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      Challenges and opportunities in mental health services during the COVID-19 pandemic

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      General Psychiatry
      BMJ Publishing Group
      COVID-19 pandemic, mental health services, challenges, opportunities

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          Abstract

          As of 12 March 2020, the WHO upgraded the status of COVID-19 from epidemic to pandemic.1 Globally, as of 20 July 2020, 14 707 451 confirmed cases of COVID-19, including 609 985 deaths, have been reported by an interactive web-based dashboard released by Johns Hopkins University.2 Strict provisions and strategies have been implemented to suppress or mitigate the spread of the COVID-19 pandemic, such as government-imposed contact tracing and quarantine, lockdown, social and physical distance measures, and closure of non-essential facilities and services. The global spread of the COVID-19 pandemic and rapid escalation response undoubtedly put enormous stress on patients with confirmed or suspected COVID-19, medical personnel and even the public, increasing the risk of mental health problems. Challenges for mental health service during the COVID-19 pandemic This unprecedented crisis poses great challenges for mental health services. First, high contagion, inherent scientific uncertainties and imposition of strict quarantine inevitably increase patients’ fear and stigma, which in turn create barriers to seeking support for appropriate medical treatment and a psychological crisis intervention. One report addressed a similar issue about stigma and discrimination during the severe acute respiratory syndrome outbreak.3 Additionally, although most people experiencing public health emergency do not succumb to negative psychosocial outcomes, some individuals are more sensitive to emotional distress owing to individuals’ biological vulnerability, psychosocial factors and coping strategies.4 A national-level and large-scale survey, involving 52 739 participants in China, assessed the magnitude of psychological burden in the general population during the COVID-19 crisis and found that almost 35% of responders experienced psychological distress.5 Psychosocial support and psychoeducation should be implemented to protect the public’s mental health. As for the front-line responders themselves (including medical staff, police, social workers, volunteers and management personnel), no specific treatment for the life-threatening viral infection, shortage of medical equipment, fear of contagion and of infecting loved ones, and overwhelming workload are among the major contributors to psychological problems. In the midst of this crisis, one survey reported that a considerable proportion of front-line medical personnel in China suffered from depression symptoms (50.4%), anxiety (44.6%), insomnia (34.0%) and distress (71.5%).6 Finally, some marginalised populations (such as the elderly, people with chronic physical illnesses, individuals residing in congregate settings and those with pre-existing psychological conditions) have largely been overlooked as much attention has been paid to infected patients, their family members, the bereaved and front-line medical personnel exposed to COVID-19. In particular, people with pre-existing psychological conditions are susceptible to adverse psychosocial outcomes (eg, anxiety, depression, insomnia, irritability and contamination-related behavioural tendencies) in the COVID-19 crisis. In light of stringent travel restrictions, strong fears of contamination and an overburdened health system, they hardly have access to maintain treatments and regular follow-up visits, yielding pre-existing symptom worsening or relapse. Mental healthcare preparedness and response in China To efficiently mitigate the mental health consequences triggered by the COVID-19 pandemic, the National Health Commission of the People’s Republic of China and the Joint Prevention and Control Office of the State Council have released comprehensive and systematic emergency psychological crisis interventions with the engagement of the whole society (including health planners and health authorities, multidisciplinary mental health teams, community-based social groups and the public) (figure 1).7 8 First, this prompt and well-orchestrated emergency response addressed