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www.thelancet.com/psychiatry Vol 7 September 2020 813
Position Paper
Lancet Psychiatry 2020;
7: 813–24
Published Online
July 16, 2020
https://doi.org/10.1016/
S2215-0366(20)30307-2
Department of Child and
Adolescent Psychiatry,
Institute of Psychiatry and
Mental Health, Hospital
General Universitario Gregorio
Marañón, School of Medicine,
Universidad Complutense,
IiSGM, CIBERSAM, Madrid,
Spain (C Moreno PhD,
Prof C Arango PhD); Institute of
Psychiatry, Psychology and
Neuroscience, Department of
Psychology, King’s College
London, London, UK
(Prof T Wykes PhD); South
London and Maudsley NHS
Foundation Trust, London, UK
(Prof T Wykes); University of
Campania “Luigi Vanvitelli”,
Naples, Italy
(Prof S Galderisi MD); CORE-
Copenhagen Research Center
for Mental Health, Mental
Health Services in the Capital
Region, Department of Clinical
Medicine, Faculty of Health
Sciences, University of
Copenhagen, Copenhagen,
Denmark
(Prof M Nordentoft DrMedSc);
Department of Psychiatry,
Pontificia Universidad Católica
de Chile, Santiago, Chile
(N Crossley PhD); Department
of Psychiatry, University of
South Florida, Tampa, FL, USA
(N Jones PhD); Department of
Psychiatry, Royal College of
Surgeons in Ireland, Dublin,
Ireland (Prof M Cannon PhD);
Department of Psychiatry,
Zucker Hillside Hospital,
Northwell Health, Glen Oaks,
NY, USA (Prof C U Correll MD);
Department of Psychiatry and
Molecular Medicine, Donald
and Barbara Zucker School of
Medicine at Hofstra/Northwell,
Hempstead, NY, USA
(Prof C U Correll); Department
of Child and Adolescent
Psychiatry, Charité—
Universitätsmedizin Berlin,
Berlin, Germany
How mental health care should change as a consequence of
the COVID-19 pandemic
Carmen Moreno, Til Wykes, Silvana Galderisi, Merete Nordentoft, Nicolas Crossley, Nev Jones, Mary Cannon, Christoph U Correll, Louise Byrne,
Sarah Carr, Eric Y H Chen, Philip Gorwood, Sonia Johnson, Hilkka Kärkkäinen, John H Krystal, Jimmy Lee, Jeffrey Lieberman, Carlos López-Jaramillo,
Miia Männikkö, Michael R Phillips, Hiroyuki Uchida, Eduard Vieta, Antonio Vita, Celso Arango
The unpredictability and uncertainty of the COVID-19 pandemic; the associated lockdowns, physical distancing, and
other containment strategies; and the resulting economic breakdown could increase the risk of mental health problems
and exacerbate health inequalities. Preliminary findings suggest adverse mental health effects in previously healthy
people and especially in people with pre-existing mental health disorders. Despite the heterogeneity of worldwide
health systems, efforts have been made to adapt the delivery of mental health care to the demands of COVID-19.
Mental health concerns have been addressed via the public mental health response and by adapting mental health
services, mostly focusing on infection control, modifying access to diagnosis and treatment, ensuring continuity of
care for mental health service users, and paying attention to new cases of mental ill health and populations at high risk
of mental health problems. Sustainable adaptations of delivery systems for mental health care should be developed by
experts, clinicians, and service users, and should be specifically designed to mitigate disparities in health-care provision.
Thorough and continuous assessment of health and service-use outcomes in mental health clinical practice will be
crucial for defining which practices should be further developed and which discontinued. For this Position Paper, an
international group of clinicians, mental health experts, and users of mental health services has come together to
reflect on the challenges for mental health that COVID-19 poses. The interconnectedness of the world made society
vulnerable to this infection, but it also provides the infrastructure to address previous system failings by disseminating
good practices that can result in sustained, efficient, and equitable delivery of mental health-care delivery. Thus, the
COVID-19 pandemic could be an opportunity to improve mental health services.
Introduction
The COVID-19 outbreak was sudden and unexpected in
most countries. The first known cases occurred in late
December, 2019, and WHO declared it a pandemic on
March 11, 2020.1 The evolution of COVID-19 remains
unpredictable, and this unpredictability is exacerbated by
the heterogeneity of health systems worldwide and
difficulties obtaining accurate infection and immunity
numbers. In view of the magnitude of the pandemic,
most countries adopted lockdown as a containment
strategy.
COVID-19 has resulted in an increase in known risk
factors for mental health problems. Together with
unpredictability and uncertainty, lockdown and physical
distancing might lead to social isolation, loss of income,
loneliness, inactivity, limited access to basic services,
increased access to food, alcohol, and online gambling,
and decreased family and social support, especially in
older and vulnerable people. Racial and ethnic disparities
in the incidence of COVID-19 (and associated mortality)
have been pronounced.2 The downturn in the economy
caused by COVID-19 will lead to unemployment, financial
insecurity, and poverty, which hinder access to health
services (especially in insurance-based systems), thereby
having deleterious effects on physical and mental health
and quality of life.3 These economic factors can induce
mental health problems in previously healthy people
and negatively affect those with pre-existing mental
disorders. The economic breakdown that is likely to occur
in the aftermath of the pandemic could exacer bate health-
care disparities and will probably dispro portionately affect
socially disadvantaged patients, including those from
ethnic minorities, who have worse access to health care
and receive poorer quality care than white populations.4
Sooner or later, health systems will be faced with
widespread demand to address these COVID-19-related
mental health needs. International organi sations, inclu-
ding WHO, advocate for integration of mental health and
psychosocial support into the COVID-19 response,5 and a
UN policy brief suggests that investments now will
reduce the mental health effects later.6 However, the
pandemic-related economic breakdown could impede an
adequate mental health response.
In view of the lack of a severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) vaccine, uncertainty about
new epidemic waves, and the likelihood of long-term
impacts on mental health, we need both short-term
adaptations and sustained responses. In this Position
Paper, an international group of mental health experts,
including service users and carer leaders, reflects on the
mental health challenges posed by COVID-19 and how
best to address potential changes in services. We describe
the mental health needs, potential systems adaptations,
and outcome measures that can help to turn a crisis into an
opportunity for improvement.
