Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138
Mental health policy reactions during the first year
of the COVID-19 pandemic in two worst-hit WHO
European countries: a narrative review and
lessons for the aftermath of mental health care.
Ekin Dagistan
European Student Think Tank, Public Health and Policy Working Group, Amsterdam, Netherlands
French School of Public Health (Ecole des Hautes Etudes en Santé Publique), Paris, France
Address for correspondence:
Ekin Dagistan, French School of Public Health (Ecole des Hautes Etudes en Santé
Publique), Paris, France. Email: edagistan@gmail.com
This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0 International
License (CC BY-NC 4.0).
©Copyright: Dagistan, 2022
Publisher: Sciendo (De Gruyter)
DOI: https://doi.org/10.56508/mhgcj.v5i2.141
Submitted for publication: 17
May 2022
Revised: 28 July 2022
Accepted for publication: 27
August 2022
Introduction
The COVID-19 pandemic has been
challenging the regional and global health care
systems unprecedentedly since it started more
than two years ago. Mental health care systems
and public well-being have also been taken a toll
due to the pandemic-related regulations and
socio-economic era (Racine et al., 2021).
Psychological well-being is strongly connected
to various personal, interpersonal and economic
elements such as financial situation, employment
status, physical well-being, and sufficient human
interaction (Kaplan et al., 2008; Santini et al.,
2020; Romash, 2020; Romash et al, 2022). These
elements have been affected drastically during the
Mental Health: Global Challenges Journal
https://www.sciendo.com/journal/MHGCJ ISSN 2612-2138
pandemic. Consequently, according to the
Organisation for Economic Co-operation and
Development (OECD), the prevalence of anxiety
and depressive disorders increased in many
countries in 2020 (OECD, 2021b). This increase
can be considered as response to an unexpected
disaster; nonetheless, the long and medium-term
effects of the pandemic are likely to become
detrimental to public mental health.
Due to the aforementioned concerns, the
governments immediately mobilised their mental
health policy strategies against the rapidly
progressing pandemic. As anticipated, many
studies hitherto showed that both the pandemic
and public health measures provoked distress
amongst various populations (Mental Health and
COVID-19, 2022; Racine et al., 2021).
According to the World Health Organization
(WHO) data, The United Kingdom (UK) and
Turkiye were two of the countries worst hit by the
pandemic in the WHO European region during the
first year of the pandemic (WHO Coronavirus
(COVID-19) Dashboard, 2021). The tsunami
effect of this disaster has been felt almost in every
part of the world, yet the populations of these
countries became more susceptible in terms of
having insufficient healthcare and lack of support
for their well-being.
A snapshot of pre-COVID conditions and
COVID-related fiscal and lockdown policies in
Turkiye and the UK
The pandemic hit hard the healthcare systems
all around the world, regardless of the income
levels of the countries. This section provides data
about the pre-pandemic conditions and COVID-
related measures of the two countries.
In 2017, the gross domestic product (GDP)
level per capita was equal to 10,591 US Dollars
($) in Turkiye whereas it was $40,361 in the UK.
The UK spent 9,8% of its GDP ($4,070) on its
health care sector, whereas Turkiye managed to
allocate 4,2% of its GDP ($1,227) (Table 1).
Table 1: Summary of Health and Financial Profiles of Turkiye and the United Kingdom
GDP-Gross domestic product,
US $- the United States Dollar
Source: World Bank data (Data for Turkiye, United Kingdom | Data, 2017; World Bank Country and
Lending Groups – World Bank Data Help Desk, 2021), OECD Health at Glance 2019 (Health at a Glance |
OECD ILibrary, 2019)
The two countries had national mental health
strategies before the pandemic. The UK spent
179,5 the Great British Pound Sterling (GBP) in
terms of the total mental health expenditure per
capita; however, this data was not available for
Turkiye (Table 2).
