 2020).

There should be a focus on developing customized psychological interventions and assistance plan for HCWs (Chen et al. 2020) such as:

• developing customized mental health training programs to strengthen and prepare HCWs to provide psychological support and tackle mental health challenges (Duan and Zhu 2020; Greenberg et al. 2020),
• establishing prevention strategies such as screening for psychological distress (Ayanian 2020),
• providing easily accessible stress management tools (Heilbron 2020),
• providing psychosocial support to HCWs, especially for those who directly work with infected patients and dead victims (Heilbron 2020; Ransing et al. 2020).

It is likely that HCWs exposed to an outbreak like COVID-19 will have long-term psychological implications, making it difficult for them to return to their daily lives (Chew et al. 2020; Kaufman et al. 2020). These complications are not necessarily considered symptomatic mental disorders but are highly dependent on family and community support to overcome them (Pan American Health Organization 2009). Previous approaches, such as a hotline support and talking to a mental health professional, have been useful, but it was found that support from family, friends, or employers is what HCWs seek the most (Heilbron 2020).

4. Development of an evidence base for mental health during and after pandemics
As a prerequisite for any policy development, conducting a systematic assessment of the status of a country, by considering local epidemiology rates, availability of existing mental health services, as well as funding mechanisms, is recommended (McDaid 2005). Conducting research to understand the extent of the mental health impact as well as the social and economic effects of the pandemic on the population will strengthen the advocacy forces (UN 2020). Understanding the potential short-term and long-term impact of the pandemic on our mental health, as well as ways to mitigate the problem, is an issue of great importance and urgency. However, in such situations, these findings and knowledge need to be quickly made available. This will require assigning research priorities, management, international collaboration, integration between different disciplines, open-data sharing, and funding (Holmes et al. 2020; UN 2020).

The direct effects of the virus and the subsequent host immunologic response on the human central nervous system and related outcomes are still unknown, despite evidence that COVID-19 has related neuropsychiatric sequelae (Troyer, Kohn and Hong 2020). Previous studies done on past pandemics have shown that different types of neuropsychiatric symptoms may accompany acute viral infection, or may appear after infection in recovered patients. For this reason, studies and neuropsychiatric monitoring should be done throughout the life course of the infection to fully understand the short-term and long-term effect of COVID-19 on patients. This calls for establishing a framework for integrating psychoneuroimmunology into epidemiologic studies of pandemics (Troyer, Kohn and Hong 2020).

Psychiatrists have two aspects of concern, people with preexisting psychiatric disorders getting infected with COVID-19 and COVID-19 patients who might develop psychiatric symptoms, such as anxiety, fear, depression and insomnia, during the infection or after treatment with antivirals (Zhang, Zhou et al. 2020). Special attention should also be given to drug-drug interactions when psychotropic drugs are used in combination with antivirals (Zhang, Zhou et al. 2020). Moreover, countries adopting the scientist-practitioner model can facilitate the development of an evidence base for mental health during and after the crisis (Newnham et al. 2016). The model emphasizes the successful integration of science and clinical practice in psychology, which increases scientific growth and improves diagnosis and therapy (Jones and Mehr 2007).

Monitoring, evaluation, and research pre-, peri-, and post-pandemic allow the tracking of outcomes that can enable informed decision-making for future responses (Zhang, Wang et al. 2020). Any intervention or program conducted during the pandemic needs to be monitored and evaluated (Holmes et al. 2020; Raker, Zacher and Lowe 2020) as it helps provide future solutions, suppressing transmission and saving lives. One of the initial steps in the preparation phase of a pandemic is establishing a solid infrastructure, such as a Mental Health Surveillance System (Ransing et al. 2020). Building a significant capacity for research and evaluation in this field will help countries improve their performance in disaster mental health intervention (Newnham et al. 2016).

The COVID-19 pandemic swept across the globe, causing universal physical and economic harm. The aftermath has resulted in exceedingly high increases in mental health conditions which are expected to have short and long-lasting effects among individuals in society. These individuals are the frontline defense against the spread of the virus in the community, and they will also play an essential role in the return to normal pre-pandemic activities. The importance of addressing psychological distress and mental health disturbances in the population cannot be overemphasized.

We urge G20 leaders to consider incorporating mental health into COVID-19 responses as a major public health imperative to ensure recovery, and optimal health and safety of the society.

Disclaimer
This policy brief was developed and written by the authors and has undergone a peer review process. The views and opinions expressed in this policy brief are those of the authors and do not necessarily reflect the official policy or position of the authors’ organizations or the T20 Secretariat.

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