How mental health care is changing in Cameroon because of the COVID-19 pandemic

In their Position Paper in The Lancet Psychiatry, Carmen Moreno and colleagues underscored that despite the challenges and devastation, the COVID-19 pandemic provides a unique opportunity to transform mental health care.¹ We agree that the impact of the COVID-19 pandemic on the burden of mental health is a global concern. Similar to many countries in sub-Saharan Africa, Cameroon is especially vulnerable to mental health problems related to COVID-19 due to the challenges of a weak health-care system, an inadequate mental health workforce, insufficient financing to pay for health care, lack of access to mental health medications, and the added complexity posed by ongoing humanitarian crises. Additionally, the stigma of mental health problems continues to hinder and discourage individuals from seeking mental health care, further exacerbating the situation.2, 3 However, Cameroon's Ministry of Public Health has taken pragmatic steps towards ensuring that mental health is part of a core health systems approach. Mental health problems are apparent in all segments of the Cameroonian population, but the approach taken towards them has been transformed during the ongoing COVID-19 outbreak, providing a great opportunity to benefit the Cameroonian population in a way that can serve as an example for low-income and middle-income countries.

On March 6, 2020, the Ministry of Public Health in Cameroon confirmed the first positive COVID-19 case via imported transmission from France.⁴ Before this, meetings had been held by the Ministry of Public Health, chaired by Mental Health sub-Directorate, and the Incident Management System to develop an epidemic management plan to enhance capacity to prevent, detect, and respond to COVID-19. As the outbreak evolved, mental health personnel were placed at the two international airports at the forefront of managing travellers who were to be quarantined for 14 days upon arrival, hostels where these travellers where hosted, and isolation sites where positives cases with mild COVID-19 were admitted. A team of psychologists from the Public Health Operation Centre (PHEOC) was involved at all levels, including delivery of COVID-19 laboratory results and contact tracing in the community. Understanding that travellers were not always psychologically prepared to spend 14 days or more in isolation, the team of psychologists proposed the integration of psychological services into the national response against COVID-19, ranging from traveller arrivals to follow-up of positive cases in the community. As a result, a psychological care sub-unit within the Incident Management System was created in April, 2020, first at the central level in Yaoundé, the capital city, and then in the ten regions of the country. Since then, health workers involved in the national response have received briefings and training from a team of psychiatrists from the PHEOC on psychological first aid, confidentiality, and stress management guidelines and procedures developed by psychiatrists and the Operational Research Unit of the PHEOC. These programmes have been further developed by the combined team of psychologists and psychiatrists using real-time integration of feedback from the field.

Community transmission that started in early April led to mandatory integration, by the PHEOC, of a mental health protocol under which mental health personnel were progressively integrated into investigation teams in nine out of ten regions of the country following their successful integration in the central region, the epicentre of the pandemic in Cameroon. Widespread misinformation about COVID-19 in the community brought about resistance to the national response team efforts. Some families declined entry of investigation teams into their houses during contact tracing, while some people with suspected or confirmed COVID-19 refused to self-isolate. It was important to reassure communities and provide information regarding the testing strategy, accuracy of the tests used, the delay for the laboratory results, and the conditions of isolation and care. On site and at the PHEOC COVID-19 response call centre, increased demand was observed for psychological support by health-care providers involved in the COVID-19 response, which led to specific follow-up of those in need by the psychological care unit based on the resources available.

Cameroon is currently in the third phase of COVID-19 pandemic, which consists of track, test and treat; mental health is being integrated into all regions of the country and all aspects of the response, including counselling before and after testing, community engagement, and patient management in isolation or in hospital. The PHEOC ensures that these services reach at-risk groups including health-care providers and exposed individuals as well as the general population. Nursing staff and non-health-care workers are also provided with pre-test and post-test counselling, prioritising their access to psychosocial support. The psychological care unit continues to manage individuals who test positive for the virus, helping them to understand their results, providing psychological support, and offering drug management for COVID-19 according to national guidelines, as well as drugs specific to mental health issues, depending on the diagnosis. People with suspected infection also receive pre-test and post-test counselling. Stress management is also carried out in the community, including in schools, an initiative that proved crucial following the government's decision to re-open schools and universities in early June.

Overall, in Cameroon between May 3 and July 31, 2020, the number of people reached with these services was 22 919 people for pre-test counselling, 21 009 for post-test counselling, 20 880 for interpreting COVID-19 laboratory results, 14 261 for psychoeducation, 4437 for psychological support, and 249 for relaxation sessions. An additional 2365 people were identified for remote psychological support through the call centre and 388 were identified for psychological support at treatment centres. After receiving positive test results, 193 people received support by communicating with psychologists via SMS messages and 586 by communicating via WhatsApp.

To strengthen the national response, the Ministry of Health is establishing a toll-free number in collaboration with the Cameroonian Red Cross for psychological support, and it will be sustained after the pandemic is over. A partnership has also been established between the German Agency for International Cooperation and iDocta Africa in Cameroon to provide remote medical and psychological support to vulnerable communities including older people and those with comorbidities.⁵ The UN Population Fund and Uni-Psy et Bien-Être have set up psychological support for pregnant and breastfeeding women including their families, as well as caregivers.

In Cameroon, key stakeholders are beginning to understand the importance of addressing mental health problems during the COVID-19 pandemic. While challenges remain, the Ministry of Health is committed to reducing the burden of mental illness, and we acknowledge that these efforts should go beyond COVID-19.