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The WHO perspective on mental health amid a psychiatric unit COVID19 outbreak in Melbourne

Introduction by Croakey: Victorian health authorities announced on Friday they were investigating a novel coronavirus outbreak at a private inpatient psychiatric facility, with 14 known cases linked to the outbreak: five patients, five staff and four household members.

Chief Health Officer Professor Brett Sutton said the first case had been diagnosed in late March, but this week  “additional patients turned up positive”.
 
In response, there has been a significant shutdown of activities at the facility, with testing of all staff and patients, active surveillance and contact tracing, precautionary quarantine, and directives for no transfers out, no new inpatients, and no group therapy, plus relevant cleaning and contamination processes underway.
 
Asked about the level of risk, Sutton said there would be more chronic illness in such a facility than in other settings, but he warned that the lessons from two regional hospitals in North West Tasmania and the Newmarch aged care facility in western Sydney are that “all close settings have that explosive outbreak potential”.
 
The outbreak underscores some of the risks in this pandemic for people with mental health issues, which are being explored at Croakey in a series of articles on issues and responses around the world by mental health policy expert Dr Sebastian Rosenberg.

In his latest article, he reports on the key mental health issues arising for the World Health Organization, including the role and impact of stigma and issues for health professionals who – as this Melbourne outbreak also shows – are one of a number of identified ‘at risk’ groups.


Sebastian Rosenberg writes:

This is a short report summarising the fifth 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. 

Dévora Kestel is a senior mental health policy specialist with more than 25 years of international experience in Europe, the Caribbean and Latin America, implementing and advising governments on national policies related to mental health systems. She is a strong advocate for the rights of people with mental health issues.

Since 2019, Kestel (right) has been the WHO Director of the Department of Mental Health and Substance Use.

Kestel is based in Geneva at the WHO and, just before the webinar began, shared feedback that COVID-19 had been a significant health issue within Switzerland and that, like in many other countries, the effect had varied considerably from region to region.

WHO’s key issues

Kestel began by outlining the key issues for mental health arising from COVID-19. In doing so it was noteworthy that her perspective focused more broadly than the health issues to also consider psychosocial issues. These are clearly a central element of the WHO’s rationale that ‘there is no health without mental health’.

For some time the WHO has noted that adversity is risk factor for both short- and long-term mental health problems.

COVID-19 causes uncertainty and anxiety for the whole community while exacerbating pre-existing mental health conditions. There is stigma for those testing positive.  Extreme psychological stress makes it difficult to comply with public health guidance. 

Concern about these issues underpinned the WHO’s interest in shifting the public discourse from social to ‘physical distancing’.

Kestel listed several issues as COVID-19’s key impacts on mental health:

  • Distancing weakens social support systems.
  • Enforced separation from friends and loved ones is difficult but particularly at times of funerals, grief, separation or missed ceremonies and celebrations. People in these situations can feel additional psychological stress.
  • There is clearly the economic impact – unemployment, bankruptcy, social dislocation, alcohol-related problems.
  • Increased concern for family safety and domestic violence.

These issues can affect anyone. But Kestel noted groups at particular risk from COVID-19 and its associated mental health impact, including:

  • Older people suffering isolation, or their carers.
  • People with disabilities, including people with existing mental health and chronic conditions.
  • Residents in group or aged care accommodation.
  • Refugees and people on the move. This group can find it difficult to access health care and already face stigma and discrimination.

Kestel also pointed that another key ‘at risk’ group are frontline health workers, often dealing with continual stress, their own or their colleagues. 

The WHO was aware of increased risk of suicidality among workers and the stigma associated with working with COVID-19 patients. 

She noted that while authorities had acknowledged the need for training of frontline workers in the use of Personal Protective Equipment (PPE) and associated safety strategies, there had been not been corresponding concern to provide training to help these workers manage the mental health stress associated with their work.

The WHO response

Kestel explained the WHO Response to the webinar.

The foundation of the WHO response is to generate easy access to factual information.  Kestel gave several examples:

  1. The WHO has prepared a resource exploring the mental health and psychosocial aspects of COVID-19. This paper has now been translated into 30 languages.The considerations presented in this document have been developed by the WHO Department of Mental Health and Substance Use as a series of messages that can be used in communications to support mental and psychosocial well-being in different target groups during the outbreak.The document is available here.
  2. My Hero is You – A new fictional book developed by and for children aims to help families understand and cope with COVID-19. This resource was developed by UNICEF and has now been translated into 90 languages.  It is available here.
  3. WHO is documenting best practice stories about responding to mental health during COVID-19 and using social and other media to disseminate.

WHO is also driving coordination across agencies in order to better respond to the needs of vulnerable groups and communities, including in relation to disabilities, human rights and health care.

These activities fit into the WHO’s concern to better orient each nation’s COVID-19 response towards psychosocial issues. Kestel made the point that this was clearly easier in some places than others.  Many developed nations had moved to online resources and services, not possible in less developed countries. 

Still a journey to recovery

Kestel stated that from WHO’s perspective, the acute phase of the COVID-19 pandemic remained too acute to shift thinking towards recovery. 

She noted that most nations went into this crisis facing a significant treatment gap, where the demand for organised mental health care far outstripped the supply.

Realistically, COVID-19 meant this gap was likely to become wider, with both existing and new clients needing more help. In this context, she stated that old models of service and care are unlikely to be fit for purpose.

And while developed nations may be moving online, developing nations are also innovating, thinking about better ways to deliver effective treatments to more people. Kestel referred here to the Zimbabwean initiative training grandmothers to provide Cognitive Behaviour Therapy.

While this may seem unbelievable, I was told the same thing by a mother in Belconnen in the ACT. Unable to get her two family members into a Dialectical Behavioural Therapy service, she studied to become a practitioner herself. 

COVID-19 has laid bare the challenge the mental health treatment gap poses for all nations.

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 Research at the Australian National University and ConNetica Consulting are 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), and here (Denmark and the Nordic countries).

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