#MHForAll Webinar: COVID-19 and the impacts of a global pandemic
Chair
Niall Boyce, The Lancet Psychiatry (Chair)
Panellists
Florence Baingana, World Health Organisation
Carmen Moreno, University of Madrid
Nev Jones, University of South Florida
Last time we talked about the effects of COVID-19 on the brain and the mind. Today we are talking about COVID-19 and mental health in a broader context, looking at public responses to the pandemic and service adaptations.
Niall Boyce
What’s your assessment of the public mental health response to COVID?
Florence Baingana
Last year WHO carried out important research with results that highlighted that while most countries do know what to do for mental health and do have a MHPPS response plan, most had not fully funded their responses. Almost all countries had disruptions in services, and it was children and young people that were often most failed. Many countries reported that when it came to repurposing units to meet the demands of the pandemic, it was often alcohol and drug treatment services that were repurposed for COVID. Social distancing and travel restrictions forced a move to telemedicine, which was used in up to 80% HICs, but less than 50% of LICs could or did take up telemedicine. This is due in large part to technological inequalities and access to resources.
Niall Boyce
Lots of clinical services have been affected by shifting of priorities, for example oncology and cardiology services have been disrupted. Has mental health been particularly impacted?
Florence Baingana
Yes - there has been a disproportionate disruption to mental health services. They were often the last to be provided with PPE, despite the reality being that they were at much greater risk than many other areas.
Niall Boyce
And Carmen, has that been your experience too? Have mental health services been affected by the pandemic?
Carmen Moreno
There has been a clear need to prioritise services. Protecting mental health has not been a priority. Tackling the needs of the virus, and the ICUs, have been at the top of the agenda. Mental health services have been broken as a result. The relationship between primary care and mental health, community care etc. has been broken. One of the biggest issues has been to adapt the way we are delivering services. This is something that everyone has had to do, and we now increasingly have more knowledge and access to equipment. We have also had to find a way to continue to work with our patients despite the risks, and how to coordinate with other providers and the wider social care sector, as well as different members of the family, who are not used to accessing technology. There are also some people who should necessarily be using technology. It is hard to evaluate all of these things.
Niall Boyce
Anxiety, depression and mood disorders are often discussed. Other conditions, such as psychosis, are not necessarily being talked about. This could be widening the inequality and tension in mental health. Would you say that is the case?
Carmen Moreno
There are some cases of psychosis that are triggered by stress. We also know that this stressful situation may also trigger other psychiatric situations, and, as has happened before with other viral infections, this could be a problem for future generations. For example we don’t know the exact effect on pregnant women. There may be important psychiatric problems in the long term.
Niall Boyce
It has been said that there was more progress in digital mental health service provision in the first 10 weeks of the pandemic than in the last decade. But do some patients suffer disadvantages as a result of the shift to digital?
Nev Jones
Absolutely. There has been acknowledgement that the pandemic has exacerbated the digital divide and inequalities regionally and globally. What has received less attention is who controls this, and who has the resources to build and develop technology, particularly moving out of just telehealth and into apps and other forms of digital interventions. There is a real risk of colonisation happening here. There have been new publications, new grants and new work has been put forward, but there are some big questions behind who is driving the development of new technology that is only really partially adaptable to local contexts. That is one of my main concerns.
Niall Boyce
Power imbalances of the past may pale in comparison to the power imbalances today with the digital giants. Innovative ways of reaching people may unwillingly exacerbate these power imbalances.
Nev Jones
In the history of medicine big pharma has been subject to a lot of criticism and concern, but here we have big technology. The role of big technology is oversized and under-discussed. COVID plays a problematic role in the sense that these gears were already in motion before the pandemic, and the reduced decisional timeframes has led to less time for considering the implications of these digital developments.
Niall Boyce
What public mental health issues do you anticipate in the next 12 months, and what can be done?
Florence Baingana
We are already getting a resurgence, and over the next 12 months this will continue. We have overwhelmed health care systems, with stressed and fatigued frontline workers. They are starting their second year of hard, intense work where they are constantly at risk. Increased cases means increased deaths, and increased number of individuals in mourning. And there will also be an increased number of survivors, perhaps with PTSD, and more people with long COVID, where the symptoms are often neurological. We need to be looking ahead and preparing for this chronic and ever-increasing mental health burden.
Niall Boyce
Can High Income Countries (HICs) learn from Low Income Countries (LICs) and Middle Income Countries (MICs)? What is the role of task sharing?
Florence Baingana
Health and mental health is about sitting with someone, making a connection with them through eye contact and observing the body. If all connections are going to be through the computer, that is going to be an issue.
When we come to task-sharing, there is a role for it to play, particularly at a community level. Peer to peer support groups, for example, is this something that can be replicated? We need peer support but we also need experts to avoid missing gaps in knowledge and expertise.
Niall Boyce
What innovations should we keep going forward after the pandemic?