The density of high-trained mental health
workforce per population in Turkiye was low: 1,64
for psychiatrists and 2,54 for psychologists. On
the other hand, the UK had higher numbers of this
workforce than Turkiye, 11 for psychiatrists and 9
for psychologists. However, not aligned with their
workforce capacity, the burden of mental health
conditions was higher in Turkiye than in the UK;
3,433 and 2,115, respectively (Table 2).
Mental Health: Global Challenges Journal
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Table 2: Mental health profiles in the two countries
EUR- Euro, GBP- the British Pound Sterling,
*Data calculated from the numbers found in the sources
Source: WHO Mental Health Atlas 2017 (Mental Health Atlas 2017, 2018)
Restriction measurements and fiscal support
schemes were similar in the countries. However,
financial allocation differed saliently between two
countries. For example, while the UK spent 32%
of its GDP to support its population financially,
Turkiye allocated only roughly 12% of its GDP for
the same purpose. Moreover, 0,3% of Turkiye's
GDP ($2 billion) was spent on the healthcare
sector as a response to the pandemic. This
amount was $145 billion in the UK, equal to 5,3%
of its GDP.
Both countries reacted the pandemic with
travel restrictions, nation-wide curfews, and
transition to teleworking. However, while the UK
permitted solo physical activities during
confinements; these activities were not excluded
from the regulations in Turkiye (Table 3).
Table 3: COVID-related measures in the two countries
GDP: Gross domestic product
Source: IMF (Fiscal Policies Database, 2021; Policy Responses to COVID19, 2021)
Mental Health: Global Challenges Journal
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In 2016, a return on investment study carried
out with 36 countries estimated that every $1
invested in mental health gives a $4 return (Jorm
et al., 2016). Despite this evidence, the budget
allocated for mental health systems has always
been notoriously low to respond to the needs
(World Health Assembly, 2012).
Purpose
This review investigated the mental health-
related policies in the two European countries
worst hit by the pandemic, two countries that also
draw a contrasting pattern of mental health care
systems, sociodemographic background, and
income level. Following this, the paper
recommended possible directions to be pursued
by the European policymakers to foster mental
health care.
It is undeniable that this study cannot cover all
the struggles we face; nonetheless, it will address
the major issues. These directions are also
controversial topics that belong to the
contemporary history of mental healthcare and
would likely to steer the future of it.
Methodology
The documents were picked from the health
policy sections from the websites of international
organizations (European Parliament, OECD,
WHO, UN), online data and policy reports of
national ministerial bodies, and general web
search. English and Turkish sources were
included in this review; “policy”, “mental health”,
“pandemic”, “COVID-19”, “ruh sağlığı”, “pandemi”,
“politika”, and their variations were used in the
general web search process.
The documents were reviewed and the author
identified the main concepts of the responses to
discuss after policy review. These concepts were
as follows: a) continuing service provision for
people with mental health conditions, b) digital
mental health care interventions, c) building
psychological resilience for citizens. The study
was designed as a review; therefore, no statistical
framework was conducted.
Review and Discussion
Mental health policies in Turkiye and UK
Turkiye
Turkiye’s first case emerged relatively later
than those in other European countries; however,
case numbers accelerated gradually, and the
country still tackles several waves of the
pandemic (Turkiye Confirms First Case of
Coronavirus, 2020).
During the initial year of the pandemic, the
Public Health Directorate issued guidelines to limit
the transmission of the virus while maintaining
health care safely (COVID-19 Rehberi [The
COVID-19 Guideline], 2020). These guidelines
included the reorganisation and adaptation of
psychiatric facilities to the situation. Consequently,
a decrease in inpatient and outpatient psychiatric
capacities was observed (Başar, 2020). The
Ministry also arranged telemedicine settings,
including psychological support lines for those
who could not visit health care facilities due to the
acute COVID-19 infection (Dr. E-Pulse: Video Call
Platform, 2020). The Ministry of Health
additionally published recommendations for video
consultation techniques. However, these were not
implemented effectively in public hospitals
because of insufficient infrastructure and supply
(COVID-19 Health System Response Monitor:
Turkiye, 2021).
