Mental Health Care for Mental Disorders in Primary Care during the Pandemic: Scope Review

Abstract

Objective was to map mental health care for mental disorders in primary care during the COVID-19 pandemic. We used the scope review methodology that employed the PRISMA-ScR, using the PCC search strategy, with “P” Population (primary health care), “C” Concept (mental disorder) and “C” Context (COVID -19). The search equation used Descriptors in Health Sciences/Medical Subject Headings (DeCS/ MeSH) and Boolean operator and: “"primary health care" and "mental disorders" and "COVID-19". Searches for studies were performed in the following electronic databases: BVS, PubMed/MEDLINE, Science Direct, Scopus, CAPES dissertation and theses databases (Coordination for the Improvement of Higher Education Personnel), in EMBASE databases, Web of Science and BDTD (Brazilian Digital Library of Theses and Dissertations). The collection was carried out in July 2021. As inclusion criteria, studies carried out from January 2020 to July 31, 2021 were determined, limited to articles with full texts, open access, published in all languages. A total of 323 publications were found: BVS (68), Embase (104), PubMed/Medline (65), Science Direct (26), Scopus (40) and Web of Science (20). No dissertation and thesis studies were found in CAPES and BDTD. It was shown that primary health care services underwent a remodelling during the pandemic, with the transition from face-to-face and home care to remote or virtual care, in order to prevent the spread of COVID-19. During this period, there was an increase in significant psychological distress such as fear, loneliness, anxiety, insomnia, posttraumatic symptoms and depression. There was a need for primary care in mental disorders, with the occurrence of discontinuity of care in mental health services due to the reduction in medical referrals and the increase in pharmacological treatment.

Keywords

Primary health care, Mental disorders, COVID-19.

Introduction

The spread of the COVID-19 pandemic, which began in Brazil in early 2020, has subjected health services to make adaptations to contain the spread of the virus and, at the same time, allow care for those infected in healthcare units. When the World Health Organization (WHO) recommended quarantine measures, social distancing to avoid crowding, mandatory use of masks, the entire health system had to reorganize itself to protect users and health teams[1,2]. In addition to sustaining these various demands triggered by the COVID-19 pandemic, primary care had to face situations of mental illness of users and health professionals. Even with no direct exposure to infection, many people experienced feelings of fear of becoming infected and dying, fear of losing family and friends, helplessness and even guilt for someone's illness [3]. An investigation carried out in Germany showed that during the pandemic people spend an enormous amount of time during the day thinking about negative aspects related to the consequences of the infection in their social life. And this fact is related to mental stressors that can surface mental disorders [4]. Other aspects related to the pandemic, such as the stigmatization and discrimination of contagion, barriers to experience the mourning of those who are dying, were decisive in influencing the increase in the demand for care for mental disorders in basic health units (LIMA, 2020). In addition to users of health services, infection by COVID-19 had an impact on the work of health professionals, due to the imminent fear of death, anguish and psychological suffering. Many had to move away from work activities and experience feelings of guilt, anger, frustration and sadness for not being able to resolve and cure patients with COVID-19[5]. From this perspective, the following question arises: what are the main care actions promoted by Primary Health Care in the management of mental disorders by COVID-19?

The research is justified by the need for knowledge about how teams of health professionals sought to solve the demands that arose with the advent of the pandemic, with a view to maintaining social isolation and the biosafety measures adopted to avoid crowding and the increase of the search for mental health disorders. Therefore, this study aimed to map the evidence on mental disorders in primary health care during the period of COVID-19.

The investigation is necessary to explain how the teams of health professionals sought to solve the demands that arose with the advent of the pandemic, in view of the maintenance of social isolation and the biosafety measures adopted to avoid crowding and the increased demand for care related to mental disorders. The objective was to map mental health care for mental disorders in primary care during the COVID-19 pandemic.

Methods

The design of this study was a scoping study or scoping review. The purpose of the scope review is to map the body of knowledge on a topic, quickly identifying and structuring the main concepts that ensure a research area, the assessment of the scope, scope and nature of the investigation, the summarization and dissemination of investigation data and the identification of existing research spaces. And, they comprise a disciplined, systematized procedure [6-8].

The steps of this review correspond to six subsequent phases

1) Identification of the question and construction of the research objective.

2) Recognition of pertinent studies that enabled the magnitude and scope of the review's purposes.

3) Selection of studies, according to predefined criteria.

4) Data layout.

