COVID-19 and global mental health

In The Lancet Psychiatry, my colleagues and I describe the mental health services and supports mobilised in the initial months of the COVID-19 pandemic in low-income and middle-income countries (LMICs).¹ In our Review, we describe how humanitarian organisations with expertise in mental health began issuing guidelines in February, 2020, to manage the pandemic's effects on mental health, and many LMICs integrated this guidance into national response plans for mental health. The Review documents widespread innovation in LMICs to increase mental illness detection and maintain treatment during lockdowns. We also reported on the integration of mental health-care principles into contact tracing, quarantine procedures, and other COVID-19 mitigation efforts.

As a US citizen who has worked internationally in humanitarian mental health for two decades, I was dismayed to see that lessons learned in this field were not applied in my own country. With the change in our leadership, there is now an opportunity to apply LMIC practices to US responses.

First, mapping of mental health-care utilisation and gaps should accompany a US national response plan. In LMICs, mental health care during humanitarian emergencies was long characterised as chaotic and inefficient because of overlap and competition among local governments, nongovernmental organisations, and foreign relief programmes. To facilitate coordination, the global Inter-Agency Standing Committee developed procedures to identify who is where, when, doing what (also called the 4Ws tool) in mental health and psychosocial support.² During the COVID-19 pandemic, this approach mitigated duplication and gaps in many LMICs. The USA requires similar mapping and coordination for its patchwork of federal and state programmes, for-profit hospitals, academic medical centres, and community-based organisations. President Biden's National Strategy for the COVID-19 Response recommends expanding mental health care and calls for more funding.³ For these efforts to be successful, mapping is vital, otherwise we risk widening existing disparities in care.

Second, non-specialists should be trained and supervised to deliver interventions for people with mental illness and psychological distress. Evidence is accumulating that non-specialists in LMICs can effectively administer psychological interventions with appropriate supervision.⁴ During the COVID-19 pandemic, non-specialists, such as community health workers, religious leaders, and lay people, were rapidly deployed in LMICs. The US Centers for Disease Control and Prevention recommended use of non-specialists in LMICs for pandemic mental health services including brief psychological treatments,⁵ but widespread investments in non-specialists to deliver interventions have not been made for the USA domestically. The Congressional bill to establish a standing Health Force and Resilience Force is an ideal opportunity to employ non-specialists in mental health services during emergencies.⁶

Third, mental health-care principles should be incorporated into efforts for infectious disease control. During the Ebola outbreak in west Africa, mental health support was part of disease control measures.⁷ Psychological first aid training was incorporated heavily into contact tracing. Community dialogues helped build support for public health initiatives. In the USA, additional training in mental health and psychosocial skills for staff involved in contact tracing, vaccination, and other programmes could foster greater public participation.

Much of the evidence for these impactful approaches in LMICs has been established through initiatives funded by the US Agency for International Development and the US National Institutes of Health, which are institutions supported by US taxpayers. During the COVID-19 pandemic, it is time to also use these strategies to assure that all people living in the USA have access to quality mental health care. There is a tremendous amount that practitioners in LMICs can teach us to make these efforts successful.