Strengthening mental health responses to COVID-19 in the Americas: A health policy analysis and recommendations.

The COVID-19 pandemic is having a major impact on the mental health of populations in the Americas. Studies show high rates of depression and anxiety, among other psychological symptoms, particularly among women, young people, those with pre-existing mental health conditions, health workers, and persons living in vulnerable conditions. Mental health systems and services have also been severely disrupted. A lack of financial and human resource investments in mental health services, limited implementation of the decentralized community-based care approach and policies to address the mental health gap prior to the pandemic, have all contributed to the current crisis. Countries must urgently strengthen their mental health responses to COVID-19 by taking actions to scale up mental health and psychosocial support services for all, reach marginalized and at-risk populations, and build back better mental health systems and services for the future. Editorial Disclaimer : This translation in Spanish was submitted by the authors and we reproduce it as supplied. It has not been peer-reviewed. Our editorial processes have only been applied to the original abstract in English, which should serve as a reference for this manuscript. Disclaimer:  The Authors hold sole responsibility for the views expressed in this article, which may not necessarily reflect the opinion or policy of the Pan American Health Organization/World Health Organization.

Introduction

The WHO Region of the Americas comprises 51 countries and territories, spanning North America, Central and South America, and the Caribbean subregions, with a population of nearly one billion. This region has been the geopolitical area most affected by COVID-19 in terms both of cumulative cases and deaths, accounting respectively for 39% of all cases and 46% of deaths globally by the end of September 2021. This public health emergency in Latin America and the Caribbean has been exacerbated by underlying social and economic challenges associated with weak social protection mechanisms, fragmented health systems and profound inequalities.

Available data from the Region show that the COVID-19 pandemic is having profoundly adverse impacts on mental health at the population level, coupled with the severe disruption of mental health services. A failure to prioritize mental health before the pandemic has hindered appropriate responses to currently high mental health needs.

In this health policy paper, we examine the impacts of the COVID-19 pandemic on the mental health of populations and mental health systems and services in the Region of the Americas. Based on our findings, we offer policy and programming recommendations to improve the mental health situation during the pandemic and strengthen mental health responses as countries transform their health systems in the post-pandemic period.

Methods

We conducted a narrative review based on a search on PubMed for articles published online or in print between January 1, 2020, and August 31, 2021, on “mental health,” “depression,” “anxiety” or “stress” and “COVID-19” in the Region of the Americas, including only articles published in English or Spanish. We also conducted Google and Google scholar searches of the grey literature using the same search terms.

Mental health prior to the COVID-19 pandemic

The global situation

One in four people worldwide will experience a mental health condition in their lifetime, more than three million people will die as a result of harmful alcohol use each year, and nearly one million will lose their lives to suicide. Mental, neurological and substance use (MNS) disorders account for 12% of all disability-adjusted life years (DALYs). Yet despite the high global burden of MNS disorders and the associated substantial economic costs —it is estimated that by 2030, mental health will cost the global economy $16 trillion dollars —mental health remains a severely neglected area of public health.

Noticeably absent from the United Nations (UN) Millennium Development Goals, mental health was included in the subsequent Sustainable Development Goals (SDGs) adopted in 2016 under Target 3.4. In 2018, the United Nations General Assembly member states expanded the focus on the principal four noncommunicable diseases and related risk factors to a five-by-five approach that included mental disorders.

However, the burden of mental health conditions continues to climb, and the vast majority of affected persons still lack access to quality treatment. Persons suffering from MNS disorders are often victims of stigma and discrimination, and even gross human rights abuses. There is a huge gap between the global mental health burden and investment, with countries spending an average of only 2% of their overall health budget on mental health, while international development assistance for mental health similarly accounts for less than 1% of all resources directed to health. While significant advances have been made in global mental health research and innovation, scaling up proven mental health strategies and interventions to meet the ever-growing needs continues to be a challenge.

The situation in the Americas

The Region of the Americas is characterized by considerable diversity in national population sizes, socioeconomic indicators, inequalities, ethnic and cultural differences, and urban-rural divides, which all contribute to the wide-ranging disparities that exist within and between countries and manifest in the burden of mental health conditions, availability and allocation of resources, and access to mental health services and treatment.

