The COVID-19 pandemic has profoundly impacted population mental health. Among the many negative impacts, it has led to sickness and bereavement, increased uncertainty, decreased human connection, and lost opportunities for work and education. However, it has led to important discoveries, too. Societally, we have a greater acknowledgement that mental health is critically important and that people who are suffering often don’t have the resources they need.
“The most important metric isn’t that mental health problems have increased, even if they have. The big issue is that we have failed to address the needs of the vast majority of people with mental health problems,” says Vikram Patel, the Pershing Square Professor of Global Health in the Blavatnik Institute’s Department of Global Health and Social Medicine at Harvard Medical School and one of the program directors of Foundations of Mental Health Care and Scaling Up Mental Health Care Services.
“The proportions of people whose needs are not met will only grow because the systems that existed before the pandemic were already inadequate,” continued Patel, who’s also the co-lead of the Mental Health for All lab and the GlobalMentalHealth@Harvard initiative.
But even with this acute problem, “many people who are in positions of leadership in mental health don’t feel empowered, usually because there’s a lack of human resources,” says Giuseppe James Raviola, M.D., director, Program in Global Mental Health and Social Change, assistant professor of psychiatry at Massachusetts General Hospital (MGH), and program director of Foundations of Mental Health Care.
So what can leaders do to help in this time of mental health crisis?
What COVID-19 Shows Us About Unmet Needs in Mental Health Care
This has been a particularly stressful time. Referencing an article from Harvard Public Health titled “The Age of Trauma,” Raviola—who’s also the associate director at The Chester M. Pierce, MD Global Psychiatry Division at MGH and director of mental health at Partners In Health—explains, “COVID, structural racism, health inequality, climate change, and all of these concurrent health, economic, and social crises are intersecting as a set of epidemics to constitute an ongoing kind of synergistic epidemic that we’re giving the name of syndemic.”
“Syndemic preparedness for the future means organizations and leaders need to attend to all of these crises as a whole, as they present a threat to the health and wellbeing of the public,” he adds.
The pandemic has opened up dialogue around mental health, although the stigma remains that treatment is something to avoid or fear. We cannot simply change these attitudes by campaigns about what mental illness is and the effectiveness of treatments, explains Patel.
“Those attitudes come from a history that goes back millennia about how mental health problems have been treated by society. The dominant images are ones of discrimination, exclusion, and—in the U.S.—suicide, violence, and being incarcerated,” he says.
Instead, the pandemic has shown that mental health challenges exist on a wide spectrum. It’s not a binary between those who are healthy and those who aren’t, but that “we all are at some point on this dimension, from coping extremely well, to having some difficulty, to having some symptoms, to having a disorder or disability,” says Shekhar Saxena, professor of the practice of global mental health at the Department of Global Health and Population at the Harvard T. H. Chan School of Public Health and program director of Foundations of Mental Health Care and Scaling Up Mental Health Care Services
Additionally, we now have an increased awareness of the mental health treatment gap. There are too few professionals to support the vast mental health needs of the population, which means professionals need to innovate around how to deliver care.
“This moment in time illustrates the need for more resources, the need for utilization of these resources more efficiently, more effectively, and for a more comprehensive coverage of mental health,” Saxena says. “It’s not only for severe mental disorders; it’s for people who have borderline conditions or who just have difficulty in coping. Identifying mental health problems early and preventing them from developing further is a sound public health policy, and a cost-effective one too.”
“COVID, structural racism, health inequality, climate change, and all of these concurrent health, economic, and social crises are intersecting as a set of epidemics.”
What’s Needed: A Fundamental Paradigm Shift in Mental Health Care
The dominant model of mental health care, according to Patel, comes down to three Ds: doctors, drugs, and diagnoses. The first step is to move away from this paradigm. “We don’t need just psychiatrists, and we don’t always need diagnoses to support the recovery of the majority of persons who are struggling with their mental health. And drugs play a role, but only for some conditions and, then too, only a relatively modest one,” he explains.
“In fact, what most people need are psychological and social interventions that are delivered by non-specialists, people like community health workers, peer support workers, and a range of other general health workers. These are provided without the need of a diagnosis but from people’s own descriptions of their mental health difficulties and the functional issues that they face.” Of course, people with severe mental illness need a more highly trained professional; mild conditions, however, may not need a pricey, in-demand specialist.
There’s a large body of implementation science to support this task-sharing model. Previously, mental health specialists have struggled to identify and integrate these functional components of mental health care delivery. Doing this more explicitly and effectively—pulling mental health out of the health sector—can help mobilize treatment. Raviola also references components of mental health care delivery, like screening and treatment of depression outside of mental health systems, that primary care physicians can complete.
The rise of digital tools and telehealth to treat patients, made essential during the pandemic, is another important step. Telemental health services and task-sharing decrease stigmatization and can help those on the milder end of the mental health spectrum, particularly improving access for those in rural and decentralized communities.
Finally, scaling up task-sharing to include other community members (like lay people, family members, colleagues, and workplace administrators) is a crucial step; Saxena references HR, chief wellness officers, and even managers as important resources.
These three steps have the power to transform mental health care. “It’s about changing the architecture of care by making care accessible in community settings, making care sensitive to personal needs and priorities, and making sure that people with mental health problems have the same rights as others in the community,” says Patel.
“To me, this is what leadership is about—embracing a rights-based approach to mental health problems that twins the right to quality care with the right to agency, citizenship, or inclusion.”
“What most people need are psychological and social interventions that are delivered by non-specialists, people like community health workers, peer support workers, and a range of other general health workers.”
A Critical Intervention for Mental Health Challenges in a Modern World
Thus, the program directors developed the Harvard T.H. Chan Mental Health Care Leadership Challenges three-part program, of which Foundations of Mental Health Care is the first module. The course centers around providing trainees with the knowledge and skills on how to reimagine mental health care by embracing the science on community priorities, the nature of mental health problems, and innovations in intervention design and delivery.
The first module addresses the aforementioned paradigm shifts and the population health approach to mental health. The second, Scaling Up Mental Health Care Services, will delve more into implementation, including deployment, scaling, dealing with pushback, and increasing resources. The third program, Mental Health Care Champions Peer Learning Collaborative, will enable participants to share experience and expertise together.
Obviously, mental health leaders are welcome to participate, but Patel underscores that health care leaders and mental health ambassadors—as well as nonprofit and civil society partners—who can help scale up care in innovative ways also have a role to play in transforming mental health care.
“A good example of an intervention is actually a university,” says Saxena. “If 20 to 30 percent of 20,000 students need support and counseling, and potentially less than 20 percent of them are actually receiving it, we need a five-fold increase in support. If a university health department representative wants to expand mental health care, that person can learn to deliver what is needed in a more effective manner.”