Abstract

This integrative review aims to identify the mental health care measures that were produced during the COVID-19 pandemic. This research was conducted on three databases (SciELO, PubMed, and LILACS) with the following descriptors in Portuguese, English, and Spanish: “SAÚDE MENTAL” or “SALUD MENTAL” or “MENTAL HEALTH” AND “COVID-19” from 2020 to 2021. In total, 3,451 articles were found, 43 of which were analyzed. Most measures were digital, stemmed from public institutions, focused on the local perspective, and were integrated with the public health care system. This study discusses the models of care in mental health based on measures to cope with the COVID-19 pandemic. It also discusses the Brazilian health care system, reiterating its resilience. In conclusion, digital measures occurred most often. This study suggest the evaluation of the accessibility of this mental health care model for most vulnerable groups. Finally, this research reinforces the importance of the Brazilian health care system for public health and access to information to cope with the COVID-19 pandemic.

Key words:
Mental health; COVID-19; Community support; Healthcare models

Introduction

Mental health is one of the most complex, transversal, multiprofessional, and broad fields in health, exceeding pathologies and symptomatology, conducted through actions, in territories, and with freedom¹.

The outbreak of the COVID-19 pandemic, which began in China but spread rapidly to the whole word, required great adaptability and resilience from health services. The initial recommendations of the World Health Organization indicated that the main actions against the spread of the new coronavirus referred to hand hygiene, the use of masks, social distancing, and the restriction of non-essential activities². Most countries have adopted these measures with a greater or lesser degree of public adherence.

Health services were forced to readjust their way of operating. According to the Pan American Health Organization Report, which addressed the situation of its 35 signatory countries, mental health services in Latin America suffered from a lack of adequate funding for the continuity of care provision³ and pointed to a lack of planning for the care of vulnerable groups, the discontinuity in the care of users of alcohol and other drug, and the worsening of specific services for the care of these populations (as well as primary care) during the pandemic to the detriment of outpatient and hospital mental health services.

Actions against COVID-19, in addition to the new ways in which mental health services operate, also worsened mental health indices ³. The levels of anxiety and depression during the pandemic have significantly increased in both the poorest and richest layers⁴4 Furtado LAC, Universidade Federal de São Paulo, Fundação Tide Setubal. Pesquisa desigualdades e vulnerabilidades na epidemia de COVID-19: monitoramento, análise e recomendações [livro eletrônico]. São Paulo: Universidade Federal de São Paulo; 2021. [acessado 2023 ago 3]. Disponível em: https://repositorio.unifesp.br/handle/11600/61363.

Previous epidemics, such as Ebola and H₁N₁, among others, evinced that the mental health of populations tends to worsen, with COVID-19 being no exception to this rule⁵5 Anjum S, Ullah R, Rana MS, Khan HA, Memon FS, Ahmed Y, Jabeen S, Faryal R. COVID-19 pandemic: a serious threat for public mental health globally. Psychiatr Danub 2020; 32(2):245-250.. According to a survey by Garrido and Rodrigues (2020), the consumption of alcohol and other drugs in the general Brazilian population increased due to the necessary social isolation to prevent COVID-19⁶6 Garrido RG, Rodrigues, RC. Restrição de contato social e saúde mental na pandemia: possíveis impactos das condicionantes sociais. J Health Biological Sci 2021; 8(1):1-9..

Another group summarily affected by public health emergencies refer to frontline healthcare providers. Due to fear of contamination, lack of protective equipment, and/or the grief from losing colleagues and patients, this population deals with several aggravating factors for life, work, and mental health conditions⁷7 Teixeira CFS, Soares CM, Souza EA, Lisboa ES, Pinto ICM, Andrade LR, Espiridião MA. A saúde dos profissionais de saúde no enfrentamento da pandemia de COVID-19. Cien Saude Colet 2020; 25(9):3465-34748..

