How to resolve the dilemma between the high prevalence of mental health needs and the low acceptability of mental health care? In order to overcome these challenges, the authors propose the following reflections and strategies so as to raise mental health awareness of the whole society, to improve the structure and mechanism of mental health responses towards public emergencies and disasters, and to maximise the effectiveness of current mental health support work.
The “universality” of mental health support during public health emergencies
Since public health emergencies like SARS and COVID-19 epidemic affect every citizen, the “universality” of mental health support should involve every sector of society. From the beginning of the outbreak, mental health professionals in China have actively taken up the role of mental health education, training and intervention, as well as the management of mental disorders related to COVID-19. This has contributed to preventing and minimizing adverse psychological consequences during the epidemic. However, such work is still regarded as activities within the premise of mental health care. The concepts of ‘no health without mental health’ and ‘parity of physical and mental health care’ are far from being well embraced in China. Therefore, in order to improve accessibility, acceptability, and effectiveness in addressing people’s mental health needs, it is important to include mental health support as an integral part in every aspect of infection outbreak prevention and control work, from political decision-making bodies to mass media, from patients to the general public, from public health promotion to all branches of medicine, and from a nation to the whole world.
Firstly, fighting with the “infodemic” requires the joint effort of the whole society [36, 37]. Inconsistent or ambiguous information, and over-exposure to adverse news can trigger widespread panic and anxiety in the public as well as undermine the confidence of front-line workers [38,39,40,41]. As such, the government and social media should work together to ensure that information released to the public is appropriate, scientific, authoritative and practical. Besides, the authorities and health professionals should clarify misconceptions and dispel myths in time, and recommend appropriate coping strategies in face of the infodemics. The legislative bodies should impose penalties on those who spread rumours that significantly cause significant disruptions in society [42]. The public should be educated to seek reliable information from authoritative channels and to remain calm and clear-minded about the massive influx of conflicting information. This will hopefully reduce the sense of confusion and loss, as well as adverse psychological stress caused by the ‘infodemic’ [36, 37, 43].
Secondly, mental health support should be integrated into the daily life of the general public. As the online mental health services have spatial limitations and may not provide sufficient support, psychosocial support (i.e., community resources and primary care settings) should be well-coordinated and actively provide services in the communities. The residents can strengthen social support in their communities by helping and encouraging each other during the epidemic. Tailored practical tips to help specific populations to build up mental health resilience should be shared online and disseminated as widely as possible. TV and radio programs could broadcast mental health related tips and skills at a fixed time every day, such as breathing and muscle relaxation exercises, body scan and mindfulness exercises. Only by integrating the knowledge and skills of mental health care into everyone’s daily life can mental health resilience be built up to alleviate the stress caused by the epidemic and prevent subsequent mental health problems.
Thirdly, mental health support should be integrated as part of all different medical specialties. Studies have shown that good clinical care, such as empathic listening to patients’ concerns, clear explanation of treatment plans and provision of emotional support, not only reduces the occurrence of adverse psychological consequences in patients’ and carers’ [44,45,46], but also prevents clinicians from burnout [47]. Therefore, mental health curriculum such as enhancing empathy and communication skills should be structurally embedded in health professionals’ training programs. Besides, mental health professionals should be included as members of multidisciplinary teams caring for different physical health needs, so that the mental health needs of both patients and care staff can be addressed in time. In addition, through collegial collaboration, mental health care could be embedded in the standard care packages of all healthcare workers, so as to enhance the acceptability and accessibility of mental health intervention. For example, if a patient receives psychological support from his or her long-term and trusted healthcare providers, the outcome may be far better than that provided by an unfamiliar psychotherapist. Only by integrating mental health care into daily medical care can the accessibility and acceptability of mental health support for patients and healthcare workers be continually improved.
Fourthly, a joint effort to establish international collaboration is needed to address the mental health challenges caused by global public health emergencies such as the COVID-19 pandemic. It includes sharing one’s own healthcare experiences among different nations and institutions, providing updates to enrich the psychological crisis intervention guidelines prepared by the World Health Organization, providing mental health training and education specific for COVID-19 by member countries with relatively more clinical expertise to those members deprived of mental health capacities through international professional associations like World Psychiatric Association, and conducting large-scale international epidemiological surveys.
