In a position paper published in The Lancet Psychiatry, a group of mental health experts and other individuals from around the world came together to discuss the influence coronavirus disease 2019 (COVID-19) poses to mental health care. The study authors noted that the pandemic reveals both system failings and opportunities for improving mental health delivery.
Potential Consequences of COVID-19
The COVID-19 public health crisis has led to a spike in known risk factors for mental health conditions, including everything from social isolation to unemployment to overall feelings of insecurity and instability. In light of these risk factors, as well as potential long-term mental health impacts, the researchers advocate for both short-term and ongoing responses.
Most general public surveys link COVID-19 to increased symptoms of depression, anxiety, and stress. Panic buying, binge-watching TV, and other unhealthy behaviors have been reported. Increased social media use, which is also reported, ups the odds of anxiety (odds ratio 1.72 [95% CI, 1.31–2.26]) and combined depression with anxiety (1.91 [1.52–2.41]). Quarantine can contribute to stress and anger and may also prompt behaviors such as online gambling.
People with COVID-19 face post-traumatic symptoms, psychological instability, depression, and anxiety. “The possibility that SARS-CoV-2 is neurotropic emphasizes the need for evaluation of potential short-term and long-term effects on the nervous system,” the study authors stated
People with pre-existing mental health conditions generally have an increased risk of infections, including SARS-CoV-2. Not only are older adults at a higher risk of severe COVID-19 illness, they also face a heightened risk of mental health issues due to possible cognitive decline. People with pre-existing mental health conditions and disorders are also especially sensitive to quarantine, physical distancing, food availability, and general disruption of their routine.
Mental Health Service Responses
The authors of the study suggest rethinking conventional mental health approaches in order to improve the cost and scale of treatment. The public health response to COVID-19 should include clear, up-to-date information about infection rates and distancing measures (to reduce uncertainty), as well as information on education, self-care, family support, and collaboration across agencies. Study authors also identified and supported steps already being taken to control infection and to promote wellness among special populations, such as healthcare workers.
Mental Health Care Adaptations
The study authors recommend an ethics- and rights-driven approach to care. They acknowledge potential discrimination “in adjudicating access to insufficiently available health interventions and applying and weighing the added risk of SARS-CoV-2 exposure in decisions about involuntary institutionalization.” Potential future service cuts, disproportionate additional illness burden, reduced service access, inadequate financial support, exacerbation of inequalities in access to health care, and the need for greater family and caregiver support are also valid concerns.
With access to care often limited, and in-person contact either limited or unavailable, patients and caregivers need to feel empowered to take ownership of their care to ensure the best outcomes, the study authors stated. Relative risks and benefits of treatment changes should be considered, especially with patients receiving clozapine, injectable medications, or electroconvulsive therapy.
“Treatment plans might need to be rapidly renegotiated, and should be based on best practices,” the researchers stated. “There is thus a need to enhance and create robust resources to support shared decision making.”
The benefit of person-centered care is noted and should not be ignored when there’s a need for rapid decision-making. Care design and delivery can be strengthened by “increased peer worker involvement in the co-design of adapted services and by increasing the number of peer workers, especially in countries with limited resources,” researchers stated.
Moving forward, the study authors suggest community monitoring and mental health screening to mitigate the potential long-term mental health effects of COVID-19. Digital health and digital phenotyping are 2 possibilities. With local needs clarified, community stakeholder groups can design interventions.
Community support services can help people experiencing acute distress, as well as those who don’t trust mainstream mental health care. Healthcare systems should thereby anticipate an increase in “unmet mental health needs” among vulnerable groups and prepare for them. Telemedicine is one way to fill gaps in care during the COVID-19 pandemic.
Provision of Mental Health Care
The authors of the study list the following indicators that should be assessed regularly during and after the pandemic, and compared with pre-pandemic data, to determine changes in delivery:
- The proportion of all mental health services provided in inpatient, emergency, institutional (eg, prisons), outpatient, community, and home-based settings
- Rates of face-to-face, video, and telephone contact with different types of mental health providers
- Rates of prescription and use of psychiatric medication
- Access to, and use of, different mental health services both by people with pre-existing mental health disorders and those with new incident cases of mental illness, and the sociodemographic characteristics of these users
- Quality of care of different mental health services (including acceptability and satisfaction with healthcare providers), with a focus on user expectations and satisfaction and on functional, vocational, and clinical outcomes (including the views of families or caregivers)
- Disparities in mental health care, with socioeconomic, race, and ethnicity data linked to quality measures
- Integration of mental health services with general health services, social welfare, and other institutions (eg, schools, prisons), and community associations
- Governmental and non-governmental financial support for mental health and social care services, and healthcare leaders should regularly monitor the use and effectiveness of mental health care. Certain indicators should be assessed regularly during and after the pandemic, and then compared with pre-pandemic data to determine changes in delivery.
“There is an opportunity to replace the old way of managing the gap between the supply of and demand for mental health care (ie, rationing) with a system that prioritizes high-quality and equitable care rather than focusing only on how much work is done,” the study authors concluded.
Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
Moreno C, Wykes T, Galderisi S, et al. How mental health care should change as a consequence of the COVID-19 pandemic. Lancet Psychiatry. 2020;7(9):813-824.