key: cord-0686880-u4odkr3z authors: Vadivel, Ramyadarshni; Shoib, Sheikh; El Halabi, Sarah; El Hayek, Samer; Essam, Lamiaà; Gashi Bytyçi, Drita; Karaliuniene, Ruta; Schuh Teixeira, Andre Luiz; Nagendrappa, Sachin; Ramalho, Rodrigo; Ransing, Ramdas; Pereira-Sanchez, Victor; Jatchavala, Chonnakarn; Adiukwu, Frances Nkechi; Kudva Kundadak, Ganesh title: Mental health in the post-COVID-19 era: challenges and the way forward date: 2021-02-09 journal: Gen Psychiatr DOI: 10.1136/gpsych-2020-100424 sha: b3e5049fc5bc8eab92265b2ba4c05ef86907861f doc_id: 686880 cord_uid: u4odkr3z nan The COVID-19 pandemic has posed a serious threat to global mental health. Multiple lines of evidence suggest that there is a varying yet considerable increase in mental health issues among the general population and vulnerable groups. 1 2 The aftermath is obscure and speculative from a social, economic, individual and public mental health perspective. Recently published studies support the existence of an emotional epidemic curve, describing a high probability of an increase in the burden of mental health issues in the postpandemic era. 3 4 Furthermore, previous major public health emergencies showed that more than half of the population developed mental health problems and required mental health intervention. 4 5 There is, therefore, an urgent need to reorganise existing mental health services to address the current unmet needs for mental health and to prepare for future challenges in the postpandemic era in terms of prevention and management. The current evidence and published literature related to previous epidemics suggest that mental health issues may arise after the peak of the pandemic, with increased prevalence among the vulnerable population and people with risk factors (box 1). 4 The surge in mental health issues may remain untreated or undiagnosed due to interrupted mental health services and other challenges for mental health services in the post-COVID-19 pandemic era. The paucity of human resources, infrastructure and burn-out of mental health professionals (MHPs) In many countries, MHPs have been redeployed for the provision of medical services in COVID-19 care centres. 6 MHPs and physicians working in COVID-19 services are experiencing an increased level of mental health issues owing to work stress and the death of patients and loved ones. 7 8 If the mental health of MHPs remains unaddressed, then these professionals may not be able to provide efficient mental health services in the postpandemic era. In low and middle-income countries (LMICs) where MHPs are scarce, this could further widen the treatment gap for mental disorders. 9 10 Assessing mental health issues In the postpandemic era, it may be difficult to identify mental disorders aetiologically related to COVID-19 (eg, anxiety due to cytokine storm) owing to a lack of specific diagnostic or screening tools. 11 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition or International Classification of Diseases 10th Revision/Eleventh Revisionbased diagnostic interviews may under-report or over-report the underlying conditions. In some countries, particularly LMICs, waves of misinformation about COVID-19 are going to persist owing to multiple reasons (eg, religious and/or political beliefs). Surprisingly, most countries are not well prepared for managing this infodemic. 3 The inability to access accurate information will strain the individual's mental health and may lead to an increase in polarisation and the occurrence of hate crimes. 12 Access to mental healthcare services Lack of preparedness, overburdened mental health services, increased prevalence of mental health issues and interrupted mental health services will limit access to mental healthcare facilities in the postpandemic era, particularly in LMICs. Many psychiatric facilities and outpatient departments are currently converted to manage COVID-19. 13 14 Therefore, people with mental illness may not seek help from these services owing to a fear of infection. Many pharmaceutical industries have changed their focus to the preparation of COVID-19related drugs, vaccines and preventive kits (sanitisers), which may hamper the production of psychopharmacological drugs. Perceived job insecurity, financial problems and unemployment contribute to significant risks for psychiatric disorders and pose an important barrier in accessing mental healthcare. The complex and ever-changing dynamics of the COVID-19 pandemic will be a challenge for psychotherapeutic services owing to a lack of physical and social connection. 15 In LMICs, the dearth of telepsychiatric services will limit accessibility to psychotherapy. 10 Adults, children, adolescents and families are affected by the loss of the structured support found in schools, childcare facilities or physical workplaces. 4 Rebuilding this extrafamilial system will be challenging. A substantial body of evidence suggests that people with the highest level of mental health needs often have the least access to services. 16 In a post-COVID-19 pandemic era, it will get exaggerated owing to economic recession, strain on resources and unemployment. Because of the limited scientific understanding of the COVID-19 pandemic and mental health thus far, postpandemic preparedness is difficult. The pandemic is an unpredictable, irregular occurrence and its impact could be difficult to measure and explore. Considering this, we recommend using the components of the mental health preparedness and action framework (MHPAF) for postpandemic preparedness. MHPAF consists of five interlinked components, including preparation and coordination, monitoring and assessment, sustainability of mental healthcare services, infodemic management and communications. 3 This framework has been used to evaluate pandemic preparedness in some countries like Kenya and the USA. 17 However, postpandemic mental health preparedness could be more challenging in countries that are inadequately prepared for pandemics. In addition to preparing for the components of MHPAF, we suggest a few additional interventions for effective and efficient management of postpandemic psychiatric services. Mental healthcare delivery COVID-19 has affected mental healthcare delivery because of the redeployment of MHPs. We need to reconsider a few practical approaches or models of care for effective delivery in the postpandemic era. Telepsychiatry needs to be developed through a government-supported service platform centred on community health service centres to enable easier access to psychiatric care, especially among vulnerable populations (eg, the elderly). However, the digital divide, access to marginalised populations and poverty are major barriers to telepsychiatry services in LMICs. This could affect the feasibility and acceptability of telepsychiatry in many countries. Considering this challenge, it is imperative that healthcare workers reach out to patients and aim at equitable access of telepsychiatric facilities. More robust regulation of social media companies by non-partisan, non-corporate, global regulators is needed to clamp down on the spreading of fake news, anti-vaccine movement and polarising content. All countries should take stringent steps towards infodemic management General Psychiatry by the formulation of guidelines for responsible media reporting. Additionally, infoveillance (information monitoring), building eHealth literacy and capacity, knowledge refinement and accurate and timely knowledge translation should be encouraged. 