Interviews were conducted with 18 key informants. See Table 1 for the categories of respondent.
Our findings are structured in relation to: (1) impacts of COVID-19 on people with MHCs in the community, prisons and residential settings, (2) mental health-related stigma and social exclusion, (3) mental health in COVID-19 quarantine, isolation and treatment settings, (4) impact of COVID-19 on the physical health of people with MHCs, and (5) changes in access and quality to mental health care.
Impacts on people with MHCs in the community, prisons and residential settings
Key informants involved in service provision and mental health service users reported that COVID-19 seriously affected the recovery process of people with MHCs. Among other factors, the disruption of medication supplies, economic burden and loss of social networks and support impacted the mental health recovery of individuals with MHCs. Respondents noted that many people with MHCs had disengaged from the daily routines that had previously served as important coping mechanisms. Inability to access their support networks and the absence of emotional supports were also reported to have impacted their mental health.
When we [service users] meet physically there is gesture, body language, hug, and human touch. We lost all of these. For a service user, these and our support networks, in general, are our copings but this has been impacted by COVID-19. This has also an impact on our recovery process [IDI01].
COVID-19 prevention and control measures were also reported to have impacted the lives of individuals with substance use problems. There was a perception that shops selling alcohol were closed, so individuals with alcohol use disorders suffered from alcohol withdrawal, especially during the state of emergency. Those who were in the process of recovery from substance use problems were also considered to be vulnerable to relapse due to lack of access to their social networks and rehabilitation services.
Participants disclosed that people with existing MHCs or other people in need in the community were not adequately supported to maintain their mental health. One reported reason was that mental health had not been integrated into community platforms in Ethiopia. As mental health care and support was only available in centralized facilities, the infrastructure to reach people with MHCs in the community during COVID-19 did not exist.
MHPSS [mental health and psychosocial support] activities were not reaching into the community except limited public communications using radio [IDI02].
Respondents reported increased household burden and economic strain due to the COVID-19 pandemic, in some cases leading to abandonment and homelessness of people with MHCs. Caregivers shared experiences of the challenges of conveying a person with a MHC to hospital. The movement restrictions, increased transportation costs and costs of commodities contributed to the economic burden.
Transportation cut down in half; means one passenger in two seats. For example, if a patient comes from far and used to pay 100 Birr [about 2USD] now he/she pays 200 Birr and for round trip means 400 Birr, if it was 50 Birr now its 200 Birr for round trip [IDI08].
Mental health professionals also recognized the burden on caregivers. They explained that since hospital admissions had been suspended, caregivers were required to take full responsibility for caring for people with MHCs when they were acutely unwell. During enforcement of the ‘stay-at-home’ regulation, caregivers were alone in providing full-time care and monitoring of their family members with a mental health condition.
There were also reported additional economic strains on people with MHCs due to COVID-19. As many individuals with MHCs were engaged in irregular income-generating activities or were dependent on their families, they were disproportionately affected by restrictions on movement and trading. Participants highlighted that, since there is a long-standing public perception that people with MHCs are unable to work or have reduced capacity, when employers reduced the number of employees during COVID-19, people with MHCs were the first victims.
My mother [spouse of a man with a severe mental health condition] is a trader. She is the one who buys things for our family. When the illness comes, she could not go to the market. You can imagine. It was very difficult for our family. He cannot help her [IDI03].
Although there were several general community initiatives to provide support for economically vulnerable sections of society, there were no data on whether people with MHCs were included. Respondents expressed the need to advocate for people with MHC and their families to be prioritized for community social, food and financial support initiatives on an ongoing basis during the pandemic.
Social care institutions providing services for the homeless and destitute reported increased numbers of people with MHCs needing their care during the pandemic. As COVID-19 infection control measures also applied to religious institutions, holy water sites in Addis Ababa were closed for some time during the early months of the pandemic. As a result, some people with MHCs who had no access to family and who would otherwise have resided within holy water sites became homeless.
The informal sector, such as holy water, accommodates the largest proportion of people with mental illness and these mental health care options have been closed due to COVID-19, of course, they are recently opening. Thus, patients could be abandoned and go to street life [IDI04].
Non-governmental organisations providing care for those who were destitute also struggled due to reduced availability of volunteers. To reduce the risk of coronavirus infection, such organisations were forced to accommodate the caregivers for extended periods (about 3 months) which also incurred additional expenses. Due to COVID-19, these organisations had to construct or rent more rooms so that they could physically distance their beneficiaries. At the same time that they faced increasing costs, social care organisations reported reduced donations during COVID-19.
