Covid-19 and the chance to build back better for mental health
By Shirah M Zirabamuzale, on 23 November 2020
My doctoral project on Sustainable and Responsible Innovation in Mental Health (SRIMH) investigates the feasibility and utility of healthcare policies and architectures that on one hand promote mental health through patient-centric designs and design responsibility, and on the other through sustainable and thoughtful environmental design embedding regenerative and adaptive reuse/preservation strategies. Mental illnesses are increasingly recognised as a leading cause of disability worldwide, yet many countries have fragmented funding models, policy structures and physical infrastructures. Mental well-being affects community spirit, education and the economy, making it a priority for governments worldwide.
The COVID-19 pandemic has disrupted and, in some cases, halted critical mental health services in 93% of countries worldwide yet the demand for mental health is increasing, as highlighted in a recent WHO survey. The survey of 130 countries provides the first global data showing the devastating impact of COVID-19 on access to mental health services and underscores the urgent need for increased funding, technological innovation and policy interventions that advance the role of the built environment and SRIMH in improving mental health for citizens.
Reset, Realign, Restart.
World Mental Health Day, which this year fell on 10 October, was a day marked in the backdrop of the multiple fault lines and vulnerabilities exposed in global mental health ecosystems by COVID-19. Shortly before this, on 6 October, WHO published the results of a survey of the impact of COVID-19 on mental, neurological, and substance use (MNS) services in 130 WHO Member States. Although 116 (89%) countries reported that mental health and psychological support was part of their national COVID-19 response plans, only 17% said they had committed additional funding for this.
Historical examples show the detrimental impact events such as a pandemic can have on the mental health of affected populations. For example, research from communities affected by outbreaks of Ebola virus disease (EVD) revealed widespread panic and anxiety, depression resulting from the sudden deaths of friends, relatives and colleagues, and stigmatisation and social exclusion of survivors. A meta-analysis found that depressed mood, anxiety, impaired memory, and insomnia were present in 33–42% of patients admitted to hospital for severe acute respiratory syndrome or Middle East respiratory syndrome, and that in some cases these effects continued beyond recovery.
Even before COVID-19, mental health conditions were prevalent, accounting for about 13% of the global burden of disease. Yet, the world was woefully unprepared to deal with the mental health impact of this pandemic. In the UK for example, 49% of the population felt anxious or worried in June due to the pandemic, the resultant restrictions and other social and economic challenges emanating from the pandemic. With mental illness already the second-largest source of burden of disease in England, a recent report from the NHS Federation revealed an expected rise of mental health cases. This is expected to rise to 500,000 additional people experiencing mental health problems, with depression being the most common.
Indeed, ‘COVID-19-exacerbated demand’ and ‘COVID-19-supressed demand’ are now quoted frequently in reports highlighting the impact of COVID-19 on mental health in the UK. Specifically, referencing the closure of numerous treatment centres and referral routes, deferred referrals of people who would have been referred to services had the pandemic not struck and deferred access to care by people with pre-existing mental illnesses. Certainly, this reveals unpreparedness on the part of government, relevant health governing bodies and mental health facilities to deal with the problem.
Furthermore, the report highlights predictions that the recent rise in mental health referrals will mean demand actually outstrips pre-coronavirus levels – perhaps by as much as 20%. The report flagged isolation, substance use, domestic violence and economic uncertainty as factors that might contribute to the need for extra support. Similarly, mental health providers report a higher proportion of their referrals are patients who are accessing services for the first time. Undeniably, the impact of COVID-19 on the social determinants of mental health will be significant. The report confirms that instability in finances, housing and personal relationships will affect a large proportion of the population, impacting negatively on mental wellbeing and recovery thereby increasing demand for mental health services in the UK.
Evidently, different services, demographic groups and geographic regions will be impacted differently. NHS reports confirm that frontline workers in the UK are experiencing increased workload and trauma, making them susceptible to stress, burnout, depression, and post-traumatic stress disorder (PTSD), particularly among BAME staff who are at greater risk from COVID-19. Similarly, there are particular concerns around the effect on those from a BAME background as this group already face stark inequalities in accessing services and recovery.
Fortunately, the NHS People Plan 2020/2021 has a strong and welcome focus on supporting the wellbeing of staff and the NHS Federation is calling for increased funding for mental healthcare and staff welfare including capital investment to support the expansion of digital approaches. The case study below highlights concerted efforts in this regard.
Case study: Providing timely and inclusive staff support at Greater Manchester Mental Health NHS Foundation Trust
Greater Manchester Mental Health NHS Foundation Trust (GMMH), which employs over 5,700 staff across more than 150 sites, swiftly established a number of Trust-wide initiatives to support staff mental health and wellbeing during the COVID-19 emergency. GMMH has created a hub of digital wellbeing resources that all staff can access via its intranet. Resources are updated on a regular basis and include information on mental and physical wellbeing, guidance on working from home, financial support and information on national offers, including access to free support apps. The trust has supported its BAME and disabled staff networks to meet virtually during the crisis and meetings have been well attended including by executive directors.
Similarly, on a global level, telepsychiatry, (which involves providing mental health care remotely, using telecommunications such as telephone or video conferencing tools), in several settings is suddenly being introduced or massively expanded to serve patients with pre-existing disorders, health professionals on the frontline, and the general population.
Many early career psychiatrists already part of the millennial generation are familiar with technology, and are channelling this strength to deliver far-reaching telepsychiatry, share online mental health-promotion resources, and connect with colleagues worldwide. Country examples as reported in a recent Lancet report include, Singapore which has increased use of online conferencing tools for educational, research, and clinical work and telephone hotlines are widely used, while Brazil and USA have seen regulations restricting the use of telepsychiatry loosened nationwide. However, countries like Colombia and Lebanon grapple with bureaucratic roadblocks to deployment and restricted access to these digital services.
It is not yet known how big a burden Covid-19 will have on mental health systems globally, and the #Reset of mental health policy calls for researchers, policy makers and stakeholders to reset, realign and restart global mental health policy to ensure we build on what we already know and advance progress in achieving the mental health objectives of universal health coverage. As Friedman once wrote: “Only a crisis – actual or perceived – produces real change. When that crisis occurs, the actions that are taken depend on the ideas that are lying around.”
In conclusion, my ongoing PhD research explores some of these issues on resetting mental health policy and building a case for patient-centred, sustainable and responsible innovation mental health service delivery. However, there is a need for concerted efforts from academics, industry and policy makers to address the local and global burdens of mental illness as a result of Covid-19 as we continue to grapple with inadequate infrastructure, inefficient architecture and lack of sufficient data to advise on implementation efforts and inform policy direction. In the meantime, operational realities and tensions between the current infrastructure, architecture and the built environment continue to constrain sustainable mental health service delivery efforts. Equally, scarcity of resources, deep uncertainty around funding and effective treatment measures, political uncertainty and disjointed community care efforts must all be promptly addressed to combat the fragmented treatment and depletion of current mental health resources.