Community Mental Health Interventions during the COVID-19 Pandemic

The Corona Virus Disease 2019 (COVID-19) pandemic has disrupted or halted critical community mental health services in 93% of countries worldwide while the demand for mental health is increasing, according to a new World Health Organization (WHO) survey [1]. This comes at a time when an essential part of the strategy for tackling the COVID-19 infection has been self-isolation and social distancing to protect from the risk of infection and minimize spread. It is important that the population’s mental health as well as physical health is prioritized at this time. Many people are understandably worried by the current situation and may feel frightened of COVID-19, confused, anxious, or low. Others have suffered deterioration in pre-existing mental illness, while some developed new mental health issues related to lock-down rules and restrictions applied across many countries. During such times, the symptoms of depression and anxiety can often go undetected, but the impact on an individual and their loved ones must not be underestimated. We report on changes implemented in our Primary care setting during the COVID-19 pandemic to help address mental health issues in the community. Screening of all patients for anxiety and depression using the validated tools of Generalized Anxiety Disorder 2-item (GAD2) and Patient Health Questionnaire (PHQ2) questionnaires at every clinical encounter with a doctor or nurse enabled early identification of mental health concerns, and appropriate early support. Additionally, availability of easy and no-cost accessible Mental Health telephone helplines during the COVID-19 pandemic helped reduce the mental health implications caused by the lack of face to face access to Primary care services.


GAD2; Primary care; PHQ2
Background COVID-19 has affected face-to-face access to General Practitioners (GPs) and Family doctors for patients around the world. Taking care of vulnerable patients has never been more important. The WHO global estimates suggest that mental disorders affect more than 1 in 4 people in the course of their lives and 1 in 10 adults at any time. The community setting of primary care is often the best site where most mental illness is identified, and indeed treated [2].
World Health Organization (WHO) and World Organization of Family Doctors (WONCA) joint report by Funk and Ivbijaro, [3] " Integrating Mental Health into Primary care: a global perspective" compared best practices in mental health across primary care settings across the globe, highlighting importance and reasons for integrating mental health into primary care [1].
Over the last 10 years the population of Qatar where we practice has risen rapidly to over 2.75 million, with expatriates making up over 80% of the country population. Primary health care services are provided by 28 Primary health care centers (PHCC) and the secondary care hub for the country is operated by Hamad Medical Corporation (HMC).
According to the 2011 Department of Mental health and Substance Misuse-Mental Health Atlas data [4], the WHO in 2008 estimated that neuropsychiatric disorders contribute to 20.8% of the global burden of disease in Qatar, but suicide rates data were not yet available. The Mental Health Atlas report in 2011 on Qatar, also confirmed no data was available in the country on the family and care support systems for people suffering with mental illness at the time, and that psychotropic medication prescribing was mainly initiated in secondary care. Until recently, there has been lack of accessible services in the Primary care health setting for mental health issues within the Middle East. This could be partly due to cultural and social barriers preventing patients seeking help for mental health from primary care or family doctors [6,7]. With globalization and increasing internet access, as all over the world, access to health care information is now easier. Mental illness is not the taboo it once was, and over the past decade the Middle East region has seen improved access to mental health services, and levels of stigma reduction related to Mental illness.

