“For whosoever hath, to him shall be given, and he shall have more abundance: but whosoever hath not, from him shall be taken away even that he hath.” This Biblical verse, Matthew 13:12, provides a rare modern-day example of religion informing science—and Science—in the form of sociologist Robert K Merton's article in a 1968 issue of that prestigious journal. Merton proposed the existence of what he called “The Matthew effect” in scientific research: one that “may serve to heighten the visibility of contributions to science by scientists of acknowledged standing and to reduce the visibility of contributions by authors who are less well known.” He added that this principle might apply not only to individual researchers, but also at an institutional level, and hence that “centers of demonstrated scientific excellence are allocated far larger resources for investigation than centers which have yet to make their mark”. 3 years after Merton, researcher and general practitioner Julian Tudor-Hart published an article on “the inverse care law” in The Lancet. He noted “that the availability of good medical care tends to vary inversely with the need of the population served”.
This pattern of advantage fuelling advantage, while disadvantage has a vicious cycle of its own, also applies to patient groups: specifically, people living with severe mental illness. Before the coronavirus disease 2019 (COVID-19) pandemic, the wants and needs of people with diagnoses such as schizophrenia rarely entered into increasing public discussion of mental health issues. Even in professional movements—such as that for global mental health—offering desperately needed help to those experiencing severe mental illness was too often secondary to the more prominent discourse around easily scaled and delivered talking therapies for common mental disorders.
Although the COVID-19 situation is frequently described as having changed everything, in some cases it has simply accentuated pre-existing trends—including neglect by the media, the public, and too many professionals of those with severe mental illness. There have been innumerable opinion columns and reports on the mental health effects of lockdown, and on the situation on medical wards and in primary care. But there has been far too little space dedicated to the status of those with severe mental illness who would usually receive community support, or on the problems faced on inpatient mental health units. There are a few honourable exceptions. Sky News in the UK has reported on West London NHS Trust's Avonmore Ward, in which nurses, psychiatrists, and other professionals provide care for individuals with severe mental illness and COVID-19. The difficulties are considerable: measures taken to reduce the risks of viral spread, such as the use of protective clothing and masks, might inadvertently appear threatening to patients experiencing emotional distress and paranoid thoughts, as well as hampering the communication techniques that might otherwise build trust and a positive therapeutic relationship. In the USA, meanwhile, NBC and the New Yorker have provided insights into the risks for both patients and staff in inpatient mental health facilities that might be antiquated and hence difficult to keep clean, and poorly supplied with the equipment and personnel necessary to contain infection. The New Yorker also reported an additional complication of the US system: the “cruel logic of business models and insurance payment”. COVID-19 has brought new challenges: but it has also had an amplifying effect on pre-existing inequities in both society and health services. In mental health care, too many things have been either patched over or left undone for too many years, and the cost of this neglect is now being paid by vulnerable people.
There are a few promising signs that change might still be possible. For example, the Royal College of Psychiatrists has issued guidance on the COVID-19 response, new initiatives such as MadCovid are coordinating service user and survivor-led projects, and the Position Paper on mental health research priorities in response to COVID-19 in The Lancet Psychiatry highlights the needs of vulnerable groups, including those with severe mental illness, learning difficulties, and neurodevelopmental disorders, as well as socially excluded groups such as prisoners, the homeless, and refugees. But further pressure from clinicians, researchers, service user advocacy organisations, and journalists is needed if societal discourse is to be shifted. The mental health effects of COVID-19 on the general population might be profound and long-lasting, and deserve serious attention; but they cannot be the exclusive focus of conversation. Those who wish to build fairer societies and health systems after the pandemic ends must learn about and prioritise the needs of people living with severe mental illness as a matter of urgency.
This online publication has been corrected. The corrected version first appeared at thelancet.com/psychiatry on May 21, 2020
© 2020 Alex Bartel/Science Photo Library