The Turkish Psychiatric Association (TPA)
provided hotlines for health care workers who
combat the pandemic in the frontline (Türkiye
Psikiyatri Derneği Sağlık Çalışanlarına Destek
Hattı Açıldı! | TÜRKİYE PSİKİYATRİ DERNEĞİ,
2020). Similarly, the Turkish Ministry of Health
also set up regional psychosocial support call
centres for the general population and health care
workforce (81 İl Psikososyal Destek Hat Bilgileri
[Psychosocial Support Line Informations for 81
Cities], 2020).
TPA continued to establish comprehensive
recommendation papers for health care workers,
the mental health workforce, and several
vulnerable groups during the pandemic (‘COVID-
19 Resources’, 2021). These papers addressed
the critical points on mental health care delivery,
telepsychiatry, treatment of mental conditions with
COVID-19 infection, and psychological self-care
techniques (COVID-19 ve Ruh Sağlığı | TÜRKİYE
PSİKİYATRİ DERNEĞİ, 2020). Some of these
recommendations were translated to Arabic or
Kurdish to protect minorities' well-being (‘COVID-
19 Resource Centre’, 2020).
The UK
The UK had to face multiple lockdowns and
waves, which had deteriorating effects on the
psychological state of its population.
Due to the re-purposing of the National Health
Service (NHS) beds to COVID-19 care and the
worsening mental health state of the population,
psychiatric inpatient clinics suffered from bed
shortages and sometimes overwhelming
occupancy (James, 2021). The increased demand
on mental health care were conveyed to
ambulatory and community care settings (The
Impact of COVID-19 on Mental Health Trusts in
the NHS, 2020). On the other hand, mental health
funding saw an increase that helped maintain the
24/7 helpline services, the closure of the outdated
mental health dormitories, and launching physical
screening programs for vulnerable groups
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(COVID-19 Health System Response Monitor:
United Kingdom, 2021).
Several organisations such as the Royal
College of Psychiatrists (RCPsych), and the
British Psychological Society prepared mental
health and COVID-19 sections that target
psychological resilience, the well-being of NHS
staff, digital interventions, ethical issues, and the
problems and solutions about the management of
mental health settings (Covid-19 Resources - The
British Psychological Society, 2021; Responding
to COVID-19 | Royal College of Psychiatrists,
2021). Additionally, major voluntary organisations
such as Mind, and the Mental Health UK shared
their tips on protecting mental health (Coronavirus
- Looking after Your Mental Wellbeing, 2020;
Covid-19 and Your Mental Health, 2020). The
NHS itself also provided novel care approaches,
guidances that depict the pandemic's
psychological effects, and possible behavioural
prevention methods for vulnerable groups (such
as young people, ethnic minorities, people with
long COVID) or those with mental health
conditions (Guidance for Parents and Carers on
Supporting Children and Young People’s Mental
Health and Wellbeing during the Coronavirus
(COVID-19) Pandemic, 2021; Guidance for the
Public on the Mental Health and Wellbeing
Aspects of Coronavirus (COVID-19), 2021).
The pre-existing psychological support lines
and groups of voluntary organisations continued
to provide service (‘Mental Health Helplines and
Services during COVID-19’, 2021). The NHS,
Public Health England (PHE), RCPsych, Mental
Health at Work and Frontline19 launched
psychological support lines, counselling and
therapy services for the NHS staff (Frontline19,
2020; NHS England » Health and Wellbeing
Programmes, 2020; ‘Our Frontline’, 2020;
Psychiatrists’ Support Service (PSS) | Royal
College of Psychiatrists, 2020).
