Addressing the public mental health challenge of COVID-19.

The rapid global spread of COVID-19 is having wide-ranging effects on population mental health, which are even greater for particular groups of individuals, including those with pre-existing mental disorder.1, 2 Furthermore, increased COVID-19 infection and mortality would be predicted in individuals with a mental disorder, given that their life expectancy is reduced by 7–25 years, mainly because of higher prevalence of physical ill health when compared with those who do not have a mental disorder.

The COVID-19 pandemic presents a triple global public mental health challenge: (1) to prevent an associated increase in mental disorders and a reduction in mental wellbeing across populations; (2) to protect people with a mental disorder from COVID-19, and the associated consequences, given their increased vulnerability; and (3) to provide appropriate public mental health interventions to health professionals and carers. This challenge is compounded by the inadequate population coverage of evidence-based public mental health interventions before COVID-19, even in high-income countries.3, 4 Since the start of the COVID-19 pandemic, the provision of some of these mental health interventions has become more limited by quarantine and lockdown measures. Interventions to prevent, treat, and mitigate the effects of COVID-19 are likely to adversely affect mental health, particularly in those with or at a higher risk of mental disorder.1, 3 However, a key opportunity exists to mitigate this challenge through early action to increase coverage of public mental health interventions.

Before COVID-19, 20% of the global disease burden was attributable to mental disorder. Factors contributing to the size of this burden include the high prevalence of mental disorders, most lifetime mental disorders arising before adulthood, and their broad effects on health, education, employment, social interaction, violence, and crime. Evidence suggests that pandemics, including COVID-19, are associated with an increased risk of developing mental disorder and poor mental wellbeing.1, 2 This increase in risk is likely to be mediated by the effects of the pandemic on risk factors, including socioeconomic inequalities, poverty, debt, unemployment,1, 2, 7 food insecurity, social factors, quarantine, physical distancing, and physical inactivity, all of which would also be expected to increase the risk of relapse in individuals with a mental disorder.1, 2, 8 Groups that are likely to experience disproportionate mental health effects from COVID-19 include those with a mental disorder, health professionals and carers, offenders, refugees, and older people, including those in care homes.

Public mental health interventions (panel ) are therefore even more important during pandemics to prevent the anticipated higher prevalence of mental disorders, the associated consequences, and poor mental wellbeing.1, 3 Delivery of public mental health interventions occurs at individual, community, and national levels, with groups at a higher risk than the general population requiring more targeted approaches to prevent widening of inequalities.

Public mental health interventions can be divided into mental disorder prevention and mental wellbeing promotion. Such interventions need to be proportionately targeted to groups at a higher risk of mental disorder and poor mental wellbeing than the general population.

Mental disorder prevention

Mental disorder prevention can occur at primary, secondary, or tertiary levels.

Primary prevention

Addresses risk factors exacerbated by COVID-19, including socioeconomic inequalities, poverty, debt, unemployment,2, 7 food insecurity, parental mental disorder, child adversity, stress at work (including in health professionals), physical ill health, physical inactivity, and social isolation (including from quarantine).

Secondary prevention

Early intervention for mental disorders and their associated effects, including those related to COVID-19.

Tertiary prevention

Intervention for individuals with an established mental disorder to prevent the associated consequences and disability through treatment, patient education, and addressing health-risk behaviour, physical illness (including from COVID-19), socioeconomic issues, social isolation, stigma, and discrimination.

Mental wellbeing promotion

Promotion involves first increasing the value that individuals and societies give to mental health and wellbeing, and then implementing interventions to enhance mental wellbeing in different situations. Interventions to enhance mental wellbeing can occur across the life course.

Starting well

Promotion of parental physical and mental health, infant attachment, and parenting programmes (including digital programmes).

Developing well

Preschool-based and school-based programmes to promote mental wellbeing, development, and physical health (including through digital programmes).

Living well

Promotion of social interaction, physical activity, care for physical health, access to green space, arts, culture, creativity, and mindfulness.

Working well

Promotion of healthy working conditions including through flexible working, training, and online psychological approaches.

Ageing well

Living well interventions (above), psychosocial interventions, and addressing sensory deficits, such as poor hearing or eyesight.

Despite the existence of effective public mental health interventions, implementation is poor.3, 4 Globally, only a minority of individuals with a mental disorder receive any treatment, and coverage of interventions that prevent the associated effects is even poorer, while coverage of interventions to prevent mental disorder or promote mental wellbeing is negligible. This implementation failure contravenes the right to health and leads to preventable suffering at a population level, with the associated effects and economic costs amplified during crises, such as COVID-19.

Public mental health practice, including during COVID-19, is a key mechanism to reduce the implementation gap and address this challenge in both the short term and longer term.1, 3 The first step involves assessing the size, impact, and cost of current and anticipated unmet need for public mental health interventions, taking into account the effects of COVID-19. This approach includes identifying appropriate public mental health interventions, and is supported by estimating the impact and associated economic benefits from improved coverage of these interventions. These steps are first required at a national level to inform both policy and transparent decisions about acceptable coverage of different interventions. This process in turn informs the extent of coverage, required resource, commissioning, and coordination between providers of different interventions. Subsequent steps involve appropriate operationalisation to support implementation of the agreed public mental health interventions, followed by evaluation of coverage and outcomes, including for high-risk groups. Appropriate communication to the general population, and health and allied professionals supports the implementation of these interventions, improves awareness and understanding, and reduces distress associated with uncertainty.

Population access to public mental health interventions, including during pandemics, can be improved in several ways.1, 3 Training of health and allied professionals improves knowledge about public mental health and COVID-19, while improving population knowledge about mental health, in general and in relation to COVID-19, is important. Digital technology can deliver public mental health interventions, support the mental health of carers and health professionals, reduce social isolation, deliver public mental health training, and facilitate contact tracing. However, risks of excessive screen time need to be mitigated, while also considering the needs of those without such technology. Setting and group approaches enable public mental health interventions to be implemented in large sections of a population, such as schools and workplaces, including through digital means during lockdown or quarantine. Existing resources can be maximised through self-help and the shifting of tasks (eg, treatment) to less trained individuals. The application of relevant legislation can be a major support to the implementation of public mental health measures.

In order to prevent the anticipated effects of COVID 19 on population mental health, there is an urgent need for population-scale implementation of effective public mental health interventions, supported by public mental health practice and innovation. Implementing these interventions will mitigate the impact of the pandemic on mental health, improve population wellbeing, prevent mental disorders from arising, and reduce relapse of mental disorders, with associated economic returns, even in the short term. Public mental health practice should be an integral part of the response to COVID-19, and will have immediate positive effects and a legacy likely to long outlast the pandemic.