Potential consequences of COVID-19 for mental
health
General public
Some evidence of COVID-19-related mental health issues
has been published (appendix pp 1–6), but it is preliminary
and needs to be supported by well designed longitudinal
http://crossmark.crossref.org/dialog/?doi=10.1016/S2215-0366(20)30307-2&domain=pdf
814 www.thelancet.com/psychiatry Vol 7 September 2020
Position Paper
studies.7 Most surveys8–21 of the general public show
increased symptoms of depression, anxiety, and stress
related to COVID-19, as a result of psychosocial stressors
such as life disruption, fear of illness, or fear of negative
economic effects. The results of these surveys are hetero-
geneous, probably because of differences in methods
used, study locations, and the timing of the studies in
terms of the course of the pandemic. Phobic anxiety,22
panic buying,23 and binge-watching television24 (which
has been associated with mood disturbances, sleep
disturbances, fatiguability and impairment in self-
regulation) have been reported, and social media exposure
has been associated with increased odds of anxiety (odds
ratio 1·72 [95% CI 1·31–2·26]) and combined depression
with anxiety (1·91 [1·52–2·41]).10
Quarantine can also contribute to stress, anger,8,11,13 and
an increase in risky behaviours such as online gam-
bling.25,26 Young people might be at particular risk. In
previous pandemics, quarantined children were more
likely to develop acute stress disorder, adjustment dis-
orders, and grief than were those who had not been
quarantined.27 An increase in young people making calls
to helplines with symptoms of anxiety has been
reported.28 Increased alcohol sales and alcohol use in the
home have also been recorded,29 which could potentially
increase alcohol use disorders and domestic violence
(both in young people and in adults).30 Although
published data are few, individuals, including children,
could be at increased risk of physical and sexual abuse at
home during the pandemic. The pandemic could also
exacerbate mental health conditions—and further limit
scarce access to mental health services—in people living
in humanitarian and conflict settings.6 Some positive
benefits might also accrue from reductions in social
pressure and exposure to chronic psychosocial stressors
(eg, commuting, office workplaces,31 bullying32,33).
People who have or had COVID-19
For people with COVID-19, lack of contact with their
families or loved ones during quarantine and hospital
stays can produce psychological instability. High rates of
post-traumatic symptoms have been reported in clinically
stable people discharged from hospital after recovering
from COVID-19.34 In a systematic review,35 the point
prevalence of post-traumatic stress disorders after severe
coronavirus infections (ie, severe acute respiratory
syndrome and Middle East respiratory syndrome) was
32·2% (95% CI 23·7–42·0), that of depression was
14·9% (12·1–18·2), and that of anxiety 14·8% (11·1–19·4).
People who have had COVID-19 can experience post-
intensive-care syndrome, which comprises cognitive,
psychological, and neurological symptoms.36 In a study
by Helms and colleagues,37 15 (33%) of 45 patients who
had recovered from COVID-19 after admission to
intensive-care units (ICUs) had dysexecutive syndrome
after ICU discharge. Emerging reports38,39 suggest the
possibility of a post-viral syndrome that resembles
depression. The possibility that SARS-CoV-2 is
neurotropic emphasises the need for evaluation of
potential short-term and long-term effects on the nervous
system.40
People with pre-existing mental health disorders
Because of their life circumstances, people with pre-
existing mental health disorders might have a higher risk
of SARS-CoV-2 infection than those without mental
health disorders.41,42 Risk factors for infection with
SARS-CoV-2 and a severe course of COVID-19 include
severe mental illness, alcohol or drug misuse, and
homelessness, all of which are associated with other risk
factors such as comorbid physical conditions.43–45 People
with mental disorders are at increased risk of infections
in general (and thereby potentially at increased risk of
COVID-19),46 and are more likely to develop severe organ
dysfunction and to die in ICUs than people without
mental disorders.47 SARS-CoV-2 might also cause
dysregulation of the stress system, which could
contribute to the development or exacerbation of
psychiatric disorders.48 Elderly people are at especially
high risk of severe COVID-19 illness and mental-health-
related consequences because they might already have
some cognitive decline.49,50 Institutions can become
epicentres for infection. Physical distancing can be
challenging in these contexts, either because the nature
of patients’ conditions makes it difficult to manage
(eg, people with learning disabilities) or because of
overcrowding (eg, prisons). Increased death rates in
assisted living facilities have been reported worldwide,51
especially among older people and people with learning
disabilities.52
People with pre-existing mental health disorders have
reported increased symptoms and poorer access to
services and supports since the onset of the COVID-19
pandemic.41,53–60 Early discharge from psychiatric units and
disruption of face-to-face psychiatric care have become
common, the negative consequences of which could
include relapse, suicidal behaviour, lack of access to
medical care, and social isolation.53 Quarantine and
lockdown might particularly affect people with pre-
existing mental health problems: increased symptoms of
anxiety and depression, and high rates of post-traumatic
stress disorder and insomnia have been reported.54 Simul-
taneously, physical distancing has reduced the availability
of many family, social, and psychiatric supports. People
with serious mental illness and associated socioeconomic
disadvantages are particularly at risk of both the direct
and indirect effects of the pandemic.55 Similarly, increased
symptoms and vulnerability have been reported during
the COVID-19 pandemic in people with eating disorders,
autism spectrum disorder, dementia, and intellectual and
developmental disabilities.56–61 Confinement at home,
disruption of daily routines, and physical distancing
could exacerbate all these conditions and represent a
challenge for service users and caregivers.62
(Prof C U Correll); School of
Management, College of
Business, RMIT University,
Melbourne, VIC, Australia
(L Byrne PhD); Program for
Recovery and Community
Health (L Byrne), Department
of Psychiatry
(Prof J H Krystal MD), School of
Medicine, Yale, New Haven, CT,
USA (L Byrne); School of Social
Policy and Institute for Mental
Health, University of
Birmingham, Birmingham, UK
(S Carr PhD); Department of
Psychiatry and State Key