5) Synthesis of results, through qualitative thematic analysis regarding the objective and question.

6) Presentation of the results, pointing out the implications for the research [9].

At first, the following question was defined: what is the scientific evidence in the world literature on mental health in primary health care during the period of COVID-19? For the research question, the PCC search strategy was used, where P - Population (primary health care), C - Concept (mental disorder) and C - Context (COVID-19). Therefore, using the PCC mnemonic helps to construct a title and problem question that provides potential readers with important information about the focus and scope of the review and its applicability to their needs. The search equation was formulated using descriptors in Health Sciences/Medical Subject Headings (DeCS/MeSH) and Boolean operator AND: “"primary health care" AND "mental disorders" AND "COVID-19". Searches for studies were performed in the following electronic databases: BVS, PubMed/MEDLINE, Science Direct, Scopus, CAPES dissertation and theses databases (Coordination for the Improvement of Higher Education Personnel) and EMBASE electronic databases, Web of Science and BDTD (Brazilian Digital Library of Theses and Dissertations)[10-15]. The collection of information in the databases and databases was carried out in July 2021 (Table 1). In the eligibility of the studies, as described in Figure 1, studies searched from January 2020 to July 31, 2021 were determined as inclusion criteria, limiting open access, full-text articles published in all languages. In the exclusion criteria, studies that did not address the theme of the search strategy “Primary Health Care” (PHC), mental disorder and COVID-19 were excluded[16-20].

Figure 1: Description of the search strategy used in the research.

In the screening of studies, exclusion of duplicity was performed using the Mendeleyev^® software, then exclusion by title, abstract, full text and data extraction were performed by two evaluators independently and differences were resolved by a third reviewer [21-29].

Data extraction from the studies was performed using an Excel ® spread sheet to obtain the findings considered relevant, described in the Figure 2 and Table 2. The study selection steps were carried out in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses – PRISMA-ScR.

Figure 2: Flowchart of the selection of publications based on the PRISMA model.

In Table 2. The studies selected by main author, year of publication, country of origin and main evidence are mapped. When analysing the country of origin of the studies, six were carried out in the United Kingdom (21%); four in Canada (14%); three in the United States of America (11%), and the same value and percentage in England; one (4%) in Germany, Australia, Belgium, Brazil, South Korea, Spain, Greece, Netherlands, Hong Kong, India and Taiwan; and a multicentre study carried out in several countries: Germany, Belgium, Greece, Netherlands, England, Ireland, Poland and Sweden.

Discussion

COVID-19 required rapid innovation across the health system[30]. This global crisis, which has spread to 188 countries and regions, is not over yet, and will still cause great impacts that will affect the future of international health systems [31]. The health service needed to increase its capacity, by strengthening primary care and social support, to meet health needs, such as mental disorders, resulting from the impact of the infection, as well as to face new waves of future outbreaks. The changes have generated new models and innovative approaches for delivering effective mental health services[32]. Primary care is therefore facing interlinked problems: inadequate reporting of COVID-19 test results; delay in the investigation or admission of sick patients; inadequate planning and discharge communication; and the need for improved and complex care for people with chronic illnesses in community settings. It remains to be seen how far these challenges will persist after the first and second waves of infection. The gap between public health and primary care was also exposed by the disease[33]. There have been substantial reductions in primary care contacts for acute physical and mental conditions after the introduction of government restriction [34]. Patient access to services was reduced, potentially putting a future burden on the service [35]. Consequences of considerable reductions in continuity of care in mental illness and primary care due to the blockage of care in the pandemic may include more severely mentally ill patients and increased incidence of fatal suicides[36]. Medical appointments missed in the psychosocial health of elderly patients with multimorbidity deteriorated markedly and absenteeism increased substantially after the COVID-19 outbreak[37]. Since the start of the first COVID-19 blockade[38], has observed that the rate of antidepressant prescriptions has increased significantly, while the numbers of referrals to mental health services have decreased substantially. This increased burden of mental health problems is being disproportionately managed by pharmacological treatments in primary care, without a corresponding increase in interventions by these services [39]. Patients with COVID-19 had psychological symptoms with significant increases in loneliness, anxiety, insomnia, post-traumatic symptoms, depression and more severe somatic symptoms [40]The global pandemic has increased the need for psychological care for vulnerable populations and frontline providers through nontraditional methods such as virtual environments; telemedicine in primary care is rapidly adapting to meet this need. Integrating more behavioural health practitioners into primary care clinics will improve access to care for a person with a mental disorder [41] Primary care health professionals are playing a key role due to their expertise in community medicine, coordinating care, embracing patient care and supporting affected families[42]. In general, patients with COVID-19 and associated mental disorders were divided into those who may have severe sequelae (such as thromboembolic complications) and those with a nonspecific clinical picture, generally called fatigue and shortness of breath. There is also a need for specialized rehabilitation of a third group, patients whose acute illness requires intensive care. The management of care in post-acute COVID-19 should occur in conjunction with the management of new or pre-existing comorbidities[43]. From the pandemic onwards, there should be a series of reflections and recommendations for the psychological care of the population and health workers, as well as the social organization of care models, such as: a) existence of psychological and psychosocial research in interconnected fields and b) new neuroscientific perspectives on emotions and their elaboration in crisis situations[44]. COVID-19 brought about a rapid change in primary care delivery. Adaptations of services in the PHC to avoid potential exposure to COVID-19 were reduced and there was a transition from face-to-face care and primary home care (HBPC) practices to virtual care or remote methods, i.e., by phone, email, and internet, which include more effective routine monitoring of the disease, greater patient satisfaction, and greater adherence.

