Mental health in post-pandemic ASEAN

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Mental health in post-pandemic ASEAN
Harry Minas
Head, Global and Cultural Mental Health Unit School of Population and Global Health The University of Melbourne
28 Dec 2020
Health, Health and COVID-19

The COVID-19 pandemic has caused a global change in most aspects of life, but the impact has been unevenly distributed as with any major change. Across ASEAN Member States, the experience of the pandemic has varied considerably. Rates of SARS-COV-2 infection per million population have ranged from five in Lao PDR to 70,624 in Indonesia, and deaths attributed to COVID-19 from 0 in Cambodia to 2,235 in Indonesia. Community transmission continues in Indonesia and the Philippines, while there are currently no cases in Brunei and sporadic cases or clusters of cases in all other AMSs (WHO COVID-19 Dashboard).

The elderly and health workers have suffered the most direct health effects, while the negative social and economic impacts that have resulted from measures taken to control the spread of infection have been disproportionately felt by already disadvantaged, marginalised, and vulnerable populations. In most societies, the pandemic has starkly revealed substantial pre-COVID social and economic inequities and the vulnerabilities associated with such inequities, including increased risk of mental disorder (Social Determinants of Mental Health, World Health Organization and Calouste Gulbenkian Foundation, 2014). Among the most vulnerable populations are the elderly, people with pre-existing physical illnesses, ethnic and cultural minorities, migrant workers, the poor, people with insecure employment, those reliant on the informal economy, women experiencing family violence, children, and young people.

The pandemic’s social and economic disruption has resulted in a global and possibly long-lasting increase in the social determinants that are known to contribute to the increased risk of mental disorder. These include isolation from family, friends, and co-workers; disrupted education; loss of employment; financial hardship and apprehension about the future; restricted movement; a sharp increase in family violence experienced by women and children; and restricted access to health and other essential services. The population mental health impact of the pandemic—including population-wide apprehension and distress, stress-related disorders, anxiety, and depression—has been severe [3] and is likely to be prolonged.

According to the UN:

As a result of the 2008 economic crisis, a rise in “deaths of despair” was recorded among working-age Americans. Suicide and substance-use related mortality accounted for most of these deaths, which were linked to loss of hope due to the lack of employment and rising inequality. As the economic burden of COVID-19 rises, a similar toll on people’s mental health may be anticipated, with a major impact on individuals, families, and the wider society.(United Nations Policy Brief: COVID-19 and the Need for Action on Mental Health, UN, 2020) .

People with mental and substance use disorders have historically been among the most disadvantaged and marginalised groups in all societies. Persons with severe and persistent mental disorders, such as schizophrenia and bipolar disorder, almost always have multiple vulnerabilities, including undiagnosed and untreated general health problems, unemployment, poverty, insecure housing or homelessness, social isolation, limited social supports, stigma, discrimination, and human rights abuses. The pandemic has exacerbated these vulnerabilities.

At the same time, as the need for mental health services has increased, pandemic response measures have resulted in the closure or reduction of mental health services and psychosocial support programs in 93 per cent of countries worldwide (Pulse Survey on Continuity of Essential Health Services during the COVID-19 Pandemic, World Health Organization, 2020). Interruption in drug supplies, closure of in-person psychological treatment services, and disruption of rehabilitation and psychosocial support programs are likely to have resulted in increasing rates of illness relapse, exacerbations of drug abuse and addiction, and an unknown number of preventable suicides. Disruption of school-based and workplace mental health programs has meant that the vital work of mental health promotion and illness prevention has been reduced just when it is most needed.

Digital technologies have been important in disseminating information about all aspects of the pandemic, including issues relevant to mental health. In the context of closure of or reduction in access to in-person mental health services, many countries have turned to digital technologies for service provision.

Many claims have been made concerning the extent to which digital technologies can enable increased mental health program reach and accessibility. However, very few have been adequately evaluated for safety and efficacy. This is an important area for research in ASEAN. An additional concern is that persons with mental and substance use disorders are more likely to be poor and lack access to digital devices and technologies. Effective implementation of digital mental health services will require programs that bridge the digital divide to ensure that inequities are not exacerbated.