Vis-à-vis mental health care was replaced with
video or telephone consultations; however,
physical appointments were also provided for
those who need them. The NHS and the RCPsych
issued guidelines for structuring the fundamentals
of telemedicine (COVID-19 - Working in
Secondary and Specialist Mental Health Settings|
Royal College of Psychiatrists, 2020; Digital -
COVID-19 Guidance for Clinicians | Royal College
of Psychiatrists, 2020; IAPT Guide for Delivering
Treatment Remotely during the Coronavirus
Pandemic, 2020).
In March 2021, the government released an
action plan that involves a multi-disciplinary
recovery approach for mental health care and
public well-being (COVID-19 Mental Health and
Wellbeing Recovery Action Plan, 2021).
Since the early era of the pandemic, the PHE
has been monitoring public mental health
reactions and well-being with surveillance reports,
academic research compilations, and evaluating
the frequency of telesupport service use (COVID-
19 Mental Health and Wellbeing Surveillance,
2020). In addition, several vocational organs and
universities also launched independent surveys or
studies to evaluate public mental health and the
psychological effects of the COVID-19 infection
(COVID-19 Surveys and Research | Royal
College of Psychiatrists, 2021).
The future of mental health care
There is not a one-and-only mental health care
approach which could be applied to every country
because of such differences in the level of
resources, cultural diversities or socioeconomic
structure (Knapp et al., 2007). However, as the
current situation helped draw attention and
funding to mental health, the pandemic could
positively transform this field instead of adding
insult to injury.
The mental health interventions taken by these
countries can be summarised in three concepts:
a) continuing service provision for people with
mental health conditions, b) digital mental health
care interventions, c) building psychological
resilience.
Continuing service provision for people
with mental health conditions
People with mental health conditions suffered
from service disruptions during the pandemic.
According to a WHO survey in 2020, more than
90% of the European countries reported that
essential mental health services had taken a toll.
Globally speaking, this rate was above 90% for
the middle or high-income countries (‘The Impact
of COVID-19 on Mental, Neurological and
Substance Use Services: Results of a Rapid
Assessment’, 2020).
Traditional mental health services are often
criticised because of their inhumane and
ostracising structure (Cohen & Minas, 2017). For
many years, Western European countries have
been designing a stepped-care approach that
improves multi-disciplinary approach including
social care and mental health organisations
instead of institutionalisation. The fruits of these
reforms can be seen in the example of the UK.
Both countries had to reduce their psychiatric
inpatient and outpatient bed capacity during the
pandemic; however, the community and
ambulatory care systems in the UK attempted to
manage this deficit with collateral wellbeing and
social care organisations. These settings aid
various vulnerable groups such as adolescents,
people with suicidal thoughts, severe mental
health conditions or in isolated settings (NHS
England » Crisis and Acute Mental Health
Services, 2021). Despite the leveraging role of
these organitsations, the UK still suffered from
shortages and insufficient care delivery (Campbell
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& editor, 2019). Looking at the current picture, it
can be argued that more funding will be needed to
face the tertiary psychological effects of the
pandemic.
The pandemic could hold a role as an
accelerating factor for funding deinstitutionalised
care. However, various WHO European countries
still tend to spend most of their mental health
budgets to traditional institutions (World Health
Organization, 2009). These facilities do not
possess evidence-based interventions compared
to other integrated models of mental health care
(Eaton et al., 2011). Community-based
intervention models seem to be both effective and
self-financing on bringing mental health care
(Knapp et al., 2011). The demand for the
treatment for mental health is likely to increase in
the near future, and this single-layered system
alone is no suitable to shoulder the forthcoming
turbulence (COVID-19 Mental Health and
Wellbeing Recovery Action Plan, 2021). An easily
accessible, multi-disciplinary and stigma-free care
environment could break this vicious cycle and
engage more users in prospect. There is a need
for novel national mental health strategy plans
taking post-COVID concerns into account for
WHO European region countries.