The “timeliness” of mental health support for public health emergencies
The timeliness of mental health support for public health emergencies needs appropriate strategies during prevention and preparedness, response, and recovery (PPRR). After the unexpected SARS outbreak in 2003–2004, the Chinese Central Government formulated and eventually published the national preparedness plan for public health emergencies in 2006 [48]. However, the preparedness plan did not include specific details about what and how mental health and psychosocial services should be organised and delivered. In 2013, the China’s National Mental Health Law proposed that the emergency response plans formulated by the national or provincial government should include mental health support [49]. The mental health law puts forward the mechanism of mental health support in response to public emergencies (i.e., central organization by the government and coordination between multiple departments). It also emphasizes that mental health education for the public should permeate schools, families, workplaces and the community. In August 2019, a few months just before the outbreak, a special team under the China’s Association for Disaster and Emergency Rescue Medicine (CADERM) was established — the mental health rescue team [50]. The rescue team recruited mental health experts experienced in psychological intervention for public emergencies all over the country and aimed to develop comprehensive preparedness plans for different kinds of disasters. Unfortunately, the preparedness plan of mental health in response to a large-scale epidemic has not been fully established by the time of the infectious outbreak [51]. Besides, there is still a severe shortage of mental health professionals to provide support for public emergency events in China [29]. With the lessons learned from the COVID-19 epidemic, a more comprehensive mental health support system in response to different emergency events needs to be established in China. Relevant national guidelines and specific mental health training programs for coping with natural and man-made disasters should be provided for health professionals, policymakers, social workers, community volunteers and mass media. As each region might have different levels of resources and resilience for emergency events, every provincial-level and town-level region in China should develop a practical preparedness plan for emergencies under the national guideline. Psychological intervention teams for emergency events should be established according to the mental health needs of regions. With different stakeholders being equipped with the knowledge and skills about mental health emergencies, different departments can then work together as a team to provide comprehensive mental health support in response to emergencies. At the same time, general public education on enhancing mental health literacy and mental health resilience should be carried out routinely. With a more specific preparedness plan established before a disaster, a more comprehensive, well-coordinated and timely response can then be promulgated at an early stage of an emergency. All these efforts will improve accessibility, acceptability and effectiveness of mental health support at the time of any outbreak.
During the response period, the mental health support system should be established timely based on the preparedness plan, with each stakeholder having a detailed work plan and a clear reporting and governance structure. In particular, for mental health professionals, each local psychological crisis intervention centre should come up with an emergency plan for the deployment of different psychological crisis intervention teams, so that resource-constrained areas can still have access to mental health services. In addition, structured supervision and evaluation system should be established in place to ensure the quality of mental health services. Regular clinical experience sharing and exchanges between different intervention teams are needed for enriching and enhancing clinical knowledge and skills accumulated from clinical work in different cities, as well as increasing sense of cohesion among the teams. Given the geographical, ethnic and religious diversities in China, mental health professionals working in different provinces should have been trained with relevant cultural mental health competencies. With culturally relevant mental health interventions being available in some cities, the acceptability of mental health care will then be greatly enhanced.
In the aftermath of an epidemic, most mental health support teams will evacuate from the front-line clinical teams. Yet it is expected that mental health problems may become more prominent after the end of the epidemic, especially in worst-affected areas (i.e., Wuhan and Hubei Province in this COVID-19 epidemic). Grief and bereavement, post-traumatic stress disorders, anxiety disorders, and depression are common mental health problems associated with disasters. From the perspective of psychiatry, more attention and effort are needed in support of mental health after the epidemic than during the epidemic. Coping with mental health need challenges after the disaster should never be underestimated.
The “scientific rigour” of mental health support during public health emergencies
Mental health support includes acute psychological stress relief work, psychological crisis intervention, and the acute and long-term management of mental disorders. Specifically, mental health resilience is essential for preventing and recovery from mental health problems. It is important for the public to learn self-help techniques for reducing mental distress during the pandemic. The general public should be entitled to receiving authoritative and scientific health information for protecting self and others, maintaining a healthy lifestyle and learning ways of positive thinking to tide over challenging times. If these self-help strategies cannot alleviate psychological distress, people should consider seeking further evidence-based psychological interventions.
The goal of crisis intervention is to minimise negative emotions and restore daily functioning. For mild psychological distress, psychological intervention serves to alleviate excessive negative emotions. For more severe mental distress, psychological crisis intervention aims at preventing further deterioration and facilitates further referral to professional psychiatric services. In order to provide evidence-based and effective crisis intervention during such mental health emergencies, the authors have the following recommendations. First, timely and accurate mental health assessment should be provided. Psychological stress needs to be proactively assessed in the most affected populations, as well as other at-risk groups as appropriate. Second, alleviation of distressing negative emotions should take precedence over challenging negative cognitions, as crisis intervention is time-limited and should focus on prompt relief of the most distressing aspects of presenting mental health problems. As such, evidence-based and easily learned emotion management techniques like muscle relaxation, breathing techniques, creating personal safe spaces and self-compassion, and emotional first-aid kits should be taught. These are short-term strategies which, if clinically indicated, should be followed by additional evidence-based cognitive-behavioural strategies like exposure therapy or imagery rescripting for post-traumatic stress disorders delivered by the next tier of expert mental health professionals. Third, at a later stage of the epidemic, the focus of mental health support should be stress-related disorders brought about by the epidemic. For instance, sense of loss of good health and loved ones, sense of alienation and marginalisation by others are two frequent difficulties faced by patients recovering from the COVID-19. Fourth, therapeutic benefits of online mental health services during public health emergencies need to be evaluated. Although some studies suggest no significant differences in clinical outcomes between smartphone-based intervention groups and face-to-face professional clinical intervention groups [52], these studies were not delivered during public health emergencies and hence might not be generalisable to such situations. As such, the effectiveness and side-effects of online psychological interventions during public health emergencies is a top priority research question. More evidence also needs to be accrued to understand how these interventions, if confirmed to be safe and efficacious, can be disseminated widely to the public and be accepted as culturally relevant and appropriate treatment approaches.