MNS disorders and suicide are significant causes of disability and mortality, accounting for more than one third (34%) of total years lived with disability (YLDs) and one fifth (19%) of total disability-adjusted life years (DALYs). Depressive disorders are the largest single cause of disability in the Americas, accounting for 7·8% of total disability, followed by anxiety disorders at 4·9%. Nearly 100,000 people die by suicide each year, with Guyana and Suriname included among the ten countries with the highest suicide rates in the world.

Large gaps remain between the number of people who need mental health care and those who receive it, with the median treatment gap reaching 82·2% for substance use disorders. Within countries, access to mental health services can differ greatly, with vulnerable groups, such as people living in situations of poverty and indigenous peoples and Afro-descendants, having reduced access.

Mental health spending in the Region, averaging around 2% of total public expenditure on health, is often inadequate and inefficiently allocated, with an average of 61% disbursed to psychiatric hospitals, (approaching 100% in non-Latin Caribbean countries). There is also a shortage of mental health human resources, averaging 10.3 mental health workers per 100,000 population (ranging from less than one per 100,000 population in low-income countries to over 50 per 100,000 population in high-income countries).

Despite the commitment of many countries in Latin America to the principles enshrined in the Caracas Declaration (1990), the psychiatric asylum model continues to dominate mental health service provision. Psychiatric hospitals still retain a large number of beds, especially in high-income countries of the non-Latin Caribbean. The Americas also has the highest percentage (20%) of in-patient stays of all WHO Regions, exceeding five years in psychiatric hospitals.

It is anticipated that mental health needs will only continue to grow in the Region of the Americas. In the coming decade, the over-60 population in Latin America and the Caribbean will represent at least 18% of the general population, a figure that will reach almost 25% by 2050 and even 30% in several countries. According to the WHO, one in five adults over age 60 suffers from a mental or neurological disorder. Furthermore, climate change, deemed “the biggest global health threat of the 21st century,” is anticipated to amplify mental health problems in the Americas. Rising temperatures have increased the number and intensity of tropical storms and floods in the Region, with 335 climate-related disasters occurring between 2005 and 2014, a 14% increase from the previous decade. Climate change has been associated with adverse mental health impacts as well as increased suicide rates.

The mental health impact of the COVID-19 pandemic in the Americas

Mental health of populations

The first case of COVID-19 in the Americas was confirmed on January 20, 2020, and the pandemic has disproportionately affected this Region. As of September 2021, there have been over 82 million COVID-19 cases and more than 2 million related deaths.

In addition to its impact on health and loss of life, the pandemic has generated significant socioeconomic consequences. In 2020, the entire region of the Americas, and particularly Latin America and the Caribbean, experienced significant increases in unemployment, poverty and food insecurity due to COVID-19. Additionally, records from helplines, police reports and other service providers indicated an increase in reported cases of domestic violence, in particular child maltreatment and intimate partner violence against women, compounding high rates of violence in the Region, reported to be three times the global average prior to the pandemic.,

Countries across the Americas have also reported a worsening of their population mental health. In the United States, rates of anxiety and depression reached as high as 37% and 30%, respectively at the end of 2020, compared to pre-pandemic frequencies of 8·1% for symptoms of anxiety disorder and 6·5% for symptoms of depressive disorder in 2019. Likewise, the proportion of Canadians reporting high levels of anxiety quadrupled and depression doubled, with rates peaking at 28% and 17% respectively, in May 2021. In Peru, the prevalence of depressive symptoms during the country's national lockdown in May 2020 was five times higher than previously reported at the national level in 2018 (34·9% vs. 6·4%, respectively). During Argentina's general lockdown, inhabitants showed substantial anxiety and depressive symptoms, with 33% and 23% of participants reporting possible depressive and anxiety syndromes. A national survey in Brazil found prevalence rates of depression and anxiety as high as 61% and 44%, respectively. One study in Mexico documented symptoms of clinically significant post-traumatic stress in 28% of the population studied. Of the studies cited, higher rates of mental health symptoms were reported by women, people aged less than 35, people with pre-existing mental health conditions, and those of lower economic status and educational levels.

People infected with and recovering from COVID-19 are experiencing high rates of mental health problems. In people with no previous psychiatric history, a diagnosis of COVID-19 was associated with increased incidence of a first psychiatric diagnosis in the following 14 to 90 days compared with six other health events. The incidence rate ratio was highest for anxiety disorders, insomnia, and dementia. The estimated incidence of a neurological or psychiatric diagnosis in the following 6 months after COVID-19 infection was 33·62%, with 12·84% receiving their first such diagnosis. Risks were greatest in, but not limited to, people with severe COVID-19.