Specialised outpatient facilities have also taken
a hit during the pandemic. This hit led to
digitalisation in mental health care as much as
applicable; on the other hand, countries like
Turkiye (lower amount of qualified mental health
workers, means of providing multi-disciplinary
approach, and allocated budget for mental health)
have become vulnerable in terms of providing
sufficient outpatient care. It should also be noted
that primary care integrated referral system and
mental health integrated primary care are absent
in Turkiye, and specialized facilities are the central
pillar for any type of treatment ranging from mild
depression to severe schizophrenia (Table 2).
Therefore, mid- and long-term policies which aim
to prevent congestions in outpatient settings must
be considered before facing the long
consequences of the pandemic.
Particularly for Turkiye and countries with
similar profiles, it is vital to identify risk factors and
plan cost-effective intervention and prevention
methods to minimize specialized care saturation.
It is known that mental health care in primary
settings is more reachable by the population
(Yeung et al., 2004). Cost-effectiveness and
clinical-effectiveness studies also demonstrate
these settings are applicable and sustainable
(Mens et al., 2018; Rost et al., 2004). Turkiye and
alike countries might not have sufficient workforce
resource to fully integrate mental healthcare
provision to primary care; however, prevention
strategies such as increasing awareness between
primary healthcare workers might help overcome
the overwhelming demand on specialised care for
easily treatable psychiatric conditions.
Digital mental health care interventions
The digitalization of medicine had already
begun before the pandemic. Nonetheless, its pace
skyrocketed with regards to a mandatory need
(OECD/European Union, 2020). The elements of
psychiatric care such as psychological therapies,
consultations or evaluations also quickly adapted
to the situation.
The prosperity of digital therapies and
smartphone apps carries a double-edged position
while it also facilitates populations to reach
treatment. Firstly, this expanding marketplace
could become a nest for unapproved methods
(Terry & Gunter, 2018). For instance, a study from
2019 showed that top-mental health apps tend to
use scientific language to evoke population,
without the lack of adequate evidence on their
effectiveness (Larsen et al., 2019). Morover, the
rate of free iPhone anxiety-targeted apps built with
evidence-based approaches was found to be very
low (Kertz et al., 2017). Secondly, the care
provided by these apps was found to be lacking
from emotional support, distracting from real life,
and yielding misinterpretations in care seekers
about themselves (Estrada Martinez De Alva et
al., 2015). Hence, it is crucial to strengthen these
interventions with convenient research studies
and combine them with face-to-face methods
when needed.
Ethical issues regarding data safety,
transparency or patient confidentiality are other
main concerns reported by healthcare workers
(Stoll et al., 2020). These concerns are bilateral in
carer taker and care seeker relationship, and
government and vocational organs should act
collaboratively in order to regulate this area.
Telemedicine helped providing care in the UK;
on the other hand, the lack of telemedicine
settings in public hospitals in Turkiye pushed
citizens to postpone their needs due to fear of
transmission and decreased face-to-face
appointment options. The gap between these two
countries indicate that digital infrastructure of
health care should be promoted and supported
across the WHO European region.
Building psychological resilience
The two countries attempted to mitigate the
immediate psychological shock of the pandemic in
varying degrees by enhancing pre-existing
infrastructures or implementing novel strategies.
Albeit, medium- and long-term effects of the
pandemic will continue to challenge mental health
wellbeing and related areas. Public or individual
well-being are bound to many social determinants,
and stakeholders need to follow a multi-systemic,
multi-disciplinary pathway in order to protect both
individual and public wellbeing (World Health
Organization and Calouste Gulbenkian
Foundation, 2014). Mental health distress could
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metamorphise to mental health conditions, if not
acted thoroughly.
Turkiye and the UK implemented several
measures in order to protect economic stability.
However, many studies in contemporary history
showed that economic shocks are likely to trigger
their detrimental psychological effects during
tertiary phase. These shocks impact mental health
in the long term due to economic instability, job
loss, uncertainty and other factors (McDaid, 2017;
Paul & Moser, 2009). It should be therefore kept
in mind that even when the pandemic settles,
time-delayed economic effects will cause
challenging consequences in public mental health.