Since there was an economic impact of COVID-19 among everyone and local donors have also been economically challenged, our organisation has got financial constraints for operational costs, employees’ payments and buying medications. As you know psychiatric medications are expensive and the number of our beneficiaries has also increased to 1500 [IDI05].
Some COVID-19 protocols of residential institutions impinged upon the rights of people with MHCs. The following quote illustrates the lack of parity between beneficiaries with mental health rather than physical health conditions who were residing in a social care institution.
Yes, we did operational changes. At some point, we had suspended social visits to our organisation. But for the survival of the organisation, to sustain donations, we then resume it. But visitors were not allowed to visit psychiatric rooms and see individuals with MHCs because they did not wear face masks [IDI06].
Disruption of mental health care and other human rights violations were also reported among people with MHCs during COVID-19 in prisons.
During COVID-19, we [EHRC office] did an assessment to monitor how the Ministry of Health COVID-19 prevention and control measures are implemented without affecting the human rights of prisoners. We found that prisoners with mental health care needs were not getting treatment and not taking their regular medications. This is due to movement restriction and the police officers fear of the infection when travelling individuals with mental health need to health care facilities. Meals were also not sustainably delivered on time. Women were also not sustainably getting sanitary pads [IDI07].
Mental health-related stigma and social exclusion during COVID-19
Long-standing mental health stigma and social exclusion served to exacerbate the adverse impacts of COVID-19 on the lives of some people with MHCs. The high levels of stigma towards people suspected of having COVID-19 or those who had recovered from COVID-19 intersected with community attitudes that people with MHCs were unpredictable and unreliable. Consequently, in some communities, people with MHCs were perceived as an infection threat. Community members kept their distance from households of a person with a MHC or harassed individuals with MHCs in relation to their possible non-adherence to COVID-19 prevention and control measures. Sometimes people with MHC were restrained due to concerns over vulnerability to infection.
Because my husband, who has a severe mental health condition, fails to wear the face mask, once he had a quarrel with a police officer because he refuses to wear the mask. He wears the mask by now, but he may not do it properly. People were distancing him [her husband], thinking as he may not protect himself [IDI08].
Other respondents emphasized that human rights abuses of people with MHCs had pre-dated the pandemic.
Before COVID-19, people with mental health conditions are not respected and fulfilled. Thus, if you ask me if COVID-19 exacerbated this, I don’t think. The problem was there, before COVID-19 and could be ongoing even after COVID-19 [IDI09]
On the other hand, respondents observed that COVID-19 had put mental health on both the national and international agenda. This had created opportunities for open discussion about mental health which were not present before the pandemic.
There were many interviews over the media about mental health. Thus, now talking about anxiety and self-care is not a shame. Normalizing the discussion about mental health is one good thing, but it was not sustained [IDI01].
Religious leaders were among those who recognized the importance of addressing mental health stigma.
Being human is esteemed by God. You are not allowed to abandon someone for his/her mental health condition because he/she is a human being. No one is immune to illness. No one is absolutely healthy on earth. We all were sick or potentially sick. I personally had experience insanity. I went to the street for three years and was naked when I was a child. Later, God had said that it is enough and restored me to my current position. So, everybody shouldn’t ignore or stigmatize people with MHCs. The one who looks healthy could be insane and the insane will also be healthy. To stigmatize is to lack God’s grace. It is better if people live with faith and love [IDI10].
Mental health in COVID-19 quarantine, isolation and treatment settings
Distressing experiences were reported for many who were admitted to COVID-19 quarantine (those waiting for test results after travel) or isolation centres (those waiting for test results after showing symptoms), but with particular impacts on vulnerable groups (e.g. domestic workers and returnees from the Middle East) and on those with existing MHCs.
One individual had thrown away himself from a building and fell down on a water rotor. His leg and his teeth were broken. There was also another one who fell down from a building. The first one was a returnee from Middle-East. When he was later evaluated by the clinicians, he had been experiencing major depression symptoms. The second one had also been taking psychiatric medications before deportation. There were more suicide attempt incidents in quarantine centres and I know about four incidents [IDI11].
