key: cord-337816-ivj1imsk
authors: Patel, Vikram
title: Empowering global mental health in the time of Covid19
date: 2020-05-20
journal: Asian J Psychiatr
DOI: 10.1016/j.ajp.2020.102160
sha: 
doc_id: 337816
cord_uid: ivj1imsk

nan

I could hardly have imagined that mental health would have become such a commonly sought after topic in a world gripped by the fear of a marauding virus. Never before have I seen so many webinars, so many pundits, and so many listeners on this topic. But then, we live in times where so much of what we took for granted has been thrown under the bus. Who could have imagined even just a few months ago that much of the world would be looking down the barrel of an economic recession unlike any witnessed in our lifetime?

But let me be clear about one thing: mental health has become a key concern globally not because of any direct impact of the virus, but as a consequence of the reaction of the media and governments to the epidemic. Just the word 'pandemic' and the dramatic way it was announced by the WHO after weeks of the epidemic unfolding around the world was a hairraising moment. Then, there was the apocalyptic messaging by modellers about the millions of dead bodies that would be littering our cities and by the media on the risk the disease posed-for example failing to communicate that the median age of death was in the mid-70s; emerging data demonstrating the vast number of asymptomatic individuals suggests the overall mortality rate is well below 1%, falling to nearly zero in young people. The ghoulish reporting of cases, without any nuancing about what those numbers actually mean, served to confirm in people's minds that the virus was inexorably sweeping the world. The final nail in the coffin were the unprecedented national lockdowns, nowhere as brutal, unplanned and sweeping as the one in India, announced with just four hours' notice late in the evening, with a scope and stringency that has never been seen in history.

In this context, unless you are an epidemiologist who is well-informed to correctly interpret the numbers and read between the lines, the wide-spread reactions of panic and fear are totally understandable. Indeed, if one considers the constant uncertainty about when, if ever, life will return to a semblance of what we used to experience, the torrent of mixed messages about the science (real or fake) around the virus, and the complete lack of consensus on what the post-lockdown scenario for the containment of the virus might look like, I think it might even be somewhat unexpected for an individual to report being in great mental health in these times! It is not at all surprising that experiences of anxiety, fearfulness, sleep problems, irritability and feelings of hopelessness have become widespread. They are mostly rational responses of our minds to the extraordinary realities that we are facing. That said, if the curve of the severity of mental health symptoms (apologies to those who are fed up of seeing the word 'curve') has shifted to the right, i.e. towards greater severity, one will also be seeing a rising incidence of clinically significant mental health problems and suicide, as was observed in a previous coronavirus epidemic in Hong Kong (Cheung, Chau, & Yip, 2008) . Furthermore, thanks to lockdowns and the pivoting of health care services to this one virus, there is emerging evidence that routine mental health care has been seriously disrupted affecting not just incident illness episodes but also the continuing care of preexisting mental health problems.

Certainly, a rise in the burden of clinically significant mental health problems is what we should expect as the impact of the economic recession, the widening of inequalities in countries, the continuing uncertainties about future waves of the epidemic and the physical distancing policies begin to bite deeper into our mental health. This would not be surprising, given the strong association between unemployment, acute poverty and indebtedness with poor mental health (Lund et al., 2018) . "Deaths of despair" have been documented as the cause for the increased mortality and reduction in life expectancy in working-age Americans following the economic recession in 2008 (Case & Deaton, 2020) . Tracing the source of these deaths ultimately to a deeply unfair economic system, the authors point out that these deaths were not so much due to material hardship but because of loss of hope due to the lack of employment and rising inequality. Suicide and substance use related mortality accounted for most of these deaths. Many low and middle income countries share the ills of US society, from its profound inequality to its weak social security net and fragmented health care systems; in addition, these countries are also home to the largest number of poor people in the world, already enfeebled by hunger and myriad diseases of poverty. This toxic combination of absolute poverty with rising levels of inequality is a recipe for a similar surge of depths of despair in the region. Mental health care systems in most countries will be illequipped to deal with this surge, not only because of the paucity of skilled providers, but also because of the narrow biomedical models which dominate mental health care.

While there has been a flourishing of initiatives to address the rising tide of mental health problems, most notably through telemedicine platforms, these suffer from the same barriers that have so limited the coverage of mental health care in the past: most rely on specialist providers who are very scarce in number. This is compounded by yet another barrier: digital literacy and adequate internet connectivity still remains a distant goal for large swathes of the world's people, particularly amongst the poor and rural populations. Still, one welcome aspect of this development is the recognition of the possibility of remote delivery and the value of psychological therapies, often ignored in mental health care and, at best, playing a poor cousin to medication options. At the same time, low-resource settings have been a laboratory for some of the most transformative innovations to improve access to evidence based psychological therapies in psychiatry with a flurry of randomized controlled trials for depression, psychoses and harmful drinking reframing the way we can enhance the coverage of these interventions. This critically important clinical and implementation science is now influencing global policies and, incredibly, also the way mental health care is organized in rich countries which enjoy so much more mental health resources.

