Reimagining mental health systems post COVID-19
Authors: Gary Belkin, Steve Appleton, Kathy Langlois
Journal: The Lancet Planetary Health (2021)

Immediate and short-term attention has been directed to the negative mental health effects of COVID-19 in many countries.1Czeisler MÉ Lane RI Petrosky E et al.Mental health, substance use and suicidal ideation during the COVID19 pandemic—United States, June 24–30, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 1049-1057Crossref PubMed Scopus (0) Google Scholar However, such attention needs to be put to more ambitious use. Now is the opportunity to make securing the emotional and mental wellbeing of humanity a common expectation of global governance. We call attention to this opportunity as part of the International City and Urban Regional Collaborative (I-CIRCLE), a consortium of mental health system leaders and managers that came together through shared involvement in the International Initiative for Mental Health Leadership. I-CIRCLE is a growing network for sharing lessons learned, to integrate mental health capacity within the work of building vibrant, just, and humane communities. Socioemotional health is key to the state of communal life and wellbeing. COVID-19 has underscored and magnified this connection, which will become increasingly pivotal as the state of planetary and civic health are severely tested by climate change and ecological destruction, of which COVID-19 is an early but not unique symptom of things to come.2Di Marco M Baker ML Daszak P et al.Opinion: sustainable development must account for pandemic risk.Proc Natl Acad Sci USA. 2020; 117: 3888-3892Crossref PubMed Scopus (202) Google Scholar Facing that future depends on facing up to the unfinished business of adequately addressing the mental health needs and emotional capacity of communities. Unless there is bold change, remediable social factors (poverty, food insecurity, unstable housing, childhoods of diminished education and nurture), racial and economic oppression, and mental health systems with too few resources and too narrow a mission, will continue to undermine the emotional health and ties that bind humanity and which are foundations for collective action to solve pressing problems. We therefore urge the global mental health community and efforts to galvanize worldwide consensus for pandemic response and recovery, such as The Lancet COVID-19 Commission, to commit to making wellbeing-centered policymaking a pillar of the future.3Biglan A Johansson M Van Ryzin M Embry D Scaling up and scaling out: consilience and the evolution of more nurturant societies.Clin Psychol Rev. 2020; 81101893Crossref PubMed Scopus (14) Google Scholar This commitment should drive future international cooperation and incorporate the following perspectives and purposes. The negative mental health effects of COVID-19 are and will remain massive, far reaching, and long term.4WHOMental health and psychosocial considerations during the COVID-19 outbreak.https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdfDate: Mar 18, 2020Date accessed: October 12, 2020Google Scholar These effects include the cumulative toll of diagnosable illness fueled by wide exposure to loss, stress, and trauma, but also reflect much more. Planetary-sized ecological ruptures like this pandemic amplify structural disadvantage and a cascade of compounding risks and multiple vulnerabilities that all result in deep social and emotional damage.5United Nations Development ProgrammeBeyond income, beyond averages, beyond today: inequalities in human development in the 21st century. Human Development Report 2019.http://hdr.undp.org/sites/default/files/hdr2019.pdfDate: 2019Date accessed: November 22, 2020Google Scholar These effects therefore not only add to clinical burdens, but also take apart social cohesion, collective efficacy, and overall health and longevity. They are a collective trauma. They reflect a degree of loss, grief, polarisation, and damaged ways of life and suffering that require far more access to services to help individuals. But they also sap the collective will, civic morale, and prosocial soul of whole communities. Such a fragile and depleted social climate disables the civic muscle needed to navigate the urgent and relentless realities of the ongoing global ecological crisis, of which COVID-19 is an opening act.6Belkin G Leadership for the social climate.N Engl J Med. 2020; 382: 1975-1977Crossref PubMed Scopus (4) Google Scholar The implications of all this should open wide the narrow box into which mental health has been put by policy makers and the health system. An individual disease-centric paradigm has frozen action and limited understanding of the breadth of social life that fuels and relies on mental health. This needs to end. Now is the time for an overdue transformation of the purposes of mental health systems and policy to ones that put the reciprocal connections between mental health, the global climate and ecological emergency, and social determinants of racial and economic oppression and inequity, at the centre. Two things