Laboratory on Cognitive and
Brain Sciences, University of
Hong Kong, Hong Kong Special
Administrative Region, China
(Prof E Y H Chen MD); Institute
of Psychiatry and Neuroscience
of Paris, University of Paris,
INSERM U1266, Paris, France
(Prof P Gorwood MD); GHU Paris
Psychiatrie et Neurosciences,
CMME, Hôpital Sainte-Anne,
Paris, France (Prof P Gorwood);
Division of Psychiatry
(National Insitute for Health
Research Mental Health Policy
Research Unit), University
College London, London, UK
(Prof S Johnson DM); Global
Alliance of Mental Illness
Advocacy Networks-Europe,
Brussels, Belgium
(H Kärkkäinen BSc);
Yale New Haven Hospital,
New Haven, CT, USA
(Prof J H Krystal); North Region
and Department of Psychosis ,
Institute of Mental Health,
Singapore (J Lee MMed);
Neuroscience and Mental
Health, Lee Kong Chian School
of Medicine, Nanyang
Technological University,
Singapore (J Lee); Department
of Psychiatry, Vagelos College
of Physicians and Surgeons,
Columbia University, NY, USA
(Prof J Lieberman MD);
Department of Psychiatry,
School of Medicine, University
of Antioquia, Medellín,
Colombia
(Prof C López-Jaramillo MD);
EUFAMI, Leuven, Belgium
(M Männikkö MSS); Shanghai
Mental Health Center,
Shanghai Jiao Tong University
School of Medicine, Shanghai,
China (Prof M R Phillips MD);
Department of
Neuropsychiatry, Keio
University School of Medicine,
Tokyo, Japan (H Uchida MD);
Hospital Clinic, Institute of
Neuroscience, University of
Barcelona, IDIBAPS, CIBERSAM,
www.thelancet.com/psychiatry Vol 7 September 2020 815
Position Paper
Health-care workers
Health-care workers,63–70 especially those working on the
frontline, have reported negative consequences as a
result of stress exposure and fear of infecting themselves
or their loved ones.63,71,72 In a cross-sectional study65 of
1257 health-care workers in 34 hospitals in China,
634 (50%) reported symptoms of depression, 560 (45%)
reported anxiety, 427 (34%) reported insomnia, and
899 (72%) reported distress. These symptoms were more
common in women than in men, in nurses than in
physicians, in respondents from Wuhan than in those
from other cities, and in frontline workers directly
engaged in diagnosis and treatment of COVID-19 or
providing nursing care for affected patients than in those
fulfilling other health-care roles.65 Common risk factors
included a lack of social support and communication,
maladaptive coping strategies, and a lack of training
(usually a lack of disaster training).65,72 Moral injury
results when people are forced to take action—or,
conversely, are unable to take action—that violates their
moral code when they are exposed to trauma for which
they are unprepared. These challenges, usually observed
in military contexts, have been faced by health-care staff
during the COVID-19 pandemic, which has necessitated
very difficult decisions about how to prioritise scant or
inadequate resources, potentially resulting in deaths that
might not have occurred under normal circumstances.73
Mental health service responses to COVID-19
The COVID-19 pandemic could provide an opportunity
to improve the scale and cost-effectiveness of different
mental health interventions.74,75 Central to this opportunity
is the willingness to rethink conventional approaches to
systems planning and greater inclusion of service users,
carers, and representatives of populations who experience
health disparities (who have been disproportionately
affected by the pandemic).
Public mental health responses and community
outreach
After the severe acute respiratory syndrome outbreak in
Canada and Hong Kong in 2002–04, most adverse
psychological consequences of physical distancing and
quarantine resolved without the need for specialised
mental health care.76–79 Problems can persist in some
people who are particularly affected by protracted
infection-containment strategies and recession-related
psychological stress. These people will need professional
psychological support and are likely to be affected by
public messaging emphasising the usefulness of voluntary
quarantine and the altruism of self-isolating.25 The public
health response to COVID-19 should not only provide
clear, concise, and accurate information about quarantine
and infection rates to reduce uncertainty, but also aim to
increase mental health literacy. Education, self-care, and
family support should form part of mental health
prevention strategies, which should involve multiagency
collaboration among housing, education, and employment
services, with support from the voluntary and mental
health sectors. These agencies should mobilise social
support networks and work with local communities to
help address identified stressors and encourage those in
need to seek help from mental health services.
Different strategies for community outreach have been
used. In the USA, for example, mental health providers
and programmes have organised food delivery for vulner-
able community members and worked with community
leaders to ensure the inclusion of mental as well as physical
health concerns in programmes.80 Voluntary-sector user-
run and carer-run service organisations in many countries
have organised emergency funds for struggling people,
virtual mutual support meetings, community conver-
sations, and online resources.81,82 Some countries have
supplemented community support systems by reassigning
staff, and volunteers have boosted staff numbers.80,83,84
Mental health-care settings
Almost all mental health services have implemented
infection-control measures.85–95 Prevention and active
surveillance measures adopted include screening patients,
staff, and visitors for viral infection, and limiting—or
eliminating—visits.89–93 Measures to promote physical
distancing include reducing the number of outpatient
appointments,88,89 the adoption of triage protocols that
recommend treating urgent issues only,94 and restruc-
turing caseloads to minimise contact among patients.95
Group psychotherapy and peer support meetings have
been reduced in size,88 cancelled,89 or moved online.93
Inpatient psychiatric units have encouraged physical
distancing by using isolation rooms, decreasing the total
number of beds available, placing greater constraints on
admission, and reducing admission duration.92,93 Wards
around the world have been converted for use by psych-
iatric patients with COVID-19 symptoms.94 These efforts
were facilitated by screening patients for SARS-CoV-2 in
the emergency department before admission and
allocating them to wards on the basis of their infection
status. Pre-admission quarantine periods have been
effective in some countries,53,88 but implementation might
be problematic in low-income countries, many of which
had insufficient bed numbers before the pandemic.
