Social inequalities and collateral damages of the COVID-19 pandemic: when basic needs challenge mental health care.

Never before has there been such a high level of mobilization around mental health during an epidemic (Pappa et al. 2020). International agencies, with the UN General Secretary at the forefront, the Director of the World Health Organization, as well as researchers, policy makers and civil society leaders have all drawn attention to the need for mental health care for people affected by COVID-19. In the so-called developed countries, many training courses and guidelines have been developed to help mental health professionals to offer telepsychotherapy in order to comply with the physical distancing measures taken to prevent the spread of the COVID-19 pandemic. In many low- and middle-income countries (LMICs), a mental health commission has been implemented within the response committees to fight the pandemic. These measures have been part of unprecedented efforts to raise awareness on mental health issues.

However, despite these efforts, many concerns rapidly arose about mental health care during the COVID-19 pandemic. Many of these measures solely target mental health symptoms (emotional and behavioral), rather than the overall well-being of individuals, families and communities. Typically formulated in high-income countries (HIC), these programs often assume that basic needs are met, and operate under the assumption that survival is not threatened. However, programs that address social inequalities and the non-fulfillment of basic needs are urgently needed, both in HIC and in LMICs. Indeed, beyond the fear of the virus or the isolation of confinement, an increasing number of people go to bed hungry and worried about what their family will eat the next day. Others are preoccupied by their unpaid rent and the risk of being thrown out of their apartments. In the USA, while more than 30 million people applied for unemployment benefits in April, two large surveys have shown that around 20% of children do not have access to enough food (Bauer 2020). In India, more than 120 million lost their jobs or economic activities, among them, some of the most vulnerable. Queues spanning more than five miles in the USA, where recently unemployed individuals are seeking food assistance, or images of the millions in India trying to reach their hometown by bus and on foot revealed the extent of social inequalities in the face of COVID-19. In some countries, confinement measures were deemed impossible to follow, because the risk of being infected was nothing compared to starving to death.

The WHO’s definition of mental health and well-being of individuals includes the fulfillment of basic human needs and rights and recommends interventions that are based on an ecosystemic approach targeting a wide range of social and psychological determinants, including social inequalities, poverty and precariousness. In the current social crisis resulting from the COVID-19 pandemic, those most in need of mental health care are those whose livelihoods have been made even more precarious because of social disparities. Yet, few of them will seek help because their basic needs are not met and our mental healthcare systems not only fail to address these inequalities but tend to individualize psychological distress (Murali and Oyebode 2004). Proposing online support and tool kits to address anxiety and depression symptoms may be very helpful when culturally appropriate. However, if survival is at stake and if this is not acknowledged as the most legitimate concern, these same resources may be perceived as a minimization or a denial of the social suffering of marginalized groups.

Thus, mental health programs may have an important role to play to help those most vulnerable to social inequality in coping with the COVID-19 pandemic, but these mental health responses should be tightly interwoven with socially and culturally adapted interventions which take into account their reality. As previous studies on similar epidemics (Cénat et al. 2020a, b), ongoing studies have shown that in addition to anxiety and fear, a high prevalence of depression, insomnia and other mental health problems have been observed in those affected by the current crisis (Pappa et al. 2020). During this critical time, contact with mental health professionals should be facilitated to help those who are struggling to cope. To do this, it is important to use innovative approaches to reach the most vulnerable. As has been shown in countries during Ebola epidemics, people need psychosocial support to be integrated with other services, in innovative and accessible ways (Cénat et al. 2019a, 2020b). For example, in queues at food distribution sites in the USA, cards with contacts of crisis centers could be distributed to promote the use of psychosocial support. Furthermore, mental health providers could be available on-site to meet those who are most in need. However, applying these principles on a larger scale would have the most significant and beneficial impact on our populations. Cities and countries should consider developing inclusive and holistic programs based on ecosystemic models that integrate both basic needs and mental health care. These measures should help reduce the psychological distress of those affected by the exacerbation of social inequalities. Promoting mental health while addressing its social determinants would also help in preventing mental disorders and related suicides.

It is also important to learn from the current situation in order to be prepared for future pandemics and crises. We will only be ready if we work to reduce social inequalities in the coming years. We will only be ready if we put in place strong and equitable social protection systems. Not only will a population mental health approach which reduces disparities serve as a protective factor for the development of mental disorders, it will also allow mental health care to be made more accessible.

Food, housing and financial insecurities which prevent people from seeking mental health care, even when urgently needed, are a global issue that concern both HIC and LMICs (Cénat 2020). In the USA, where black people have been overwhelmingly and disproportionately impacted by COVID-19 and where most are suffering from bereavement related to the pandemic, very few will access mental health care. The same is true for many unemployed people, whether in developed countries or in LMICs, who are more preoccupied about their immediate day-to-day needs than about protecting themselves from COVID-19.

Only by reducing social inequalities will we be ready in the future. In the meantime, mental health programs must be integrative and ecosystemic, addressing both basic needs and mental health issues, because when basic needs challenge psychosocial well-being, no matter how urgent it is, mental health care will wait.