Given the considerations outlined above how should countries respond to the mental health challenges posed by the pandemic?

The first and, in the long term, the most important response is to bring about an attitudinal shift among leaders and the broad community that recognises that mental health and physical health are of equal importance. Although such an attitude is encapsulated in the WHO slogan, There is no health without mental health; this has not been turned into sufficient practical action. The post-pandemic period of recovery is an opportunity to make this change, which will=for the first time, enable the attention and investment required to adequately promote and protect the mental health of individuals, families, and populations.

The ASEAN Comprehensive Recovery Framework and Implementation Plan, adopted at the 37th ASEAN Summit, sets out the pathway to recovery, and the principles, objectives, strategies and priorities, that will guide the recovery. Three of the five broad strategies are particularly relevant to the task of mental health system development: Enhancing Health Systems, Strengthening Human Security, and Accelerating Inclusive Digital Transformation.

In the short term, three priorities are essential.

The first is wide dissemination of information about mental health and illness: how to maintain mental health, recognise emerging mental health problems and get access to mental health support, treatment and care when this is required. Accurate, accessible public information about mental health and illness is as important as information on hand hygiene, social distancing, mask wearing, and testing.

The second is to ensure capacity for early identification of mental health problems and rapid and effective response. COVID-safe availability of mental health services and expanded service capacity are urgent priorities. Closed or restricted mental health services should be reopened as soon as it is safe to do so. Where the mental health impact of the pandemic has been severe, it will be necessary to substantially increase service provision capacity to meet increased population needs.

The third is that information and services, whether in-person or digital, should initially be targeted to population sub-groups that are at increased risk of significant mental health problems. Among these groups very high priority should be accorded to women and children experiencing family violence, women in the perinatal period, elderly people who are socially isolated, young people at risk of suicide, and people with severe mental or substance use disorders who may have had their treatment and care disrupted.

In the mid- to long-term, attention must turn to substantially strengthening mental health systems.

Mental health services in many ASEAN Member States were already inadequate prior to the pandemic (ASEAN Mental Health Systems, ASEAN Mental Health Taskforce, 2016; The Impact of COVID-19 on Mental, Neurological and Substance Use Services – Results of A Rapid Assessment, World Health Organization, 2020). They were beset with inadequate investment, insufficient and inequitably distributed human resources for mental health, poorly developed mental health information systems, and little capacity to scale up mental health services quickly to respond to mental health emergencies.

The UN stated:

Good mental health is critical to the functioning of society at the best of times. It must be front and centre of every country’s response to and recovery from the COVID-19 pandemic. The mental health and wellbeing of whole societies have been severely impacted by this crisis and are a priority to be addressed urgently” (United Nations Policy Brief: COVID-19 and the Need for Action on Mental Health, UN, 2020)

In a constrained post-pandemic fiscal space, it is difficult to see how sustained and large-scale mental health system development can happen if there is no focused and sustained leadership at the highest levels of government. While substantial investment will be needed to develop effective mental health systems, it is important also to consider the social and economic costs of failing to make the necessary investment. An indication of the economic costs may be gained from the recent report of the Australian Productivity Commission (2020): “In total, mental illness, on a conservative basis, is costing Australia about $200-220 billion per year. To put that in context, this is just over one-tenth of the size of Australia’s entire economic production in 2019.

Attention to mental health must be understood as an essential component of the ASEAN economic recovery. To ensure the necessary mental health leadership and the extensive inter-ministerial and inter-sectoral collaborations and partnerships that will be required to build comprehensive and effective mental health systems, ASEAN Member States may wish to consider the whole-of-society benefits of creating the position of Minister for Mental Health.

Simply returning to pre-pandemic levels of mental health system capability would neglect what has been learned from the pandemic about the importance, and the current relative neglect, of population mental health and would constrain the post-pandemic social and economic recovery.