This becomes extremely important when the
current economic instability and increased cost of
living within the European Union are considered
(EA and EU Economic Snapshot - OECD, 2022).
European policymakers should take into account
that the monitorisation of suicide rates, levels of
depression, anxiety, or substance use is
particularly essential in vulnerable economic
settings.
A study from the Netherlands shows that
people without mental health conditions had a
greater negative impact on their mental well-being
than those with pre-existing mental health
conditions during the first year of the pandemic
(Pan et al., 2021). The most affected groups
consisted of ethnic or racial minorities, women,
people with low-income, students, young or
elderly people (OECD, 2021a, 2021b; Saladino et
al., 2020; Tai et al., 2021). This deteriorating
effect was also present in the English population
demonstrated by the surveillance reports of the
Public Health England (Public Health England,
2020b, 2020a). Such reports and studies indicate
that governments should strengthen their hands to
protect general and vulnerable populations. Key
organisations such as independent bodies, local
governments or initiatives have already been
promoting self-help techniques, peer support
groups, psychological first aid teams or hotlines in
Western countries. In other WHO European
countries, where these organisations are absent
or less active, the deficit can be filled by using key
community members as pillars. Micro- or meso-
level actors could stem from backgrounds such as
religious leaders, union members, managers,
school teachers or local authorities, as the studies
show that these actors are extremely beneficial in
community-based mental healthcare (The
Community Mental Health Framework for Adults
and Older Adults, 2019). According to a study,
religious/spiritual advisors were seen by 35% of
treatment-seeking Asian Americans with a lifetime
mental disorder (John & Williams, 2013). Another
study from the United States also indicated that at
least 57,3% of respondents with mental health
disorders first contacted professionals not working
in mental health area (Wang et al., 2003). Training
the actors from these settings could help monitor,
identify, or control mental distress levels
effectively whereas preventing unnecessary
specialised or primary care consultations.
A Eurofund report from 2017 showed that
remote workers tend to spend more time on work
than those in offices, possibly due to uncertain
working hours (Eurofound and the International
Labour Office, 2017). This impact could become a
risk for working population as the pandemic
catalysed the shift to teleworking rapidly
(European Commission, 2020). According to the
OECD data, the high prevalence of mental health
conditions among the working-age population is
linked to the high economic cost of mental health
conditions (OECD, 2020). Countries with middle-
or high-income, namely most Western countries,
should regularly monitor the mental
consequences of teleworking in terms of
increased loneliness, isolation and burn-out.
The need to address migration-related mental
health issues is increasing as the world has been
seeing the highest numbers of human migration in
the latest years (Jennings, 2011). Unsurprisingly,
the pandemic and migration carry the same
devastating effects: loneliness, feeling of isolation,
discrimination (for instance, racist accusations
about the origin of COVID-19) (Banerjee & Rai,
2020; Fernández et al., 2017). Therefore, the
countries with a higher density of refugee or
immigrated population, notably Western European
countries or countries that have land frontiers with
war territories, should particularly pay attention to
these adverse psychological effects which could
stem from the combination of immigration and the
pandemic (Foad et al., 2015).
Conclusions
The concepts mentioned above and
recommendations reflect the future directions for
mental health policies. Uniquely, they entail a
cross-sectoral structure, namely the "mental
health in all policies” approach, which includes
areas such as technology, healthcare, labour, and
economy (Mental Health In All Policies » Mental
Health and Wellbeing, 2013). A public health
strategy ignoring these areas and only focusing
on treating mental health conditions will not be
sustainable in delivering healthcare during the
post-pandemic era. As the pandemic and its
consequences reshape our society, it is essential
to address these issues to protect and foster a
multi-level mental healthcare system.
Conflict of interest
The author declares that she has no conflicts of
interest.
Mental Health: Global Challenges Journal
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