Conclusion

It is scientific evidence published during the pandemic showed that primary health care services underwent a remodeling in primary health care, with the transition from face-to-face and home care to remote or virtual care, in order to prevent the spread of COVID-19. During this period, there was an increase in mental disorders, the need for primary care to contain psychological distress, and a discontinuity in people's mental health care due to the reduction in medical referrals to specialized services and the increase in the prescription of psychotropic drugs. Also, there was a discontinuation of care for chronic conditions and a reduction in patients with clinical complaints.

References

1. Arksey H and O’malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Meth. 2005; 8:19-32.
2. Armitage, R. Antidepressants, primary care, and adult mental health services in england during COVID-19. Lancet Psychiatry. 2021; 8:e3.
3.  Nabuco. The impact of the COVID-19 pandemic on mental health: What is the role of primary health care? Rev Bras Med Fam Community. 2020; 15:2532.
4. Ashcroft R, et al. Experiences of primary care teams in mental health during the COVID-19 pandemic: A qualitative study. BMC Family Pract. 2021; 22:143.
5. Barbosa AS. Work process and mental health care at the Uerj Psychosocial Care Centre in the Covid-19 pandemic. BJHBS. 2020; 19:11-19.
6. Barros, et al. Report of sadness/depression, nervousness/anxiety and sleep problems in the Brazilian adult population during the COVID-19 pandemic. Epidemiology and Health Services.2020; 29:4.pe2020427.
7. Bauer-Staeb, et al. The early impact of COVID-19 on primary care psychological therapy services: A descriptive time series of electronic healthcare records. Research Paper.2020; 37:p100939.
8. Blecher GE, et al. Crisis as an opportunity: How COVID-19 can reshape the Australian healthcare system. Med J Aust.2020; 213:196-198.
9. Bossche, et al. Community health workers as a strategy to tackle psychosocial suffering due to physical distancing: A randomized controlled trial. Int J Environ Res Public Health.2021; 17:3097.
10. Carr, M.J, et al. Effects of the COVID-19 pandemic on primary care-recorded mental illness and self-harm episodes in the UK: A population-based cohort Study. Lancet Public Health. 2021; 6:pe124-e135.
11. Chang, et al. Ready for a long fight against the COVID-19 outbreak: An innovative model of tiered primary health care in Taiwan. BJGP Open. 2020; 4:2.
12. Donnelly, et al. J Interprofessional primary care during COVID-19: A survey from the provider perspective. BMC Family Pract. 2021; 22:31.
13. Duarte, et al. Nursing and mental health: A reflection in the midst of the coronavirus pandemic. Revista Gaúcha de Enfermagem . 2021;42: pe20200140.
14. Franzosa, et al. At home, with care”: Lessons from New York City home‐based primary care practices managing COVID‐19. Am Geriatric Soc. 2021; 69:300-306.
15. Galvã, et al. Main items for reporting Systematic reviews and meta-analyses: The PRISMA recommendation. Epidemiology Serve Health. 2015; 24:335-342.
16. Giannopoulou, et al. COVID-19 pandemic: Challenges and opportunities for the Greek health system. Ir J Psychol Med. 2020; 37:226-230.
17. Greenhalgh, et al. Post-acute COVID-19 treatment in primary care BMJ.2020; 370: m3026.
18. Nabuco, et al. The impact of the COVID-19 pandemic on mental health: What is the role of primary health care? Rev Bras Med Fam Community.2020;15:2532
19. Jetty, A, et al. Primary care capacity to provide telehealth in the United States. J Am Board Fam Med. February 2021; 34.
20. Kanzler, et al. Addressing trauma and stress in the COVID-19 pandemic: Challenges and the promise of integrated primary care. Psychol Trauma.2020.
