It has been about 2 years since the COVID-19 pandemic started, which continues to have broad-ranging global implications. The majority of research has been conducted in High-Income-Countries (HICs) despite the fact that 83% of people worldwide live in Low-and-Middle-Income Countries (LMICs) (as cited in Kola et al., 2021).
Covid-19 has only served to widen the already sizeable treatment gap in LMICs. Its impact on wellbeing (Gillard et al., 2021, Anjana Greedharee’s Mental Elf Blog) is clearly illustrated through lockdowns, allocation of resources to COVID care, difficulties making a living, and interruptions in education. Evidence suggests that neuropsychiatric or other medical conditions like diabetes increase one’s risk of developing COVID-19, with the latter growing more common in LMICs.
The critical nature of the ongoing situation is underscored by the fact that 100 million people have been projected to live in severe poverty because of a 5-8% reduction in global economic growth (Mahler et al., 2020). However, HICs can still learn a lot from the resourcefulness of LMICs under heavy financial constraints, with non-integrated healthcare systems, and minimal access to at-risk groups (Altiraifi & Rapfogel, 2020).
This blog examines a narrative review (Kola et al., 2021) which addressed the pandemic’s mental health impact on LMICs and the measures taken by countries to counter this. Furthermore, the authors discuss the findings as a step towards reshaping global mental health and make proposals for mental health system development in the years to come.
The authors conducted a search for peer-reviewed evidence written in English only using PubMed between the 1st of January to the 31st of July 2020 using specific search terms listed in their review.
Grey literature including reports from non-governmental organisations and the World Health Organisation were included, as were findings from search engines and leading informants. A large group of global researchers, including prominent global mental health specialists, evaluated the findings in multiple stages.
They summarised the review’s findings after engaging in discussion, narrowing down the most pertinent information for synthesis in recurring cycles of evaluation. LMICs were categorised according to 2019 World Bank Country and Lending Groups data.
The impacts of the COVID-19 pandemic on mental health
Kola et al., (2021) remind us that people are to an extent having normal reactions to extremely challenging circumstances. Health care workers and other frontline workers have been struggling more so with their wellbeing (see also Greene et al, 2021; Mental Elf Blog by Will Kapurura). Government responses, misinformation, and uncertainty around COVID-19 have affected mental wellbeing.
Social determinants, such as economic, demographic, neighbourhood and sociocultural factors, have contributed significantly to mental health issues in LMICs. The mortality rate and severity of COVID-19 are higher in elderly people (see also Giebel et al., 2021; Mental Elf Blog by Catherine Talbot), which can be further exacerbated by existing health issues, loneliness, or access to healthcare. Other vulnerable groups include people with disabilities (see also Kavanagh et al,, 2021; Mental Elf Blog by Jill Manthorpe), or in prisons and psychiatric hospitals.
In the long run, the pandemic is potentially laying the grounds for increased suicide rates because of factors including financial issues, unemployment, isolation, less community support and difficulty accessing mental health support. Substance use disorder is likely to be another source of higher mortality rates due to socioeconomic issues, such as the recession. School closures have been detrimental to children from underserved backgrounds, as this is often where they develop their socio-emotional skills, build support networks, avoid difficult home situations, and get food to eat, among other things.
Response to mental health needs
Briefings have been published at a population level, but these often use approaches to addressing disasters that were developed prior to the COVID-19 pandemic. National action plans were released by countries such as India and South Africa, and self-help guides were created by the WHO. Detection systems have been created to pinpoint individuals at risk of mental health issues through the phone, in-person, and using artificial intelligence.
Fewer people have been accessing psychiatric services because of concerns related to COVID-19 infection, while many services have been interrupted, and people with neuropsychiatric conditions have been neglected due to the emphasis on COVID-19. Sometimes measures such as halting alcohol sales have been taken, but this has other repercussions like forced withdrawal.
Fortunately, some services have been carried out remotely including the provision of providing psychological first aid to healthcare workers and task sharing/shifting to increase access to mental health and psychosocial support (MHPSS) by equipping non-specialists with the skills to do so.
COVID-19 is projected to increase premature mortality, lead to stunted economic growth, cause social breakdown, and to further worsen wellbeing. Kola et al., (2021) propose that this is a monumental chance for fostering change and improving our response to world-shaking events, such as pandemics.
The authors emphasise the importance of considering diversity in experiences, enhancing mental health funding, and extending to social determinants outside the biomedical model. The right approach to improving mental healthcare would work towards breaking the stigma, moving mental health up the list of priorities, and establishing that mental health issues are more common than people think.
