The Seismic Shift in Mental Health Care Since COVID-19
Governance

The Seismic Shift in Mental Health Care Since COVID-19

Isolation, job loss, and gender based violence contributed to the uptick in people living with anxiety and depression

who survived after she tried to take her own life in April outside Thailand's finance ministry building, during the coronavirus disease (COVID-19) outbreak, cries during an interview with Reuters, at her home in Samut Sakhon province, Thailand, May 29, 2020.
A woman, who survived after she tried to take her own life in April outside Thailand's finance ministry building, cries during an interview, on May 29, 2020. REUTERS/Athit Perawongmetha

COVID-19 has wreaked havoc on mental health worldwide, exacerbating what was already a crisis before the pandemic hit. In 2019, mental health was one of the leading causes of disease burden worldwide. Then, as COVID-19 cut short millions of lives, orphaning children and traumatizing families and friends in its wake, the number of people living with major depressive disorder and anxiety disorders increased by more than a quarter globally in 2020.

While COVID has deepened the global mental health crisis, it has also provided an opportunity for leaders to better address long-neglected and stigmatized health problems. As COVID-19 shuttered schools, closed businesses, and forced billions of people to stay home, some countries responded quickly, developing and deploying interventions to mitigate the mental health effects of the pandemic.

Revamping approaches to mental health could not be more urgent. Although effective treatments for depression, anxiety, and other mental disorders exist—such as talk therapy and medication—the rollout of these interventions has historically been slow, with people most in need left behind. Even in a wealthy country like the United States, more than two-thirds of people living with mental health issues do not receive treatment, and fewer receive the recommended course of treatment. And in China and Nigeria, only about one-tenth of people with severe mental disorders received treatment. Further raising the stakes, we now know that COVID-19 poses a greater risk to people with existing mental health problems due to their increased risk of other health conditions, such as cardiovascular diseases and diabetes. People may also face more challenges accessing health care.

Leading Causes of Disease Burden in 2019

Encouragingly, the pandemic has created a seismic shift in the ways that mental health care can be delivered. Access to telehealth appointments for mental health concerns has blossomed—a promising development. Before the pandemic, leaders in the field of mental health had pushed for this change as a way to meet needs in areas with low access to care, but it took a global pandemic to catalyze this change.  For example, in some low-income countries, there may be only one or two trained psychiatrists in the entire country, and in high-income Australia, the number of psychiatrists per 100,000 people in major cities is nearly seven times higher than it is in extremely remote areas.

As countries went into lockdown, telehealth consultations—providing mental health service via phone or video call—increased. Countries from Italy to India have provided mental health care in this manner during COVID-19. To ensure that access to telehealth services is equitable, however, mental health experts have urged leaders to consider the needs of people with low digital literacy and/or who lack access to the internet. In areas where people lack access to internet due to lack of infrastructure, or for individuals who cannot afford a mobile phone, telehealth visits can remain out of reach.

Global Burden of Depression and Anxiety by Age and Sex in 2020

Another way that countries have tried to meet the demand for mental health care during the past two years is by providing free counseling via hotlines. In a review of low- and middle-income countries' response to the mental health effects of COVID-19 published in Lancet Psychiatry, Lola Kola and colleagues describe how counseling hotlines in Nigeria, the Philippines, and India have received a high volume of calls during the pandemic. Also, in Indonesia, the Ministry of Health established a hotline providing free counseling staffed by volunteers from the Indonesian Psychology Association.

In addition to providing mental health care via telehealth and hotlines, there are other ways that countries have attempted to break down barriers to in-person interactions and treatment erected by the pandemic. In France, for example, authorities allowed people to fill expired prescriptions at pharmacies so that they wouldn't risk running out of their medications. Other countries eased monitoring requirements for certain psychiatric drugs. And as many inpatient mental health services were curtailed during the pandemic, providing hospital-like care at home has emerged as a strategy to improve people’s access to care while reducing their chances of being admitted to a hospital.