This study is part of a broader research, funded by the São Paulo Research Foundation (FAPESP) - PPSUS, coordinated by researchers from Universidade Federal de São Paulo (UNIFESP) in collaboration with Brazilian and Portuguese public universities, and supported by the São Paulo State Department of Health (SES-SP) and the Council of Municipal Secretaries of São Paulo (COSEMS-SP).

Thus, this study seeks to find the mental health care measures that were implemented during the pandemic based on the following research question: What measures have been produced for mental health care in the context of the COVID-19 pandemic?

Methodology

An integrative review was chosen as the methodology for this research, which, according to Mendes et.al (2008)⁸8 Mendes KDS, Silveira RCCP, Galvão, CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm 2008; 17(4):758-764., seeks, in the literature, to agglutinate productions that have results and reflections in everyday practices and to synthesize these findings.

Based on the research question, the following descriptors were defined as search strategies: “SAÚDE MENTAL” or “SALUD MENTAL” or “MENTAL HEALTH” AND “COVID-19.” The following databases were used: SCIELO, LILACS, and PubMed. The search was carried out with these descriptors in Portuguese, English, and Spanish on 01/18/2022 to retrieve articles published from 2020 to the date of the search in 2022.

A total of 3,451 productions were found for the aforementioned period: 92 on LILACS, 245 on SciELO, and 3,114 on PubMed. The next step of data collection was the exclusion of duplicates. The titles and abstracts of the selected publications were read, leading to the exclusion of those that were neither scientific articles nor answered the guiding question of this research. The final stage of this research included fully reading the remaining articles, and those that neither offered full access, nor provided free access, nor answered the question of this research were excluded.

Figure 1 shows each stage of the article selection process and their total number at the end of each phase. The final corpus included 43 selected articles.

Results and discussion

The 43 chosen articles addressed mental health care measures produced or fostered due to the COVID-19 pandemic (Chart 1).

Analysis classified the read articles based on the following criteria: type of study, target audience, scope, nationality, measure modality, purpose of the measure, nature of the measure, integration with the public health network, coverage in the health network, community measure, and intervention period.

Most studies used experience reports (51.1%), followed by interventions (20.9%). The target audience of the measures mainly involved healthcare providers (39%), mental health service users (16%), and the general population (11%). The intervention period of the research mainly dates to the first half of 2020.

Most articles with mental health measures were conducted in Brazil (23%), the United States (18%), Canada (9%), and China (9%), and every continent showed at least one study. The scope of the measures, although not described in all articles, indicates that they were developed at the municipal (30.2%), national (27.9%), and internal (23.2%) levels.

Studies included in-person and/or digital measures, and, in some cases, the same measure took place in a hybrid way, i.e., in both modalities. Chart 2 shows the division of digital measures into six categories: social media, applications to cope with COVID-19, hotlines, telecare, telemonitoring, and health education. The most common modality involved digital measures (80%).

Regarding purpose, the analysis in this study categorized findings into self-care, diagnosis, health education, and therapeutic. A measure could fit more than one purpose, with therapeutic taking place most often (83.7%) (Graph 1).

Most measures were public (49%)⁴⁴44 Dupont M. Salud mental y apoyo psicosocial (SMAPS): dispositivos de cuidado de equipos sanitarios de primera línea de respuesta telefónica ante COVID-19. Subjetividad Procesos Cognitivos 2020; 24(2):212-243. and some were integrated with the health care network (55%). Sometimes, the same measure involved different parts of the care network, and, at other times, a measure reported as integrated into the network lied in an unspecific point (as in the case of countries without universal health systems). Among measures related to the health network, they were developed in specialized/outpatient (45.8%), primary (33.3%), and hospital care (20.8%). Finally, 74.5% of articles reported measures without community participation (74.5%)⁹9 Gray M, Monti K, Katz C, Klipstein K, Limc S. A "Mental Health PPE" model of proactive mental health support for frontline health care workers during the COVID-19 pandemic. Psychiatry Res 2021; 299:113878.^,1111 Feinstein RE, Kotara S, Jones B, Shanor D, Nemeroff CB. A health care workers mental health crisis line in the age of COVID-19. Depress Anxiety 2020; 37(8):822-826.^,3232 Cavalcante F, Oliveira I, Costa M, Silva V, Caetano J, Neto N, Barros L. Intervenções para promoção da saúde mental durante a pandemia da COVID-19. Psic Saude Doenças 2020; 21(3):582-593..