Carmen Moreno
The needs and scale are going to be completely different. People with lost relatives, with long COVID etc., will all come with a new set of needs and in a new context. The same for those working on the frontline who still aren’t even able to grieve. We should see more mental health necessities now than before, and these problems are going to be here for a long time still. In terms of innovations, we need to rethink the ways of connecting effectively. We also need to reinforce community mental health. This is a moment to shift care, and can move towards home based treatments. We need to create a sustainable way of coordinating efforts, from thinking through treatment plans to supervising. We should also take into consideration and include those people attending and their families.
Niall Boyce
People are going through a difficult time at the moment, job losses, bereavement, social isolation etc. Are these to do with mental health and mental health services, or are they normal responses to a stressful situation?
Nev Jones
We know that this can set off a chain for some people that can lead to a sustained series of problems that are more widely recognised to be psychiatric problems. At the same time there is another tendency that we have so embraced this universalist understanding of mental health, moving away from a pathologizing view of mental health and neglecting “serious” mental health. Mental health awareness rarely includes discussion that will likely change the lives of those with long term and serious mental health challenges.
Niall Boyce
There is now a valid but nebulous concept of “wellbeing”. Has the pandemic changed attitudes towards mental health?
Nev Jones
It has normalised mental health challenges in the mildest sense - there is an understanding that people are stressed and suffering. But that is a far cry from what people in institutions or who are homeless are experiencing. The pandemic has accelerated the cultural tendencies that preceded it, by neglecting serious issues and turning the discussion to everyone feeling depressed or anxious. The normalising conversations are both good and bad, but the exclusion or neglect of serious illness is very problematic.
Niall Boyce
How do we turn talk into sustainable action when it comes to mental health?
Florence Baingana
We should think about building back better - how we can build back a system that was stronger than when it started. The people who need to be engaged are the policy makers, the decision makers. The error we make is that we get emergency funding, but it is not necessarily sustainable or able to respond to any other emergency that comes up. Preparedness and response, and prioritisation within this, is important. Strengthening our response to mental health generally, but also within the response to COVID-19, is key.
Niall Boyce
How do we make that a reality in terms of service delivery?
Carmen Moreno
Flexibility is key. We have seen this before. One of the things that systems need to do is to self-reflect. We must be conscious that it is not possible for hospitals to function the same way in 20 years time. We need to be able to shift priorities and understand current needs, otherwise things will stop being useful.
Niall Boyce
There are so many divisions, political, ideological etc., in mental health, and sometimes that can stand in the way of creating a diverse but united mental health community. Do you think the pandemic might change this?
Nev Jones
Mental health in the broadest sense includes everything from childhood intervention, at risk intervention, to long term serious conditions. In the US there is a historical push and pull between substance use services and mental health, including a fight for funding. At some level there will always be competition for scarce resources across different groups. COVID has not improved this, but pulled public discourse into a generalist discussion of mental health. This can lead to increased funding in awareness work, but a lack of funding for actual service provision, and that is a worry.
Niall Boyce
What efforts need to be made to promote youth mental health education? And what about developments in youth mental health in general?
Florence Baingana
The Africa region has the biggest proportion of youth population in the world. A lot of the youth have very low social capital, living in low income neighbourhoods and feeling disenfranchised. Right now we have not done much [on mental health] specific to youth and COVID-19, but last year WHO put out Helping Adolescents Thrive guidelines and there is the suicide interventions guidance, Live Life.
Some work had to be put on hold when COVID hit. Much of the world’s youth has had to change how they go to school, if they go to school at all. There have also been high pregnancy rates among young people, even as young as 13. Overall we have not done enough to help youth, we have the strategy but it’s now a question of how we implement it.
Carmen Moreno
We talk a lot about youth mental health but rarely get into the details of it, getting into the details of the problems. We know that bullying is one of the biggest predictions of mental health problems, as well as substance use and abuse. Even in HICs sometimes the interventions that should be reaching schools and psychiatric care are not delivering enough. This is not very complex, it’s just a question of going to talk to the adolescents where they are and asking what their needs are.
Niall Boyce
One final round up question - do you anticipate that the pandemic will move mental health up or down the global health agenda?
Florence Baingana
Mental health has already moved up the agenda with the endorsement of a resolution to prioritise mental health within emergencies [at the WHO Executive Board, January 2021]. But are countries ready? If a country was provided with a million dollars this year to do what they want with mental health services, I don’t think they’d be ready. So let’s work on readiness.
Carmen Moreno
It’s going up in that there is more discussion. But real mental health problems are going to be diluted into this “wellness” discussion. If the increased attention doesn’t come with money and increased financing, this is going to be more cosmetic than actual mental health care.
Nev Jones
It will go up and down depending on the set of conditions and reinforcing long-standing inequalities.
Niall Boyce
The clear message that I’m getting is that it's up to us as stakeholders to take control of the interventions and of planning for the future.
