The COVID-19 outbreak was sudden and unexpected in most countries. The first known cases occurred in late December, 2019, and WHO declared it a pandemic on March 11, 2020. The evolution of COVID-19 remains unpredictable, and this unpredictability is exacerbated by the heterogeneity of health systems worldwide and difficulties obtaining accurate infection and immunity numbers. In view of the magnitude of the pandemic, most countries adopted lockdown as a containment strategy.

COVID-19 has resulted in an increase in known risk factors for mental health problems. Together with unpredictability and uncertainty, lockdown and physical distancing might lead to social isolation, loss of income, loneliness, inactivity, limited access to basic services, increased access to food, alcohol, and online gambling, and decreased family and social support, especially in older and vulnerable people. Racial and ethnic disparities in the incidence of COVID-19 (and associated mortality) have been pronounced. The downturn in the economy caused by COVID-19 will lead to unemployment, financial insecurity, and poverty, which hinder access to health services (especially in insurance-based systems), thereby having deleterious effects on physical and mental health and quality of life. These economic factors can induce mental health problems in previously healthy people and negatively affect those with pre-existing mental disorders.

The economic breakdown that is likely to occur in the aftermath of the pandemic could exacerbate healthcare disparities and will probably disproportionately affect  socially disadvantaged patients, including those from ethnic minorities, who have worse access to health care and receive poorer quality care than white populations. Sooner or later, health systems will be faced with widespread  demand to address these COVID-19-related mental health needs. International organisations, including WHO, advocate for integration of mental health and psychosocial support into the COVID-19 response, and a UN policy brief suggests that investments now will reduce the mental health effects later. However, the pandemic-related economic breakdown could impede an adequate mental health response.

In view of the lack of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine, uncertainty about new epidemic waves, and the likelihood of long-term impacts on mental health, we need both short-term adaptations and sustained responses. In this Position Paper, an international group of mental health experts, including service users and carer leaders, reflects on the mental health challenges posed by COVID-19 and how best to address potential changes in services. We describe the mental health needs, potential systems adaptations, and outcome measures that can help to turn a crisis into an opportunity for improvement.


The COVID-19 pandemic has already affected mental health, and some of these effects might persist. The psychological toll of the disease is already apparent both in the general population and specifically in people with mental disorders (particularly those with severe mental illness and cognitive impairment) and frontline workers. Mental health systems have rapidly changed during the pandemic and a sustained response to the challenges posed by COVID-19 needs to be coordinated. Despite heterogeneity in political, social, and health systems, mental health services worldwide have implemented acute responses that focus on infection control, continuity of care for mental health service users, and facilitating access to mental health assessment and care for patients with new-onset issues and high-risk patients.

Some new approaches that have been developed seem efficacious, but they might still be associated with risks. Implementation of a COVID-19-related physical and mental health monitoring system that includes outcomes related to mental health service use would inform practice, and could help to shape optimal mental health care for the times to come. Retaining existing services and promoting new practices that expand access and provide cost-effective delivery of effective mental health services to individuals who already have mental disorders or who have developed them during the pandemic should be a priority. Service provision needs to be individualised: effective practices already in place should be refined and scaled up, and both the usefulness and limitations of peer support and remote health delivery should be recognised. A focus on accountability based on routine measurement of meaningful and valued out- comes, co-production of service design and evaluation with expansion of health insurance coverage of mental health, and promotion of primary care support and its greater integration with secondary care could further help to sustain mental health care in the aftermath of the pandemic.

The economic implications of the COVID-19 pandemic are serious. It is important to be cognisant of the risks of promoting cheap solutions to broadening access to mental health care. Low-quality mental health care based on affordability without assessment of quality or monitoring of needs and efficiency will only contribute to increasing inequalities and worsening mental health globally. Now more than ever, we need to put in place service provision that targets health needs and reduces disparities, both globally and within individual countries. Despite sub- stantial cross-national differences in social and mental health systems, we believe that such an approach is feasible with some location-specific adaptations. It could even turn the COVID-19 pandemic into an opportunity to improve mental health care for everyone.

For the full article: Lancet Psychiatry S2215-0366(20)30307-2


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