Digital model

The main finding of this study refers to the massive use of digital measures with several types of intervention proposals that essentially aimed at offering teleconsultations, diagnoses, or specific mental health monitoring lines.

As the COVID-19 pandemic configured an unprecedented health event in the last century, some studies used digital media to spread news and educational information about the disease¹⁴14 Guan I, Kirwan N, Beder M, Levy M, Law S. Adaptations and innovations to minimize service disruption for patients with severe mental illness during COVID-19: perspectives and reflections from an assertive community psychiatry program. Community Ment Health J 2021; 57(1):10-17.^,3737 Sánchez-Guarnido AJ, Domínguez-Macías E, Garrido-Cervera JA, González-Casares R, Marí-Boned S, Represa-Martínez Á, Herruzo C. Occupational therapy in mental health via telehealth during the COVID-19 pandemic. Int J Environ Res Public Health 2021; 18(13):7138.. This dissemination of scientific knowledge also promoted well-being, mental health, and the search for social and community support⁴⁹49 Yang Q, Wu Z, Xie Y, Xiao X, Wu J, Sang T, Zhang K, Song H, Wu X, Xu X. The impact of health education videos on general public's mental health and behavior during COVID-19. Glob Health Res Policy 2021; 6(1):37..

Digital resources also served to telemonitor confirmed cases of COVID-19¹⁵15 Oppel M, Camino S, Smith JM, Godoy A, Strejilevich S. Adaptación de la práctica psiquiátrica en instituciones de salud mental públicas y privadas de la Ciudad de Buenos Aires durante la pandemia de COVID-19. Vertex 2021; 32(153):40-44.^,3636 Moreira WC, Sousa KHJF, Sousa AR, Santana TDS, Zeitoune RCG, Nóbrega MDPSS. Mental health interventions implemented in the COVID-19 pandemic: what is the evidence? Rev Bras Enferm 2021; 74(Suppl. 1):e20200635.^,4747 Calvetti PU, Vazquez ACS, Silveira LMOB. Teleatendimento psicológico em universidade pública da saúde no enfrentamento da pandemia: da gestão com pessoas à telepsicologia. Rev Bras Psicoter 2021; 23(1):31-43., aiding the detection of preventive factors against the worsening of the disease and of the mental health status due to it and the protocols required for infected people, such as isolation and physical distancing. The described measures followed people with COVID-19 daily, some of which included anxiety and depression scales to monitor symptoms in isolated patients²⁴24 Lee SH, Chiu YR, Hung YT, Chen QG, Zhang A, Yang Y, Zhi P, Li Y, Zhu X, Chang PL. Establish a real-time responsible home quarantine and monitoring management mHealth platform. AMIA Annu Symp Proc 2021; 2020:697-706..

