Global mental health in the time of COVID-19

Just months ago, who could have imagined that the world would be looking down the barrel of a spiraling health crisis and economic recession unlike any witnessed in our lifetime? Now, in a world gripped by the fear of a marauding virus, mental health is emerging as a key concern.

Diverse pathways to poorer mental health

The reaction of the media and governments to the epidemic served to fuel anxiety. The dramatic way the term “pandemic” was announced by the WHO after weeks of watching the epidemic unfolding around the world was a hair-raising moment. Apocalyptic messaging about millions of dead bodies littering our cities followed, even though experts had identified vulnerable populations — people who are elderly or chronically ill, and those who live in group facilities like nursing homes — early on.

The breathless questions mounted. When, if ever, would life return to a semblance of what we used to experience? Within the torrent of mixed messages about the science, what was real or fake? What might the post-lockdown scenario for containing the virus look like? All of this played on an endless daily newsreel, rounded out by rising figures on illnesses, hospitalizations, and deaths around the world and close to home.

Not surprisingly, experiences of anxiety, fearfulness, sleep problems, irritability, and feelings of hopelessness are widespread. These are mostly the rational responses of our minds to the extraordinary realities that we are facing. But economic recession, widening inequalities, continuing uncertainty about waves of the epidemic still to come, and the emotional impact of physical distancing policies will continue to bite deeper into our mental health. A rise in clinically significant mental illnesses and suicides may well follow.

Unemployment, acute poverty, and indebtedness are strongly associated with poor mental health. A recent report documents “deaths of despair,” mostly through suicide and substance use, as the cause for increased mortality and reduced life expectancy in working-age Americans following the 2008 economic recession. The profound inequality in the US, coupled with its weak social security net, deeply polarized society, and fragmented health care system, are a toxic recipe for a similar surge of deaths of despair on this occasion.

Emerging evidence suggests that the lockdowns and the pivot of health care services to this one virus has seriously disrupted mental health care in many parts of the world. Access to mental health care — including vital continuing care — has not been available for many people experiencing new-onset episodes of depression and anxiety, or exacerbations of pre-existing mental health problems.

Transforming mental health globally

Fortunately, we know what needs to be done and how to achieve it. Further, we know the resources invested are excellent value-for-money. The pandemic presents a historic opportunity to reimagine mental health care.

The GlobalMentalHealth@Harvard initiative was launched in 2017 to marshal the rich, inter-disciplinary expertise within the university and to scale up this knowledge with a worldwide network of partners. In response to the pandemic, the initiative is prioritizing actions to transform and build resilient mental health care systems globally, using three strategies:

• EMPOWER deploys a range of digital tools to build a mental health workforce. It enables front-line providers, such as community health workers and nurses, to learn, master, and deliver evidence-based brief psychosocial therapies. Two examples are behavioral activation for depression and psychological first-aid for acute mental health crises.
• CHAMPIONS builds on time-tested executive leadership training, twinning it with hands-on mentoring by experienced faculty. It aims to build leadership capacity to scale up evidence-based mental health care. CHAMPIONS will create a global peer group of mental health leaders across the US and the world to take forward the critical work of building back — and improving — mental health services.
• COUNTDOWN is developing a set of common core metrics, such as availability of skilled providers and quality of care, to evaluate the performance of these mental health care systems and make them more accountable. COUNTDOWN can perform many roles in the context of the pandemic. A few examples are tracking population-level mental health across and within countries, identifying where the unmet need for services is greatest, and evaluating the impact of investments.

Together, these three essential, interwoven strategies can achieve the transformation of mental health care systems that the global community so urgently needs.

Only with significant resources can we realize such ambitious projects. But here we need to anticipate the pandemic’s biggest threat to mental health: pushing back, once again, mental health from the global health agenda.

Back in the 1990s, it appeared that the world’s leading development agencies would finally recognize mental health as a priority. Yet the Millenium Development Goals of 2000 left it off the table. Fifteen years later, mental health found its rightful place in the Sustainable Development Goals. Now, once again, all funding and health care action is pivoting toward one disease, as mental health risks are being shoved back into the shadows.

Investing in mental health enables each individual to regain hope for the future. It will also contribute to making societies healthier, economically productive, and socially cohesive. There cannot be a more important investment in the face of the most serious crisis to test the global population in a century. Let’s work together to realize our shared mission.

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