The LANCET Journal – Psychiatry – published a great paper discussing the changes that it sees are required in the system to address the evolving needs of the population during and post pandemic. While it is based on a global experience the conclusions and observations are valid in the Ontario context. Here are the summary and conclusions sections of the report and you can read the entire article here.
How mental health care should change as a consequence of the COVID-19 pandemic
Carmen Moreno, PhD
Prof Til Wykes, PhD
Prof Silvana Galderisi, MD
Prof Merete Nordentoft, DrMedSc
Nicolas Crossley, PhD
Nev Jones, PhD
Published:July 16, 2020DOI:https://doi.org/10.1016/S2215-0366(20)30307-2
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.
The COVID-19 outbreak was sudden and unexpected in most countries. The first known cases occurred in late December, 2019, and WHO declared it a pandemic on March 11, 2020.
COVID-19 has resulted in an increase in known risk factors for mental health problems. Together with unpredictability and uncertainty, lockdown and physical distancing might lead to social isolation, loss of income, loneliness, inactivity, limited access to basic services, increased access to food, alcohol, and online gambling, and decreased family and social support, especially in older and vulnerable people. Racial and ethnic disparities in the incidence of COVID-19 (and associated mortality) have been pronounced. The downturn in the economy caused by COVID-19 will lead to unemployment, financial insecurity, and poverty, which hinder access to health services (especially in insurance-based systems), thereby having deleterious effects on physical and mental health and quality of life. These economic factors can induce mental health problems in previously healthy people and negatively affect those with pre-existing mental disorders. The economic breakdown that is likely to occur in the aftermath of the pandemic could exacerbate health-care disparities and will probably disproportionately affect socially disadvantaged patients, including those from ethnic minorities, who have worse access to health care and receive poorer quality care than white populations. Sooner or later, health systems will be faced with widespread demand to address these COVID-19-related mental health needs. International organisations, including WHO, advocate for integration of mental health and psychosocial support into the COVID-19 response, and a UN policy brief suggests that investments now will reduce the mental health effects later. However, the pandemic-related economic breakdown could impede an adequate mental health response.
Quarantine can also contribute to stress, anger, and an increase in risky behaviours such as online gambling. Young people might be at particular risk. In previous pandemics, quarantined children were more likely to develop acute stress disorder, adjustment disorders, and grief than were those who had not been quarantined. An increase in young people making calls to helplines with symptoms of anxiety has been reported. Increased alcohol sales and alcohol use in the home have also been recorded, which could potentially increase alcohol use disorders and domestic violence (both in young people and in adults). Although published data are few, individuals, including children, could be at increased risk of physical and sexual abuse at home during the pandemic. The pandemic could also exacerbate mental health conditions—and further limit scarce access to mental health services—in people living in humanitarian and conflict settings. Some positive benefits might also accrue from reductions in social pressure and exposure to chronic psychosocial stressors (eg, commuting, office workplaces, bullying).
People who have or had COVID-19
For people with COVID-19, lack of contact with their families or loved ones during quarantine and hospital stays can produce psychological instability. High rates of post-traumatic symptoms have been reported in clinically stable people discharged from hospital after recovering from COVID-19.34 In a systematic review,35 the point prevalence of post-traumatic stress disorders after severe coronavirus infections (ie, severe acute respiratory syndrome and Middle East respiratory syndrome) was 32·2% (95% CI 23·7–42·0), that of depression was 14·9% (12·1–18·2), and that of anxiety 14·8% (11·1–19·4). People who have had COVID-19 can experience post-intensive-care syndrome, which comprises cognitive, psychological, and neurological symptoms.36 In a study by Helms and colleagues, 15 (33%) of 45 patients who had recovered from COVID-19 after admission to intensive-care units (ICUs) had dysexecutive syndrome after ICU discharge. Emerging reports suggest the possibility of a post-viral syndrome that resembles depression. The possibility that SARS-CoV-2 is neurotropic emphasises the need for evaluation of potential short-term and long-term effects on the nervous system.40
People with pre-existing mental health disorders
Because of their life circumstances, people with pre-existing mental health disorders might have a higher risk of SARS-CoV-2 infection than those without mental health disorders.41, 42 Risk factors for infection with SARS-CoV-2 and a severe course of COVID-19 include severe mental illness, alcohol or drug misuse, and homelessness, all of which are associated with other risk factors such as comorbid physical conditions.
People with pre-existing mental health disorders have reported increased symptoms and poorer access to services and supports since the onset of the COVID-19 pandemic. Early discharge from psychiatric units and disruption of face-to-face psychiatric care have become common, the negative consequences of which could include relapse, suicidal behaviour, lack of access to medical care, and social isolation.53 Quarantine and lockdown might particularly affect people with pre-existing mental health problems: increased symptoms of anxiety and depression, and high rates of post-traumatic stress disorder and insomnia have been reported. Simultaneously, physical distancing has reduced the availability of many family, social, and psychiatric supports. People with serious mental illness and associated socioeconomic disadvantages are particularly at risk of both the direct and indirect effects of the pandemic
The COVID-19 pandemic has already affected mental health, and some of these effects might persist. The psychological toll of the disease is already apparent both in the general population and specifically in people with mental disorders (particularly those with severe mental illness and cognitive impairment) and frontline workers. Mental health systems have rapidly changed during the pandemic and a sustained response to the challenges posed by COVID-19 needs to be coordinated. Despite heterogeneity in political, social, and health systems, mental health services worldwide have implemented acute responses that focus on infection control, continuity of care for mental health service users, and facilitating access to mental health assessment and care for patients with new-onset issues and high-risk patients. Some new approaches that have been developed seem efficacious, but they might still be associated with risks. Implementation of a COVID-19-related physical and mental health monitoring system that includes outcomes related to mental health service use would inform practice, and could help to shape optimal mental health care for the times to come. Retaining existing services and promoting new practices that expand access and provide cost-effective delivery of effective mental health services to individuals who already have mental disorders or who have developed them during the pandemic should be a priority. Service provision needs to be individualised: effective practices already in place should be refined and scaled up, and both the usefulness and limitations of peer support and remote health delivery should be recognised. A focus on accountability based on routine measurement of meaningful and valued outcomes, co-production of service design and evaluation with expansion of health insurance coverage of mental health, and promotion of primary care support and its greater integration with secondary care could further help to sustain mental health care in the aftermath of the pandemic.
The economic implications of the COVID-19 pandemic are serious. It is important to be cognisant of the risks of promoting cheap solutions to broadening access to mental health care. Low-quality mental health care based on affordability without assessment of quality or monitoring of needs and efficiency will only contribute to increasing inequalities and worsening mental health globally. Now more than ever, we need to put in place service provision that targets health needs and reduces disparities, both globally and within individual countries. Despite substantial cross-national differences in social and mental health systems, we believe that such an approach is feasible with some location-specific adaptations. It could even turn the COVID-19 pandemic into an opportunity to improve mental health care for everyone.