COVID-19 and global mental health – Authors' reply
Authors: Lola Kola, Eliza Yee Lai Cheung, Julian Eaton, Charlotte Hanlon, Brandon A Kohrt
Journal: The Lancet Psychiatry (2021)

We appreciate the insightful responses to our position paper on global mental health and COVID-19. We note the consensus that the COVID-19 pandemic is an opportunity to strengthen mental health care globally, and particularly that the emergence of a global pandemic has highlighted the value of learning from countries with experience in regularly responding to such outbreaks and other emergencies. The examples given of lessons in mental health and psychosocial support that can be applied in the USA are very well observed. It is worth noting that diversity and inequity within countries is often greater than between countries, so that the categorisation of countries as high-income versus low-income is often artificial and potentially misleading. A greater openness to mutual and reciprocal learning challenges the historical arrogance of assuming that knowledge and expertise should only flow from high-income countries (HICs) to low-income and middle-income countries (LMICs) and represents a good return on Official Development Assistance investment; therefore highlighting the importance of maintaining the political will for these investments. The integration of mental health has been a key pillar of COVID-19 recovery responses in many countries with previous experiences of humanitarian disasters, with recognition and formal support coming later in HICs. The key solution now is to provide the evidence for what to do in practice and to garner worldwide support to make implementation a reality. This is exactly where learning from all parts of the world can, and must, have a role. As noted in our position paper,1Kola L Kohrt BA Hanlon C et al.COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health.Lancet Psychiatry. 2021; 8: 535-550Summary Full Text Full Text PDF PubMed Scopus (396) Google Scholar it is important that partnerships between mental health researchers in HICs and LMICs are based on equity. We also agree that a crucial yet practical means of achieving this is to create pathway opportunities for capacity building among researchers in LMICs. We are aware that technology use for care delivery could lead to the exclusion of some populations in need. Our argument for the use of digital interventions in mental health care is not to undermine the importance of face-to-face care, but to also highlight the need to take advantage of the progress made in digital health to remodel the delivery of mental health services. The flexibility introduced by digital options has the potential to foster more person-centred care by connecting people with shared experiences beyond the limitations of geography. The novel solutions to mental health care delivery through the use of digital technology in a time of untenable crisis, especially in the first 2 months of the COVID-19 pandemic, is an illustration of the therapeutic roles technology can have in scaling up care in some settings.2Ben-Zeev D The digital mental health genie is out of the bottle.Psychiatr Serv. 2020; 71: 1212-1213Crossref PubMed Scopus (47) Google Scholar Although not replacing face-to-face care, these developments have reinforced that in-person models of care alone are inadequate for increasing coverage. We recognise the efforts of the Partners in Health programme in rural Mexico. There are other examples of task-shared interventions for common mental health disorders implemented by stand-alone programmes that seek to integrate access to mental health care with social support and economic interventions.3The Mental Health Innovation NetworkResources for mental health and psychosocial support during the COVID-19 pandemic.https://www.mhinnovation.net/collaborations/resources-mental-health-and-psychosocial-support-during-covid-19-pandemicDate accessed: April 4, 2021Google Scholar With our reimagining, we are proposing that the needs, priorities, and preferences of people with lived experience of mental health conditions and the communities within which they live should be the starting point for service reform. One result of this might be to shift the focus from individualised psychological approaches to distress to a primary emphasis on economic support and livelihoods or spiritual health or addressing gender-based violence, within which mental health interventions could be embedded. LK receives support from the US National Institute of Health (1K43TW011046), the UK Medical research Council (MR/S001255 and MR/P025927), and the US Council for Advancement in Global Mental Health. JE receives support from the Foreign, Commonwealth and Development Office through a SUCCEED grant (EPPHZT74) using UK aid from the UK Government. The views expressed in this Correspondence are those of the authors and not necessarily those of the Foreign, Commonwealth and Development Office. CH receives support from the National Institute of Health Research (NIHR) RIGHT grant (NIHR200842) and through the NIHR Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa, King's College London (GHRU 16/136/54) using UK aid from the UK Government. The views expressed in this Correspondence are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. CH also receives support from the African Mental Health Research Initiative as part of the DELTAS Africa Initiative (DEL-15-01). BAK receives support from the US National Institute of Mental Health (R01MH120649) and UNICEF with funding from USAID. EYLC declares no competing interests. COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental healthMost of the global population live in low-income and middle-income countries (LMICs), which have historically received a small fraction of global resources for mental health. The COVID-19 pandemic has spread rapidly in many of these countries. This Review examines the mental health implications of the COVID-19 pandemic in LMICs in four parts. First, we review the emerging literature on the impact of the pandemic on mental health, which shows high rates of psychological distress and early warning signs of an increase in mental health disorders. Full-Text PDF COVID-19 and global mental healthIn The Lancet Psychiatry, my colleagues and I describe the mental health services and supports mobilised in the initial months of the COVID-19 pandemic in low-income and middle-income countries (LMICs).1 In our Review, we describe how humanitarian organisations with expertise in mental health began issuing guidelines in February, 2020, to manage the pandemic's effects on mental health, and many LMICs integrated this guidance into national response plans for mental health. The Review documents widespread innovation in LMICs to increase mental illness detection and maintain treatment during lockdowns. Full-Text PDF COVID-19 and global mental healthIn The Lancet Psychiatry, Lola Kola and colleagues1 suggested three dimensions that could change the way global mental health is framed to achieve equitable mental health coverage worldwide: context, stakeholders, and sectors. Here we share one of our interventions as an example of how these dimensions should be addressed. Our organisation, Partners in Health Mexico (Compañeros En Salud), has been working for 10 years in the rural Sierra and Fraylesca regions of Chiapas, Mexico. Chiapas has severe socioeconomic adversity, with 77% of the population living in poverty. Full-Text PDF COVID-19 and global mental healthWe are inspired by the optimistic tone of the comprehensive Review by Lola Kola and colleagues1 of mental health initiatives in low-income and middle-income countries (LMICs) during the COVID-19 pandemic. However, reading the paper from the point of view of Latin America and the Caribbean (LAC), we are not as optimistic as the authors, for three reasons. LAC has been deeply affected by the pandemic,2 even more than other LMICs; the region has structural inequities and a high prevalence of informal work;3 some countries in LAC already faced challenges to the implementation of mental health care reform before the pandemic. Full-Text PDF COVID-19 and global mental healthWe welcome the review in The Lancet Psychiatry by Lola Kola and colleagues1 on COVID-19 and mental health in low-income and middle-income countries (LMICs). Our view is that this could have gone further to call on universities in high-income countries (HICs), and academics working within them, to make changes to improve equity with universities and academics in LMICs. Given that universities in HICs hold disproportionate power and funding, we propose that a fundamental shift is needed. Imbalances in power and privileges are seen right across global health, with one study finding that 80% of leaders of global organisations active in health were citizens of HICs, 90% were educated in HICs, and 70% were men. Full-Text PDF