The fight against COVID-19 has brought the world together to address the major public health challenge of our time—containing the spread of a deadly virus. Together, countries are searching for a vaccine, closing and reopening borders, and learning from each other’s responses. But too little discussed is the global mental crisis that has accompanied the pandemic, which although seemingly less dramatic, is at least, if not more, pervasive.
The United States is failing deeply in containing the pandemic, but it also failing to provide the mental health services that this moment demands. We have therefore much to gain from a global lens not only on the virus, but on the crisis in mental health as well. Shekhar Saxena is professor of the Practice of Global Mental Health at Harvard’s T.H. Chan School of Public Health. He previously spent 20 years working for the World Health Organization, the latter decade as Director of the Department of Mental Health and Substance Abuse. Associate editor Sophia Crabbe-Field spoke with Shekhar Saxena on July 10 about addressing the glaring lack of mental health care in the United States, what we can learn from other countries, and how we can make mental health a global public good.
Sophia Crabbe-Field: I know that you were part of the Lancet Commission on global mental health and sustainable development where, in 2018, you spoke of reframing the global mental health agenda, using the sustainable development goals as a historic opportunity to make mental health a global public good and to remove the attached stigma by placing mental health along a continuum. I’m wondering if you see COVID and the uptick in mental health issues that it’s created as another historic opportunity to reframe the global mental health agenda in these ways?
Shekhar Saxena: I do. In fact, the kind of issues that we talked about in 2018 are actually in some ways becoming more validated and more useful during the mental health crisis associated with the COVID disease. And when I say COVID-19 disease, I mean two things. One is, of course, that a very large number of people are getting infected. And some of them are seriously sick and, unfortunately, some are dying because of that. But a much, much larger number of people are affected by restrictions put in because of COVID-19, as well as by the economic and social impact, including economic difficulties and joblessness, that a large number of people are facing.
In addition, inequities in society are increasing. So all of these are actually showing us how some of the actions that we recommended are even more important and timely now. Let me give you a few examples. You already referred to the dimensional approach to mental health that we emphasized. That is becoming so relevant now, because, as we said, the world simply cannot be divided into two groups of people: one who has a mental disorder, and the other who doesn’t. We are all at some point on the mental health spectrum. And we move on that as we go through different kinds of situations in our lives. Some people are able to cope very well and have no current mental health problems. Others aren’t able to cope very well and may have mental distress and some symptoms. Some others have a current mental disorder. And lastly, some people have a disorder and a disability. When we are going through a lot of stress, and economic and social changes, people who were coping well, cannot cope well now. And others who had an established disability but had the social network to support them are suddenly losing that network. So their disability increases. And that is, in an unfortunate way, a classic example of how the dimensional approach is even more important right now.
And the corollary of that is that all of us need help. The people who are not able to cope better may need some kind of self-help or may need to be talking to their family and colleagues and relying on informal social support. And there I must point out that the directive of “social distancing” is actually very unhelpful. Actually, what we need is physical distancing, which is a requirement to decrease the infections, but enhanced social connectedness and support.
And we also know that the rate of mental disorders increases to almost four or five times during a severe crisis like this. People who have a disorder need to be provided with a continuum of care so that their disability doesn’t increase, and people who have disability need to be given even more social support than was possible earlier. Mental health needs are currently higher and the access is lower. So it just reinforces the need for looking at mental health as a dimension and also as a social good.
SC-F: So what do we do, then, about the fact that, in the United States, we have this increasing part of the population that needs access to mental health, but at the same time, people are losing their insurance and facilities are closing?
SS: The perspective should be a population-wide program rather than a clinical program. Obviously, clinical programs are important, but the focus should be on how we can protect, promote, and preserve the mental health of people on the entire spectrum. So it’s not only the health department, it’s an overall policy approach to see to it that the social-economic impacts are reduced. And also the inequalities are at least in some ways responded to, because we do know that racial minorities, as well poor people and those who are uninsured and those who are in some ways marginalized in society anyways, had more mental health problems and now are facing these factors much more and so will have much larger unmet mental health needs. And the access of these people to mental health care is becoming lower. We need to have policies that protect people who are especially vulnerable. These include income support, job protection, and social sustenance.