The impressive body of evidence generated by global mental health researchers has generated a range of innovative strategies aimed at addressing the structural barriers to the scaling up of psychosocial therapies, notably the demonstration that pared down 'elements' of complex psychological treatments packages can be just as effective as standardized treatment protocols (for e.g. behavioural activation for depression, compared with cognitive behaviour treatments); that providers can be trained to learn a library of such 'elements' targeting specific types of mental health experiences (for example, mood problems, anxiety problems, trauma related problems) and to use simple decision making algorithms to 'match' patients' problems with specific treatments elements; that one does not require a formal diagnosis to trigger care, greatly simplifying the dissemination of effective treatments; that these pared down treatments elements and trans-diagnostic protocols can be effectively delivered by non-specialist "therapists", such as community health workers; that these delivery models are highly acceptable to consumers; show recovery rates comparable to specialist care models, and economic analyses show they are excellent value for money (Kohrt et al., 2018; Singla et al., 2017) . More recent innovations seeking to scale up these approaches demonstrate the acceptability and effectiveness of digital training in the delivery J o u r n a l P r e -p r o o f of psychological treatments and of peer supervision for quality assurance (Muke et al., 2019; Singla et al., 2014) . This range of innovations, when combined and scaled up, can transform access to one of the most effective interventions in medicine. This is exactly the goal of the EMPOWER program, an initiative of Harvard Medical School (https://globalhealth.harvard.edu/empower-building-mental-health-workforce) which is seeking to scale up evidence based psychological therapies, with an initial implementation focus on communities in the USA and India. Over the coming years, we intend to build on the ongoing work of the ESSENCE program, a NIMH funded research Hub, led by Sangath in partnership with the government of Madhya Pradesh, to digitize the curriculum of a brief behavioural activation treatment for depression (Patel et al., 2017) , its competency assessments and the supervision and quality assurance protocols. Ultimately, this platform will offer a career path which enables front-line providers an opportunity to achieve the status of an expert, motivating them and ensuring sustainability of the most expensive mental health professional resource. Future enhancements include evaluating the effectiveness of the scaling up on population mental health and harnessing big data opportunities to develop prediction models to refine treatment element selection algorithms to optimize patient outcomes. The use of digital platforms for building the workforce is not only aligned with the use of tele-medicine but also with the urgent need for digital approaches for training and supervision in the light of physical distancing policies.

But, of course, implementers will need significant resources to realize these kinds of ambitious projects and here we need to anticipate the biggest threat to mental health consequent to Covid19: the pushing back, once again, of mental health from the global health agenda. I recall this happening way back in the late 1990s when it appeared that mental health would finally be recognized as a priority by the world's leading development agencies only for it to be left off the table by the Millenium Development Goals of 2000. Fifteen years later, mental health found its rightful place in the Sustainable Development Goals and I could begin to sense its inclusion in the priorities of funders who had previously given it a pass. And now we are in the first half of 2020 and all funding and health care action has entirely pivoted towards one disease-Covid19. Already some of the funding I had come close to securing for EMPOWER has been stalled. And some of it may never be realized. It is deeply worrying that despite the strong mental health concerns in the light of the pandemic, there seems to be no meaningful role played by mental health professionals in guiding public policies on the epidemic. Once again, mental health risks are being shoved back into the shadows. This is a timely moment for diverse stakeholders concerned with mental health, from psychiatric associations and global mental health practitioners to civil society advocates, to unite with one message, that the pandemic and its socio-economic consequences will have profound effects on population mental health and that some of the financial resources being pumped into the Covid19 response must be allocated to 'build back better' mental health care systems in all countries.

J o u r n a l P r e -p r o o f

Deaths of Despair and the Future of Capitalism

A revisit on older adults suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong

The Role of Communities in Mental Health Care in Low-and Middle-Income Countries: A Meta-Review of Components and Competencies

Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews

Acceptability and feasibility of digital technology for training community health workers to deliver brief psychological treatment for depression in rural India

The Healthy Activity Program (HAP), a lay counsellor-delivered brief psychological treatment for severe depression, in primary care in India: a randomised controlled trial

Psychological Treatments for the World: Lessons from Low-and Middle-Income Countries

Improving the scalability of psychological treatments in developing countries: an evaluation of peer-led therapy quality assessment in Goa, India