A vital strategy to address mental health is raising awareness and reducing stigma, and giving people tools to cope with pandemic-related stress. In Lebanon, the Ministry of Public Health distributed educational materials on stress-reduction techniques in quarantine centers and health care settings, and provided tips on stress management for children and adults via social media and WhatsApp. In China, the government has used WeChat, Weibo, and TikTok to provide education about mental health to medical providers and the public.

Job loss during the pandemic has been a major driver of the increase in mental illness

Job loss during the pandemic has been a major driver of the increase in mental illness. Studies of past financial crises in China and Greece have shown that losing income and livelihoods have a profoundly negative impact on mental health. But from Canada to Oman, the financial assistance that many governments provided during the pandemic likely offset some of the adverse emotional effects of COVID-19. Pre-pandemic, research from South Africa and Brazil showed that people’s mental health improved after receiving financial assistance for needs such as child support. A conditional cash transfer program in New York City—where low-income families received payments after hitting targets for education and preventive health care for their kids and reaching specific employment goals—increased levels of hope. When people are more hopeful, they tend to have better mental health outcomes.

An additional trigger can be gender-based violence, which likely worsened during the pandemic. But efforts to prevent gender-based violence may have helped protect mental health. In Spain and the United Kingdom, officials launched national programs to help reduce domestic violence. People experiencing domestic violence could go to pharmacies and mention a code word, which would alert pharmacy staff to contact emergency responders. And in the Philippines, United Nations agencies and the Department of Health launched a two-year initiative, Project BRAVE (Building COVID-safe Responses And Voices for Equity), funded by the Australian government to strengthen systems to address gender-based violence and child protection.

Responses to the mental health crisis during COVID-19 provide a potential template for leaders as they seek to address mental health challenges during both pandemic and non-pandemic times. Still, despite promising COVID-related developments, knowing the best way to improve mental health during a pandemic remains uncharted territory. For health professionals and others on the front lines of health care, the biggest priority has been providing assistance during an emergency, not assessing the impact of the response. Investing in understanding the impact of countries' mental health interventions during COVID-19 is important for preparing for the future and the next pandemic, and for navigating the current one.

While COVID-19 has worsened mental health, it has also brought much-needed attention to an issue that is shrouded in stigma in many societies. The pandemic provides an opportunity to finally start making progress on this long-overlooked global health challenge.

Sandra Cruz, who lost her job because of the coronavirus disease (COVID-19) outbreak, and fell four months behind on her rent and is fearing eviction, and her daughter Gabriella wait for a ride after picking up free groceries distributed by the Chelsea Collaborative in Chelsea, Massachusetts, U.S., July 22, 2020.
A woman who lost her job due to the effects of the COVID-19 outbreak waits with her daughter for free groceries in Chelsea, Massachusetts, on July 22, 2020. REUTERS/Brian Snyder

EDITOR'S NOTE: The authors are affiliated with the University of Washington's Institute for Health Metrics and Evaluation (IHME), which leads the Global Burden of Disease study described in this article. IHME collaborates with the Council on Foreign Relations on Think Global Health. Drs. D. Santomauro and A. Ferrari are affiliated with the Queensland Centre for Mental Health Research, Australia and the University of Queensland, School of Public Health, Australia. All statements and views expressed in this article are solely those of the individual authors and are not necessarily shared by their institution.

AUTHORS' NOTE: In the absence of quality data that allow disaggregation by gender, we utilize data that disaggregate by sex, with the understanding that outcomes for people outside the gender binary are often less equitable than they are for cis women or men.

ACKNOWLEDGEMENTS: The authors would like to thank Rebecca Sirull for assistance with fact checking.

Katherine Leach-Kemon is the Policy Translation Manager at the University of Washington's Institute for Health Metrics and Evaluation (IHME). 


Damian Santomauro is a senior research fellow for the Policy and Epidemiology Group based at the Queensland Centre for Mental Health Research.


Alize Ferrari is a research fellow within the policy and epidemiology team at the Queensland Centre for Mental Health Research and an affiliate assistant professor of health metrics sciences at the University of Washington.


Ruri Syailendrawati is an engagement officer at the Institute for Health Metrics and Evaluation (IHME).

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