05. How Mental Health Care Should Change as a Consequence of the COVID-19 Pandemic

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We are all aware of plenty of negatives associated with the COVID-19 pandemic. How about some positive things that might emerge? For some ideas about that, here are some suggestions about how mental health care should change due to COVID-19, from an international group of 24 clinicians, including mental health experts and mental health services users.

This is a Quick Take of a position paper in Lancet Psychiatry led by Carmen Moreno of the Complutense University School of Medicine in Madrid. The paper begins by noting many of the problems associated with this viral pandemic: the lockdown and physical distancing which can lead to social isolation and loss of income, loneliness, inactivity, limited access to essential services, increased difficulty with access to food, more access to alcohol, online gambling, decreased family and social support, among many others. These changes can negatively affect people with preexisting mental problems and induce mental health problems such as depression in previously healthy people.

So, per the article’s title, “How Mental Health Care Should Change,” they offer various suggestions. A few are COVID specific, and then comes a long list of changes that many of us have wished to see for years. First, we have some virus-related changes that the authors hope might emerge from this pandemic, like less crowding on inpatient units with a reassessment of the necessary length of stay, and a reevaluation of the need for compulsory treatment. They also mention increased emphasis on home-based care, including domiciliary care and so-called in-home hospitalization, in addition to community-based crisis and respite care. Other suggestions are flexible prescription coverage with the increased acceptability of phone-in prescriptions, long-acting injectables, and adjusting substance use treatments to more flexible individualized plans—the development of group outpatient treatments with online formats. The list also includes less risk-averse approaches to monitoring side effects, such as changing the clozapine protocols and perhaps for lithium, with a greater focus on shared decision-making and biometric monitoring. Finally, they suggest the reassessment of telemedicine and video medicine to facilitate the appropriate delivery of care, but that includes data protection, reimbursement strategies, and seeing patients at home with the associated problems of access, particularly for the less privileged members of society. This includes a reassessment of telemedicine technology leverage to facilitate rapid, flexible, and efficient team communication methods––they cite specifically mental health and primary care.

We have another list; the authors suggested some steps that many of us have been advocating long before COVID-19. I think it is helpful to hear all of these listed at once and to know that this is what 24 clinicians and service users came up with. They include increased overall mental health literacy in the population––this is in the context of educating about the mental health effects of COVID-19. Also, they emphasize the importance of self-care, coping strategies, and family support. They mention the stimulation of nonprofit or nongovernmental organizations to support mental health services. The promotion of healthy physical and mental health lifestyle measures is also on the list. There should be a low threshold destigmatized psychosocial evaluation and support services. Lastly, other ideas are peer support systems with mobilization of volunteers and retirees and, where necessary, hiring new personnel.

Now, while offering these suggestions, the authors take care to highlight the ethnic and racial disparities in access to mental health care, noting “numerous social justice concerns about the distribution of resources and underlying social drivers of inequality.” Interestingly, they credit the second wave of the Black Lives Matter Movement for drawing attention to how systemic racism and discrimination affect health outcomes. So, we have this acknowledgment and this language in a psychiatry journal––that seems very new and encouraging. Some of the recommendations in this position paper might be ascribed not just to the COVID-19 pandemic but also to the concurrent Black Lives Matter Movement taken very broadly.

Finally, another movement is evident here, driving many of the suggestions for change, namely, service users’ strong voice. Looking through the list of author affiliations, I found only 2 of the 24 who seem to represent patients and families, such as a representative from EUFAMI, a federation of 39 family and mental health associations. However, the service users’ perspective seems to have been ritually incorporated through this position paper in addition to a section that’s entitled “Service User Knowledge and Involvement.” So, we detect an emphasis on, for example, “service users should be centrally involved in not just creating robust resources to support shared decision making but in the very design of mental health care systems”––systems which are more changeable now that the coronavirus has made old ways less workable. Moreover, they offer examples from countries worldwide that they cite as evidence that such changes are possible.

In summary, this position paper represents a clear and bold statement of the changes one might envision arising from the COVID-19 pandemic. Some of the recommendations are virus-specific, and some are broader capitalizing on this upheaval. For more, I think you will find just skimming the article itself rather uplifting––a consensus of 24 dedicated clinical and experience-based experts on what needs to change.

Abstract

How Mental Health Care Should Change as a Consequence of the COVID-19 Pandemic

Carmen Moreno, Til Wykes, Silvana Galderisi, Merete Nordentoft, Nicolas Crossley, Nev Jones, Mary Cannon, Christoph U Correll, Louise Byrne, Sarah Carr, Eric Y H Chen, Philip Gorwood, Sonia Johnson, Hilkka Kärkkäinen, John H Krystal, Jimmy Lee, Jeffrey Lieberman, Carlos López-Jaramillo, Miia Männikkö, Michael R Phillips, Hiroyuki Uchida, Eduard Vieta, Antonio Vita, Celso Arango

The unpredictability and uncertainty of the COVID-19 pandemic; the associated lockdowns, physical distancing, and other containment strategies; and the resulting economic breakdown could increase the risk of mental health problems and exacerbate health inequalities. Preliminary findings suggest adverse mental health effects in previously healthy people and especially in people with pre-existing mental health disorders. Despite the heterogeneity of worldwide health systems, efforts have been made to adapt the delivery of mental health care to the demands of COVID-19. Mental health concerns have been addressed via the public mental health response and by adapting mental health services, mostly focusing on infection control, modifying access to diagnosis and treatment, ensuring continuity of care for mental health service users, and paying attention to new cases of mental ill health and populations at high risk of mental health problems. Sustainable adaptations of delivery systems for mental health care should be developed by experts, clinicians, and service users, and should be specifically designed to mitigate disparities in health-care provision. Thorough and continuous assessment of health and service-use outcomes in mental health clinical practice will be crucial for defining which practices should be further developed and which discontinued. For this Position Paper, an international group of clinicians, mental health experts, and users of mental health services has come together to reflect on the challenges for mental health that COVID-19 poses. The interconnectedness of the world made society vulnerable to this infection, but it also provides the infrastructure to address previous system failings by disseminating good practices that can result in sustained, efficient, and equitable delivery of mental health-care delivery. Thus, the COVID-19 pandemic could be an opportunity to improve mental health services.

Reference

Moreno, C., Wykes, T., Galderisi, S., Nordentoft, M., Crossley, N., Jones, N., Cannon, M., Correll, C. U., Byrne, L., Carr, S., Chen, E. Y., Gorwood, P., Johnson, S., Kärkkäinen, H., Krystal, J. H., Lee, J., Lieberman, J., López-Jaramillo, C., Männikkö, M., … Arango, C. (2020). How mental health care should change as a consequence of the COVID-19 pandemic. The Lancet Psychiatry, 7(9), 813-824.