By Anna D. Bartuska, Programme Coordinator, Community Psychiatry PRIDE, Massachusetts General Hospital and Dr. Luana Marques, Associate Professor, Department of Psychiatry, Harvard Medical School, Clinical Psychologist, Massachusetts General Hospital, Director, Community Psychiatry PRIDE

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This blog is part of a series on tackling COVID-19 in developing countries. Visit the OECD dedicated page to access the OECD’s data, analysis and recommendations on the health, economic, financial and societal impacts of COVID-19 worldwide.

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Prior to the COVID-19 pandemic, there was a mental health crisis in many areas of the world. In 2017, Our World in Data reported that 970.81 million people had a mental health or substance use disorder. People living with mental health conditions have a 20 year reduction in life expectancy—two times greater than the estimated years lost from cigarette smoking. Despite the overwhelming global need for mental health services, up to 85% of individuals with mental health conditions in developing countries do not receive care due to lack of resources and investments. Unmet mental health needs bear a significant economic burden. The Lancet Commission on global mental health and sustainable development reports that unaddressed mental health conditions will cost the global economy US$16 trillion between 2010 and 2030.

Mental health complexities during the COVID-19 pandemic

The current pandemic presents an added burden to the existing mental health crisis due to complex and intersecting emotional challenges. The story of a healthcare worker, Maria, truly exemplifies the burden experienced by many. Working on the frontlines of the crisis, Maria has had to face constantly shifting work schedules, a lack of protective equipment, and watching individuals pass away without the opportunity to hug their loved ones. At the end of the day, she takes extra precautions to protect her family from COVID-19 by socially distancing whenever possible. Without the ability to freely visit family members, Maria feels helpless as her grandmother spends each day lonely and afraid. After many nights of restless sleep, Maria finds herself irritable and has difficulty concentrating at work. Maria wonders how much she can take.

Maria is not alone, as many people are experiencing COVID-19 related stress. Rampant job loss has led to financial strain and loss of health insurance. Stay-at-home orders have exacerbated relationships and may increase the risk of interpersonal violence. Simultaneously, separation from others has led to feelings of isolation, and individuals who have lost loved ones have been left to grieve without traditional mourning and burial practices. The shifting circumstances of the COVID-19 pandemic have led to intertwined emotional experiences of anxiety, depression, grief, and trauma.

Consequences of the COVID-19 pandemic on mental health

Initial evidence points to the short- and long-term mental health consequences of this pandemic. A study conducted in Ethiopia in April 2020 suggests that 33% of the population is experiencing depression symptoms, a 3-fold increase from pre-pandemic rates. In Iran, 60% of the population reported distress symptoms earlier this year. Concerningly high rates have also been documented among healthcare workers. For example, large numbers of healthcare workers in Pakistan have reported moderate (42%) to severe (26%) distress.

Despite efforts to understand and address the mental health impact of COVID-19, the long-term mental health consequences are unknown. Prior research from the 2003 severe acute respiratory syndrome (SARS) outbreak, suggests that survivors showed concerning levels of anxiety, depression, and stress with 64% reporting a likely psychiatric disorder. Similarly concerning rates of anxiety, depression, and posttraumatic stress disorder (PTSD) were reported a year after the initial Ebola outbreak in 2014 with 43% of individuals reporting clinical levels of PTSD in Sierra Leone.

Alarming current and long-term mental health consequences are accompanied by new challenges for mental health services. Ongoing closures of healthcare facilitates and limits on group gatherings have forced both clinical services and community support systems to temporarily shut down or adapt to remote care. In countries with pre-existing insufficient access to mental health treatment, challenges to delivery have the potential to exacerbate unmet needs.

Responding and rebuilding to transform the landscape of mental health

“…mental health needs must be treated as a core element of our response to and recovery from the COVID-19 pandemic. A failure to take people’s emotional well-being seriously will lead to long-term social and economic costs to society.”

–Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization

As COVID-19 continues to threaten the economic stability and health of developing countries, addressing mental health is essential. Prior work in underserved communities globally serves as a valuable blueprint for transforming the landscape of mental health to address pre-existing challenges and consequences of the COVID-19 pandemic. Two novel delivery methods have emerged as promising solutions for increasing access to care: technological innovation and workforce development.

The shift to remote work has the potential to revolutionize mental health care delivery. Immediate action in Egypt, Kenya, Nepal, Malaysia, and other countries has led to the development of emergency mental health hotlines. Mental health care delivered by phone or video (i.e. telemental health) has been shown to be an effective alternative to in-person treatment. Although the prospect of increasing access to care through digital technologies is exciting, resource shortages pose significant challenges. Lack of space and privacy can make telemental health care difficult for clients and providers. Internet access, once considered a luxury, has become a necessity for individuals seeking mental health care. According to the World Bank, only 35% of the population in developing countries have internet access. Innovative ideas, such as the use of balloons to deliver wireless internet in Africa, are being developed to increase broadband. However, additional efforts to address pre-existing inequities are needed to harness the full potential of technology-based mental health care.

Prior to the pandemic, a global workforce shortage significantly contributed to rates of unmet mental health needs. According to the World Health Organization, the rate of mental health workers can be as low as 2 per 100,000 people in developing countries. Even within high-income countries, client needs frequently exceed workforce capacity. To adequately address the mental health consequences of COVID-19, the makeup of mental health workforces needs to be reimagined. Most mental health professionals have received 2-10 years of training, a cost- and time-prohibitive process for many. Yet, prior research conducted in developing countries revealed that trained paraprofessionals can effectively deliver mental health care. Instead of training external experts, stakeholders should consider building a local workforce imbedded within the community. Schools, community clinics, and non-profits are all potential areas to integrate flexible skill-based programmes for both preventing and addressing mental health problems.

As the cases of COVID-19 continue to rise in developing countries, response and recovery efforts must consider mental health. In the era of COVID-19, mental health needs continue to outpace our systems of care. Under our current circumstances, all countries can be considered developing countries in terms of mental health. Collaborative efforts are needed to address the emotional toll of economic instability, loss of loved ones, and ongoing uncertainty worldwide.