Physical-distancing requirements might further decrease
their limited capacity.96 Rapid discharge to minimise the
risk of hospital-acquired infection, especially of people
who were compulsorily detained, poses broad ethical and
practical questions (related to threshold of risk deter-
mination, detention periods, and availability of suitable
community services, for example).97 Services for the home-
less have implemented mobile testing for SARS-CoV-2
and evacuation to special quarantine facilities.98,99
Mental health-care adaptations for infection-control
reasons could have been detrimental to people whose
treatment has been reduced or who have been confined
alone in hospitals with greatly reduced therapeutic
Barcelona, Spain
(Prof E Vieta PhD); Department
of Clinical and Experimental
Sciences, University of Brescia,
Brescia, Italy (Prof A Vita PhD);
and Department of Mental
Health and Addiction Services,
Spedali Civili Hospital, Brescia,
Italy (Prof A Vita)
Correspondence to:
Dr Carmen Moreno, Department
of Child and Adolescent
Psychiatry, Institute of Psychiatry
and Mental Health, Hospital
General Universitario Gregorio
Marañón, 28009 Madrid, Spain
cmoreno@hggm.es
See Online for appendix
816 www.thelancet.com/psychiatry Vol 7 September 2020
Position Paper
programmes. Services have promoted changes to facilitate
access, including widespread use of telehealth and virtual
meetings for medication management, nursing, case
management, vocational interventions, and peer sup-
port.92,93,100–102 In some cases, these changes have neces-
sitated changes to laws and legislation con cerning
confidentiality and privacy to enable the wider use of
technology.80,92 Services have also strength ened home-
based treatment (including domiciliary care and so-called
in-home hospital isation)58 in addition to community-
based crisis and respite care. Home-based treatment is an
essential part of COVID-19 mental health services and
will be key to future service configurations to prevent the
spread of infection and perhaps also as a more acceptable
alternative to inpatient treatment for some service users
and their families. Efforts need to be made to maintain
community support for people with severe mental
illness.103
The threshold for hospital admission for mental illness
varies among individuals and depends on the risk of
hospital-acquired infection, which will change over time.
Admission decisions are therefore complex, require
continuous adaptation, and should be informed by the
availability of community support. Access to appropriate
psychiatric (voluntary or involuntary) and medical treat-
ment (including ICU treatment) needs to be guaranteed
for SARS-CoV-2-positive patients with mental disorders.
Most countries have strengthened public health
protocols, including guidance on how to access mental
health support.88,104 Policy changes have included adjust-
ments to access policies, insurance coverage, privacy
laws,92 and access to controlled drugs.105 Countries have
also allowed pharmacies to accept expired prescriptions53
and have loosened monitoring requirements for
drugs with potential side-effects, such as lithium or
clozapine.106 The consequences of these policies should
be evaluated.
Mental health needs of special populations
Many countries have dedicated teams (comprising
managers and volunteers) to provide mental health
support for health-care workers6,73,107 and psychiatric
liaison services.95 The support needed depends on the
stage of the pandemic. Initially, in China, teams set up
psychological treatment services for health-care
workers, but few people used them.63 In the UK, a
national hotline was established for health-care workers
experiencing mental health difficulties, and although it
is used, it has not taken the place of local solutions.73 In
light of the Chinese experience,63 along with some
improved contact with families, hospitals in Italy,108
Spain,86,95 the UK,73 and the USA109 have provided local
supportive services for staff (eg, rest and recharge
rooms) and implemented strategies to facilitate access
to support for the most vulnerable staff. In the UK,
these measures proved very popular, with one acute-
care hospital noting a footfall of 700 staff through the
room on its third day (Cross S, King’s College Hospital,
personal communication). Teams of health-care
workers should be encouraged to support and monitor
each other, and team leaders should be trained to
identify serious issues.73 As stigma related to mental
health continues to affect help-seeking in many
countries, peer counselling services for clinical staff
might also be useful.110
For the family members and loved ones of people with
COVID-19, coping with the people they care about having
to deal with illness alone and possibly dying in isolation
is potentially traumagenic. Increases in complicated
grief are likely to occur due to the circumstances of death
during the pandemic.111 Prevention programmes have
been implemented for relatives of people who died from
COVID-19 in some countries.86 In view of the high levels
of psychological and cognitive deficits that are expected
in people who have recovered from COVID-19
(particularly those who were admitted to ICUs),35,36,38 the
establishment of specialised post-COVID-19 clinics in
general hospitals, with multidisciplinary teams encom-
passing psychiatrists, psychologists and specialists in
respiratory and intensive-care medicine, should be
considered.
Sustainable adaptations of mental health
delivery
Ethics-driven and rights-driven considerations
COVID-19 raises numerous ethical questions and
dilemmas, including potential discrimination (related to
both SARS-CoV-2 status and mental ill health) in
adjudicating access to insufficiently available health
interventions and applying and weighing the added risk
of SARS-CoV-2 exposure in decisions about involun-
tary institutionalisation.6,112–114 Service users and family
organisations have expressed concerns about potential
future service cuts, disproportionate additional illness
burden, reduced service access, inadequate financial
support, exacerbation of inequalities in access to health
care, and the need for greater family and carer support.115
Some service-user groups have noted an erosion in
involvement and co-production efforts,116 both in coun-
tries where such involvement was common and in those
without a strong history of involvement, that has
persisted through the pandemic.
Ethnic and racial disparities in access to mental health
care raise numerous social justice concerns about the
distribution of resources and underlying social drivers of
inequality. The emergence of the second wave of the
Black Lives Matter movement has drawn attention to
how systemic racism and discrimination affect health
outcomes and other domains central to recovery from
the COVID-19 pandemic (eg, employment, education,
housing).117,118 These racial disparities also affect service-
user involvement schemes, and the lack of representation
and influence that Black and other ethnic minority
populations have needs to be addressed.119,120
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Position Paper
Service user knowledge and involvement
For the best outcomes, the users of mental health services
and their families need to feel empowered to take
ownership of their healing journey.121 This requirement is
arguably more important now than ever, when service
access is limited and face-to-face contact is often
unavailable. The relative risks and benefits of treatment
changes to limit potential exposure to SARS-CoV-2
(eg, for users receiving clozapine, injectable medications,
or electroconvulsive therapy) should be considered.
Treatment plans might need to be rapidly renegotiated,
and should be based on best practices. There is thus a
need to enhance and create robust resources to support
shared decision making.
Service users should be centrally involved in the
development of mental health-care services and systems.