Note also the types of applications to fight COVID-19¹²12 Fiol-DeRoque MA, Serrano-Ripoll MJ, Jiménez R, Zamanillo-Campos R, Yáñez-Juan AM, Bennasar-Veny M, Leiva A, Gervilla E, García-Buades ME, García-Toro M, Alonso-Coello P, Pastor-Moreno G, Ruiz-Pérez I, Sitges C, García-Campayo J, Llobera-Cánaves J, Ricci-Cabello I. A mobile phone-based intervention to reduce mental health problems in health care workers during the COVID-19 pandemic (PsyCovidApp): randomized controlled trial. JMIR Mhealth Uhealth 2021; 9(5):e27039.^,2727 Liu M, Neri Mini F, Torres C, Kwete GM, Boudreau AA, Hunter ML, Parra MY, Lopez W, Izen A, Price SN, Perkins ME, Taveras EM. Fostering resilience in pregnancy and early childhood during the COVID-19 pandemic: the HUGS/Abrazos Program design and implementation. Front Public Health 2021; 9:633285.^,4545 Song J, Jiang R, Chen N, Qu W, Liu D, Zhang M, Fan H, Zhao Y, Tan S. Self-help cognitive behavioral therapy application for COVID-19-related mental health problems: a longitudinal trial. Asian J Psychiatr 2021; 60:102656., with diagnostic, therapeutic, educational, and self-care purposes. An example developed in Brazil refers to the “COM-VC” application, which had a therapeutic and diagnostic purpose in mental health for healthcare providers and education, with information about COVID-19²²22 Fukuti P, Uchôa CLM, Mazzoco MF, Cruz IDGD, Echegaray MVF, Humes EC, Silveira JB, Santi TD, Miguel EC, Corchs F; COMVC-19 program; Fatori D, Campello G, Oliveira GM, Argolo FC, Ferreira FM, Machado G, Argeu A, Oliveira GMR, Serafim AP, Siqueira LL, Rossi L, Rios IC, Oliveira TR, Antoniazzi LCK, Gagliotti DAM, Abelama Neto E, Oliveira Junior PN, Correia AV, Gonçalves LS, Tortato LS, Busato WMM, Guimarães-Fernandes F, Alves M, Leite Netto OF, Schoueri PCL, Roque MA, Merlin SS, Boer GCM, Sallet PC, Malbergier A, Spedo MA, Kamitsuji CS, Faria E, Moreira MVG, Kaufman A, Abdo C, Scanavino MT, Lancman S, Tavares H, Polanczyk G, Brunoni AR, Forlenza OV, Barros-Filho TEP. COMVC-19: a program to protect healthcare workers' mental health during the COVID-19 Pandemic. What we have learned. Clinics (Sao Paulo) 2021; 76:e2631..

The main digital measure refers to teleservice³⁴34 Kemp J, Chorney J, Kassam I, MacDonald J, MacDonald T, Wozney L, Strudwick G. Learning about the current state of digital mental health interventions for Canadian youth to inform future decision-making: mixed methods study. J Med Internet Res 2021; 23(10):e30491.^,5050 Lai FH, Yan EW, Yu KK, Tsui WS, Chan DT, Yee BK. The protective impact of telemedicine on persons with dementia and their caregivers during the COVID-19 Pandemic. Am J Geriatr Psychiatry 2020; 28(11):1175-1184. in different formats, such as video calls, digital media applications, telephone calls, among others, targeting different audiences, including individual and group services²⁹29 Ferrari SML, Pywell SD, Costa ALB, Marcolino TQ. Grupos de terapia ocupacional em telessaúde na pandemia de Covid-19: perspectivas de um Hospital-Dia de Saúde Mental. Cad Bras Ter Ocup 2022; 30:e3019.^,3535 Feijt M, Kort Y, Bongers I, Bierbooms J, Westerink J, IJsselsteijn W. Mental health care goes online: practitioners' experiences of providing mental health care during the COVID-19 pandemic. Cyberpsychol Behav Soc Netw 2020; 23(12):860-864.^,4242 Graziano S, Boldrini F, Righelli D, Milo F, Lucidi V, Quittner A, Tabarini P. Psychological interventions during COVID pandemic: telehealth for individuals with cystic fibrosis and caregivers. Pediatr Pulmonol 2021; 56(7):1976-1984..

Lai, Yu, and Yee (2020) point out that teleservices should preferably take place as video calls so those served can see with whom they are communicating. They stress that, in the population with dementia and their caregivers, video consultations promoted greater well-being and mental health than telephone ones⁵⁰50 Lai FH, Yan EW, Yu KK, Tsui WS, Chan DT, Yee BK. The protective impact of telemedicine on persons with dementia and their caregivers during the COVID-19 Pandemic. Am J Geriatr Psychiatry 2020; 28(11):1175-1184..

Liberal et. al (2021) emphasize that telecare still shows implementation difficulties, such as lack of professional training and of guidelines to carry them out³⁰30 Liberal SP, Bordiano G, Lovisi GM, Abelha L, Dias FM, Carvalho CO, Morais LRN, