Mental Health Service Challenges during the Early Stage of the COVID-19 Pandemic: Experience and Best Practices from China

The COVID-19 pandemic sweeping the world causes complicated social problems and psychological problems. ¹ As summarized by Vigo and colleagues, ² the pandemic has grave impact on the mental health of the general population, on people with preexisting psychiatric and substance use disorders, on people who provide essential services including health care workers and first responders, and on people who contracted the virus. These mental health issues lead to an enormous burden on the mental health system (MHS) in every country.

After the outbreak of COVID-19, the MHS of China pivoted its services to meet the needs created by the pandemic. To share experiences, leaders of major psychiatric institutions (see Authors’ Note for experts list) in China and Canada convened an online Summit, “Mental Health Service Challenges during the COVID-19 Pandemic” in April, 2020. The psychiatric experts who worked frontline in Wuhan were invited. We summarized some of the responses of the MHS in China to each of the specific mental health impacts raised by Vigo and colleagues.

Impact on the Mental Health of the General Population

Rumors about the pandemic can cause large-scale panic. Therefore, it is important for government sectors to release real information in time and clarify false information. In China, the numbers of confirmed cases or suspected cases are displayed on traditional and social media to ensure information access to all citizens. People with suspected positive contact history can self-report online, which helps medical staff to trace and follow-up. Meanwhile, local mental health institutions provide mental health education to the general population on media.

A major challenge is to identify people with mental illness (e.g., anxiety disorders) from those with expected emotional reactions (e.g., fear and worry). ¹ Many people have distressing emotional reactions that resolve spontaneously or with minimal self-management. Others will have significant emotional symptoms that meet diagnostic threshold for mental disorders and require further professional assessment or intervention. To rapidly differentiate these two groups and focus resources on those who require care, several online platforms were adopted for self-screening for problems with depression, anxiety, suicidality, sleep quality, social support, life event, and coping strategy. Medical case workers give feedback after the screening, including advice and self-management tool kits. People with more severe symptoms are advised to contact mental health providers online or off-line.

Emotional isolation, depression, stigma, and other mental health issues related to this public health emergency may cause an increasing number of suicide behaviors. Local governments and mental health institutions expanded crisis intervention services online and on 24-hour hotlines. These services involved psychological consultants with crisis intervention training. Anyone who needs help can access these services for free.

Mental Health of People with Preexisting Mental or Substance Use Disorders

The risk of cross-infection in psychiatric hospitals makes it urgent to strengthen the management of inpatient wards. The mental health institutions in China adopted strict admission criteria and ward management policies, such as canceling visitors and discontinuing patient passes. Personal protective equipment (PPE) and daily necessities were provided to patients. For patients with severe mental illness who need to be accompanied (like patients with dementia), the caregivers are allowed to live on the same ward with patients, but they cannot leave the facility and are tested regularly until patients were discharged. If patients with mental illness contracted the virus, they were managed in general hospitals by the multidisciplinary teams (MDT).

Most outpatient mental health facilities were closed during the quarantine period, and it was difficult to obtain medication prescriptions, leading to challenges for provision of follow-up care and medication adherence. Novel solutions included new telehealth services offering virtual follow-up care ³ and arranging medication delivery via express service companies. Previously, e-health was limited to 24-hour hotlines, online booking of appointments, and viewing medical reports. During the pandemic, Chinese apps (e.g., WeChat) expanded services to online health consultations and follow-up. Several internet companies provided videoconferencing services for virtual health that were adopted by hospitals (e.g., Dingtalk). In particular, this expanded use of virtual health gives the opportunity, “[to] increase the coverage of underserved populations by leveraging innovative delivery platforms.” ¹ However, when developing virtual mental health services, equity barriers, such as limited wireless access, without equipment, resources, or knowledge to access these services, must be addressed.