Mental health care for people held in COVID-19 quarantine or isolation centres was reported to be scarce and not timely. One participant reported an unsuccessful effort to include mental health in the COVID-19 response at the level of regions and below, with low awareness and stigma in administrators and officials serving as an important barrier. Initially, mental health professionals were not an integral part of the COVID-19 health professional teams linked to quarantine, isolation and treatment centres. The national level COVID-19 task force included mental health professionals, but this aspect of the COVID-19 response was not operational at regional levels and below.
Yes, especially individuals with unstable mental conditions in COVID-19 isolation were not getting mental health care. Health care providers fear people with mental illness. They avoid them or don’t want to engage to treat and support them because they suspect them as a source of risk for coronavirus infection. They also perceive them as a threat, causing harm because the health care providers have limited mental health literacy [IDI12].
Key informants reported that when people with known MHCs were admitted to COVID-19 treatment centres, health professionals withdrew from delivering the required care to the same standard as other patients without mental illness. This was related to their perceptions that people with MHCs would infect them or harm them.
At COVID-19 treatment centre, I saw one patient with bipolar disorder. I observed that HCWs did not approach her and listen to her complaints. They put her in a separate room. This might not be due to COVID-19 rather it was due to stigmatizing people with MHCs [IDI02].
People with severe mental illness admitted to treatment centres, inadequate management of the person’s mental health state was reported to affect COVID-19 outcomes.
A woman with mental illness was admitted to COVID-19 treatment centre. Her baby was COVID-19 negative. Then it was a big mess to separate the baby from her. The mother was suspicious and believes others do harm her daughter. With the mess-up process of this, her baby was infected to COVID-19 because the baby was with her for a longer time before isolating the baby was done [IDI13].
Impact of COVID-19 on the physical health of people with MHCs
Intersecting vulnerabilities for coronavirus infection were reported for people with MHCs in the community. Due to the impoverishing effects of living with an MHC, many could not afford to sustainably buy protective equipment. Respondents also reported that people with MHCs were not able to access comprehensible information about COVID-19 that was tailored to their situation. There were only a few public health communication campaigns targeting people with MHCs, and this only happened about six months into the pandemic and was limited to Addis Ababa. Some audio-video messages, leaflets and posters designed for people with MHCs were disseminated at quarantine and isolation centres. People with MHCs were also not adequately protected from COVID-19 in institutional settings.
Let me tell you the tragedy. Initially, almost more than half of the people with MHCs were showing COVID-19 symptoms. When we request COVID-19 testing, many found COVID-19 positive. Then we should have to admit them, but we were not allowed. Patients with acute disturbance and showing clear psychiatric symptoms were not allowed to be admitted and had no way to refer for COVID-19 treatment. People with MHCs were denied COVID-19 services. Leaders said they [people with MHCs] will disturb others if they get admitted with other people who are without MHCs. This was very sad. Finally, we were forced to admit a few of them with other psychiatric patients who were COVID-19 negative. So other psychiatric patients were systematically vulnerably to be infected. I personally was also infected when working with them being without standard COVID-19 infection prevention protocol [IDI14].
Mental health stigma was reported to have complicated the physical health care of people with MHC during the pandemic. Health care professionals feared infection with COVID-19 from people with MHCs. They perceived that people with MHCs did not properly wear face masks and might touch them or put them at risk for infection. As a consequence, health workers reportedly either neglected the physical health care needs of the person or they expected that people with MHCs should be restrained or held down by caregivers during the clinical consultation. There was a perception that long-standing problems with referring people with MHCs for physical health care were exacerbated during COVID-19. Social care institutions also suspended referring people with MHCs for physical health care during the early few months of the pandemic since health facilities were not fully functioning. Participants from primary health care and social care settings reported that they could only deliver essential or emergency health care services.
We [social care institution] suspended physical rehabilitation. Physiotherapy service has been completely discontinued which had been very important for our beneficiaries [IDI05]
A mental health service user reported that since the health care facilities made operational changes to their services, people with MHCs were hardly accessing physical health care.
I know people with mental health conditions who came from the rural areas to get physical health care in Tikur Anbessa and St Paulo’s hospital but they went back without getting the service [IDI15].