Discussion of Community-Based Interventions
Our health center has around 36 Full Time Equivalent GPs covering a population of 100,000 patients. During the COVID-19 pandemic, patients receiving telephone consultations would not always speak to their named GP. Most patients understood given the scale of the worldwide pandemic.
Some populations will suffer more from this lack of face to face access to their usual doctor, including vulnerable patients who find it difficult to develop a relationship with their GP. In some situations, it has taken years for the patients to reach the level of trust they have with us.
Fear, worry, and stress are normal responses to perceived or real threats, and at times when we are faced with uncertainty or the unknown. So, it is normal and understandable to experience fear in the context of the COVID-19 pandemic. According to the WHO, the COVID-19 pandemic has disrupted or halted critical mental health services in 93% of countries worldwide while the demand for mental health is increasing [1]. A recent report by the National Health Service (NHS) Confederation in the United Kingdom flagged isolation, substance use, domestic violence and economic uncertainty as factors that might contribute to the need for extra support [8].
As two colleagues with a special interest in Mental Health in primary care, we shared a responsibility for early identification of mental health problems.
The first key initiative implemented in our community setting since the start of the pandemic is that in our Practice, doctors and nurses were encouraged to screen all patients for anxiety and depression using GAD2 and PHQ2 questionnaire. This enabled early identification and access to support. The 2-item Generalized Anxiety Disorder scale ( Figure 1) had high sensitivity and specificity for detecting GAD in primary care [9]. Using a cutoff of 3 the GAD2 has a sensitivity of 86% and specificity of 83% for diagnosis generalized anxiety disorder [10]. The Patient Health Questionnaire (PHQ-2) (Figure 2) is also a commonly used and validated screening tools with excellent sensitivity, essential for any screening tool. The PHQ-2 has a 97 percent sensitivity and 67 percent specificity in adults, whereas the PHQ-9 has a 61 percent sensitivity and 94 percent specificity in adults [11].  The second community intervention involved collaboration between The Ministry of Public Health, The Primary Health Care Corporation, and The Mental Health Service in Hamad Medical Corporation. A new free-call helpline was launched to provide support for people experiencing mental health problems as a result of the current COVID-19 pandemic. Patients with or without a history of mental illness, and indeed health care staff or caregivers with any worries about COVID-19 and the lockdown, or those feeling increased stress could call the helpline. Calls are answered by a team of mental health professionals who provide assessment and support to callers triaged as four main categories: Children and parents, adults, older people, and frontline healthcare workers [12]. Qatar's population is made up of over 80% expatriates, and while most speak English, Mental health staff manning the helpline speak a range of languages and every effort is made to enable callers to communicate in their first language of choice, where possible.
In our practice, patients positive on GAD2 or PHQ2 screening were offered additional support via the aforementioned national mental health helpline. Additional Tele-Psychiatry support is available for patients needing expert input following initial consultation via the hotline. Access to medication was available in health centres that provided face to face consultations if required. Primary and community care teams have been very proactive with regards to mental health promotion during COVID-19 pandemic.

Conclusion
Factors such as screening, accessible counselling services, streamlined mental health guidelines, prescribing, and increased patient awareness within primary care can have a positive effect in reducing the burden on psychiatric secondary care services. When this is part of a bigger programme of integrating Mental Health services into the community and primary care then this is more likely to have a beneficial public health effect.
Family doctors in Primary care are equipped with knowledge and training to deal with mild to moderate cases of anxiety and depression without the need for patients to be referred to secondary care psychiatric services. When equipped with additional resources such as the helpline or access to community based Cognitive Behavioural Therapy (CBT), patient outcomes are likely to improve still further. It is also important for better continuity of care to encourage patients to seek help in their usual GP setting with the doctor and team they are used to. GPs in the community have an even more vital role during exceptional situations such as the COVID-19 pandemic, when access to services may be limited or difficult. Integrating social care and substance misuse services into primary care is also important [13].
In our practice, during the pandemic, the two communitybased interventions highlighted the important mental health role of primary care. Using simple screening questionnaires for each patient allowed the opening of a discussion regarding mental health and wellbeing, where the opportunity may not have otherwise arose. Along with providing a free and accessible telephone helpline giving patients the option of seeking advice anonymously if they wished. The helpline also provided an outlet for underpressure front-line staff to access assistance for themselves or their patients from any place and at any time [14].
The mental health service provision described above in our practice was advertised internally and externally, utilizing carefully designed mental health prevention and promotion messages to reduce stigma and improve access to mental health services. The overall goal was to increase screening for anxiety and depression during the COVID-19 pandemic, while maintaining the strategic aims of integrating mental health care into the community primary care setting, and increasing public awareness of mental health and well-being which will drive change and inform future service improvements.