mental health issues at the organisational level through planning and evaluating evidence-based interventions, specific intervention strategies for target populations and the involvement of social services. Specifically, health planners and practitioners incorporate theoretical and empirical evidence into planning and evaluating psychological crisis interventions. Multidisciplinary mental health teams (including psychiatrists, psychologists, psychiatric nurses, occupational therapists and social workers) have been established to eliminate psychological barriers and provide specialised psychosocial interventions in quarantine sites. Occupational therapists and social workers have provided psychological support and psychoeducation to infected patients, especially to those living in high-prevalence areas. Those with serious mental health problems need referrals for psychiatrists, and sometimes a combination of psychotherapy and medication is needed. Meanwhile, community-based social workers and mental healthcare workers are not only dedicated to providing resources and health supports for the vulnerable populations but they also play an important role in maintaining patients’ mental health after discharge. As for front-line responders themselves, specialised infection prevention and control training, enough supply of personal protective equipment, and the establishment of psychosocial support for their families should be encouraged to address their concerns and stress. Experiencing the COVID-19 crisis, the public strives to create a good social atmosphere for those with mental health problems and to eliminate the stigma surrounding mental health issues. The COVID-19 pandemic has both alarming implications and opportunities for integrating mental health services into the public health response system and ultimately improving mental health crisis response services. Figure 1 The progress of mental health services during the outbreak in China. Adapted from the Guiding Principles of Emergency Psychological Crisis Intervention for the COVID-19 pandemic launched by the National Health Commission of the People’s Republic of China.7 8 Second, due to human-to-human transmission of COVID-19, the ever-increasing internet and social media (eg, WeChat, TikTok and Zoom) have been harnessed to perform online psychological crisis interventions. National and provincial psychology organisations have rapidly launched online self-help books to raise public awareness of emotional prevention and established knowledge transfer and internet-based platforms to provide online counselling and intervention for vulnerable populations. For instance, psychologists and psychiatrists in Shanghai Mental Health Center have launched audio and video training courses and tutorials for the general population and stretched medical staff to combat mental health conditions (eg, insomnia, fear and anxiety).9 In addition, the widespread availability of digital services undoubtedly facilitates spontaneous and efficient communication and cooperation among health providers. Given that most workers in healthcare settings have no or little experience in dealing with mental health problems, implementation of internet-delivered psychological counselling and guidance enables health providers to quickly identify patients’ psychosocial health needs. During the public mental health crisis, internet-based screening and psychological intervention are reshaping traditional mental healthcare patterns, providing new insights into the development of online mental health services. Opportunities and suggestions During this crisis, opportunities to improve mental health services must be seized by integrating psychological crisis interventions into COVID-19 healthcare preparedness and response. Undoubtedly, the COVID-19 crisis is a double-edged sword for mental health services. In case of a similar public health crisis in the future, government and local authorities should formulate a multi-tiered response to intervention and integrate this structured psychological intervention into public health emergency preparedness and response. With the ever-emerging online mental health services, specialised psychiatric hospitals and general hospitals should enhance multidisciplinary collaborations and jointly carry out remote consultations to improve the quality of emergency psychological crisis interventions.

