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

Maria Salete Bessa Jorge1, José Reginaldo Pinto1, Cybelle Façanha Barreto Medeiros Linard2*, Kamyla de Arruda Pedrosa1, Lídia Andrade Lourinho1

1State University of Ceará (UECE), Fortaleza, Ceará, Brazil

2Ceará State University, Estácio do Ceará University Center, Fortaleza, Ceará, Brazil

*Corresponding Author:
Cybelle Façanha Barreto Medeiros Linard
Department of Psychiatric and Mental Health Ceará State University
Estácio do Ceará University Center and Uninassau University Center Centro
Canindé Brazil
Tel: + 55 85 999515429
E-mail: [email protected]

Received Date:  30/08/ 2021; Accepted Date:30/09/2021; Published Date:02/10/2021

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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].

Data base search strategy Number of articles
BVS "primary health care" AND "mental disorders" AND COVID-19 68
EMBASE 104
PUBMED/MEDLINE 65
SCIENCE DIRECT 26
SCOPUS 40
WEB OF SCIENCE 20
CAPES 0
BDTD 0
nursing-health-sciences-strategy

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.

nursing-health-sciences-flowchart

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

Main Author/Year of Publication Country of Origin Title of Work Main Evidence from Studies
Mansfield [1] United Kingdom Acute indirect effects of the COVID-19 pandemic on physical and mental health in the UK: a population-based study. There were substantial reductions in primary care contacts for acute physical and mental conditions after the introduction of restrictions.
Benjamen [2] Canada Access to mental health services for refugees and migrants during the first six months of the COVID-19 pandemic: a clinical survey of Canadian refugees. Most physicians reported that technology-assisted psychotherapy seems feasible, acceptable, and can increase health equity for their refugee patients. However, the main limitations of virtual care included technological barriers, communication and privacy issues.
Carr [3] United Kingdom Effects of the COVID-19 pandemic on registered mental  illnesses in primary care and episodes of self-harm in the UK: a population- based cohort study. Consequences of considerable reductions in mental illness and self-harm in primary care may include more patients subsequently experiencing greater mental illness severity and increasing the incidence of non-fatal self-harm and suicide.
Schers [4] Holland The COVID-19 pandemic in Nijmegen, the Netherlands: Changes in health problems and demand for primary care. There was a significant increase in telephone / email / internet
consultations in the months after the outbreak.
Ramírez [5] Spain COVID-19 pandemic and mental health: initial considerations in primary health care in Spain. A series of reflections and recommendations for the psychological care of the population, health workers and social organization was proposed by the pandemic.
Lee [6] South Korea COVID-19 online mental health assessments of patients in South Korea. Patients with COVID-19 had more severe symptoms, including post-traumatic symptoms, depression, anxiety and somatic symptoms than control groups (participants with disaster experience).
Bauer-Staeb [7] England The initial impact of COVID-19 on primary care psychological therapy services: a descriptive time series of electronic health records. Services seemed to adapt to provide continuity of mental health care. However, patient access to services has been reduced, potentially putting a future burden on care.
Ashcroft [8] Canada Experiences of primary care teams in mental health during the COVID-19 pandemic: a qualitative study. Regarding the impact of the COVID-19 pandemic on mental health care in primary care teams, we identified three main themes: i) the high demand for mental health care, ii) the rapid transformation to virtual care and iii) the impact on providers.
Leung [9] England Managing high-frequency users of an electronic consultation system in primary care: a quality improvement project. Managing high-frequency users of an electronic consultation system in primary care: a quality improvement project.
Lemanska [10] United Kingdom Study on the COVID-19 crisis using data from consultations and mental health prescriptions in primary care. The significant reduction in the number of consultations and the increase in the number of prescriptions represents part of the crisis.
Bossche [11] Belgium Community health agents as a strategy to face psychosocial suffering due to physical distance: a randomized clinical trial. The intervention led to a significant improvement in self-rated
change in psychosocial health.
Jetty [13] USA Primary Care Ability to Provide Telehealth in the United States. Primary care practices have transitioned to telehealth visits to keep patients at home and decrease disease transmission. It is also noteworthy the fact that, as of 2016, most outpatient telehealth care was carried out by telephone.
Pingel [14] Brazil Committing to continuity: primary care practices during COVID-19 in a Brazilian urban neighborhood. The long-standing relationship between the clinic and neighborhood residents has facilitated the ongoing management of physical health and mental conditions.
Donnelly [15] Canada Interprofessional primary care during COVID-19: a survey from the provider's perspective. The provision of the service changed from face-to-face assistance to the telephone. Waiting times to access team members have decreased. They also reported a reduction in health care provision for several chronic conditions, including diabetes, cardiovascular disease and chronic pain. An increase in mental problems were noted.