The COVID-19 pandemic has also contributed to relapse and the exacerbation of mental health symptoms in people with pre-existing mental health conditions. People with prior psychiatric conditions showed significantly higher scores on scales for general psychological disturbance, posttraumatic stress disorder, and depression. Furthermore, individuals with a recent diagnosis of a mental disorder were found to be at increased risk for COVID-19 infection and to also have a higher frequency of adverse outcomes, representing an additional risk factor for worsening mental health.

Health and frontline workers who face increased physical risks, high work demands, and social stigmatization have also been heavily impacted by the pandemic. By May 2021, the number of health workers who had been infected with COVID-19 in Latin America and the Caribbean exceeded 1.8 million, while 9000 had died from the virus. Additionally, 53·0% of U.S. public health workers reported symptoms of at least one mental health condition in the preceding two weeks, including depression (32·0%), anxiety (30·3%), PTSD (36·8%), and suicidal ideation (8·4%). Studies from Argentina, Chile, Mexico, and Trinidad and Tobago also found high rates of depression, anxiety, stress, and insomnia among health workers.

In March 2020, over 154 million children (95% of those enrolled) in Latin America and the Caribbean, were out of school due to COVID-19. One year later, 114 million of these children had yet to return to school. In addition to school closures, which disrupt daily routines, learning and socialization, children and adolescents have faced the loss of loved ones and heightened adversity in their home environments, including an increased risk of domestic violence. In 2020, 27% of adolescents and young people surveyed in Latin America and the Caribbean reported feeling anxiety and 15% depression in the previous week. Another study of 15 to 29 year-olds in Latin American and Caribbean countries found that 52% had experienced more significant stress, and 47% had episodes of anxiety or panic attacks during their quarantine. Adolescents in Guyana experienced high rates of anxiety (44%) and depression (31%), and more than one third reported increased drug use and one quarter considered acts of self-harm.

Caregivers of children also face mental health challenges; 85% of caregivers surveyed in Colombia, Costa Rica, El Salvador, and Peru reported at least one symptom of deteriorated mental health during the pandemic, including feeling sad (48%), fearful (60%) and having insomnia (59%). Parents, unpaid caregivers of adults, and parents-caregivers (persons in both roles) in the United States had significantly worse mental health than adults not in these roles, including five times the odds of any adverse mental health symptoms (parents-caregivers).

The Region of the Americas has a large population of indigenous peoples (54·8 million in Latin America and the Caribbean and 7·6 million in North America). While data on the mental health of ethnic minorities and indigenous populations during the pandemic is limited, it is evident that indigenous populations were adversely impacted. Prior to the pandemic, indigenous communities who have historically been marginalized, experienced higher rates of mental health problems compared to non-indigenous communities, including high rates of substance use and substantially higher suicide rates among youth. Greater susceptibility to COVID-19 and related mental health challenges, as well as disproportionate rates of pre-existing mental health conditions, have all been relevant factors.

Data suggest that mental health has progressively worsened in many countries in the Americas during the first year of the pandemic. A study for the World Economic Forum found that one year after the onset of the pandemic, an average of 45% of adults from 30 countries surveyed reported that their emotional and mental health had deteriorated. Respondents from Argentina, Brazil, Canada, Chile, Peru and the United States reported worse mental health at levels higher than the global average. There are also reports of improvements in mental health symptoms from studies in the United States and Canada, although frequencies of depression and anxiety have not returned to pre-pandemic rates, and these national rates may mask disparities among subpopulations. While data on the mental health impacts of COVID-19 from low- and middle-income countries are quite scarce, it is likely that these countries, which have slower vaccination rates and delayed economic recovery, will continue to experience prolonged mental health consequences.

The pandemic has also been associated with changes in alcohol and substance use behaviours. A study of US adults reported that 13·3% had either started or increased use of illicit substances to cope with stress or emotions related to COVID-19, and additional data suggest an acceleration of overdose deaths during 2020. Similarly, 23·3% of Canadians surveyed reported drinking more alcohol compared to the pre-pandemic period . More Canadians also required hospital care for harm caused by substances such as alcohol, opioids and stimulants between March and September 2020, compared with the same period in 2019. A survey conducted by the Pan American Health Organization in 2020 in 33 countries and two territories in Latin America and the Caribbean, concluded that quarantine measures were associated with online social drinking and drinking with a child present. There was also a positive association between anxiety and patterns of alcohol consumption such as drinking before 5 pm and heavy episodic drinking.