In settings where physical and mental health care was integrated, like Dire Dawa Dilchora hospital, it was easier to sustainably deliver physical health care for people with MHCs during the pandemic. They only needed to make some modifications, including increased time between follow-up appointments, and were able to continue delivering both mental and physical health care. Where physical and mental health care was not integrated, long-standing mental health stigma among health care providers was perceived to complicate care and referral for physical health care. At mental health care facilities, COVID-19 services were reported to be inefficient. The settings were not safe and there were limited resources for COVID-19 infection prevention and control. Thus, the health facilities implemented problematic procedures, as perceived by clinicians.
Our system of secluding people with MHC in our hospital looked problematic. Every patient suspected of COVID-19 would be in a room and did not allow being outside of the room. A patient would be allowed to go out from the secluded room only after testing for COVID-19. The intention is to avoid the risk of infecting other patients, but the process of taking a sample for COVID-19 testing has been taking some time; up to 2 to 4 days. For patients, staying in a secluded room had been very challenging and unacceptable [IDI09].
Mental health services during COVID-19
Availability and utilization of mental health care
Disruption to mental health care services because of the pandemic was reported at all levels of the health system. In many instances, mental health care had still not been restored to pre-pandemic levels at the time of reporting. As a result, the mental health treatment gap, which was already very high, had widened. In Addis Ababa, PHC facilities were not functioning to their full capacity during the early months of the pandemic due to many being dedicated as COVID-19 isolation centres. Redeployment of mental health professionals to the COVID-19 response resulted in a shortage of mental health professionals. For physical health care, professionals who were not working in the public health system were trained and deployed for the COVID-19 response, but this had little impact on mental health care since the numbers of mental health professionals in the private/NGO sector were small. During the pandemic, many hospitals back-referred people with MHCs to locally available PHC facilities. But since many primary health facilities did not have services for people with MHCs, this left a gap in the service. There were people with MHCs disorders who were attending follow-up care in PHC before COVID-19, but during COVID-19 mental health service utilization was reported very low. Participants reported that people with depression and anxiety disorders feared COVID-19 infection from health facilities and might prefer to stay at home.
Respondents reported that mental health services in general hospitals and mental health specialized hospitals were substantially disrupted by the pandemic. Many people with MHCs were discharged precipitously from in-patient care to decrease the risk of COVID-19 infection. Other in-patient mental health care facilities were designated as COVID-19 care facilities. Participants reported that the shift of the new Eka Kotebe hospital (which had 175 psychiatric beds pre-pandemic) to become a COVID-19 treatment facility was unexpected and unwelcome.
…and then we discharged all patients. Only a few of them with critical health conditions were referred to Amanuel hospital [the only dedicated psychiatric hospital]. We only have tried to resume the outpatient service at least on a partial scale. Previously, the hospital had about 175 beds for mental health services. After a month or so we managed to have 26 beds for patients with the psychiatric emergency, but only for males [IDI13].
In addition to Eka Kotebe in Addis Ababa, other mental health facilities across Ethiopia were closed due to the pandemic, including the Catholic Church Missionaries of Charity and Sabian General Hospital in Dire Dawa and Karamara Hospital in the Somali region. Respondents perceived that this would result in many people with MHCs unable to access care and would increase the volume of people attending the remaining mental health care facilities. For example, when two hospitals were closed in a single city, the patient volume increased at another adjacent hospital. In other health facilities, mental health services were either partially reduced or suspended for several months during the pandemic.
In our hospital, patient volume was significantly reduced. We used to see about 400 to 500 patients per month before COVID-19, but during COVID-19, we only had to see about 200 patients per month on average [IDI16].
In other mental health facilities, there was disruption of psychiatric emergency and substance use disorder rehabilitation services. In most settings, it was reported that rehabilitation services for people with substance use disorders and psychotherapy services had still not fully resumed at the time of reporting. Three addiction rehabilitation centres in Addis Ababa stayed closed for many months during COVID-19. Another rehabilitation centre remained open throughout the pandemic, but patient contact was reduced by half compared to usual.
In our hospital, the private wing was closed where many patients with emergency conditions were mainly getting services. The number of patients attending emergency services, in general, was also reduced. It creates a treatment gap [IDI17].
Electroconvulsive therapy (ECT) was also discontinued from April 2020 – February 2021, meaning that some critically ill people could not access potentially life-saving care. Even after ECT was resumed, it was discontinued again temporarily in March 2021 after some people with MHCs were infected with coronavirus during the process of ECT due to lack of adequate infection control equipment and procedures. It was resumed after COVID-19 rapid test was made mandatory prior to receiving ECT.