21. Lee, et al. A qualitative exploration of the experiences of school nurses during COVID-19 pandemic as the frontline primary health care professionals. Nurs Outlook. 2021; 69:399-408.
22. Lemanska, et al. Study into COVID-19 crisis using primary care mental health consultations and prescriptions data. Stud Health Technol Inform. 2021; 27:759-763.
23. Leung and K qureshi S. Managing high-frequency users of an electronic consultation system in primary care: A quality improvement project. BMJ Open Qual.  2021; 10: p e001310.
24. Levac, et al. Scoping studies: Advancing the methodology. Implement. sci.2010; 5:5-69.
25. Lima, R.C. Social distancing and isolation by COVID-19 in Brazil: Impacts on mental health. Physic: Journal of Collective Health.2020; 30:2.
26. Mansfield, et al. Indirect acute effects of the COVID-19 pandemic on physical and mental health in the UK: a population-based study. Lancet Digit Health. 2021; 3:e217-e230.
27. Mansfield, et al. Changes in presentations with potentially predictive features of cancer in primary care during the COVID-19 pandemic: a retrospective cohort study. BMJ Open. 2021b; 11:e050131.
28. Miner Vino, et al. Challenges in mental health during the pandemic: Experience report. Bioethics Magazine. 2020; 28:pp. 647-654.
29. Medina, M.G. et al. Primary health care in times of COVID-19: What to do? Public Health Notebooks. 2020;36:8.pe00149720
30. Bagatini, D.G. Nursing and mental health: A reflection in the midst of the coronavirus pandemic. Rev Gaucha Enferm. 2021; 42: e20200140.
31. Arksey H and O’malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Meth.2005; 8:19-32.
32. Munn, E, et al. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approaches. BMC Med Res Methanol. 2018; 18:143.
33. Nabuco, et al. The impact of the COVID-19 pandemic on mental health: what is the role of Primary Health Care? Rev Bras Med Fam Community. 2020; 15:2532.
34. Park, et al. A Strengthening UK primary care response to COVID-19. BMJ 2020; 370:m3691.
35. Petzold, M.B. et al. Risk, resilience, psychological distress, and anxiety at the beginning of the COVID-19 pandemic in Germany. Brain Behave. 2020; 10:e01745.
36. Pingel, et al. Committing to Continuity: Primary Care Practices During COVID-19 in an Urban Brazilian Neighbourhood. Health Educ Behav.2021; 48:29-33.
37. Ramirez, et al. Mental health in epidemics: A perspective from the Spanish primary health care. Aten Primaria.2020; 52:93-113.
38. Rosa-alcázar Á, et al. coping strategies in obsessive-compulsive patients during COVID-19 lockdown. Int J Clin Health Psychol.202; 21:100223.
39. Schers, et al, T. The COVID-19 Pandemic in Nijmegen, the Netherlands: Changes in presented health problems and demand for primary care. Ann Fam Med.2021; 19:44-47.
40. Schmidt, et al. Management of COVID-19 ICU-survivors in primary care: - A narrative review. BMC Fam Pract. 2021; 22:160.
41. Shan wong, et al. Impact of COVID-19 on loneliness, mental health, and health service utilisation: A prospective cohort study of older adults with multimorbidity in primary care. Br J Gen Pract.2020; 70: e817–e824.
42. Tricco, et al. Knowledge syn- thesis methods for generating or refining theory: A scoping review reveals that little guidance is available. J clin Epidemiol.2016; 73:36-42.
43. Wanat, et al. S. Transformation of primary care during the COVID-19 pandemic: Experiences of health professionals in eight European countries. Br J Gen Pract .July 29, 2021; 71: e634-e642.
44. Wang, P.W. et al. Subjective deterioration of physical and psychological health during the COVID-19 pandemic in Taiwan: Their association with the adoption of protective behaviours and mental health problems. Int J Environ Res Public Health.202; 17:682.