Mental health services

The COVID-19 pandemic has also led to significant disruptions in mental health services across the Americas. According to a 2020 WHO rapid assessment of service delivery for mental, neurological and substance use disorders, completed by 29 countries and four territories, in one-quarter of countries, at least 75% of MNS-related services were reported as being completely or partially disrupted. MNS outpatient and community-based services, such as daycare and home care services, were particularly disrupted. At a time when they were most needed, mental health services for some of the most vulnerable groups, such as women needing antenatal and postnatal interventions, children and adolescents with mental health conditions or disabilities, and people with substance use disorders, were also severely disrupted.

The second round of a WHO pulse survey on essential health services conducted during the period January-March 2021, with data from 29 countries in the Americas, documented persisting disruptions of MNS services in 60% of countries. This health program area experienced the highest rates of disruption. Of note, services for MNS disorders experienced similar or greater levels of disruption in 2021 compared to the survey's initial evaluation, conducted in 2020. These findings are presented in Table 1.

Table 1

Key disruptions in services for mental, neurological and substance use (MNS) disorders resulting from COVID-19: Comparison of Rounds 1 and 2 of the WHO national pulse survey on continuity of essential health services during the COVID-19 pandemic.,

Type of MNS service	% of countries experiencing disruption (proportion of responding countries experiencing disruption)
	Round 1: May-July 2020	Round 2: January-March 2021
Management of MNS emergency manifestations	44% (11/25)	52% (12/23)
Counselling for MNS disorders	61% (17/28)	71% (17/24)
Prescriptions for MNS disorder medicines	41% (11/27)	48% (11/23)
Services for children and adolescents with mental health conditions/disabilities	69% (18/26)	62% (13/21)
Services for older adults with mental health conditions/disabilities	62% (16/26)	67% (14/21)
School mental health programs	80% (20/25)	69% (9/13)
Suicide prevention programs	62% (13/21)	57% (8/14)
Overdose prevention and management programs	67% (10/15)	50% (3/6)
Critical harm reduction services	75% (12/16)	50% (3/6)

The way forward

Countries in the Region of the Americas must take immediate action to strengthen their mental health systems and services to meet the increased demands for mental health and psychosocial support. Furthermore, governments must see the COVID-19 pandemic as an opportunity to reinforce their mental health systems in preparation for future emergencies as they seek to build back better and fairer. While the degree to which countries can strengthen and reform mental health will vary based on their diverse national contexts, there are key mental health policy and programming recommendations that apply to all countries in the Region during the pandemic and in the post-pandemic period.

Scaling up emergency MHPSS

Good mental health is not only essential for physical health and overall wellbeing, it is also a fundamental human right. During a crisis of the scale of the COVID-19 pandemic, all people must have equal and uninterrupted access to quality MHPSS that meets their needs and respects their human rights. Countries must prioritize and provide adequate resources for mental health and psychosocial support. These services should address population needs and be integrated into systems such as primary care, education, social services and community support systems, to reach more people and reduce stigma. Given the degree of mental health service disruptions, countries must employ these innovative approaches to ensure that all have access to MHPSS.

Capacity building in mental health is a key strategy for countries to meet the increased demand for MHPSS. Non-specialized health workers, including primary care providers, can play an important role in delivering MHPSS in the community, given the limited human resources. This personnel should be trained in tools such as the WHO's Mental Health Gap Programme Intervention Guide (mhGAP-IG), which guides detecting, managing and providing follow-up for common mental disorders including depression, psychoses and self-harm/suicide, among others. The mhGAP Humanitarian Intervention Guide (mhGAP-HIG), which is adapted to humanitarian emergency contexts, also includes modules on acute stress, grief and post-traumatic stress disorder. Refresher training is essential to reinforce skills learned, as are continued support and supervision by mental health specialists. Master trainers can also support the delivery of a cascade model, in which these facilitators train additional groups of non-specialized providers (i.e. train-the-trainers). To make the integration of mental health into primary health care more effective and sustainable, and to continue strengthening the mental health capacities of professionals, countries must operationalize mhGAP by outlining an overall mhGAP training program, its implementation, monitoring, supervision, follow-up, and evaluation. Additionally, frontline workers and community members serve an important role and can be trained to provide psychosocial interventions such as Psychological First Aid (PFA), with culturally appropriate training in MHPSS designed to address the needs of different at-risk groups.

