Two Years Later: Reflections on COVID-19 and Mental Health

Dr. Giuseppe (Bepi) Raviola, co-director of mental health at Partners In Health, writes this reflection as the world settles into a third year of the COVID-19 pandemic, in which at least 500 million people have tested positive and 6.2 million have died from the virus, vaccines remain inequitably distributed, and access to treatment is scarce globally.

May is Mental Health Awareness Month, a time when we at Partners In Health emphasize the need to support our friends, family members, neighbors, and colleagues who live with mental illness in its many forms. In 2022 not only are mental disorders among the leading causes of disability globally, but COVID-19 and associated stressors over the past two years have increased this burden, particularly depression, anxiety and stress-related conditions. People living with pre-existing mental disorders are also at greater risk of severe illness and death from COVID-19. Before COVID-19 only a minority of people with mental health problems received treatment. Now it has become an even greater challenge to find clinical care, if it is needed.

Each year millions of Americans face the reality of living with a mental illness, and this year the National Alliance on Mental Illness will focus on advocacy for a better mental health system in the United States. While in the U.S. there are approximately 42,000 psychiatrists, a recent study noted that upwards of 40% of Americans who had attempted suicide were not receiving services. Despite significant resources, the political commitment to mental health systems reform is inadequate.

The situation in the U.S. remains one of fragmented, expensive, piecemeal services that are not integrated into a “system of care.”

The situation of mental health in the U.S. is not one that any provider can resolve without a broader public health approach to embedding mental health support within all sectors of society. Given the challenges to mental health associated with rapid social change, economic insecurity, health inequity, climate change, migration, addictions, and global geopolitical insecurity, we should increasingly prioritize the building of a resilient social climate by integrating mental health practices through task sharing. This is a practice that Partners In Health revolutionized for TB and HIV care, for example, in which trained community health workers provide patients basic mental health assessments and refer them to specialized care, when necessary. Accepting the unique stresses of the current moment and coming times, a mental health in all policies approach—moving mental health out of the clinical world into our everyday lives—should become our national public health priority, hand-in-hand with the development of comprehensive, collaborative, community-based approaches to care.

Model for Mental Health Care

How does PIH raise awareness regarding mental health? First and foremost, we’ve concentrated on building systems to take care of people—one person at a time—living with complex mental health conditions. By complex we mean conditions that are severe, and that co-occur with other mental health conditions (for example depression, anxiety, and addiction), or with medical conditions, and which also occur in contexts of great challenge, such as poverty. As there are no formal mental health services available to people in most of the world, we’ve built our programs to foster the development of the “staff, stuff, space, systems, and social support” needed to increase access to mental health care for all of the people we serve.

We’ve done this by putting into practice a model that emphasizes care delivered by community health workers during home visits, yet it does so with these providers as one component of functional, sustained system of mental health care delivery that strengthens the health system as a whole, from district hospitals to primary care clinics to community-based care, and sometimes even national psychiatric hospitals. Community health workers operate in extremely challenging conditions, and to expect a mental health system to depend on them completely would be a serious disservice to them. This means that there is a need to strengthen all levels of care systems, including primary care systems with nurses and physicians, and hospital systems as well, to support the management of more severe illness.

In Haiti and Rwanda each, over more than 12 years, we’ve developed systems of care that could be useful in the U.S. context as well. These models have sought to develop coordinated care for both severe mental disorders (psychotic illness) and common mental disorders (depression, anxiety, and stress-related conditions), care delivered both at health centers (that is, delivered by nurses and physicians) and in communities by community health workers, as well as care that ensures availability of pharmacologic and psychological treatments, psychosocial support, and social support.

Across PIH sites we’ve used crises and disasters as opportunities to strengthen systems, for example in our cross-site response and in our Peru response to COVID-19. This work has most fundamentally been based in solidarity with people living with illness—one person at a time— and with our peers delivering needed care in very difficult conditions. This work is done across 12 countries, in collaboration with governments, through a functional cross-site learning collaborative that expands access to care, improves the quality of services, and pilots implementation strategies to strengthen mental health services provided to their communities. PIH now works as a lead partner to at least five government ministries of health in supporting implementation of their national mental health plans. The work is multinational and multidisciplinary.

In the U.S. we also responded to COVID-19, leading the mental health component of the Massachusetts Community Tracing Collaborative, and took the opportunity to build a staff wellness program for the organization. We are now also applying our learning and practice in collaboration with the Family Van, a mobile wellness unit increasing access to health care in Boston. Through this work we seek to show what is possible.

Dr. Paul Farmer's Impact

In facilitating our work, building platforms, articulating theories, and providing moral support and friendship, Dr. Paul Farmer opened up new worlds in health care delivery, including in mental health. In a piece in the journal Science on Paul’s radical intellectual vision, Matt Bonds, an associate professor of Global Health and Social Medicine at Harvard Medical School and co-founder of PIVOT—a PIH partner in Madagascar, writes about Paul as a fearless, complex systems thinker, “not reductionistic, but constructive, integrative, and radically inclusive. He planted seeds and trees…What he created is nothing less than the modern global health movement. ‘Don’t fetishize your model,’ he would often say. ‘Be the house of yes.’” This effectively captures the inspiration that he provided for us in being bold in our aspirations for building comprehensive mental health systems. To build models, but hopefully not lose our hearts in the process. While he and other colleagues provided us with blueprints for effective global health delivery, which for example we adapted into a set of practices to guide systems building in mental health care, he most importantly provided us with moral clarity and an unrelenting commitment to go the extra mile, every day. This is exemplified in the mental health work at each PIH site.

PIH’s work in mental health is grounded in Paul’s concept of accompaniment and social support for the most vulnerable.

In his new book, Healing: Our Path from Mental Illness to Mental Health, the former director of the National Institutes of Mental Health, Dr. Tom Insel, credits Paul’s idea of accompaniment and describes how he applied it to mental health. He writes: “’To accompany someone is…to break bread together, to be present on a journey with a beginning and an end. There’s an element of openness, of mystery, of trust, in accompaniment.’ Farmer argues that accompaniment or social connection cannot only lead to recovery, it is essential for recovery. That is why I have come to think of mental illness as a medical problem that requires a social solution.” This speaks to the spirit of our work and its applicability of mental health care delivery across low- and high-income countries.

Grief in the Time of COVID-19

What have I learned from the past few years? At the outset of the COVID-19 crisis, I wrote about steps that we could take to manage the emotional challenges of social distancing. I ended by noting that, should anything positive come from this tragic situation, it’s that we will all understand our interconnectivity, the importance of being present for those we love, and the necessity of caring for the most vulnerable in our communities — wherever that may be. Today I can add that the past few years have brought a grief, individual and societal, to which we each must try to attend, so as to enhance our capacities for love, support, and compassion. These are very personal journeys. It is this kind of internal work that will strengthen our individual and collective mental health as we move forward, being able to be present for others, and to also bear witness, see and transcend the world as it is, in its suffering, and in all its beauty.

Dr. Giuseppe (Bepi) Raviola, MD, MPH, is the co-director of mental health at Partners In Health with Dr. Stephanie Smith, MD. He is also an assistant professor of psychiatry, global health and social medicine at Massachusetts General Hospital and Harvard Medical School. In 2021-22 he was named an Outstanding Psychiatrist in the Commonwealth of Massachusetts by the Massachusetts Psychiatric Society, a Distinguished Fellow of the American Psychiatric Association, and was a recipient of the Bruno Lima Award of the American Psychiatric Association for outstanding contributions in the care and understanding of victims of disasters.