We also need to have health education messages that are credible and helpful, because as soon as you have more uncertainty and the lack of credible messages, the population’s level of anxiety increases. And that leads to increasing mental health problems.
And the last part of the continuum is, if people have a disorder, then access to social services has to be increased rather than allowed to be compromised. And there, we do understand the need to not open up services and increase the infection, but a lot of mental health care can actually be delivered using remote care. And so all of those tele-mental health advances, which had proven their worth earlier, need to be implemented immediately.
And finally, the financing mechanisms and reimbursements needs to be streamlined legally, as well as in practice, to see to it that care providers who are there, who can provide help, are not prevented from providing that help simply because the administrative mechanism doesn’t exist for that. And some states have moved very well on that, to see to it that people can still provide support and therapy remotely and be covered through insurance. But much more needs to be done.
SC-F: Have you seen other countries that are doing things better than the United States in terms of mental health that we can be learning from at the moment?
SS: Absolutely. As they often say, when it comes to mental health, all countries are developing countries. So that is a fundamental point that we need to accept for a country like the USA; we do have a lot to learn. In fact, I will even propose that the U.S. system for mental health care is quite dysfunctional. So incremental improvement in that is unlikely to succeed, especially during a crisis like this. This means that we need to find a different way of working and also of using innovative mechanisms. Now, all that might seem abstract. So let me give you examples.
A large number of countries are using non-specialised health-care providers to deliver basic mental health care. So one should not necessarily be required to go to a psychiatrist or psychologist, but instead trained nurses and doctors can identify and treat a number of mental health problems. And even trained primary health-care workers can actually do a lot. And there are many, many examples of that. In fact, WHO’s program of mhGAP, which is for training non-specialists in providing mental health care, has been implemented in more than a hundred countries. And that is what some of the high-income countries need to do. They need to accept that a lot of care is possible, at least for common mental disorders like anxiety and depression, in the hands of non-specialists and that is the only feasible way to scale up services.
And, incidentally, that also decreases stigma because a lot of people don’t go to psychologists and psychiatrists because they feel that that will be something that will jeopardize their standing in society, even their careers. And if they go to the doctor for depression, just like when they have fever, that will be less stigmatizing and incidentally less costly too. This is one innovation that the United States needs to implement. The second innovation is using community support systems for mental health care. A lot can be done by peer counselling, by group sessions, with a professional or even without. There are mental health groups that can be run just on a peer-to-peer basis, which are the least expensive and can be very effective, not for all conditions, but for many conditions. So those opportunities need to be created.
You may have heard about the Friendship Bench, which is an experiment that was started in Zimbabwe, one of the least economically developed countries, but is now being replicated in New York, where grandmothers and other laypeople were quickly trained in listening and in psychological support. Many scientific articles have been written on the effectiveness of the Friendship Bench. These kinds of experiments and innovative practices need to be adopted in the USA and other high-income countries so that they can extend the care that can be provided within the resources that they have.
SC-F: These community-based programs that you speak of, do you feel that at the WHO you were able to have an influence on creating them at the state level? Also, do you think that that the United States pulling out of the WHO will have an effect in the area of global mental health?
SS: Let me just clarify that I worked for the WHO earlier, but I don’t work for the WHO now, so I’m not speaking for them. But having had the experience of working for the WHO for 20 years, I feel that in all areas of health, but especially in the area of mental health, global guidance and support is important for all countries. WHO is not only about low- and middle-income countries, it’s about all countries. And they can all benefit from guidance and technical assistance. So the recent attempt by the USA to dissociate itself from the WHO is likely to have a negative impact on overall health status within the USA, including on mental health. The WHO has a wide variety of guidance and recommendations for mental health in general, but also for coping with the overall COVID-related issues of mental health, and all countries can benefit from that. This is all very practical, technical material, which needs to be used during crises to cope with the excess burden of mental health.