Strengths and limitations
The authors were from across the world, suggesting that the findings were not dictated by Western, Educated, Industrialised, Rich, Democratised (WEIRD) perspectives. The review was comprehensive as it synthesised varied sources of evidence, but a future review post-pandemic would be pertinent. Since LMICs have limited research and resources, this narrative review methodology might have been a logical choice at the time the paper was written, as evidence was still growing.
However, the lack of detailed information on the review’s methodology could prevent researchers from replicating findings, which is important given the movement towards Open Science and establishing generalisability. Additionally, the reasons papers were included or excluded weren’t outlined. In contrast, systematic reviews tend to be more objective and can be evaluated for quality using frameworks like PRISMA. To enhance the rigour of narrative reviews, the use of tools like SANRA (Baethge et al., 2019) – a Scale for the Assessment of Narrative Review Articles – might be apt. It would have been helpful if the authors created a summary of takeaways from this narrative review, delineating a clear call to action.
Concerning the search terms, these reflect more commonly known neuropsychiatric conditions which means that issues less well-known in LMICs – such as those related to personality or dissociation – weren’t examined. Surprisingly, there was no mention of obsessive-compulsive disorder (OCD). Though there are stereotypes of OCD that portray it as solely excessive hand-washing or cleanliness, it’s likely that people with OCD were affected in unique ways by the pandemic. Hence, they should be a group of interest in such a review. Perhaps the choice of search terms was limited to those which are more commonly used in LMICs, but nevertheless, this is an important consideration. I speak as a loved one of a person with OCD.
Implications for practice
There is insufficient evidence as the pandemic is ongoing and there aren’t enough resources to investigate the efficacy of mental health programmes in LMICs. LMICs should be contributing to decisions about research priorities rather than solely HIC funders or researchers. We should not treat these countries as “data collection sites” because HICs can learn a lot from LMICs with interventions such as the friendship bench being a great example. As mentioned in an article by the United Nations Department of Economic and Social Affairs, “No one is safe, until everyone is safe”. HICs and LMICs need to unite so that we can get through this pandemic.
A more recent update by Mahler et al., (2021) indicates that though rates of poverty are set to decrease in comparison to 2020, the situation in low-income countries will continue to steeply decline because of COVID-19. Whereas HICs are set to bounce back better than projected this year, the situation in countries which were impoverished prior to the pandemic will only worsen. This doesn’t mean HICs should get complacent because the situation is ever-changing, as illustrated by the introduction of the Omicron variant. We need to find better ways to define what a “successful” response to COVID-19 entails as some countries have fewer resources.
Interventions and policies which consider syndemic theory – “local sociocultural, economic, and political conditions contribute to patterns of multimorbidity, and that settings without the same contextual features will not share these multimorbidity patterns” (Kola et al., 2021) – will play a fundamental part in improving mental health by addressing socio-cultural and economic determinants, such as inequality. Recognising the relationship between mental and physical health in each socioeconomic context will lead to more effective interventions. (Misra et al., 2019; Mental Elf blog by Tessa Roberts).
Kola et al., (2021) state that it is vital to acknowledge the overall gap in care, the role of local leadership plus the community, the need for other sectors to work in tandem with healthcare, and the general need for awareness about mental health. To achieve this “framework shift”, they recommend considering “context (i.e., where), stakeholders (i.e., who), and sectors (i.e., what)”. LMICs need to continue developing their healthcare services, and HICs can support them through funding or resources.
The disability rights movement slogan “Nothing about us, Without us” (Charlton, 2000) captures the need for participatory action from people with lived experiences in LMICs and HICs alike. Moreover, supporting community stakeholders (families, health workers, traditional healers) to get involved might be particularly important, as they can help with mental health issues and also “effective infectious disease control” (Kola et al., 2021).
Emotional first aid training will help contact tracers to work more efficiently by building trust. The International Federation of the Red Cross and Red Crescent Societies (IFRC) outlines a “five-pillar response for effective disease control” (Kola et al., 2021): community engagement, monitoring, and contact tracing, handling cases and interventions, ensuring both respectful and hygienic funerals, and mental health and psychosocial support (MHPSS). This might be useful for the UK’s National Health Service (NHS) to consider moving forward in their response to the population’s mental health needs.
Statement of interests
Kola, L., Kohrt, B. A., Hanlon, C., Naslund, J. A., Sikander, S., Balaji, M., Benjet, C., Cheung, E. Y. L., Eaton, J., Gonsalves, P., Hailemariam, M., Luitel, N. P., Machado, D. B., Misganaw, E., Omigbodun, O., Roberts, T., Salisbury, T. T., Shidhaye, R., Sunkel, C., … Patel, V. (2021). COVID-19 mental health impact and responses in low-income and middle-income countries: Reimagining global mental health. The Lancet Psychiatry, 8(6), 535–550. https://doi.org/10.1016/S2215-0366(21)00025-0
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