Challenges and Opportunities Beyond COVID-19

SPECIAL REPORT: GLOBAL PSYCHIATRY

The COVID-19 pandemic has had a devastating impact on economies, social structures, and health systems, and it has disproportionally affected low- and middle-income countries (LMICs) as well as low-resourced, disadvantaged settings in high-income countries (HICs).^1,2 Even before COVID-19, the world confronted substantial challenges in meeting demands for mental and substance use disorder (MSD) care, particularly in low-resource settings. Now, increases in affective symptoms, substance use, suicidality, and cognitive dysfunction have been linked to COVID-19 and its social consequences.^3-5 Compared with other acute health events, adults have at least twice the risk of receiving a new MSD diagnosis after COVID-19 diagnosis.^3,5 In turn, psychiatric history is an independent risk factor for COVID-19 infection,⁵ and COVID-19’s impact is worse among individuals with MSDs, possibly related to similar inflammatory processes in COVID-19 and psychiatric disorders.^3,5,6 This article summarizes the challenges of addressing—and the opportunities to address—the resulting growing global MSD treatment gap.

COVID-19 and the Social Determinants of MSD

Social determinants of MSD that drive global inequalities include poverty, unemployment, stigma and discrimination, lower access to health care and digital infrastructures,⁷ and gender, all of which have been exacerbated during the pandemic. COVID-19 has resulted in greater sex differences in MSD prevalence, with women’s mental health likely to be affected more by the pandemic’s social and economic consequences.⁸ Stigma toward mental illness is among the most important determinants of MSD.^7,9-11 MSD-associated stigma influences policies, research funding, and resource allocation for services. It can have a deleterious effect on providers’ training and intentions to treat patients with MSDs. Low levels of knowledge about MSDs and prejudice and discrimination against people with MSDs serve to delay or prevent access to treatment.¹² Not surprisingly, most of the research on interventions to reduce or prevent MSD stigma and discrimination has taken place in HICs.¹²

COVID-19 and MSD Disparities

In HICs, disenfranchised and minority populations (eg, African Americans, Latinx, impoverished rural populations, migrants, gender minorities in the United States)^7,9,13 face MSD disparities that have increased during the pandemic.² The impact is even worse in LMICs, where the MSD treatment gap was already vast with 75% to 85% of populations (vs 35% to 50% in HICs) having no access to MSD care.¹²

People with MSD experience poor physical health and have an average life expectancy 15 to 25 years shorter than that of the general population.¹⁴ In the Global Burden of Diseases, Injuries, and Risk Factors Study, MSDs were the leading causes of global health-related burden before 2020^15,16 across both sexes, the entire lifespan, and world regions.¹⁵ Despite evidence-based interventions (EBIs; eg, short-term psychotherapy treatments, medications) that reduce MSD impact, there has been no reduction in global MSD prevalence since 1990.¹⁷ Unfortunately, EBI scale-up has not been a global priority. Because mental health systems in most countries are underresourced, poorly coordinated, and without supporting policies, access to quality MSD care is limited, especially in LMICs,^17-19 which is where 90% of the global population resides.

The Global MSD Research Gap Challenge

This gap is among the most important challenges faced by LMICs in implementing MSD EBIs.²⁰ The Table depicts the science-, health system–, and context-level factors necessary for sustainable scale-up of EBIs. MSD epidemiology, validated measures, and efficacy studies are advanced in HICs, but below average in LMICs. However, the more complex research studies addressing effectiveness and implementation, which are necessary to bridge the research-to-practice gap, are almost as scarce in HICs as in LMICs and they tend to address mostly depression. Few effectiveness and implementation studies address more than 1 disorder at a time.^21,22 Only 1 addresses all MSDs²²: an effectiveness-implementation scale-up study in 20 districts and 80 clinics in Mozambique.²²

The Vast Global Research-to-Practice Gap Challenge

Only half of evidence-based clinical innovations make it into routine delivery in real-world community and clinical settings in HICs—and even fewer do in LMICs.²³ Research through which MSD EBIs are developed and tested typically uses research psychologists to deliver EBIs for single disorders in well-controlled sites. Yet, in the less-resourced and more complex settings in which EBIs actually must be delivered for population impact, clinical personnel may not be as highly well trained and supervised, and patients tend to have multiple psychiatric comorbidities and do not receive incentives for participation.²³ Furthermore, because researchers disseminate their work through traditional academic conferences and publications, MSD EBIs are seldom implemented by underresourced public health systems.²⁴

Dissemination and implementation science addresses this research-to-practice gap by tackling multilevel contextual barriers and facilitators that influence adoption of EBIs in diverse real-world clinical and community settings and by testing strategies that facilitate EBI implementation.^23,25 However, the health research continuum process (Figure 1) to achieve intervention implementation is slow and expensive. Furthermore, it typically is undertaken for single MSDs rather than the more typical MSD comorbidities. Thus, the health research continuum, while rigorous, is not the most efficient process for addressing the urgent health care needs faced by HIC low-resource settings and LMICs, particularly in the context of COVID-19—a case, perhaps, in which “perfection is the enemy of progress.”²⁶ Perhaps the National Institutes of Health Clinical and Translational Science Awards vision of expedited translational research from laboratory discoveries to patient treatments should invest in strategies to expedite the translational process for MSD EBIs.