The role of service users in guiding person-centred
approaches in mental health services is well established
(if not consistently implemented) in Australia, Canada,
New Zealand, the UK, and the USA,122 is rapidly
becoming more common in Scandinavia,123 and is
developing slowly in some Asian and Latin American
countries.124–126 The need for rapid decision making
should not be used to justify the circumvention of co-
production protocols, and in countries where such
involvement is not the norm, the COVID-19 pandemic
and the renewed discussion of racial inequalities and
inequalities in the availability of adequate and adapted
health-care access should be viewed as an opportunity to
build user-involvement support and infrastructure.119,120,127
Clinical service design and delivery can also be
strengthened by increased peer worker involvement in
the co-design of adapted services and by increasing the
number of peer workers involved in service delivery,
particularly in countries with limited resources for
mental health. Most importantly, decision makers must
commit to maintaining adequate mental health service
provision for current and future needs.
Longer-term mental health needs
Many questions remain about how to mitigate the mental
health effects of the COVID-19 pandemic. Community
monitoring and mental health screening could be
implemented in selected groups, or digital health and
digital phenotyping could be used to switch from
individual-based approaches to population-wide screen-
ing.128 After local needs have been clarified, stakeholder
groups (including service users and families) could
update available services, develop new ones, identify and
arrange for the training of potential providers, seek
additional funding to expand services, and establish
evaluation protocols for all novel interventions to regularly
revise or terminate the interventions on the basis of their
efficacy. Mental health professionals with experience in
social sciences and community-based services should
also advise regulators to develop, implement, and assess
strategies for dealing with the pandemic and its aftermath.
For people experiencing acute distress who are at risk of
developing long-term conditions and those who do not
trust or engage with mainstream mental health services,
the facilitation of diverse and flexible access to mental
health care is particularly important. Local community-
led, user-led, and family-led organisations and small
independent peer-support initiatives have quickly
mobilised to provide immediate help and guidance
during the pandemic.129 These community support
services have proactively responded to COVID-19
differently from mainstream clinical services, and could
expand cost-effectively to support an expected increase in
demand for services.130 However, they might not be
appropriate or sufficient for everyone, and thus should
complement, but not replace, mainstream mental health
care.
In many countries, resources have been diverted from
other areas to the COVID-19 response. Vulnerable
populations, including patients with mental health
issues, have been disproportionately affected by changes
to public transportation systems, housing and emergency
shelter infrastructure, and unemployment, as well as by
social isolation and loneliness.25,131 The people who are
most likely to require mental health support as a result of
the social and economic consequences of the pandemic
and pre-existing health-care inequalities—eg, ethnic
minorities, people living in poverty, people living in
conflict situations—are also the people who have been
hit hardest by COVID-19.99,132 In the UK and the USA,
grassroots and community organisations run by and for
Black and other racial minority communities, who have
been disproportionately affected by COVID-19, are
providing mental health support.133 Health-care systems
should anticipate an increase in unmet mental health
needs in these vulnerable groups and promote
adaptations that narrow gaps in access to care.
Remote therapy
Remote community treatment and support has long
been suggested, but has not previously been implemented
widely because of barriers and challenges from both
health-care staff and service users. Since the onset of the
COVID-19 pandemic, the situation has changed in most
countries.134 To fill the gaps in face-to-face care, telehealth
was rapidly adopted, with remote video or phone
conferencing, online blended or coached therapies, and
self-help therapies provided through apps. There is
already some evidence of short-term success,100,135 and
remote service delivery could also have longer-term
advantages, especially in countries with low investment
in mental health services and low capacity.136
However, there are also challenges and drawbacks
associated with the use of remote therapies, especially in
people who might be in most need. Potential issues
include access to the requisite technology (and the
knowledge to use this technology), internet access, data
allowance costs, and privacy and data security. Digital
818 www.thelancet.com/psychiatry Vol 7 September 2020
Position Paper
therapies thus might not be appropriate for older people,
people with reading difficulties, poor people, or people
who are not technologically adept.137 People who find
remote com muni cation more challenging than face-to-
face inter actions might disengage from treatment, and
their loneliness could increase without this in-person
contact. Knowledge from countries with a history of
deploying digital services for widely dispersed popu-
lations (eg, Australia, Canada) should be harnessed.
Australian research138 suggests that information techno-
logy staff should be available to offer technical support
during the early stages of switching to video-conferencing
to deliver treatment, particularly for older people or
people with low technological literacy. Free internet is
sometimes available in public places, but gatherings of
people at these sites to access this service could
complicate physical distancing. Homeless people and
asylum seekers generally do not have internet access,
and when they do, it tends not to be private. A systematic
approach to internet and device access is suggested for
vulnerable popu lations,139 and needs to be a key funding
consider ation. In addition to technological proficiency,
therapists and others offering support need to develop a
so-called webside manner to support and maintain the
important therapeutic alliance that mediates recovery.
The rules governing remote therapy in countries
including the USA have been relaxed, so that some
medications can be prescribed remotely without the need
for routine face-to-face contact.140 However, it is unclear
whether telehealth services will be reimbursed differently
from face-to-face services, which will probably increase
inequalities in fractured health-care systems. If telehealth
care is to be continued, the minimum acceptable levels
of privacy and security need to be clearly defined, as do
the processes by which this flexible form of care can be
securely organised and reimbursed.
In addition to telehealth, there are opportunities for
digital services to track health via passive and active
monitoring.141 These tools have promise, but the long-term
usefulness of these complementary therapies is unclear in
view of data suggesting poor adherence without human
support.142 Service users have been enthusiastic about
these tools, but only as adjuncts of face-to-face care, and in
some countries they are increasingly promoted as best
practice.143,144 Telehealth and digital services should not
replace face-to-face treatment for patients in need—
particularly those requiring intensive mental health
treatment and support—when in-person contact is once
again safe.
Ways of working
The COVID-19 pandemic has been difficult for everyone
working in mental health services. The need to be flexible
has required rapidly and constantly adapting teamworking
and problem solving in response to changing needs.
Teams have had to develop efficient, multipronged com-
munication strategies, which are especially valuable in
times of confusion. Experience from previous pandemics
and global research have provided mental health teams
with the information needed to adapt services. Strategies
that mental health service users have successfully used to
adapt to coping during the pandemic, at least during the
acute phase, should be researched and leveraged.7
Technological solutions to support collaboration between
general practice and community and inpatient teams have
advanced,145 and facilitate moves between different services.