Franzosa [16] USA “At home, with care”: Lessons from primary home care practices in New York City managing COVID-19. Balancing virtual care with the necessary personal contact were strategies applied to maintain the patient's trust and support the team connection through daily meetings and emotional support during the increase in deaths. Keeping older and clinically complex patients safe in their homes required considerable flexibility, transparency, teamwork and partnerships with outside providers.
Armitage [17] England Antidepressants, primary care and adult mental health services in England during COVID-19. The rate of prescription of antidepressants in general practice has increased substantially, while the number of people in contact with adult mental health services and the number of referrals to these services have decreased substantially. It may be due to concerns of patients and primary care physicians about overloading other services.
Scott [18] United Kingdom Changes in presentations with potentially cancer-indicating features in primary care 18during the COVID pandemic 19: a retrospective cohort study. The number of patients who consulted and had symptoms that could indicate cancer decreased during the first wave of the COVID-19 pandemic.
Kendzerska [19] Canada The effects of the health system response to the COV21ID-19 pandemic on chronic disease management: a narrative review. Higher rates of telemedicine use compared to the pre-COVID period 19. Benefits include more effective routine monitoring of the disease, greater patient satisfaction, and higher treatment adherence and follow-up rates. The scarcity of drugs used to control chronic conditions due to disruptions in the global supply chain.
Wanat [20] England, Belgium, Netherlands, Ireland, Germany, Poland, Greece and Sweden Transformation of primary care during the COVID-19 pandemic: experiences of health professionals in eight European countries. PCPs (European primary care professionals) have rapidly transformed the provision of primary care, despite a number of challenges.
Schmidt [21] Germany Management of COVID-19 ICU survivors in primary care: a narrative review. Primary care physicians play a key role in treating post-ICU sequelae because of their experience in comprehensive medicine, coordination of care, embracing patient self-care, and long-term knowledge of the medical history of patients and their families.
Blecher [22] Australia Crisis as opportunity: how COVID-19 can reshape the Australian healthcare system. Our health systems have evolved over time not so much as a coherent "system" but as sequential improvisations with mixed funding models, poor integration, inconsistent governance, environmentally unsustainable practices and, ultimately, inequalities in access and care, revealed these inadequacies.
Kanzler [23] USA Coping with trauma and stress  in the COVID-19 pandemic: challenges and the promise of integrated primary care. The global pandemic will increase the need for post-traumatic stress-related psychological care for vulnerable populations and frontline providers through traditional and virtual methods; integrated primary care environments are rapidly adapting to meet this need.
Chang [24] Taiwan Ready for a long fight against the COVID-19 outbreak: an innovative model of primary health care in Taiwan. Our plan is based on a tiered primary health care network of clinics set up by community health groups and community screening stations to treat patients with mild symptoms in community clinics so that hospitals and medical centers can focus on severe cases. Close coordination of hospitals and community care providers is critical to protecting the medical system from a possible collapse due to sudden outbreaks of unknown pathogens.
Shan [25] Hong Kong Impact of COVID-19 on loneliness, mental health and use of health services: a prospective cohort study of elderly people with multimorbidity in primary care. The psychosocial health of elderly patients with multimorbidity deteriorated markedly, and missed medical appointments increased substantially after the outbreak of COVID-19. There were significant increases in loneliness, anxiety and insomnia after the onset of the COVID-19 outbreak. Women were more likely to increase anxiety and insomnia.
Greenhalgh [26] United Kingdom Post-acute COVID-19 management in primary care. Post-acute COVID-19 management should occur in conjunction with the management of new or pre-existing comorbidities.
Sudhir [27] India A primary care  alternative  to  a hospital-based approach to COVID-19 in India. Primary care and practitioners with a knowledge of basic medicine can correct hypoxia and determine when to escalate to higher levels of care when interventions aren't working. Other simple, low-cost interventions such as steroids, antibiotics for secondary pneumonia, bronchodilators, and prophylaxis against venous thromboembolism can also be administered in these facilities.
Giannopoulou [28] Greece COVID-19 pandemic: challenges and opportunities for the Greek health system. The health system needs to increase its capacity by strengthening primary health care and social support in order to meet non-existent health needs, the impact of the pandemic on mental health, as well as to face new waves of future outbreaks.
Park [29] United Kingdom Strengthening the UK primary care response to COVID-19. Primary care will also have to offer a massive expansion of the flu prevention program as well as future COVID-19 vaccinations. The training of new health professionals must be adapted to this service environment.

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

mesambursa