The COVID-19 pandemic has brought about rapid innovation in mental health care, and the move to telemedicine is likely here to stay to at least some degree, but research led by University College London and King's College London cautions that serious barriers still need to be overcome.
In a survey in the UK and an international review of evidence from 29 countries, mental health care staff report how the pandemic and lockdown have been harmful to some people accessing mental health services.
The international review identified multiple reports that the pandemic exacerbated symptoms for people with mental health conditions. Many people had increased anxiety due to concerns about getting infected, while others struggled with the loss of routine, or social isolation and loneliness. Numerous studies raised concerns that social adversities and inequalities may continue to worsen.
Director of the MHPRU, Professor Sonia Johnson (UCL Psychiatry and Camden and Islington NHS Foundation Trust), corresponding author of both studies, said: "People working in mental health care settings across the UK and globally have reported rapid innovation at their workplaces, including the rapid adoption of telemedicine, after years of slow progress.
"Most people we surveyed support partial adoption of remote working, but they caution that telemedicine doesn't work for everyone, and there are still major challenges to be addressed for it be truly effective. The voices of the digitally excluded are especially in danger of not being heard."
Internationally, mental health professionals anticipate an increased need for services as the pandemic drags on, which could be coupled with reduced capacity, with particular concerns for inpatient and residential care settings. Many expressed concerns that coping strategies that have helped people through the lockdown may not be sustainable long-term.
The researchers write that while there is not much official data available yet, mental health care staff from numerous countries reported reduced referrals and visits to mental health services in the very early stages of the pandemic. Potential explanations include fears of infection, beliefs that help would not be available, or concerns about being a burden.
The international survey also identified recurring ethical concerns about maintaining professional standards and human rights in a fast-changing environment. Some sources raised concerns that access to physical health care has become inequitable for people with mental health conditions, due to stigma and policies in some countries to keep them in psychiatric units rather than general hospitals. Others have raised concerns that mental health care might have become less ethical due to some new restrictions and regulations.
In the UK survey, the authors note that a key challenge continues to be managing to combine infection control with a good therapeutic environment. Numerous respondents raised concerns about difficulties with infection control including problematic ward and office layouts, a lack of personal protective equipment (PPE) or of facilities for its proper use, and some service users finding it difficult to understand and adhere to social control.
Christian Dalton-Locke (UCL Psychiatry), co-first author of the UK-focused paper, said: "We found that balancing infection control requirements with maintaining therapeutic relationships with patients who may be distressed, suspicious, or struggling to comprehend the situation, remains an important priority, and, as we have seen with reports of Covid-19 deaths among people subject to the Mental Health Act, the price of failure is potentially very high."
MHPRU co-director, Professor Alan Simpson (King's College London's Institute of Psychiatry, Psychology & Neuroscience, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, and South London and Maudsley NHS Foundation Trust), and senior author on both papers, said: "We found that in the UK and in other countries, mental health care providers have demonstrated considerable agility and flexibility in responding to the pandemic, but staff remain concerned for the future.
"Regarding telemedicine, our sources have given a clear warning that substantial technological, social and procedural barriers remain, and that its use should remain selective, complementing rather than replacing face-to-face contact."
Dr Luke Sheridan Rains (UCL Psychiatry), co-first author of the international paper, said: "Mental health care staff in many countries are concerned about a potential delayed wave of increased demand, putting strain on services with limited resources. The potential long duration of the pandemic suggests that avoiding a crisis in mental health care should be a global priority."
The studies were funded by the National Institute for Health Research (NIHR) Policy Research Programme.
Purpose: The COVID-19 pandemic has many potential impacts on people with mental health conditions and on mental health care, including direct consequences of infection, effects of infection control measures and subsequent societal changes. We aimed to map early impacts of the pandemic on people with pre-existing mental health conditions and services they use, and to identify individual and service-level strategies adopted to manage these.
Methods: We searched for relevant material in the public domain published before 30 April 2020, including papers in scientific and professional journals, published first person accounts, media articles, and publications by governments, charities and professional associations. Search languages were English, French, German, Italian, Spanish, and Mandarin Chinese. Relevant content was retrieved and summarised via a rapid qualitative framework synthesis approach.
Results: We found 872 eligible sources from 28 countries. Most documented observations and experiences rather than reporting research data. We found many reports of deteriorations in symptoms, and of impacts of loneliness and social isolation and of lack of access to services and resources, but sometimes also of resilience, effective self-management and peer support. Immediate service challenges related to controlling infection, especially in inpatient and residential settings, and establishing remote working, especially in the community. We summarise reports of swiftly implemented adaptations and innovations, but also of pressing ethical challenges and concerns for the future.
Conclusion: Our analysis captures the range of stakeholder perspectives and experiences publicly reported in the early stages of the COVID-19 pandemic in several countries. We identify potential foci for service planning and research.
Luke Sheridan Rains, Sonia Johnson, Phoebe Barnett, Thomas Steare, Justin J. Needle, Sarah Carr, Billie Lever Taylor, Francesca Bentivegna, Julian Edbrooke-Childs, Hannah Rachel Scott, Jessica Rees, Prisha Shah, Jo Lomani, Beverley Chipp, Nick Barber, Zainab Dedat, Sian Oram, Nicola Morant, Alan Simpson
University College London material
Social Psychiatry and Psychiatric Epidemiology abstract