Escola Paulista de Medicina
Postgraduate in Collective Health

Translating science into policy: mental health challenges during the COVID-19 pandemic


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Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has affected millions of people worldwide, imposed major burdens on all health systems, and become an unprecedented challenge to a whole generation. Brazil is a continental country with an estimated population of more than 200 million, diverse geographic regional realities, and alarming social inequality. The disease dissemination path illustrates Brazil’s diversity: it first struck urban areas and then spread to more rural areas, ultimately reaching even isolated indigenous populations. Inequality is also reflected by the effects of the pandemic; differences in contamination rates and mortality suggest distinct disease patterns.1 The initial measures aimed at controlling disease spread and establishing infrastructure to deal with more severe clinical cases. However, the perspective of mental health suffering and psychiatric morbidity caused by pandemic, and compounded by the effects of quarantine, social isolation, and economic crisis, has received comparatively little attention.

In the case of these intriguing biological organisms designated “human beings” the symbolic order must necessarily be included. So, the series (organism-group-population-environment) can be read as (subject-family-society-culture). The first order can be termed the “biodemographic” hierarchy, and the second, the “sociocultural” hierarchy.2,3 Mental disorders, for example, are a consequence of biological and sociocultural-environmental interactions, and the pandemic created an imbalance between risk and protective factors, exacerbating many existing risk factors and generating additional ones. Despite the challenges posed by this new, unprecedented reality,4 it could be catalytic in improving the way health systems and society are organized to protect and promote vulnerable populations’ mental health. Population health science focuses on pervasive, ubiquitous factors and how their distribution shapes individual health within and across populations. The case for applying this approach to the field of mental health has been made with the rationale that even small changes in upstream, macrosocial factors can substantially impact the health of populations. Thus, every scenario requires specific solutions, while balancing best-evidence practices and available resources.

COVID-19 should therefore be viewed and addressed from a syndemic approach, acknowledging the importance of biological and social interactions for prognosis, treatment, and health policy.5 For instance, available evidence has already identified a threefold increase in psychological distress, loneliness, and depression symptoms in the United States.6,7 Considering the syndemic effect of social determinants on heath, a recent online survey was conducted with a convenience snowball sample of essential workers from Brazil and Spain (n=3,745), and found a high prevalence of depression and anxiety (27.4%), largely and closely associated with social inequalities.8 Social isolation due to quarantining and self-isolation has been devastating for everyone, but especially for the vulnerable, such as those with severe mental disorders,9 who experience additional anxiety and distress in response to changes caused by the pandemic. Even food security was a major problem, as many patients had no means to eating properly during the pandemic.10

Children and adolescents are the least affected group in terms of direct clinical outcomes resulting from the COVID-19 pandemic, but paradoxically, they likely constitute the most vulnerable group regarding potential psychological consequences of pandemic-related family/societal disruptions.11 Physical distancing, school closures, economic losses, and the unemployment of parents/caregivers have negatively impacted the social, educational, and emotional support systems that children and adolescents typically rely on, even during emergencies.12

Within this multifaceted scenario, how will Brazil, one of the countries most affected by COVID-19 and struggling with health care deficits even before the pandemic, cope with such a challenge? All these pressing needs are a call for the adoption of new technologies and more rational use of resources. The Brazilian Unified Health System (Sistema Único de Saúde, SUS) is unprepared to handle the oncoming mental health crisis, but the population has never needed mental health care as much as it does now. Thus, we aim to present recommendations to policy-makers regarding the future of mental health by taking Brazil as an example of the challenges that have emerged during the pandemic, by making the best use of available human resources, innovative technologies, and the reorganization of mental health services.

Professora Zila van der Meer Sanchez Dutenhefner

Publicado em REVISTA BRASILEIRA DE PSIQUIATRIA, v. 43, p. ahead of print, 2021.

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