Similarly, liaison psychiatry has increased collaboration
with other medical specialties and helps to organise the
services required to support mental health teams, patients,
and their families.86
Assessment of mental health outcomes in
clinical practice
Adaptations have been implemented in response to the
COVID-19 crisis (table), and it is essential to syste matically
assess their effects on defined indicators and outcomes
Potential negative effects Potential positive effects
Focus of health-care
system on identification,
prevention, and
management of
COVID-19
Main educational focus on physical health; focus on social distancing
instead of physical distancing while staying connected; resource
reallocation to physical health-care needs; fewer in-person meetings
within and across treatment teams; physical and mental strain on health-
care workers; shortages of health-care workers
Education about mental health effects of COVID-19 could increase overall mental health
literacy in the population; opportunity to emphasise the importance of self-care, coping
strategies, and family support; stimulation of non-profit or non-governmental
organisation support for mental health services and multiagency efforts to mobilise social
support networks; leveraging of technology to facilitate rapid, flexible, and efficient
methods of team communication and cohesion within and across teams (eg, mental
health and primary care); promotion of healthy physical and mental lifestyle measures;
provision of low-threshold, destigmatised psychosocial evaluation and support services;
peer-support systems; mobilisation of volunteers and retirees; hiring of new personnel
Restricted access to
other types of health
care as a key method for
controlling the spread of
COVID-19
Triage protocols limiting cases to urgent issues only; reduced outpatient
visits (including for prescription or dispensing of medication), emergency
room visits, inpatient care, and access to pharmacies; cancellation or
reduction in size of group psychoeducation, group psychotherapy, and
peer-support groups; decreased opportunities for cardiometabolic and
adverse effect monitoring; reduction in total inpatient beds; constraints
on hospital admission; curtailed hospital stays; premature discharge to
minimise risk of hospital-acquired infection, especially for people who
were compulsorily detained
Reassessment of appropriate provision, delivery, data protection policies, and
reimbursement of telemedicine and video-medicine, digital health care, and at-home
treatment options; adjustments in access policies (eg, online formats), insurance
coverage, privacy laws, flexible prescription coverage, and use of controlled substances;
increased acceptability of phone-in prescriptions and long-acting injectable medications;
development of group outpatient treatments with online formats; less risk-averse
approaches to monitoring of side-effects (with a greater focus on shared decision making
and biometric monitoring); less crowding on inpatient units; reassessment of necessary
length of inpatient stays; re-evaluation of need for compulsory treatment
Table: Potential effects of health service changes on access to, and quality and outcomes of, mental health care during and after the COVID-19 pandemic
www.thelancet.com/psychiatry Vol 7 September 2020 819
Position Paper
before new long-term mental health practices are planned
and developed. Comparison of data for the transmission
of SARS-CoV-2 and COVID-19 morbidity and mortality in
people with mental health disorders with the corres-
ponding data in the general population by country
and region should help to elucidate which procedures
effectively control disease spread in mental health settings,
which approaches have the greatest positive effect on
COVID-19-associated morbidity and mortality (panel),
and which strategies should be prioritised should a similar
situation occur in the future. Similarly to Holmes and
colleagues,7 we consider prevalence assessments of
mental health oucomes and comorbidities in different
popu lations to be essential in the post-COVID-19 era.
These data will aid the design and development of
appropriate mental health treatments and help to identify
patients with a continued need for care.
In this new climate, the use and effectiveness of mental
health services—including those already available and
new or adapted services—should be regularly monitored.
This monitoring should focus on accessibility (especially
for elusive populations, such as frontline workers, people
with severe mental disorders, and racial minorities) and
clinical outcomes associated with different mental health
services before, during, and after the pandemic. Routine
monitoring of health-care disparities that links socio-
economic, race, and ethnicity data with measures of
quality measures is also crucial (panel).146
There is an opportunity to replace the old way of
managing the gap between the supply of and demand for
Panel: Proposed intermittent monitoring for COVID-19-related mental health issues
COVID-19 monitoring and use of mental health services in
individuals with pre-existing mental disorders
The availability and uptake of COVID-19 related health
information; the prevalence of severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) diagnostic tests,
antibody tests, and vaccination (if and when available); and,
among people who test positive for SARS-CoV-2, the prevalence
of outpatient, inpatient, intensive-care, and ventilator
treatment for COVID-19, and COVID-19 mortality, should be
assessed on an ongoing basis in clearly defined cohorts of
persons with pre-existing mental disorders and cognitive or
intellectual disabilities (including psychiatric inpatients and
outpatients and people with mental or cognitive disorders in
residential settings, prisons, etc). These data should be
compared with the corresponding data in the general
population.
The frequency of face-to-face, video, and telephone contact
with different types of mental health providers; rates of
prescription and use of psychiatric medication; rates of
emergency mental health treatment and psychiatric
hospitalisation; and the proportion of patients with severe
mental disorders lost to follow-up should be compared with
the corresponding data from before the pandemic.
Mental health outcomes
In people with pre-existing mental or cognitive disorders,
the incidence and prevalence of changes in the severity of the
underlying disorder, medication or treatment adherence, social
or occupational dysfunction, and suicidal behaviour, and the
potential emergence of comorbid substance use problems
should be compared with the incidence and prevalence of these
outcomes before the emergence of COVID-19 (objective and
subjective measures should be used).
In people with no pre-existing mental or cognitive disorders
(and people with previously resolved mental disorders)—both
the general population and specifically people at high risk of
psychological problems (eg, frontline health-care workers,
isolated elderly people, relatives of people who died from
COVID-19)—the incidence, severity, and duration of all types of
mental disorders, including common mental disorders
(primarily anxiety and depression), post-traumatic stress
disorder, substance use disorders, behavioural disorders,
(in children and adolescents), and suicidal behaviour should be
compared to the incidence, severity, and duration of these
outcomes before the emergence of COVID-19.