In response to restrictions on in-person mental health services, the pandemic has required alternative approaches to MHPSS service delivery, including remote interventions. Tele-mental health is recognized as an effective alternative to in-person care for a variety of mental health conditions, and the pandemic has accelerated innovations including the adoption of new legislation and regulations to advance the use of these services. A total of 82·8% of countries in the Americas reported using telemedicine/teletherapy to overcome service disruptions, while 79·3% used helplines, and 58·6% employed self-help or the digital format of psychological interventions. These technological developments have not been uniform, however, as some countries still lack basic infrastructure and policy frameworks. Moreover, inequitable access to remote MHPSS in settings with restricted phone, electricity, or Wi-Fi access, as well as limited access for persons with disabilities and sensory impairments, remain issues of concern. Countries must work to improve and scale up tele-mental health by building infrastructure, developing policy frameworks and legislation, and facilitating relevant workforce training while striving to minimize inequities. In the post-pandemic period, it will also be important for countries to sustain and build on advances in tele-mental health made during the pandemic by replicating successful practices and developing new technologies.

Leaving no one behind

In ensuring access to MHPSS for all during the pandemic, countries must reach populations shown to be in greater need of mental health support, including but not limited to frontline and healthcare workers, children and adolescents, women, people with pre-existing mental health conditions, racial and ethnic minorities, and indigenous peoples. Appropriate policies must be implemented to prevent and mitigate the consequences of social inequities, violence and discrimination against these groups. Social protections that provide economic support, food and housing assistance, livelihood protection and childcare are also essential to minimize risk factors for mental health conditions for groups in situations of vulnerability. Those at greater risk of contracting COVID-19, such as health and frontline workers, but also people with severe mental disorders, indigenous peoples, migrant groups, and those living in vulnerable situations, should be prioritized for COVID-19 vaccination. Communication materials that not only provide information on COVID-19 but also promote psychosocial wellbeing and connect people to appropriate MHPSS services are another key component of MHPSS during this public health emergency and must be adapted to reach at-risk groups. These materials should be age-appropriate, accessible to people with disabilities, use local languages and be disseminated via appropriate platforms for their intended audiences. Communication campaigns that combat COVID-19 related stigma, particularly against vulnerable groups, are also important. To better understand the mental health needs of at-risk groups to inform appropriate interventions, countries must prioritize data collection, involving the key at-risk groups in the decision-making process and reporting outcomes disaggregated by relevant factors.

Transforming mental health systems for the future

The COVID-19 pandemic represents a unique opportunity for countries in the Americas to catalyze mental health reform and build back better mental health systems post-emergency. The heightened visibility and prioritization of mental health as a result of the pandemic provides a window from which to advocate for long-term mental health change. The pandemic has highlighted longstanding gaps and failures in mental health, the importance of mental health to overall health and wellbeing, and the essential role of mental health in emergencies. Building back better mental health systems and services will require integrating mental health into Universal Health Coverage (UHC); scaling up and reallocating funding for mental health; and a renewed commitment to community-based mental health care, grounded in human rights.

The COVID-19 pandemic has exposed existing gaps in mental health service coverage, emphasizing the importance of integrating mental health into UHC, where all people receive quality health services that meet their needs, without exposure to financial hardship in obtaining these services. In 2018, the Lancet Commission on Global Mental Health and Sustainable Development identified mental health as an essential component of universal health coverage. Key strategies for successful integration include the incorporation of mental health into national health legislation, policies and programs, in particular within UHC reforms; adopting a rights-based approach; integrating mental health into primary health care; including care for mental, neurological and substance use disorders in health care benefit packages and insurance schemes; and increasing investment in mental health.

Increasing and reallocating long-term funding for mental health is essential to reducing the mental health treatment gap and achieving UHC. Investing in mental health yields strong returns; for every U.S. dollar invested in treating depression and anxiety, there is a $4 return in better health and ability to work. A study conducted in Jamaica showed returns on investments for interventions addressing anxiety, depression, and psychosis. It is estimated that increasing expenditure on mental health to just 5–10% of total health budgets would increase coverage by 40–80%, depending on the resource setting. Alternative sources of financing for mental health could include taxes on tobacco, alcohol and sugary drinks, which can simultaneously reduce the consumption of harmful products that contribute to disease and premature mortality and increase domestic resource mobilization for mental health. Countries can also maximize mental health spending by reallocating the large percentage of funds still dedicated to psychiatric hospitals to community-based services, resulting in more effective treatment.