SC-F: Do you think that if Americans had had better access to mental health care before the crisis hit we would be looking at a very different landscape right now in terms of mental health burden?
SS: Yes, of course. Mental systems in most countries have been very poorly resourced, as well as to some extent inefficient to begin with. And that prepares the population less well for coping with these kinds of crises. And with the dimensional model that I introduced earlier, wherever people are on it, their readiness to either improve their mental health or to at least cope with the additional difficulties is dependent on how well prepared they are within themselves, but also as a part of the community, and what kind of resources they know about and can access when needed. And that has all been compromised because our mental health system is not as robust as it should be. And the mental health system could also not cope with the excess demand and the limitations that are being put on it because of COVID.
So, on both sides, we need a better community support system as well as a better mental health care system for any future crises. And let’s also think about the fact that this crisis is not going away very soon. So from acute, it’s already becoming a chronic crisis. There could be no better time to actually improve things. And, “building back better” is something that we need to start doing now.
SC-F: Right now we’re also seeing the protests over police brutality and persistent racism come to the fore. A lot of people have talked about the fact that police are intervening in times when a mental health professional should be. I’m just wondering if you have any thoughts on that.
SS: I have two comments: one, that people don’t live in a vacuum; anything that happens in the larger society including racial discrimination or violence does impact them. And this impacts not only the people within the racial minority groups, but it affects everybody. So that, and also overall violence, including domestic violence, are very important predictors of population mental health. Anything that can be done to decrease these assaults on our body as well as our mind will definitely be helpful in decreasing the incidence of mental health problems, as well as increasing the awareness of people who have been victims of that to be able to seek help.
The second part of that is that the inequalities become even more glaring for access to treatment. And that is something that we need to improve. Mental health-care systems need to be proactive about reaching people who are ordinarily being ignored. And that means we need to have a care system that is proactive rather reactive. And there, the number of people who are uninsured is increasing. And in spite of the Parity Law that the United States has had for a number of years, we do know that access to mental health services is restricted and in some cases actively denied by care providers because of many restrictions inserted as fine print. These are issues that we need to take care of right away. And this dual crisis of COVID as well as racial issues is actually forcing us to think about these things in a much more in-depth manner than we did earlier. Action is immediately needed to decrease inequalities and to ensure access to mental health care to those who need it the most.
SC-F: Do you see any sort of policies or laws being proposed right now that could help us live up to the Mental Health Parity Act?
SS: I believe that civil society organizations have a responsibility to highlight non-compliance with the Parity Law. Media also needs to highlight the kind of violations that are being practiced. I would also like to point out the need for involving people with lived experience. People who need help, are trying to get help and are being denied—they need to point out that it’s important for them. And that will go a long way. And again, this is the right time for them to do that because the needs are high, as I said earlier, and access is especially low.
SC-F: How do we support the mental health needs right now of those who on the frontline of the crisis?
SS: Well, you have raised a very important issue and I’ve been actually very actively involved in that for the last four months. You might like to look up an initiative of the Harvard T.H. Chan School of Public Health, along with Thrive Global and Creative Artists Agency. The initiative is called #FirstRespondersFirst, and it exists exactly to serve the needs that you have pointed out. We do know that frontline health workers, as well as other frontline workers, have a great need at this time. They’re overworked; they’re in danger of getting infected, including infecting their families, and are finding it difficult to cope. They have a lot of mental health and wellness issues, and this initiative is actually making some very practical attempts to look after those needs. Of course, we need much more. This also brings to the fore the need to look after the public health-care system, which has been ignored for a long time, and the people who run that. If those people are not healthy, if those people are not well, they cannot make the society well and healthy.