Global mental health and COVID-19.

The COVID-19 pandemic has disrupted the delivery of mental health services globally, particularly in many lower-income and middle-income countries (LMICs), where the substantial demands on mental health care imposed by the pandemic are intersecting the already fragile and fragmented care systems. The global concern regarding the psychosocial consequences of COVID-19 has led major funding bodies and governments to increasingly call for proposals to address these effects. Although assessments of high-quality systematic data that address the immediate psychosocial problems of the pandemic are pertinent, the generation of evidence that advances the objectives of global mental health within the context of the pandemic is also vital.

In the past decade, global mental health researchers have made considerable progress in the development and testing of innovative approaches within mental health care. Trials have shown the clinical effectiveness and cost-effectiveness of mental health interventions, despite the large gaps in care for mental disorders globally.3, 4 To address shortages in service delivery, the 2018 Lancet Commission on global mental health and sustainable development identified mental health as an essential component of universal health coverage. Among its key messages, the Commission re-emphasised the call to scale up mental health care and recognised the potential of digital health to increase access to mental health services. The case for repeating these key messages is compelling as mental health professionals devise urgent strategies to address the mental health consequences of COVID-19. How can we create notable actions from existing strategies in global mental health to improve coverage of mental health services in the coming months?

Two successful global mental health strategies are relevant to research on mental health services in the context of COVID-19. The first is task shifting—the use of trained lay health workers to deliver health care in non-specialist settings. With regard to the data on global care gaps for mental disorders, the situation is least favourable in LMICs. Task shifting has led to the success of many innovative mental health services, with evidence of promise in low-resource settings, despite several implementation challenges limiting their use. Increasing pressure on health systems resulting from COVID-19 highlights the need to re-examine task shifting, to further investigate how it can be widely implemented to improve the access and reach of mental health services. Task shifting can be used to address the urgent need to build a provider base in developing countries, given the flexible workforce it can provide for service delivery at the community level, within homes, schools, work places, and care centres. These settings can serve as service outlets for mental health promotion and awareness programmes, and for service provision via community engagement with trained lay mental health providers. However, in implementing task shifting, important aspects are to build on past successes by recognising its limits as a system intervention, and give attention to implementation barriers to scale-up and sustain the use of successful approaches. Essentially, to optimise uptake of new or existing evidenced-based mental health innovations, adopting and adapting task-shifting strategies within health systems and implementation research frameworks will be necessary. Such approaches will allow targeted problems to be identified, studied, and addressed within some or all of the complex service levels within the six building blocks of the health system (service delivery, health workforce, information technology, medical products, financing, and governance and leadership), which will be crucial to wide-scale implementation and coverage.

The second strategy is the use of digital health technology to strengthen health systems. Widespread adoption of mobile phones in LMICs has led to their increasing use for health interventions. Although evidence supporting large-scale adoption of virtual interventions for mental health care in LMICs is sparse, and high-income countries (HICs) currently dominate digital innovations, the COVID-19 pandemic has led to increasing global adoption of virtual care to reduce the risk of infection among health workers. Furthermore, despite several questions surrounding digital innovation, even in HICs, their potential to increase access and coverage in hard-to-reach areas calls for more research on their effectiveness in LMICs. Mobile phones can assist the delivery of quality services by facilitating access to training, supervision, and support among care providers, and making health records available remotely. A basic mobile phone function such as text messaging can have a range of uses, from delivering bulk health information on prevention and promotion programmes, to uses in supporting patient recovery even in cases of severe mental illness such as psychosis. Additionally, International Telecommunication Union reports have indicated high usage of mobile internet networks in LMICs (>91% 3G users and >78% Long Term Evolution or Worldwide Interoperability for Microwave Access network users), meaning online video calls and mobile phone applications can be used to support patient care in real time. The availability of internet data from mobile networks can also allow for follow-up care and empowerment of patients and their families during the recovery process via various online platforms. Digital health care can be personalised to daily life1, 8 by the direct delivery of psychological treatment to patients—an avenue that also addresses cost and stigma-related barriers to health care. From a research perspective, digital technology provides an efficient and cost-effective way to recruit patients and provide easy access to care, particularly in this time of physical distancing. The high use of mobile phones in LMICs presents health-care planners and researchers with opportunities to develop or adapt virtual preventive and treatment interventions that have been successful in HICs, to minimise the mental health consequences of COVID-19. However, despite the incentives to increase uptake of digital health, an important caveat is the possible lack of access for vulnerable people needing health care. To address this limitation, the Lancet Commission on global mental health recommended adoption of digital interventions alongside traditional treatments, rather than as replacements.

The psychosocial burden of COVID-19 will become increasingly evident in the coming months as the effects of social measures such as physical distancing, loneliness, death of friends and family members, and job losses manifest. Efforts to respond to these mental health needs present researchers with an important opportunity to build on what we know and advance progress in achieving the mental health objectives of universal health coverage.