Provision of mental health care
The following indicators should be continuously assessed
during and after the pandemic and compared with
corresponding indicators before the COVID-19 pandemic to
establish COVID-19-related changes in local and national
delivery systems for mental health:
• The proportion of all mental health services provided in
inpatient, emergency, institutional (eg, prisons),
outpatient, community, and home-based settings
• Rates of face-to-face, video, and telephone contact with
different types of mental health providers
• Rates of prescription and use of psychiatric medication
• Access to, and use of, different mental health services
both by people with pre-existing mental health disorders
and those with new incident cases of mental illness, and
the sociodemographic characteristics of these users
• Quality of care of different mental health services
(including acceptability and satisfaction with health-care
providers), with a focus on user expectations and
satisfaction and on functional, vocational, and clinical
outcomes (including families’ or carers’ views)
• Disparities in mental health care, with socioeconomic,
race, and ethnicity data linked to quality measures
• Integration of mental health services with general health
services, social welfare, and other institutions (eg schools,
prisons) and community associations
• Governmental and non-governmental financial support
for mental health and social care services, and for research
focusing on the monitoring and improvement of mental
health services
820 www.thelancet.com/psychiatry Vol 7 September 2020
Position Paper
mental health care (ie, rationing) with a system that
prioritises high-quality and equitable care rather than
focusing only on how much work is done. Subjective
experience and acceptability of new approaches should
guide changes and inform the need to adapt to changing
mental health needs. Service users and carers have
identified clinical outcome measures that adequately
capture their experiences.147 These groups should be
involved in the design of mental health services and in
monitoring the quality of these services. This approach
requires a reorientation towards user-defined outcomes,
including the family view, and mechanisms to collect
service users’ views on evolving expected outcomes. The
outcomes of regular monitoring should be reported,
along with outcomes of the other measures proposed.
Conclusion
The COVID-19 pandemic has already affected mental
health, and some of these effects might persist. The
psychological toll of the disease is already apparent both
in the general population and specifically in people with
mental disorders (particularly those with severe mental
illness and cognitive impairment) and frontline workers.
Mental health systems have rapidly changed during the
pandemic and a sustained response to the challenges
posed by COVID-19 needs to be coordinated. Despite
heterogeneity in political, social, and health systems,
mental health services worldwide have implemented
acute responses that focus on infection control,
continuity of care for mental health service users, and
facilitating access to mental health assessment and care
for patients with new-onset issues and high-risk patients.
Some new approaches that have been developed seem
efficacious, but they might still be associated with risks.
Implementation of a COVID-19-related physical and
mental health monitoring system that includes outcomes
related to mental health service use would inform
practice, and could help to shape optimal mental health
care for the times to come. Retaining existing services
and promoting new practices that expand access and
provide cost-effective delivery of effective mental health
services to individuals who already have mental disorders
or who have developed them during the pandemic
should be a priority. Service provision needs to be
individualised: effective practices already in place should
be refined and scaled up, and both the usefulness and
limitations of peer support and remote health delivery
should be recognised. A focus on accountability based
on routine measurement of meaningful and valued out-
comes, co-production of service design and evaluation
with expansion of health insurance coverage of mental
health, and promotion of primary care support and its
greater inte gration with secondary care could further
help to sustain mental health care in the aftermath of the
pandemic.
The economic implications of the COVID-19 pandemic
are serious. It is important to be cognisant of the risks of
promoting cheap solutions to broadening access to mental
health care. Low-quality mental health care based on
affordability without assessment of quality or monitoring
of needs and efficiency will only contribute to increasing
inequalities and worsening mental health globally. Now
more than ever, we need to put in place service provision
that targets health needs and reduces disparities, both
globally and within individual countries. Despite sub-
stantial cross-national differences in social and mental
health systems, we believe that such an approach is
feasible with some location-specific adaptations. It could
even turn the COVID-19 pandemic into an opportunity to
improve mental health care for everyone.
Contributors
CM and CA conceived the Position Paper and did the literature search.
All authors attended two online meetings to establish the structure and
scope of the Position Paper. Thereafter, participants joined one of
six writing groups to produce the first draft. CM and CA participated in
all meetings to ensure coherence and continuity, and drafted the final
manuscript. CM coordinated the writing and editing of the Position
Paper, which was reviewed, revised, and approved by all authors.
Declaration of interests
CM reports personal fees from Janssen, Angelini, Servier, Nuvelution,
Otsuka, and Lundbeck. SG reports personal fees from Lundbeck, Janssen,
Sunovion, Gedeon Richter-Recordati, and Angelini; and has consulted or
served on advisory boards for Millennium Pharmaceuticals, Innova
Pharma-Recordati Group, Janssen, Gedeon Richter-Recordati,
and Angelini; and non-financial support from Gedeon Richter-Recordati.
CUC has been a consultant or advisor for Alkermes, Allergan, Angelini,
Boehringer-Ingelheim, Gedeon Richter-Recordati, Gerson Lehrman,
Indivior, IntraCellular Therapies, Janssen, Johnson & Johnson,
LB Pharma, Lundbeck, MedAvante-ProPhase, Medscape, Merck,
Neurocrine, Noven, Otsuka, Pfizer, Rovi, Servier, Sumitomo Dainippon,
Sunovion, Supernus, Takeda, and Teva; has received honoraria from
Angelini, Gedeon Richter-Recordati, IntraCellular Therapies, Janssen,
Johnson & Johnson, Lundbeck, Otsuka, Pfizer, Sumitomo Dainippon,
Search strategy and selection criteria
In April and May, 2020, an international panel of mental health
experts, service users, and family carers from 14 countries,
acting in a personal capacity and as representatives of two
international patient organizations (Global Alliance of Mental
Illness Advocacy Networks-Europe and EUFAMI), assembled to
assess the potential effects of the COVID-19 pandemic on
community mental health and changes to mental health
services. We systematically searched MEDLINE with the terms
[(coronavirus OR covid* OR SARS-CoV-2) AND (anxiety OR
depress* OR mania OR manic OR psych* OR schiz* OR
attention OR autism OR “intellectual disability” OR
oppositional OR conduct OR emotion* OR stress* OR alcohol
OR abus* OR addiction OR “use disorder*” OR suicid* OR injur*
OR behav* OR neuro* OR brain OR cogniti* OR psychol* OR
psychiatric* OR mental* OR prevent* OR outcome OR social OR
psychosocial OR neurobehavioral OR adaptation OR coping OR
resilience)] for articles published in any language up to
May 15, 2020 (the date of our final search). We included
28 articles about mental health issues related to COVID-19 and
24 about adaptations of mental health services during the
COVID-19 pandemic from this search.
www.thelancet.com/psychiatry Vol 7 September 2020 821
Position Paper
and Sunovion; provided expert testimony for Janssen and Otsuka; served
on data safety monitoring boards for Lundbeck, Rovi, Supernus, and Teva;
received grant support from Janssen and Takeda; and holds stock options
in LB Pharma. PG received fees for presentations at congresses or
participation in scientific boards from Alcediag-Alcen, Angelini,
GlaxoSmithKline, Janssen, Lundbeck, Otsuka, SAGE, and Servier.