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          An interactive web-based dashboard to track COVID-19 in real time

          In December, 2019, a local outbreak of pneumonia of initially unknown cause was detected in Wuhan (Hubei, China), and was quickly determined to be caused by a novel coronavirus, 1 namely severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The outbreak has since spread to every province of mainland China as well as 27 other countries and regions, with more than 70 000 confirmed cases as of Feb 17, 2020. 2 In response to this ongoing public health emergency, we developed an online interactive dashboard, hosted by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University, Baltimore, MD, USA, to visualise and track reported cases of coronavirus disease 2019 (COVID-19) in real time. The dashboard, first shared publicly on Jan 22, illustrates the location and number of confirmed COVID-19 cases, deaths, and recoveries for all affected countries. It was developed to provide researchers, public health authorities, and the general public with a user-friendly tool to track the outbreak as it unfolds. All data collected and displayed are made freely available, initially through Google Sheets and now through a GitHub repository, along with the feature layers of the dashboard, which are now included in the Esri Living Atlas. The dashboard reports cases at the province level in China; at the city level in the USA, Australia, and Canada; and at the country level otherwise. During Jan 22–31, all data collection and processing were done manually, and updates were typically done twice a day, morning and night (US Eastern Time). As the outbreak evolved, the manual reporting process became unsustainable; therefore, on Feb 1, we adopted a semi-automated living data stream strategy. Our primary data source is DXY, an online platform run by members of the Chinese medical community, which aggregates local media and government reports to provide cumulative totals of COVID-19 cases in near real time at the province level in China and at the country level otherwise. Every 15 min, the cumulative case counts are updated from DXY for all provinces in China and for other affected countries and regions. For countries and regions outside mainland China (including Hong Kong, Macau, and Taiwan), we found DXY cumulative case counts to frequently lag behind other sources; we therefore manually update these case numbers throughout the day when new cases are identified. To identify new cases, we monitor various Twitter feeds, online news services, and direct communication sent through the dashboard. Before manually updating the dashboard, we confirm the case numbers with regional and local health departments, including the respective centres for disease control and prevention (CDC) of China, Taiwan, and Europe, the Hong Kong Department of Health, the Macau Government, and WHO, as well as city-level and state-level health authorities. For city-level case reports in the USA, Australia, and Canada, which we began reporting on Feb 1, we rely on the US CDC, the government of Canada, the Australian Government Department of Health, and various state or territory health authorities. All manual updates (for countries and regions outside mainland China) are coordinated by a team at Johns Hopkins University. The case data reported on the dashboard aligns with the daily Chinese CDC 3 and WHO situation reports 2 for within and outside of mainland China, respectively (figure ). Furthermore, the dashboard is particularly effective at capturing the timing of the first reported case of COVID-19 in new countries or regions (appendix). With the exception of Australia, Hong Kong, and Italy, the CSSE at Johns Hopkins University has reported newly infected countries ahead of WHO, with Hong Kong and Italy reported within hours of the corresponding WHO situation report. Figure Comparison of COVID-19 case reporting from different sources Daily cumulative case numbers (starting Jan 22, 2020) reported by the Johns Hopkins University Center for Systems Science and Engineering (CSSE), WHO situation reports, and the Chinese Center for Disease Control and Prevention (Chinese CDC) for within (A) and outside (B) mainland China. Given the popularity and impact of the dashboard to date, we plan to continue hosting and managing the tool throughout the entirety of the COVID-19 outbreak and to build out its capabilities to establish a standing tool to monitor and report on future outbreaks. We believe our efforts are crucial to help inform modelling efforts and control measures during the earliest stages of the outbreak.
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            Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019

            Key Points Question What factors are associated with mental health outcomes among health care workers in China who are treating patients with coronavirus disease 2019 (COVID-19)? Findings In this cross-sectional study of 1257 health care workers in 34 hospitals equipped with fever clinics or wards for patients with COVID-19 in multiple regions of China, a considerable proportion of health care workers reported experiencing symptoms of depression, anxiety, insomnia, and distress, especially women, nurses, those in Wuhan, and front-line health care workers directly engaged in diagnosing, treating, or providing nursing care to patients with suspected or confirmed COVID-19. Meaning These findings suggest that, among Chinese health care workers exposed to COVID-19, women, nurses, those in Wuhan, and front-line health care workers have a high risk of developing unfavorable mental health outcomes and may need psychological support or interventions.
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              A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations

              The Coronavirus Disease 2019 (COVID-19) epidemic emerged in Wuhan, China, spread nationwide and then onto half a dozen other countries between December 2019 and early 2020. The implementation of unprecedented strict quarantine measures in China has kept a large number of people in isolation and affected many aspects of people’s lives. It has also triggered a wide variety of psychological problems, such as panic disorder, anxiety and depression. This study is the first nationwide large-scale survey of psychological distress in the general population of China during the COVID-19 epidemic.
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                Author and article information

                Journal
                Gen Psychiatr
                Gen Psychiatr
                gpsych
                gpsych
                General Psychiatry
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2517-729X
                2020
                30 August 2020
                30 August 2020
                : 33
                : 5
                : e100275
                Affiliations
                [1] departmentShanghai Mental Health Center , Shanghai Jiao Tong University School of Medicine , Shanghai, China
                Author notes
                [Correspondence to ] Dr Zhen Wang; wangzhen@ 123456smhc.org.cn ; Dr Yifeng Xu; xuyifeng@ 123456shmc.org.cn
                Author information
                http://orcid.org/0000-0003-4338-967X
                http://orcid.org/0000-0003-4319-5314
                http://orcid.org/0000-0002-0403-1141
                Article
                gpsych-2020-100275
                10.1136/gpsych-2020-100275
                7462145
                ae4386aa-1451-45b8-a72c-721952258ef9
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 19 May 2020
                : 29 July 2020
                : 31 July 2020
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