Respondents reported that structural stigma towards mental health became evident during the pandemic, manifested in low political attention and commitment. They expressed their frustration that there had not been a more active resistance from mental health professionals and other mental health advocates.
We [Mental health care professionals] should have done a very organized voicing for people with mental health conditions and protect mental health resources. They [people with MHC] can’t label themselves saying “I am mentally ill”. There is a kind of double stigma. They will not be a voice for themselves. They need others to be a voice. We didn’t say anything when their resources were taken from them. We just clamp our hands and accept the decision. We didn’t say anything. We should have been strong advocates for the rights of people with mental health conditions. I found myself on the side of the oppressors or among those who introduced structural stigma for people with mental illness. So, next time, this should not be the case. We should not be like this [IDI09].
Alongside reduced availability of mental health care, there was also reduced utilization of centralized mental health care facilities. This was reported to be largely driven by fear of infection, as well as the escalating transport costs. For example, at psychiatric nurse-led units in regional centres, while mental health care was available, monthly contact was reduced.
Overall patient flow was reported to be lower but new cases have increased at some health facilities. We [mental health care workers] used to report about 600 follow up patients per month, but it was reduced to 500 and later reached 400 [IDI18].
At Amanual Mental Specialised Hospital in Addis Ababa, there was a statistically significant reduction in the number of admissions since March 2020 (Fig. 1), particularly during the state of emergency. The Health Management Information System (HMIS) in-patient data were reduced by about 60 percent for several months compared to 2019.
Given the closure of other mental health services, out-patient service utilization was expected to increase but actually remained relatively comparable for the years 2019 and 2020. See Fig. 2.
Table 2
Results of the segmented regression comparing mental health service utilization before and after the pandemic
| |
In-patient service utilization
|
Out-patient service utilization
|
| |
AIRR*
|
95%CI
|
AIRR
|
95%CI
|
|
Time since the 1st month of 2019 to the last month of 2020
|
1.03
|
1.01, 1.05
|
1.01
|
0.99, 1.02
|
|
Time when there is no COVID-19 and where there is the incidence (dichotomous measure)
|
0.74
|
0.50, 1.09
|
1.19
|
1.01, 1.40
|
|
Incidence of state of emergency (dichotomous measure)
|
0.98
|
0.64, 1.48
|
0.86
|
0.77, 0.97
|
|
12 months period since COVID-19 incidence
|
0.95
|
0.89, 1.01
|
0.99
|
0.96, 1.01
|
| *AIRR: Adjusted Incidence Risk Ratio |
The segmented poisson regression results (Table 2) show an increasing trend in mental health service utilization both prior and after the COVID-19 pandemic, but that inpatient mental service utilization was significantly decreased by the introduction of the nation-wide state of emergency (AIRR = 0.86; 95% confidence interval 0.77, 0.97).
Quality of mental health care during COVID-19
As well as reduced availability of mental health care, respondents also reported concerns about the quality of mental health care. One of the indicators for poor mental health quality was the long periods between follow-up appointments, up to six months in some cases. This meant that people with MHCs were not able to be actively engaged in their care through discussions with mental health professionals. If they experienced medication side effects, they had no opportunity to consult their mental health care provider.
We [clinicians] were forced to appoint patients after six months. This had a negative impact on the quality of mental health care. It is impossible to know whether the medications work or not and whether medications induce side effects or not [IDI17].
The absence of family visits to people receiving in-patient care and the lack of recreational activities compromised the quality of mental health care.
Clinicians also reported challenges with conducting psychiatric assessments and consultations. Face masks and physical distancing were considered barriers to assessment and therapeutic communication. In a few private mental health facilities, psychiatrists interviewed people with MHCs using mirrors so that they could attend to non-verbal communication. But such initiatives were not reported in public mental health facilities. A psychiatrist reported his experience as:
Patients had not been getting appropriate service during the early months of the pandemic. Although many patients didn’t come, those who visited us were also not properly assessed and consulted. Both of us, the patient and the clinician, were talking wearing face mask. In a psychiatric interview, it is difficult to know the external emotional changes over the face of the patients. It is difficult to understand non-verbal communication since face mask is a barrier. In addition, due to fear of the infection, we interview patients for a limited brief period of time. Due to the risk of infection, we also rarely engage caregivers during the clinical interview. Thus, we are only able to get a limited amount of information about their illness [IDI09].