Health System Challenges

Health system–level factors are highly dependent on context-level factors and present infrastructure barriers to implementing MSD EBIs. In HIC low-resource areas and in LMICs, not only are limited MSD services available, but geographic, cultural, and financial access barriers decrease services utilization.²⁷ Task-shifting—that is, shifting specific service delivery tasks from professionals with higher qualifications to those with different qualifications (eg, physicians to nurses) or a new cadre with specific training and supervision (eg, lay personnel),¹² trained and supervised by specialists—is an effective approach to addressing MSD workforce challenges, strengthening health systems, and increasing MSD care access.²⁰

By shifting service delivery for less complex cases to lay providers, MSD specialists can focus on more complex cases in a stepped-care model, in which quality and efficiency of care delivery improve as resources are distributed according to illness severity and need.²⁸ First-line treatment is provided by trained, task-shifted lay personnel who screen for MSDs and offer EBIs for less severe cases within primary or community care as well as for rehabilitation for people with chronic mental illness.¹⁷ In second-line treatment, integration of depression care into primary care (ie, collaborative care) addresses the needs of more symptomatic patients for antidepressant medication.²⁹ More intensive and expensive treatment by MSD specialists is then reserved for complex cases. The collaborative care model has gained momentum in HICs, while task-shifting with lay community health workers (CHWs) within primary or community care has been used in LMICs.³⁰

Like many other studies in LMICs,30 PRIDE-Mozambique combines a stepped-care model using task-shifting in rural clinics where no MSD specialists are available.²² Screening for all MSDs in the community is not easy, when CHWs already are charged with addressing multiple health issues (eg, HIV, pregnancy, malaria, tuberculosis, parasitosis, diarrhea). To address this challenge, the US-Mozambique collaboration developed and validated an ultrabrief 3-step screening, triaging, and treatment digital tool—the Electronic Mental Wellness Tool (E-mwTool; Figure 2).³¹

As is customary, in the first step, a CHW gathers household members’ health information from a main household informant. By asking 3 questions about each member, the CHW can identify presence of any MSD with 73% sensitivity. Second, the same 3 items are repeated with the identified member. With 94% sensitivity, CHWs can identify presence of any MSD. Third, for individuals screening positive, 9 more items are used to identify diagnostic categories (eg, severe mental disorders, common mental disorders, substance use disorders, suicide risk) with good specificity, allowing for triage to appropriate EBIs.³¹ E-mwTool is being validated in HICs and other LMICs, and added assessment of social determinants of MSD will enable even more specific interventions.

Education and Training Challenges

Task-shifting, stepped care, collaborative care, and community-based care for MSD require strengthening MSD training for all health care providers, including CHWs, to create equitable MSD care access.¹⁷ In addition to increasing knowledge about treating MSDs and addressing provider stigma, health and MSD professional education and training must incorporate both public health and MSD perspectives to go beyond a focus on individual care, which can generate disparities and inequities.

Context-Level Challenges

Services funding, development assistance, and policies that guarantee MSD parity with other health problems are basic for reducing treatment gaps across settings. HICs spend between 5% to 10% of their health budget on MSD. Upper middle-income countries spend about 3%, LMICs about 2%, and low-income countries less than 1%.¹⁷ Consequently, in LMICs, public health system options for psychiatric medications are few.³² International development support dedicated to MSD is 0.3% of all development assistance for health; it is about 150 times lower than for HIV and 50 times lower than for tuberculosis and malaria.³³

Most LMICs lack MSD service-related policies, and those that are available do not address the treatment gap. For example, many LMICs only allow MSD specialists to prescribe psychiatric medications; this guarantees virtually no access to psychotropic medications, given the limited numbers of MSD specialists. HICs fare better, but policies still are insufficient to guarantee appropriate access to MSD care, even for those with health insurance.

Use of information and communication technologies in MSD services is a novel approach that can overcome delivery barriers. Although this is a growing area of research in HICs, very few studies (eg, PRIDE) take place in LMICs.³⁴ COVID-19 has led to an exponentially increased use of telehealth to address social distancing guidelines. However, in spite of its health and MSD care benefits for populations that have access to digital tools, telehealth’s use beyond the pandemic may be limited by policies, legislation, and health insurance reimbursements. Low digital-resource settings in HICs and LMICs are unable to use this option without the support of funding, policies, and infrastructure.

Concluding Thoughts

The COVID-19 pandemic has increased urgency for governments and policy makers to strengthen their MSD systems and integrate an MSD response that addresses social determinants of MSDs within their COVID-19 recovery plan.^1,30 So far, mental health has received an inadequate proportion of health funding in HIC low-resource settings and in LMICs relative to its burden. The COVID-19 pandemic has worsened social determinants of health, and the resulting increased prevalence of MSDs has worsened the global MSD treatment gap. Nevertheless, recognition of the pandemic’s impact on MSDs creates a unique opportunity to work across sectors to increase MSD prevention as well as treatment funding, research, and implementation.

Mental health must be integrated into the global COVID 19 response, with the ability to build capacity for researchers, clinicians, funders, and policy makers to overcome barriers and challenges. Global MSD research must link with policy-making so that EBIs and programs are sustainably adopted and scaled-up within a country’s existing health, educational, and other public systems. HICs and LMICs must transform health provider training to incorporate a public health lens and to counter stigma and discrimination. Ministries of health must generate policy for scale-up of stepped-care and community MSD care using EBIs, strengthening existing mental health systems to tackle the pandemic.

Dr Wainberg is a professor of clinical psychiatry at Columbia University and New York State Psychiatric Institute; director of the Mental Wellness Equity Center at Columbia University/ New York State Psychiatric Institute; director of the National Institute of Mental Health (NIMH)-funded Columbia University Global Mental Health Implementation Science T32-Post Doctoral Fellowship, NIMH/Fogarty International-funded Portuguese-speaking African countries Mental Health Implementation Research Training Program; and co-director of the NIMH/Fogarty International-funded Capacity development in HIV and MEntal health Research in Asia (CHIMERA). He is also founding chair of the Caucus of Global Mental Health and Psychiatry of the American Psychiatric Association, and medical director of the Columbia University HIV Mental Health Training Project.

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