The pandemic also presents an opportunity for countries in the Americas to advance the reorganization of mental health services. Thirty years ago, as part of the Caracas Declaration, Latin American countries supported the restructuring of psychiatric care, from the traditional model of psychiatric institutions to a community-based care model, grounded in the rights of mental health service users. However, psychiatric hospitals continue to play a large role in providing mental health care in many countries in the Americas, and rising cases of COVID-19 in these institutions highlight the challenge of persisting human rights abuses in these settings. Countries must therefore advance the transition from mental health care in psychiatric hospitals to community-based care by developing and strengthening mental health services in the community and reducing the number of long-stay beds in psychiatric institutions. This will necessitate sustained planning, resources and political will.

Applying a whole-of-society approach with high-level political commitment

In order to fully address increased mental health needs during the pandemic and to effectively deliver mental health and psychosocial support to all, countries must implement a whole-of-society approach to MHPSS. MHPSS during the current pandemic and other emergencies necessitates multi-sectoral responses that include not only healthcare, but collaboration with other sectors including education, employment, housing, and social welfare to tackle mental health risk factors exacerbated by an emergency. It is also critical to ensure adequate program funding (approximately one-quarter of countries in the Americas reported having full funding for the MHPSS component of their national COVID-19 response plans). Governments must establish multisectoral MHPSS coordination mechanisms such as multisectoral technical working groups, to respond to COVID-19 and other emergencies, and these mechanisms should include a diversity of actors, both governmental and non-governmental, across sectors. Partnerships with local organizations and civil society may also be crucial to enhancing the mental health response during the pandemic. Thinking beyond COVID-19, however, countries should actively work now to incorporate MHPSS into all existing and future national emergency and disaster plans, including it as an integral part of all emergency phases (preparedness, response, and recovery).

The commitment of high-level decision-makers, such as heads of state, can transform into mental health advances. An example is Chile's SaludableMente (Healthy Mind) initiative established by the Office of the President to address mental health needs and provide psychosocial support during the COVID-19 pandemic. SaludableMente counts on the collaboration of seven government ministries, and achievements include the establishment of an expert committee on mental health and a mental health advisory council, resources developed to specifically support the mental health of the health workers, and an online platform that provides mental health support and guidance for the population.

Conclusions

Mental health has long been a neglected area of public health in the Region of the Americas. Before the COVID-19 pandemic, low public expenditure contributed to under-resourced mental health systems and services that were unable to meet the high demand for mental health conditions. The pandemic has significantly exacerbated the mental health crisis, increasing the need for mental health services and simultaneously disrupting services for MNS disorders. There is an immediate need for countries in the Americas to scale up and improve mental health and psychosocial support services during the pandemic and to build back better mental health systems in anticipation of future emergencies, including climate change.

Resumen

La pandemia de COVID-19 está teniendo un gran impacto en la salud mental de las poblaciones de las Américas. Los estudios muestran altas tasas de depresión y ansiedad, entre otros síntomas psicológicos, especialmente entre las mujeres, los jóvenes, las personas con condiciones de salud mental preexistentes, los trabajadores de la salud y las personas que viven en condiciones vulnerables. Los sistemas y servicios de salud mental también se han visto gravemente afectados por la pandemia. La falta de inversiones financieras y de recursos humanos en los servicios de salud mental, la limitada implementación del enfoque de atención descentralizada basada en la comunidad y las políticas para abordar la brecha de salud mental en la Región antes de la pandemia, han contribuido a la crisis actual. Los países de las Américas deben reforzar urgentemente sus respuestas de salud mental al COVID-19 adoptando medidas para ampliar los servicios de salud mental y de apoyo psicosocial para todos, llegar a las poblaciones marginadas y en riesgo, y volver a crear mejores sistemas y servicios de salud mental para el periodo pospandémico.

Funding

This work received no funding.

CRediT authorship contribution statement

Amy Tausch: Conceptualization, Writing – original draft. Renato Oliveira e Souza: Conceptualization, Supervision, Writing – review & editing. Carmen Martinez Viciana: Writing – original draft, Writing – review & editing. Claudina Cayetano: Writing – original draft, Writing – review & editing. Jarbas Barbosa: Supervision, Writing – review & editing. Anselm JM Hennis: Conceptualization, Supervision, Writing – review & editing.

Declaration of interests

None.