Community-based decentralized mental health services are essential to prevent the epidemic turn of post-Covid mental disorders in Bangladesh: A call to action.

Abstract

The number of people suffering from mental illnesses has increased across the world.1-5 Mental health has become an important issue than ever during the ongoing Covid-19 pandemic.6-9 The pandemic has tremendously affected the health and life of people across the world. The prevalence of anxiety and depression has increased by 25% due to the Covid-19 pandemic worldwide.10 The European Union (EU) countries reported mental disorders ranging from 16.1% to 54.8% since the beginning of the ongoing Covid-19 pandemic.11 Factors associated with the poor mental health of people in 26 European countries were female sex, scarcity of healthcare services, financial crisis, and job loss during the Covid-19 pandemic.11 Moreover, a meta-analysis reported that both sexes have similar infection rates; however, the increased severity and mortality due to Covid-19 were associated with the male sex.12 Another meta-analysis showed that people aged 70 years or more have a higher risk of infection, a higher risk of developing severe symptoms, a higher need for intensive care support, and a higher risk of mortality than individuals under 70.13 As a developing country in South East Asia, many people in Bangladesh have lost their jobs and income sources during the Covid-19 pandemic. Unemployment and poverty have increased throughout the country due to pandemic effects.14 Also, additional fear of getting infected, death of close relatives and family members, and altered lifestyle to manage the pandemic crisis severely impacted the mental health of people across the globe.15-20 We reported in our previous study that the prevalence of different mental disorders ranged from 38% to 73% among the general population in Bangladesh during the Covid-19 pandemic.1, 2 We anticipate that the actual prevalence and gravity of mental disorders are more serious than the reported results. Over the past few decades, the healthcare system across the world has improved to ensure better medical care for people. Medical care is now more self-directed, information is now more accessible, and health-driving factors are now a top priority for global authorities.21 Bangladesh is a densely populated lower-middle-income country in Southeast Asia.22 A door-to-door prevalence survey reported that 18.7% of adults and 12.6% of children met the criteria of mental disorders in Bangladesh. At least 30 million people in Bangladesh have mental disorders.23 Therefore, primary, secondary, and tertiary level mental health services (MHS) are essential in Bangladesh. But the country does not have a structured mental healthcare system. In Bangladesh, mental health professionals (MHP) include psychiatrists, nurses, clinical psychologists, and counseling psychologists.24 The country has about 260 psychiatrists (0.16/100,000 population) that are only one psychiatrist for every 300,000 people seeking MHS. Moreover, 700 nurses (0.4/100,000 population) and 565 psychologists (0.34/100,000 population) are working at mental health specialty care hospitals. The total number of people involved in MHS is less than 1000 against 162 million population. Due to the severely low and city-centric mental health care system, general people cannot afford the necessary medical care for their mental health in Bangladesh. There are 36 government medical colleges in Bangladesh. Among them, 16 have no mental health or psychiatry department.25 Therefore, the undergraduate medical curriculum (MBBS) does not include adequate psychiatry learning and assessment contents. And so many new doctors are finishing their MBBS degree without completing some fundamental courses on mental health. Also, the expenditure on mental health is roughly 0.05% of the total health budget in Bangladesh.21 However, the study says that depression will be the biggest obstacle to human productivity by 2030.26 Moreover, a study reported that the prevalence of loneliness, depressive symptoms, generalized anxiety disorder, and sleep disturbance among the healthcare professionals (HCPs) in Bangladesh were 89%, 44%, 78%, and 87% during the early stage of Covid-19 pandemic.8 Therefore, early intervention can prevent the epidemic turn of mental health problems in Bangladesh during and after the ongoing Covid-19 pandemic. At first, we should recognize mental illness as a disease and ensure the treatment of patients seriously. Bangladesh should take necessary short and long-term plans to face the upcoming mental health problems.27-30 The establishment of the National Institute of Mental Health in the capital city in 2001 was a milestone for MHS in Bangladesh. However, a specific and robust mental health policy is absent in Bangladesh.31 Therefore, we recommend the policymakers formulate a robust mental health care policy in Bangladesh as well as other low-income countries focusing on a decentralized and community-based approach. Also, the authority should establish mental health or psychiatry departments in every government and nongovernment medical college for institutional training of healthcare providers on MHS. This initiative might help to increase the number of psychiatrists and psychiatric trainees in Bangladesh. The authority can offer courses on MHS from different tertiary level educational institutions to ensure adequate mental health or psychiatric trainees at the community level. The availability of MHS at the community level would reduce the burden at tertiary care centers to ensure the quality of MHS in Bangladesh. The healthcare authority can introduce specialized psychosocial interventions at district-level hospitals. Also, they can imply a referral system to ensure the quality and availability of MHS in Bangladesh. Moreover, increments of mental illness are usual during disease outbreaks, and the Covid-19 pandemic has created barriers to mental healthcare interventions.32, 33 The leading international academic organizations that have expertise in mental health interventions are recommended to share their experiences and guidelines with low- and middle-income countries to tackle the mental health crisis followed by the Covid-19 pandemic.34 We can prevent mental illness by taking proper care of our mental health. Awareness and cooperation can make an outstanding contribution in this regard. However, social stigma is a barrier to sharing and discussing mental health issues in Bangladesh.35 Therefore, knowing the correct information from MHP and informing others might help to reduce this social stigma. Authorities can organize workshops and training sessions on mental health in educational institutions, offices, or workplaces involving MHP. Also, the healthcare authority can involve religious leaders, teachers, and local government opinion leaders to promote mental health. The healthcare authorities should increase the scope of mental health screening at community levels. The government authorities should ensure primary MHS at different government and nongovernment hospitals. In Bangladesh, the resources available for MHS are limited. But everyone has the right to get proper care of their mental health. Technology has spread over the country, and most people in Bangladesh have access to it.36, 37 Some earlier studies suggested that MHP must raise their voices in the scientific outlets as well as in public discussions through airwaves.38 The authority can utilize technology to ensure good mental health for all. Using this widespread information technology, they can provide app-based mental health care in underserved areas. Also, the telemedicine system would be an option to provide psychological services to the people at the rural level. Regular monitoring and follow-up with online prescription can spread the MHS at the door-steps of people in Bangladesh. Researchers, mental healthcare workers, health authorities, and policymakers jointly can ensure community-based decentralized mental healthcare services to prevent the epidemic turn of post-Covid mental health disorders and promote good mental in Bangladesh. The global healthcare authorities are overburdened with ensuring adequate MHS to the general population during the ongoing Covid-19 pandemic. Mental health problems have tremendously increased across the world. We are anticipating that there is a chance for an epidemic turn of post-Covid mental disorders. Poor and developing countries are fighting with limited healthcare resources and infrastructures against this increased mental health burden. Bangladesh is a developing country with a high population and limited healthcare infrastructure and support. Therefore, authorities should be prudent in utilizing their healthcare resources. The authorities in Bangladesh can extend MHS to divisions, districts, thanas, and community levels in rural and urban areas. For this decentralization of mental healthcare services, they should integrate MHS with the primary healthcare infrastructure using the existing healthcare delivery system. The authority can set up dedicated mental health service centers for high-risk and vulnerable populations. Also, they can utilize digital platforms to increase the easy access of rural people to MHS. Md. Rabiul Islam: Conceptualization; writing – original draft. Mohammad Saydur Rahman: Conceptualization; writing – original draft. MMA Shalahuddin Qusar: Conceptualization; writing – review and editing. The authors declare no conflicts of interest. The ethics statement is not available. The lead author affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.