Crisis within a crisis – the fragility of acute psychiatric care delivery
Authors: Andres R. Schneeberger, Christian G. Huber
Journal: World Psychiatry (2022)

Johnson et al1 provide a comprehensive account of the different service models aimed to address mental health crises, focusing on assessment and immediate management of the crisis, intensive treatment following crisis, further perspectives on crisis care including prevention, and crisis care in low- and middle-income countries. They conclude that a variety of options exist, but also that the evidence based on robust studies is scarce, and that most studies and policies reflect a clinician rather than a patient or consumer perspective. Generations of mental health care providers and consumers have strived to improve management of mental health crises, and the extensive synopsis of these efforts is striking in many ways. On the one hand, it illustrates the complexity of the issue; on the other, it shows the creativity needed in trying to address it. However, the plethora of models that the authors describe also reflects the general inadequacy of the services available and the failure of experts and service users alike to identify effective solutions. In addition, complex systems tend to be ineffective, complicating the pathways to care, increasing the time for a patient to receive adequate support, and increasing direct and indirect mental health costs. The COVID-19 pandemic has introduc­ed many new challenges to our societies, especially affecting the most vulnerable populations, including people with mental illness. While the united efforts of scientists worldwide have yielded the unprecedentedly rapid development of immunization strategies, health care service delivery in general, and mental health care delivery in particular, have suffered2. As an unintentional global stress test for health care systems, COVID-19 has revealed structural weaknesses in our acute mental health care services. COVID-19 infection itself causes acute mental health disturbances as well as long-lasting neurological and psychiatric sequelae. In addition, the forced reduction in social contacts and activities during lockdowns, anxiety and stress in the face of impending economic hardship, and uncertainty during a global crisis have exposed previously undetected mental health problems, led to increased rates of relapse of existing psychiatric illness, and induced new psychiatric problems. This increase in psychiatric morbidity has led to a surge in service use, for which most mental health systems were not prepared3. Mental health care workers and admin­istrators alike are struggling to uphold mental health care provision, resorting to creative measures, including new e-health solutions. Despite these efforts, it is proving impossible in many cases – and especially in institutional settings – to sustain services at pre-pandemic levels, leading to a degradation of the therapeutic alliance, one of the most critical success factors in psychiatric treatment4. The mental health crisis within the pandemic crisis has exposed a lack of robust policies backing the interventions needed to help people with mental illness, and can be taken as an indicator for the fragility of mental health care delivery. In addition, as Johnson et al1 describe in their review, patient or consumer access to acute psychiatric care is often characterized by a loss of autonomy and self-de­termination. Aggressive behavior and vio­lence in psychiatric patients are used to jus­tify more restrictive settings in inpatient fa­cilities, in the interest of maintaining safe­ty when dealing with patients who might otherwise harm themselves or be a danger to the community. However, recent evidence points in another direction: more open and empowering treatment approaches promoting reduction of coercion are able to reduce aggression and violence in emergency psychiatric settings5, suggesting that it is feasible to implement and uphold services with a minimum use of coercion and maximal patient autonomy. However, this is a demanding and long-term effort. Again, the COVID-19 pandemic shows how easily this progress can be lost. In times of a pandemic crisis, the level of involuntary admissions and coercive mea­sures increases6. This is not necessarily caused by an increase in psychopathology, but also due to an increased need for safety of the population and mental health care workers during times of uncertainty7. Normative attitudes outweigh moral doubts in times of crises and may lead mental health care workers to use more coercion in treatment settings. Lastly, the COVID-19 pandemic reminds us of the importance to focus not only on interventions for mental health crises, but also to help prevent these crises if possible. The mental health system should provide interventions to promote resilience and well-being, to facilitate self-care, and to support informal care. As the topic of Johnson et al1 is acute psychiatric care, they understandably only give a short overview of secondary and tertiary prevention efforts. However, the importance of prevention cannot be underestimated in its value to counteract the development of mental health crises, thereby reducing the suffering of the affected persons as well as the strain on the mental health care system and health care costs. We agree with the authors that new research and policies need to be promoted and that integrated local crisis care systems should be created to address the diverse needs of people with mental health crises. It is crucial to include people who use services, their families, communities and staff in all relevant sectors of mental health care delivery to design service systems that address the specific needs of patients and consumers. The COVID-19 pandemic has demonstrated the demand for better and more enduring service structures for people with mental illness. To achieve this goal, it is paramount to focus on the empowerment and de-stigmatization of service users8. In order to counter the structural stigmatization of mental health, politicians and policy makers need to be challenged and held accountable to include mental health care provision specifically in pandemic policies. The focus must shift from a fragmented, complex service system, including multiple crisis service models and leading to service gaps and unmet medical and psychiatric needs, toward a full continuum of psychiatric care9. Governments and agencies need to support and fund the development of comprehensive continua of mental health care, from inpatient beds in psychiatric institutions to low-threshold services, based on evidence-based public policies and practices on a national level. International research groups, including scientists and service users from low- and middle-income countries, are the key to the collection and timely dissemination of data on the best models and practices, with the goal to provide the evidence for sustainable acute psychiatric care delivery.