Isolation and inclusion.

The COVID-19 crisis will touch the life of everyone in some way. While viral transmission, incubation times, and care of severely affected patients rightly dominate the news, it is heartening that mental health is given plenty of airtime. Symptoms of anxiety and depression are to be expected in times of stress. Concerns more specific to the COVID-19 outbreak that might have more lasting consequences are the features that prevent health-care staff, carers, and families from having personal contact with patients: working from behind a mask, limiting physical interaction, and not being able to visit ill relatives. Bereavement will be particularly painful without the chance to say goodbye. Children seem to be least affected by infection with SARS-CoV-2, but might experience adverse effects from missing school and being confined indoors.

The National Health Commission of China acknowledged these burdens in January, when it published a list of basic principles for emergency psychological crisis interventions. This list was informed by the experience of the 2003 SARS outbreak, and recommended that mental health care should be provided for patients infected with SARS-CoV-2, health-care professionals caring for them, close contacts, suspected cases who are isolated at home, and families and friends of affected people. Doctors highlighted various other groups at risk of mental distress, such as older people, or pregnant women, but it soon became clear that risk pertained to everyone.

What about people already living with mental health disorders, who are all especially vulnerable in times of crisis, but in different ways? Crucial mental health services are generally being protected from closure and reassignment of staff to treat patients with COVID-19—eg, in Lombardy, Italy, the regional authority specified that mental health and substance misuse services should maintain full functionality. The reassessment of services recommended by Armando D'Agostino and colleagues for their hospital in Milan illustrates practical ways to optimise use of resources, such as closure of certain specialist outpatient units, use of technology for remote consultations, encouraging longer-term prescriptions, and identifying patients with comorbidities that put them at risk from infection with SARS-CoV-2 and contacting them to ensure they understand how to adhere to social isolation requirements.

From perspective, many who would not have previously considered their mental health as part of their identity now find that they have common experiences with those living with mental illness and confined to home by social anxiety, OCD, or agoraphobia. Many of the adjustments to working life echo calls made for years by disability activists. In the UK, recent legal changes reflect this possible reduction in otherness experienced by those living with mental illness, with the Coronavirus Act 2020 assigning police powers of detention and compulsory assessment over people they suspect of being infected with SARS-CoV-2. Full parity between mental and physical illness is not achieved, because the Coronavirus Act does not extend to compulsory treatment, but the Act might prompt some to reflect on the implications of involuntary treatment for mental health disorders.

Like many things in these days of change, psychotherapy services are moving online far faster than anyone could have envisaged only weeks ago. While it might work for established patients, the application of telemedicine to new patients is a less certain prospect. Remote sessions are also easier for some types of psychotherapy than for others. John Markowitz describes the challenges for interpersonal psychotherapy and guidance on how to overcome these. It would be good to embed research projects around such new ways of working, to assess feasibility, efficacy, and above all acceptability. Are they a temporary means to an end or the sign of things to come?

In times of crisis, research might seem a low priority, but as with all crises, it is essential that we monitor innovations and collect high-quality data so that, at a later date, we can learn what worked and what did not. Such research must be done, as far as possible, according to normal standards and complying with ethical best practice. It is also important that the invaluable resources of longitudinal cohort studies around the world are maintained as much as possible, because they will be essential when we have time to examine the long-term consequences of the COVID-19 pandemic for our mental health. Our world of social isolation has never been so inclusive: once the pandemic has passed, may the benefits endure and the disadvantages fade away.

For the National Health Commission of China announcement (in Chinese) see www.nhc.gov.cn/jkj/s3577/202001/6adc08b966594253b2b791be5c3b9467.shtml