Investing

Mental health: time to invest in quality

The theme of this year’s World Mental Health Day, on Oct 10, is increased investment in mental health. Why invest, and why now? The answer is simple. At the best of times, good mental health is needed for a society to thrive. During a pandemic, good mental health is more important than ever. Without a focus on mental health, any response to COVID-19 will be deficient, reducing individual and societal resilience, and impeding social, economic, and cultural recovery.

2020 has been a difficult year for mental health. The threat of infection, repeated lockdowns, social isolation, and economic uncertainty have created widespread fear and anxiety. A Rapid Review published in The Lancet showed the negative psychological effects of enforced quarantines. Many people who previously thought themselves unaffected by mental health issues have discovered that they, too, are vulnerable. Those with pre-existing mental health conditions have often found their difficulties increased. The precise neurological and psychiatric consequences of infection, meanwhile, remain unknown but demand careful monitoring. What investment is needed from governments and non-governmental organisations to mitigate the mental health impact of COVID-19 and, more importantly, to improve mental health globally?
In 2018, the Lancet Commission on Global Mental Health and Sustainable Development identified mental health as an essential component of universal health coverage and provided recommendations to improve mental health—eg, to involve a broader range of stakeholders in planning and delivering mental health services, most importantly those who have lived experience of mental health disorders. Their voices need to be not only heard but welcomed into the development of new systems of service delivery.

Regrettably, despite commitment from world leaders to include mental health care in universal health coverage as part of the Sustainable Development Goals in 2015, this pledge was not translated into reality. Universal health coverage would provide a lifeline for those trapped in the vicious cycle of economic hardship and poor mental health, where poverty is both a contributing factor to mental health problems and a barrier to accessing services that might help. Investment needs to increase in quantity and in terms of quality. For example, great strides have been made in the delivery of telepsychiatry over the past 10 months; individuals who receive these services must be instrumental in their future use and development. This involvement will ensure that telepsychiatry is used in an intelligent, targeted manner that provides appropriate support, rather than being a cost-saving, one-size-fits-all measure that risks exacerbating health inequalities or inadvertently reinforcing social isolation.

According to a WHO survey, people with pre-existing severe and enduring mental health conditions have been most affected by COVID-19-related disruptions of mental health-care systems. Other vulnerable groups include children and adolescents, many of whom have been impacted by school closures, stretched health systems, restricted access to nutritious food, breakdown in family relationships, neglect, and abuse. Older adults are also vulnerable. Many with pre-existing health conditions are terrified and lonely, afraid of infection, dying, and losing family members while physically distanced from loved ones and peers. Finally there are health-care workers themselves, who also face a greater risk of infection, stigmatisation, and stressful workloads, with the attendant psychological repercussions. Investment in mental health is also about investment in health-care workers.

The economic argument for investment in mental health services is clear and has been made many times, but there is also an ethical imperative for investment, both to redress historic wrongs done to vulnerable communities and to right current inequities. On a global scale, this strategy involves the empowerment of individuals and communities, the admission that high-income countries have much to learn from the innovations of low-income and middle-income settings, and the recognition of the central role of mental health in global health security now and in the future. Investment must be about more than just money if mental health services are to be made fit to address the challenges of the COVID-19 and post-COVID-19 era and to become resilient against future public health crises. There must be an investment of thought, time, and a commitment to change.

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