18 Integrative care National public health policies should be designed to provide integrated care for mental health in different settings such as hospitals, primary care services, communities, schools, universities, colleges and workplaces. 19 Formalising liaison between these settings with mental health services would help to promptly identify and holistically address emerging mental health needs. Developing support groups, screening of at-risk groups, peer counselling services, establishing dedicated crisis helplines, preparation for long-term plans and expanding support services can facilitate early access to mental health needs. Community mental health services should be well prepared to screen, identify people at risk, provide psychological first aid and facilitate onward referral services. 20 Primary healthcare workers and organisational gatekeepers (eg, pharmacists, geriatric caregivers and school teachers) should be trained to identify individuals at risk and direct them to proper evaluation and treatment. Human resources, education and training Current redeployment of, and potential burn-out among, MHPs in the COVID-19 setting is affecting preparations for the delivery of mental health services for the postpandemic era. Policymakers and stakeholders should consider this as a priority. In many countries (like India), grass-roots medical staff (Accredited Social Health Activist-ASHA, teacher) are playing an important role in prescreening and triage, door-to-door visits, follow-up and on-site screening of COVID-19. Therefore, grass-roots workers should be trained in identifying and managing pandemic-associated psychiatric and psychosocial issues. Many people have been exposed to similar health risks, isolation, grief and economic uncertainty, individually and with their families. Therefore, certain common themes should be used to formulate guidelines to improve access to care. The use of a toolkit or stepped care or matched care model through primary care physicians can improve the coverage of mental health services in the postpandemic era by allowing them to manage common mental disorders of mild severity. 20 In anticipation of an increase in suicide rates, efforts should be made to reduce access to means (eg, more stringent gun control) and for better resourcing with suicide prevention agencies along with global decriminalisation of suicide/attempt(s). In addition, early screening for mental illness and treatment should be encouraged. Prospective cohort studies should be carried out to identify risk factors and exposure levels, track outcomes and compare outcomes among subgroups. These studies are important to monitor the effect of various interventions and strategies. Interventions are needed to reduce stigmatisation and discrimination towards minority or vulnerable groups and to inform policy changes. 21 22 General and specific interventions should be directed towards identification of drivers (eg, misinformation), facilitators (eg, lack of regulations) and intersecting factors (eg, occupation such as healthcare workers) towards reducing stigma and discrimination. 21 Approach for addressing postpandemic mental health and services Addressing emergent challenges with appropriate interventions could be challenging in many countries particularly in low-resource settings. Therefore, efforts should be taken for the prevention of mental health issues on a large scale and organisation of services for early identification of mental health issues. These approaches to mental healthcare prevention and treatment after the COVID-19 crisis can be classified as universal, selective or indicated. 23 24 Universal approach This is a population-wide intervention that will help reduce the overall burden of mental health issues (stress, anxiety and fear) through prevention; therefore, it is imperative to have a universal approach for each country (box 2). It should be used for an individual having the risk factors for developing mental health issues. For example, a vulnerable population and individuals with risk factors mentioned above. A screening toolkit or guidelines should be developed to identify these groups of people. 20 It should be designed for individuals having signs and symptoms of the mental issues as mentioned above. This approach ought to be guided by well-defined guidelines General Psychiatry before the intervention. Some people with mental health issues might not seek help because of fear of COVID-19 infection, stigma and poor motivation. It is therefore important to identify these individuals through a network of hospitals and community health workers. It can be helpful for people with a history of psychiatric disorders, COVID-19 survivors and older adults. To conclude, there is an immediate need to identify the long-term mental health consequences of the COVID-19 pandemic. Clinicians, researchers and policymakers are expected to be prepared for these mental health issues in terms of assessment, interventions and the model of care in the postpandemic era. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations Mental health status of students' parents during COVID-19 pandemic and its influence factors. 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COVID-19 pandemic and mental health consequences: Systematic review of the current evidence Psycho-Neuroendocrine-Immune interactions in COVID-19: potential impacts on mental health Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UKwide surveillance study The psychological impact of COVID-19 and other viral epidemics on frontline healthcare workers and ways to address it: a rapid systematic review Yoga for COVID-19 and natural disaster related mental health issues: challenges and perspectives Recognizing the role of animal-assisted therapies in addressing mental health needs during the COVID-19 pandemic National helpline for mental health during COVID-19 pandemic in India: new opportunity and challenges ahead Acknowledgements The authors wish to thank the Early Career Psychiatrists Section of the World Psychiatric Association (WPA) for being a supportive network that allowed early career psychiatrists from different countries to work together on this initiative.