Many countries are currently experiencing the unprecedented impact of the COVID-19 outbreak. The situation has become dire as we search for a vaccine to prevent more infections and stop the loss of thousands of lives. In many affected countries all health care services are currently subjected to enormous stress and extraordinary challenges while mental health and psychosocial support needs of people ‒ of those already using services as well as citizens experiencing insurmountable levels of stress ‒ continue to rise. Everyone is affected and no-one escapes the impact on our mental health professionals working at the coalface of providing care yet suffering in silence.
We know that “There is no health without mental health”, as declared by the World Health Organization many years ago. The World Federation for Mental Health envisions a world in which mental health is a reality for all people and where public policies and programmes reflect the crucial importance of mental health in the lives of individuals. The mission of the World Federation for Mental Health is to promote the advancement of mental health awareness, prevention of mental disorders, advocacy, and best practice recovery-focused interventions worldwide.
It is undisputed that the current COVID-19 emergency will have long-lasting consequences and effects on the mental health of all people, affecting the general population with astonishingly heightened stress. On the other hand, impoverishment of services, their reduction and mergers, and the shortage of staff that are already present due to the economic crisis place mental health at the bottom of the list of health priorities.
The mental health of those with pre-existing conditions and disorders before the pandemic is of great concern. They are some of the most vulnerable people to the contagion and may lack access to proper information and medical care. Their human rights, safety, protection, and even their environment, are at risk. More than ever, they could be forgotten, neglected and exposed to additional suffering because of the shortage of mental health services operating within communities. Cutting funds, diverting staff to other services, dedicating existing psychiatric facilities to urgent functions to the care of the outbreak are some of the factors that cause serious concern. There are some examples of psychiatric hospital units that have been converted into COVID-19 departments while there is severe and limited access to community mental health centres and facilities that in some areas have been closed. Outpatient services are restricted to emergencies only, limiting the offer of services. Few mobile teams are still operating in communities to assist people with psychosocial needs and social priorities. Many residential facilities, especially those for more disabled and fragile people, are experiencing outbreaks affecting both staff and residents. In many countries, there is little, if any opportunity, for self-isolation by infected persons in these facilities due to limited space.
There is a severe shortage of rehabilitation interventions, socialization activities and daycare centres. Personal support, home and educational assistance services, mainly carried out by NGOs, have slowed down or stopped completely in the absence of innovative remote mental health services.
As an immediate consequence, certain people with mental disorders who need “closer” care are the most affected by “physical distancing”. An increase in demand for involuntary treatments is beginning to surface in many areas.
Families who have now become the primary carers of their relative with severe mental illness battle to cope without the necessary support that may have ordinarily been offered such as respite care, counselling, guidance and support. Many people are alone and helpless or find themselves living in poverty and/or highly congested communities where self-isolation or lockdown is virtually impossible thus increasing their exposure to the virus. Large populations of homeless people are lost as many of their natural support systems are no longer available.
The social impact of the virus on low and middle-income countries (LMIC), where mental health care provision is already limited, should be a concern. People with severe mental illness who live in places such as mental hospitals, nursing homes, halfway homes, social care homes, correctional facilities and other institutions are at risk, as these places become more unsafe and provide less protection against contracting the virus. They are at higher risk as many are on medication requiring monitoring and may already be suffering from other physical conditions, and those with cognitive disabilities do not know how to avoid infection or its spread as the information has not been interpreted in Easy to Read or verbally. Another group that is of concern would be the socially disadvantaged in the broader sense, and the migrant populations living in special centres and camps. They need psychosocial support and health protection as well as a response to their primary needs. Measures that are normally activated during disasters such as feeding camps, work for food, and food relief (food parcels) are not necessarily made available in all countries during the COVID-19 lockdown. We have heard narratives from individuals suffering due to a lack of access to food saying that they will die from hunger before they die from the virus.
We therefore urgently call for proactive actions and measures to address the mental health, physical health as well as the social needs of all during this crisis. We believe it is essential for all countries, especially those who are fighting the hardest consequences of the pandemic, not only to focus on the medical aspects of the COVID-19 but also to urgently prioritise all psychosocial and economic needs and to address this with all the intelligence, compassion and skills at their disposal. We call for an immediate implementation and operational mental health emergency plan. We believe it is the government's responsibility to transmit centralized basic indications to services and to the general population. Even before the current pandemic occurred, the World Health Organization, in the current draft for the renewed Global Action Plan (2020-2030), added a specific objective concerning “Mental health in humanitarian emergencies”. Among the actions of the new WHO action plan, mental health is required to be placed on national emergency committees.
In particular, countries are asked to apply the following actions:
“During emergencies, ensure coordination with partners on the application of the Sphere Project’s minimum standard on mental health and the guidelines mentioned above (IASC);
After acute emergencies, build or rebuild sustainable community-based mental health systems to address the long-term increase in mental disorders in emergency-affected populations.”
Governments are expected to provide guidance and technical advice during these times and can call on international stakeholder organizations such as the World Federation for Mental Health and the World Health Organization about ways to manage and support their existing mental health systems and services to provide effective mental health protection for their population.