need to change to do this: first, mental health care itself, as it is currently constituted; and second, the absence in this transformation of active and coordinated participation and leadership from a vast array of stakeholders outside of the mental health field. Changing how mental health care works is important; specialised providers of mental health care can be at the forefront of this change through adopting the following. First, mental health and community wellbeing should be participatory, coalition-driven, hyperlocal work that permeates and engages all policies and the whole of society, and sees non-clinicians and non-specialists as experts in local needs and co-owners of healing practices. Second, the growing field of task-sharing (which refers to the adoption of skills and tools by non-specialists, lay people, and peers to do much of the work of care, prevention, and promotion) needs to be scaled up and mainstreamed.7Singla D et al.Psychological treatments for the world: lessons from low- and middle-income countries.Annu Rev Clin Psychol. 2017; 13: 149-181Crossref PubMed Scopus (382) Google Scholar In this way, specialist clinicians can be capacity-building partners and backup care providers for an array of other front-line workers. This framework, rather than the prevailing illness-driven specialist office-based model, should be the starting point for building systems and policy that finally acknowledge that most of the mental and emotional suffering on the planet is driven by social conditions and choices that are under our control to change. Third, these commitments should challenge old habits including: over medicalisation, specialist and illness focus, hierarchical knowledge and practice, and little attention or actionable capacity to deliver on promotion and prevention of, and resilience and attention to, social determinants. Finally, the new normal should also include: pervasive incorporation of an equity lens in all of our research, teaching, and care practices; necessary investments in cultural change, learning, and leadership to drive these changes; and a shift in resources to communities that have historically been discriminated against and historically colonised and impoverished nations. The prize is the wellbeing of all people. The mental health field faces an overdue reckoning that it can no longer dodge. The field has the chance to bring and reshape what it knows and does to be relevant to the task of maintaining humane and equitable steward communities. These actions should be integral to any serious effort at safeguarding population mental health and be part of the long-term COVID-19 response, meeting the UN Sustainable Development Goals, and facing up to our imperiled ecological future. This reimagining of how mental health fits within wider society is urgently needed and will require changes to what makes up the mental health system. Other stakeholders, users, community members, and sectors can lead and co-create this widened scope and purpose for mental health systems. Expanded ownership will only add value to, rather than detract from, the system's traditional focus on specialist care of illness. At the same time mental health professionals should be familiar with, and advocate for, broader social policies crucial to future population mental health, including pursuit of equity,8Black Thrive PartnershipBlack Thrive aims and outcomes.https://www.blackthrive.org.uk/black-thrive-outcomes/Date: 2020Date accessed: November 22, 2020Google Scholar income security,9Government of CanadaCanada Emergency Response Benefit (CERB): closed.https://www.canada.ca/en/services/benefits/ei/cerb-application.htmlDate: Jan 22, 2021Date accessed: November 15, 2020Google Scholar and budgeting that prioritises wellbeing.10Government of New ZealandThe wellbeing budget.https://www.treasury.govt.nz/sites/default/files/2019-05/b19-wellbeing-budget.pdfDate: May 30, 2019Date accessed: November 15, 2020Google Scholar It is possible to take charge of how emotional and mental wellbeing is mutually interdependent with its social, economic, and environmental drivers. Our urgent task and challenge is to step up and deliver the contributions that the mental health field can make in securing, with others, a sustainable, symbiotic path for the human future. In conclusion, although the COVID-19 pandemic has previewed deep obstacles for the global future, it has also shown the possibilities for people to come together in collective mobilisation, mutual aid, and solidarity, and the tangible linking together of mental health, illness, and suffering with the aims and paths of broader social progress and justice. There is much to build on. Let us begin. The signatories to this statement (listed in the appendix pp 1-2) urge this change to mental health and wellbeing's priority of place in the work of governments and communities. The global COVID-19 pandemic and ongoing ecological crises make this imperative. We urge others to join this work. We declare no competing interests. Download .pdf (.21 MB) Help with pdf files Supplementary appendix