COVID-19 Webinar 6: COVID-19 beyond face to face
The Lancet Psychiatry, Mental Health Innovation Network, MHPSS.net and United for Global Mental Health have launched a series of weekly webinars designed to provide policy makers and the wider health community with the latest evidence on the impact of COVID-19 on mental health and how to address it.
Chair: Shekhar Saxena, Professor of the Practice of Global Mental Health, Global Health and Population, Harvard T H Chan School of Public Health
Panellists:
Ken Carswell, Technical Officer, WHO, Switzerland
Piers Gooding, Research Fellow, Melbourne Social Equity Unit, University of Melbourne, Australia
Aparna Joshi, Faulty member of Tata Institute of Social Sciences, Mumbai, India
Ifedayo Ward, Executive Director, Mentally Aware Nigeria
Fran Silvestri, President and CEO, International Initiative for Mental Health Leadership (IIMHL), New Zealand
Shekhar Saxena
We know that mental health services are underfunded at the best of times, even before the COVID-19 pandemic. Right now, in many places across the world, health services are focussing all of their resources to COVID-19, and other services are falling behind. Just like we are now using technology to host this meeting, many services have moved online.
Piers, you have recently reviewed the literature around the use of digital technology for mental health care. Can you give us an idea of ways in which digital technology can assist mental health care?
Piers Gooding, University of Melbourne
I recently co-edited a special issue of The International Journal of Law and Psychiatry, called Mapping the rise of digital mental health technologies: Emerging issues for law and society.
This was a mapping exercise of a range of digital technologies that are used for mental health services. It included telehealth (between clinicians and service users); information sharing; clinical support such as online assessment tools; computer assisted prescribing; machine counselling such as chatbots mimicking Cognitive Behaviour Therapy (CBT); and tracing applications such patient and population monitoring. The range of functions suggests use of digital technology goes much further - beyond telehealth and telemedicine. Similarly service users could use digital platforms for peer group counselling
Shekhar Saxena
We know that WHO has become more active on digital mental health during the last few years. As the lead technical person for this work, can you tell us what have been your recent products that are available for anybody to use?
Ken Carswell, WHO
The move to a digital world due to COVID-19 was somewhat timely given the WHO’s bigger role in digital health over the last few years. We can categorise the WHO mental health resources into two categories: self help and guided self help; and training and supporting providers in delivering mental health support.
As part of Self Help we have developed this tool: Doing what matters in times of stress, an easy to follow guide, which was originally designed as an illustrated book to be printed, but is now available on any smart phone or device. This tool includes mindfulness based approaches such as “unhooking” or “grounding” yourself during stress, as well as ideas and suggestions of how to live by values. The information can be downloaded and adapted. We are incredibly excited by the range of adaptations and different ways this can be used. The information is currently being translated into different languages. Another resource we have developed is an illustrated story book for children to help them understand and come to terms with Covid19. This is called My Hero Is You - and you can find it here.
These are both good examples that digital health doesn't have to be high tech or complicated in order to be effective.
On training and supporting providers, WHO has released an e-learning project related to quality rights. This trains people in the rights of people with mental health conditions and psychosocial disabilities. They have also developed modules with providers to ensure helpers to get support remotely.
Shekhar Saxena
India is a country with massive needs and you have established a psycho-social helpline to assist people in need. Can you describe briefly what service your helpline provides and what changes have you seen since the COVID-19 pandemic hit the country?
Aparna Joshi, iCall
I think it is helpful to break this down to the impact in terms of COVID-19 and India first. Mental health was a late entrant in India’s response to the pandemic and lockdown. We see that the impact (in india) needs to be conceptualised as psycho-social not just mental health.
iCall receives a lot of calls related to the impact of lockdown, the topics of these can be categorised as personal, interpersonal or economic stress. iCall is a national level psychosocial service which is free for the community. Apart from its usual services it has also started a Covid-19 specific helpline, this has a specific focus on marginalised communities, which is especially vital as Covid-19 has brought out the existing economic and structural cracks in the communities.
It is important that mental health support is given in a personalized voice, especially when people are also calling with realistic concerns of food, rations and economic hardship. Help to be given is more social than psychological.
Shekhar Saxena
We know that the care gap in Africa for mental health problems is very large. You have established Mentally Aware Nigeria Initiative that is run by young people and serves the needs of young people. Can you briefly describe the use of technology in this initiative?
Ifedayo Ward, Mentally Aware Nigeria (MANI)
Technology drives most of MANI’s activities, even before the outbreak. In Nigeria we are starting to normalise mental health conversations via social channels. Collectively we have 100,000 followers across our channels. These go beyond Nigeria to other African countries, with people offering to volunteer or also asking for support. Volunteers are trained to spot suicidal or distressed messages on social media. We also provide mental health support via social channels and virtual platforms - such as whatsapp and digital based platforms. We offer five free counselling sessions before we refer someone for longer term support.
