Never before has there been such a high level of mobilization around mental health
during an epidemic (Pappa et al. 2020). International agencies, with the UN General
Secretary at the forefront, the Director of the World Health Organization, as well
as researchers, policy makers and civil society leaders have all drawn attention to
the need for mental health care for people affected by COVID-19. In the so-called
developed countries, many training courses and guidelines have been developed to help
mental health professionals to offer telepsychotherapy in order to comply with the
physical distancing measures taken to prevent the spread of the COVID-19 pandemic.
In many low- and middle-income countries (LMICs), a mental health commission has been
implemented within the response committees to fight the pandemic. These measures have
been part of unprecedented efforts to raise awareness on mental health issues.
However, despite these efforts, many concerns rapidly arose about mental health care
during the COVID-19 pandemic. Many of these measures solely target mental health symptoms
(emotional and behavioral), rather than the overall well-being of individuals, families
and communities. Typically formulated in high-income countries (HIC), these programs
often assume that basic needs are met, and operate under the assumption that survival
is not threatened. However, programs that address social inequalities and the non-fulfillment
of basic needs are urgently needed, both in HIC and in LMICs. Indeed, beyond the fear
of the virus or the isolation of confinement, an increasing number of people go to
bed hungry and worried about what their family will eat the next day. Others are preoccupied
by their unpaid rent and the risk of being thrown out of their apartments. In the
USA, while more than 30 million people applied for unemployment benefits in April,
two large surveys have shown that around 20% of children do not have access to enough
food (Bauer 2020). In India, more than 120 million lost their jobs or economic activities,
among them, some of the most vulnerable. Queues spanning more than five miles in the
USA, where recently unemployed individuals are seeking food assistance, or images
of the millions in India trying to reach their hometown by bus and on foot revealed
the extent of social inequalities in the face of COVID-19. In some countries, confinement
measures were deemed impossible to follow, because the risk of being infected was
nothing compared to starving to death.
The WHO’s definition of mental health and well-being of individuals includes the fulfillment
of basic human needs and rights and recommends interventions that are based on an
ecosystemic approach targeting a wide range of social and psychological determinants,
including social inequalities, poverty and precariousness. In the current social crisis
resulting from the COVID-19 pandemic, those most in need of mental health care are
those whose livelihoods have been made even more precarious because of social disparities.
Yet, few of them will seek help because their basic needs are not met and our mental
healthcare systems not only fail to address these inequalities but tend to individualize
psychological distress (Murali and Oyebode 2004). Proposing online support and tool
kits to address anxiety and depression symptoms may be very helpful when culturally
appropriate. However, if survival is at stake and if this is not acknowledged as the
most legitimate concern, these same resources may be perceived as a minimization or
a denial of the social suffering of marginalized groups.
Thus, mental health programs may have an important role to play to help those most
vulnerable to social inequality in coping with the COVID-19 pandemic, but these mental
health responses should be tightly interwoven with socially and culturally adapted
interventions which take into account their reality. As previous studies on similar
epidemics (Cénat et al. 2020a, b), ongoing studies have shown that in addition to
anxiety and fear, a high prevalence of depression, insomnia and other mental health
problems have been observed in those affected by the current crisis (Pappa et al.
2020). During this critical time, contact with mental health professionals should
be facilitated to help those who are struggling to cope. To do this, it is important
to use innovative approaches to reach the most vulnerable. As has been shown in countries
during Ebola epidemics, people need psychosocial support to be integrated with other
services, in innovative and accessible ways (Cénat et al. 2019a, 2020b). For example,
in queues at food distribution sites in the USA, cards with contacts of crisis centers
could be distributed to promote the use of psychosocial support. Furthermore, mental
health providers could be available on-site to meet those who are most in need. However,
applying these principles on a larger scale would have the most significant and beneficial
impact on our populations. Cities and countries should consider developing inclusive
and holistic programs based on ecosystemic models that integrate both basic needs
and mental health care. These measures should help reduce the psychological distress
of those affected by the exacerbation of social inequalities. Promoting mental health
while addressing its social determinants would also help in preventing mental disorders
and related suicides.
It is also important to learn from the current situation in order to be prepared for
future pandemics and crises. We will only be ready if we work to reduce social inequalities
in the coming years. We will only be ready if we put in place strong and equitable
social protection systems. Not only will a population mental health approach which
reduces disparities serve as a protective factor for the development of mental disorders,
it will also allow mental health care to be made more accessible.
Food, housing and financial insecurities which prevent people from seeking mental
health care, even when urgently needed, are a global issue that concern both HIC and
LMICs (Cénat 2020). In the USA, where black people have been overwhelmingly and disproportionately
impacted by COVID-19 and where most are suffering from bereavement related to the
pandemic, very few will access mental health care. The same is true for many unemployed
people, whether in developed countries or in LMICs, who are more preoccupied about
their immediate day-to-day needs than about protecting themselves from COVID-19.
Only by reducing social inequalities will we be ready in the future. In the meantime,
mental health programs must be integrative and ecosystemic, addressing both basic
needs and mental health issues, because when basic needs challenge psychosocial well-being,
no matter how urgent it is, mental health care will wait.