People with serious mental illness are particularly affected by the pandemic. Vigo and colleagues suggested that “task shifting to provide psychosocial and peer-based support is an underutilized innovation, and COVID-19 can help increase uptake by health systems.” ¹ This was done successfully in China where each community was administered as a unit to implement anti-epidemic measures and health tracking for at-risk populations. Many community workers (community doctors, workers of neighborhood committee, or village council officials) and volunteers were engaged to help vulnerable individuals in the corresponding community, including helping them access online resources. For the homeless, local civil affairs departments are responsible for providing support. First, the staff strengthen inspections in the street to find homeless, provide them with PPE, and connect them with relief agencies. Second, the relief agencies provide temporary shelters for homeless and implemented anti-epidemic measures and health education. Third, cooperating with medical institutions to provide health services for homeless with mental illness or serious physical disease, referring those who have suspected symptoms of COVID-19 to specialized medical institutions.

Quarantine is a high-risk period for addictive behaviors (such as gambling, gaming) to become problematic. Stress, fear, anxiety, and depression are also risk factors for substance abuse and dependence. During this time, people with preexisting substance abuse/dependence and addictive behaviors are at risk for relapse, especially if treatment is interrupted or stopped. In China, psychiatric experts contributed to public education, guidelines, regulations, expert consensus, and training on these topics. For example, staff at methadone clinics provide education to patients with opioid dependence, who must attend daily, on how to protect themselves against viral infection. The substance abuse clinics also provide online follow-up and consulting services.

Mental Health of People Who Provide Essential Services

The administrative workers and volunteers in frontline health care have increased risk of contact with COVID-19. Medical workers in particular are under tremendous stress because of carrying a heavy clinical load while dealing with a high risk of personal infection and death. Medical workers from other provinces in China went to the COVID-19 epicenter to relieve the pressure of local workers. Psychosocial support was offered to frontline workers ⁴ with online courses for mental health and access to individual counseling online or by phone. The online courses included modules for understanding the causes of psychological problems, learning how to identify common psychological problems, learning methods of self-regulation and accessing professional services. The MDT also provide in person group counseling (6∼8 people/group) and individual psychotherapy (online or off-line) for medical workers.

Mental Health of People Infected by the Virus

The principle of anti-epidemic efforts in China is to leave no patient with virus unattended. Hence, many fever clinics, COVID-19 wards, makeshift hospitals, and mobile cabin hospitals were created for patients with different service needs. The MDT approach was vital both for patients and frontline medical staff. MDTs included medical staff, the logistical support groups, social workers, administrators, public welfare institutions, and volunteers. The MDT recognizes the unique contributions of specialized staff that are needed to adequately address the physical, psychological, and social aspects of anti-pandemic work on the frontline care. Among them, the psychiatric doctors provide liaison-consultation services to patients with severe COVID-19 in closed-wards, as well as group counseling regularly or individual psychotherapy to frontline medical workers online or off-line. The nonpsychiatric medical staff deliver basic psychosocial care (e.g., mental health education, delivering psychological support, encouraging proper aerobic exercise, building peer group) to patients with mild cases in mobile cabin hospitals to alleviate anxiety, depression, and fear.

Although the COVID-19 pandemic in China is currently under control, the effects of the virus and the severe restrictions will likely continue for some time. The psychological reactions of the public are likely changing, and more data about public mental health and needs in this postacute pandemic stage are required. There may be stigma and discrimination against patients with COVID-19 when they return to communities. The public may worry about new waves of the pandemic. The frontline medical staff and community workers may develop occupational burnout or post-traumatic stress disorders. These impacts mean that significant mental health resources will be needed to deal with the postpandemic stress issues. Hence, an integrated mental health service plan for long-term interventions should be made as soon as possible.

In summary, identifying the mental health challenges and evaluating the service responses will be helpful not only for the primary COVID-19 pandemic crisis but also for any secondary surges after relaxing of quarantine and distancing restrictions and for future pandemics that may occur. Many of the services provided by the MHS in China addressed the broad recommendations outlined by Vigo and colleagues. ¹ The China–Canada COVID-19 Mental Health Summit was an excellent event to share expertise and best practices and to recognize that all humankind should be united to face these global pandemics and disasters.