In line with our values and principles, some priorities are listed emerging from the debates, discussions and best practice interventions at national and international levels on which significant consensus and agreement have been reached, namely to:
1. Adopt a "Whole of Society approach", as stated in the Interim Briefing Note Addressing Mental Health and Psychosocial Aspects of COVID-19 Outbreak (developed by the IASC’s Reference Group on Mental Health and Psychosocial Support), that involves and coordinates all existing components and resources for mental health and psychosocial support systems, mapping, providing guidance and basic training;
2. Provide guidance on mental health and psychosocial support for health workers, managers of health facilities, caregivers looking after children, older adults, people in isolation and members of the public more generally;
3. Engage communities: help the general population to cope with distress, anxiety, uncertainty, sadness and grief caused by the pandemic; balance and integrate professional interventions with community involvement in terms of solidarity and caring actions; enhancing the general sense of belonging to a community;
4. Provide people with mental health needs with the same quality of information regarding COVID-19 awareness and prevention given to all citizens, wherever they are, at home or in an institution. They have the same need for information and would require additional support should they be infected;
5. Strengthen Primary Care roles to safeguard and guarantee health prevention, healthcare responses with the best possible care pathways, including mental health;
6. Ensure psychiatric care and psychosocial support for people with severe mental illness who are at risk of neglect as well as infection;
7. Strengthen community-based interventions, through many forms of home support and care, with a multidisciplinary and multisectoral approach, alongside the highest level of caution and protection of both mental health user and staff;
8. Pool resources available for mental health support and overcome fragmentation, foster inter-sectoral referral pathways in public mental health care and the social services third sector alliance, for a comprehensive response to the needs of care and assistance;
9. Involve stakeholder organizations, especially those related to people with lived experience and carers, in gathering emerging needs, in defining essential services and actions, and in all steps of coordination and decision-making process;
10. Protect people with severe mental illness living in institutions, hospitals, prisons, shelters, nursing homes, group homes and other special facilities ensuring overall care and prevention of COVID-19 infections, while avoiding human rights violations; create alternative lockdown accommodation if facilities are full;
11. Organize humanitarian aid and response to basic needs (food, shelter, clothing, medication) for all people affected and living in poverty and, in particular, persons with mental illness who are homeless, unemployed and socially deprived of these basic needs;
12. Support the volunteer sector, non-profit organizations, social enterprises and cooperatives that are suffering particularly from the closure of their programmes and services, through direct economic interventions and special projects;
13. Support families who alone cannot act as social safety nets for the emergency except for very short periods, in the absence of other supports, and actively monitor daily life conditions to prevent domestic violence on women, children and disabled family members;
14. Build a system of services via Internet or telephone to reach out to people, communicate and interact with them to retain contact, as suggested in e-mental health experiences; access to teletherapy for outpatients already engaged in care to avoid loss of continuity and follow-up and prevent relapses;
15. Create a network of local aid programmes for first contact, active listening and support, as offered by diverse entities, volunteers or even private specialists, by coherently organizing them through the establishment of national toll-free numbers.
Recommended essential actions are as follows:
Provide nationwide coordinated mental health services and collaboration with local decision-makers and all stakeholders;
Prepare and train mental health staff in the management of emergency and especially preventive measures;
Prioritize protection to mental health service users and staff during their interaction (e.g.use of PPE2, physical distancing, self-isolation);
Ensure that information on pandemic and preventative measures to mental health care users are properly addressed and received; develop Easy to Read pamphlets that explain COVID-19 awareness and prevention information in simple and understandable symbols and basic words for persons with cognitive disabilities and those with low literacy;
Limit the use of communal spaces in service locations;
Accommodate working from home, tele and videoconferencing, tele and video counselling and support groups, all forms of tele-healthcare and distance communication either with clients or with providers and other partners, and remote teams to ensure programmatic activities from phone to the home using affordable telephone Apps capabilities;
Guarantee that basic mental health services, e.g. medication and psychosocial support are provided;
Use various telephone Apps to facilitate grapevine communication or support groups to facilitate contact, support and care for service users in PSR programmes or parents/carers including staff engaged in service delivery;
Shield at-risk patients with co-morbidity;
Ensure quick assessment of people in crisis and provide alternatives to admissions as much as possible;
Minimize involuntary treatments and hospitalizations to reduce exposure to risk, through preventive and alternative programs, taking into account ethical considerations;
Support staff in supported housing and residential facilities in the interpretation of safety rules for themselves and the residents;
Ensure that during a lockdown, activities and programs continue within the residential or semi-residential facilities using creative innovative measures;
Ensure pathways of mental health users in the mainstream health care to fulfill the right to physical and mental health, limit designated services for those who are COVID-positive, and ensure that all other technologies are used to facilitate contact and support;
Provide (tele-) forums for staff and clients to share experiences locally and nationally and involve all private providers.
It should be taken into consideration that on the one hand it is presumed that the outbreak will last a long time, and on the other that the real impact on mental health will occur mainly with the loosening of the current grip and with the beginning of the recovery of a “normal” life. People will encounter the consequences of human and economic losses together with depressive and anger feelings, post-traumatic symptoms and other conditions.
We believe that through the implementation of an extraordinary emergency plan, the system of mental health services must and can continue, requiring leadership and flexibility, and using proactive and innovative interventions.
On Behalf of the World Federation for Mental Health Board
Dr Ingrid Daniels, President, WFMH
Dr Roberto Mezzina, Vice President (Europe), WFMH