Shekhar Saxena
We have just heard about the initiatives in India and Nigeria. Let's now turn to some high income countries. We have Fran Sylvestri with us to share the experiences from some of these countries. Fran- what are leaders in high income countries focusing on as some of them struggle with a high infection and mortality rate due to COVID-19?
Fran Silvestri, President and CEO, International Initiative for Mental Health Leadership (IIMHL)
The focus of IIMHL is mental health leadership issues and the stress experienced by mental health leaders handling and making decisions. We have been looking at what their needs are and what technology can help them. The mental health leaders we have surveyed have highlighted four areas of concern; new innovations, ideas and programmes; how to build community capacity to support them now and post-COVID19; how to become a better leader during traumatic events; and how to build leadership resilience. IIMHL provides weekly newsletters for mental health leaders that focus on one or two macro trends; organises virtual meetings e.g. between 18 cities working together and the rural and remote network; and does linking between countries e.g. linking New Zealand and Canada to do psycho-social support across the country; and organises webinars for members to communicate and learn.
Shekhar Saxena
Piers - having learnt the scope of digital technology for mental health care and heard some real-life examples of how these are being used, can you describe briefly what concerns you have regarding regulation, privacy and use of data?
Piers Gooding
Regarding catalysing mental health care online, the appropriate governance would normally happen over years but it has happened in weeks. This could pose serious limitations with respect to governance. There are a lot of unresolved legal and ethical issues. These usually evolve around data security, privacy etc. Technology can be effective but only if people are involved early in the governance and development of this technology.
Shekhar Saxena
Ken - what can we expect from WHO in the coming few years?
Ken Carswell
In terms of WHO work and work with digital health, COVID-19 has been a game changer. I wouldn't be surprised if we see a lot happening in the next few months with regards to digital mental health and regulation etc. There could be content that is tested in randomised control trials - through app, twitter, book etc. There are multiple ways for decent content to be used and adapted to meet multiple different needs. Many things are in the pipeline and have research testing. One intervention that is new is the Stress Management App - a PDF book - “doing what matters in times of stress” - with audio exercises.
Shekhar Saxena
Aparna, what do you see the scope of helplines for psychosocial support in India in the medium term and who should scale them up? Academic departments like yours, civil society or the government?
Aparna Joshi
So many helplines in India are being established by the government, CSOs or the private sector. Whoever does this has to ensure the technology is accessible to many people in India - a third of people in India have access to telephones. Younger people moving towards text based instead of talk based helplines. We need to keep choices available for people.
Human resources are as important as technology. Governments should be providing the helplines because they have the widest reach and the mechanism to integrate them into existing mental health programmes. But India cannot go only into digital service provision - there needs to be a blend of online and offline solutions. For example, depression is difficult to assess via phone. It is important to train helpline teams to know the limits of their technology.
Shekhar Saxena
Ifedayo, did you have difficulty recruiting volunteers?
Ifedayo Ward
Right now we have many people reaching out to us to volunteer with us. We also put out calls to professionals to volunteer and work in our support centre. There has been a huge surge in the number of volunteers. Our support centres are fully run by volunteers and medical professionals.
Shekhar Saxena
A question from someone dialing into the webinar: marginalised people such as those from the LGBTQ community need to be supported. We need to keep these populations clearly in mind and we need to have clear plans for these populations to access services digitally and otherwise.
Fran, having heard from Piers about the concerns on the use of digital mental health, how well prepared are some of the high-income countries to deal with these concerns?
Fran Silvestri
Piers has laid out some major questions which many leaders are concerned about. Thousands of applications being marketed around countries for services. Mental health leaders are looking more towards portals instead of apps. These allow them to input information and track symptoms. How do we certify apps? We need to make sure they are tested and provide proper information. In Australia and New Zealand - Orygen and Like Minds develop their services with service users at the table.
Shekhar Saxena
What is the final message from each panelist?
Ken Carswell -Technology offers huge opportunities but it must be done within a healthcare system that has a range of other opportunities for people. Needs to be part but not everything.
Piers Gooding - Let’s keep thinking about responsible governance and responsible public input.
Ifedayo Ward - Mental health involves everyone- not just mental health professionals but individuals as advocates. We can use channels to provide education about mental health.
Fran Silvestri - Apps are useful but they don't replace strong relationships between people.
Aparna Joshi - Digital services yes, but psycho-social support in consultation with people, offline and online is what is needed.
Thank you to the panellists. The next webinar is on May 19 at 14:00 BST on Mental Health & COVID-19: People in Vulnerable Situations. You can sign up via this link, please email any questions to webinars@unitedgmh.org.