EYHC reports grants from Janssen and Otsuka; personal fees and
non-financial support from Janssen, Otsuka, and DSK BioPharma;
and received support for a psychoeducation programme from Janssen and
DSK BioPharma. JHK reports personal fees from AstraZeneca, Biogen,
Biomedisyn, Bionomics, Boehringer Ingelheim, COMPASS Pathways,
Concert, Epiodyne, EpiVario, Heptares, Janssen Research & Development,
Perception Neuroscience, Spring Care, Sunovion, Takeda, Taisho, Bioasis,
Biohaven, BioXcel, BlackThorn Therapeutics, Cadent Therapeutics,
Cerevel Therapeutics, Lohocla, Novartis, PsychoGenics, and Biological
Psychiatry; holds stock in Biohaven, Sage, and Spring Care; holds stock
options in Biohaven, BlackThorn Therapeutics, EpiVario, and Terran Life
Sciences; has served as a consultant for Otsuka; and has served on science
advisory boards for Terran Life Sciences. Additionally, JHK holds patents
related to the treatment of mental disorders (US patent numbers 5 447 948
and 8 778 979 B2; US application numbers 14/197 767, 14/197.767;
provisional use patent application number 61/973/961; and US Patent and
Trademark Office docket number Y0087.70116US00), and two other
patents are pending (US provisional patent application numbers
62/444 552 and 62/719 935). JL has received grants and non-financial
support from Alkermes, Boehringer Ingelheim, Lilly/DeNovo, Teva, and
Taisho, non-financial support from Alkermes, Boehringer Ingelheim,
IntraCellular Therapies, Karuna, Lilly/DeNovo, Pierre Fabre, Teva, and
Taisho, and medication supplies for investigator-initiated research from
Lilly/DeNovo; has served as an advisory board member for IntraCellular
Therapies, Karuna, and Pierre Fabre; and has a patent to Repligen issued.
HU reports grants and personal fees from Eisai, Otsuka, Sumitomo
Dainippon, and Meiji-Seika. EV reports personal fees from Abbott,
Allergan, Angelini, Janssen, Lundbeck, Sage, and Sanofi, and grants from
Sumitomo Dainippon, Ferrer, and Janssen. AV reports personal fees from
Angelini, Innovapharma, Janssen-Cilag, Lundbeck, Otsuka, and
Recordati, and grants from Boehringer Ingelheim, Janssen-Cilag,
Lundbeck, Otsuka, and Takeda. CA reports personal fees from Acadia,
Angelini, Gedeon Richter, Janssen Cilag, Lundbeck, Minerva, Otsuka,
Roche, Sage, Servier, Shire, Schering Plough, Sumitomo Dainippon,
Sunovion, and Takeda. All other authors declare no competing interests.
Acknowledgments
CM and CA are co-financed by the European Regional Development Fund;
have received support from the Spanish Ministry of Science and
Innovation, Instituto de Salud Carlos III (SAM16PE07CP1, PI16/02012,
PI17/02227, and PI19/024), the European Commission; CIBERSAM, the
Madrid Regional Government (B2017/BMD-3740 AGES-CM-2), Fundación
Familia Alonso, Fundación Alicia Koplowitz, and Fundación Mutua
Madrileña; and have received European Union Structural Funds via the
European Union Seventh Framework (FP7-4-HEALTH-2009-2.2.1-2-241909,
FP7-HEALTH-2013-2.2.1-2-603196, and FP7-HEALTH-2013-2.2.1-2-602478)
and the European Union H2020 programme under the Innovative
Medicines Initiative 2 Joint Undertaking (115916 and 777394).
TW acknowledges support from the National Institute for Health Research
Maudsley Biomedical Research Centre at the South London and Maudsley
NHS Foundation Trust and King’s College London (IS-BRC-1215-20018)
and the National Institute for Health Research Senior Investigator Award
(NF-SI-0514-10028). MRP acknowledges support from the National Natural
Science Foundation of China (81371502 and 81761128031).
EV acknowledges the support of the Spanish Ministry of Science and
Innovation (PI15/00283 and PI18/00805), funding that was integrated into
the Plan Nacional de I+D+I and co-financed by the ISCIII—Subdirección
General de Evaluación and the Fondo Europeo de Desarrollo Regional;
the Instituto de Salud Carlos III; CIBERSAM; the Secretaria d’Universitats
i Recerca del Departament d’Economia i Coneixement (2017 SGR 1365);
the CERCA Programme; and the Departament de Salut de la Generalitat
de Catalunya (PERIS grant SLT006/17/00357). MC is supported by a
European Research Council Consolidator Award (iHear 724809).
We acknowledge Giulia Maria Giordano (University of Campania
“Luigi Vanvitelli”, Naples, Italy) and Pasquale Pezzella (University of
Campania “Luigi Vanvitelli”, Naples, Italy).
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© 2020 Elsevier Ltd. All rights reserved.
Introduction
Potential consequences of COVID-19 for mental health
General public
People who have or had COVID-19
People with pre-existing mental health disorders
Health-care workers
Mental health service responses to COVID-19
Public mental health responses and community outreach
Mental health-care settings
Mental health needs of special populations
Sustainable adaptations of mental health delivery
Ethics-driven and rights-driven considerations
Service user knowledge and involvement
Longer-term mental health needs
Remote therapy
Ways of working
Assessment of mental health outcomes in clinical practice
Conclusion
Acknowledgments
References
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