The impact of COVID-19 on mental health: foundations for success in Taiwan

Introduction by Croakey: Mental health policy expert Dr Sebastian Rosenberg has been taking Croakey readers on a journey around the world to examine mental health issues and responses emerging in the coronavirus pandemic.

His latest takes us to Taiwan which has managed to control the coronavirus from the start, reporting far fewer cases of COVID-19 than many of its neighbours, due to early and effective detection and prevention work.

It should be noted, of course, that Taiwan is excluded from World Health Organization membership due to objections from China, which considers the island one of its provinces.

Reuters on Tuesday reported that Taiwan has been lobbying to attend, as an observer, this month’s meeting of the WHO’s decision-making body, the World Health Assembly (WHA), and says its exclusion has created a dangerous gap in the global fight against the coronavirus.

Sebastian Rosenberg writes:

This is a short report summarising the seventh in a series of e-presentations about the international impact of COVID-19 on mental health, jointly hosted by the Centre for Mental Health Research (CMHR) at the Australian National University and ConNetica Consulting as a community service to share expert knowledge during the pandemic.

There have been hundreds of participants across the webinar series, which has also been viewed/downloaded more than 1,300 times.

The presenter for this webinar was Chia-Yi (Jenny) Wu, RN, PhD, Associate Professor, School of Nursing, College of Medicine, National Taiwan University. She is currently the vice CEO of Taiwan Suicide Prevention Centre and Board Director of the Taiwan Society of Suicidology.

Taiwan’s appears to have been a success story in the control of COVID-19. While its population is similar to Australia with around 23 million, as at Tuesday it had reported only 438 cases and six deaths (versus Australia’s 6,825 cases and 95 deaths). 

What can we learn about pandemic management arising from the Taiwanese experience?

The webinar began with ConNetica Consulting’s John Mendoza highlighting those areas of the world with more significant problems associated with COVID-19 (see darker colours).

As the seasons change in both hemispheres, Mendoza characterised the situation as more akin to the end of the beginning rather than the beginning of the end. This situation meant communities needed to consider how best to remain flexible and vigilant into the future.

He quoted Rick Lesser and Martin Reeves, Boston Consulting Group, who said:

COVID-19 has made every organisation aware of the limits of its ability to learn quickly in an extremely fast-moving environment, in which ten days of hesitation can lead to the quadrupling of infections and to an escalation of business and societal disruption.”

Mental health in Taiwan

Associate Professor Wu began by stating that Taiwan has had almost 70 years of liberal democracy. Part of this evolution has been a commitment to a system of public health. 

Perhaps uniquely in Asia, Taiwan has universal access to public health services, from hospitals, community health centres, primary care clinics and outreach services. This array includes mental health services. Overall there are close to 800 mental health service centres across Taiwan.

Allied to this service infrastructure Taiwan is also able to deploy sophisticated data infrastructure. It tracks suicides and suicide attempts. It has a Central Epidemic Control Centre (CECC) that monitors and rapidly mobilises national policy for pandemics like COVID-19. 

Illustrative of the speed of its response was the Government’s announcement of Level 1 travel restrictions within a week of the first communications from China to the WHO on an atypical cluster of pneumonia cases. In addition, Taiwan has well-organised and resourced capacity for public health surveillance, including in mental health.

Lessons from experience

On top of this service and data infrastructure, Wu explained that Taiwan can also draw on the hard lessons of experience in relation to pandemic response. 

Much was learned from the earlier experiences with both SARS and H1N1, going further back to an enterovirus outbreak in 1998 that killed more than 400 people.

These experiences with serious public health crises, together with the infrastructure described above, meant that Taiwan was extremely well prepared to manage and respond to the challenge of COVID-19.

There were four key planks to the COVID-19 response:

• Planning and preparation
• Control, including control of physical elements (like borders) and controlling or managing stress, increasing coping and resilience
• Harm reduction – public health surveillance and ongoing access to public health services
• Treatment – eventually a vaccine.

Practically, the COVID-19 response in Taiwan rested on four key elements:

• Taking action as soon as it became clear it was needed – unlike in some other countries, there was no delay in putting in place a coordinated national action plan.
• Transparent and high-tech information dissemination – to keep the public informed with quality, accurate, timely information. Government videos were a regular, trusted source of information.
• Rapid mobilisation of hospital infection control (activated from 2 January), the use of smart technology to distribute masks and other resources and best practice infectious disease control across all health services.
• Active screening and investigation of suspected cases.

From a mental health perspective, Wu stated there were four particular issues of concern:

1. Case identification: fear of being diagnosed.
2. Isolation of suspected and diagnosed people with a mental illness – causing distress, anxiety, depression, insomnia, stigma etc.
3. Contact tracing/monitoring: stress/fear/panic of being monitored, life uncertainty – this affects the general public as well as people with mental illness.
4. The impact of quarantine policy: social isolated, feeling lonely, helpless, hopeless, depressed, and even suicidal.

Wu pointed out that while the negative mental health impacts of this kind of public health emergency had been documented, also noted were some positive impacts.

In Taiwan, previous experience with SARS for example had increased social and family supports, mental health awareness and lifestyle changes. These positive factors could be seen in Taiwan to ‘cushion’ the impact of COVID-19.

Taiwan’s response focuses on the use of multidisciplinary teams, clear communication, security of access to health services, including e-health care and regular screening. 

Wu stated that people with mental illness are regularly assessed as part of a psychosocial response to their situation and risk. There is free information and a national phone help line.

There is also a ‘mood thermometer’ which permits the simple self-monitoring of mood and feelings. This device is based on the five item Brief Symptom Rating Scale (BSRS) which is used nationally.

This survey has been turned into an app, permitting people in Taiwan to monitor their own mental health.

Interestingly, as part of this process, the Taiwan Ministry of Health and Welfare recommended that people limit their consumption of COVID-19-related news to 30 minutes per day. This can minimise feelings of concerns or despair and promote greater calm.

Taiwan is now helping other countries with their COVID-19 responses.

Dr Sebastian Rosenberg was a public servant for 16 years, working in health in state and federal governments. He was Deputy CEO of the Mental Health Council of Australia from 2005-2009. He is Head of the Mental Health Policy Unit at the Centre for Mental Health Research at ANU and holds a position as Senior Lecturer at the Brain and Mind Centre, University of Sydney.

The virtual meeting described above is one of a series of meetings that The Centre for Mental Health Researchat the Australian National University and ConNetica Consultingare jointly hosting with mental health leaders around the world to better understand responses to COVID-19.  A recording of the presentations and discussions is available here: https://rsph.anu.edu.au/research/centres-departments/centre-mental-health-research/past-events. 

See the previous articles in this series here (Italy), here (Spain), here (London), here (Denmark and the Nordic countries), and here (the WHO picture).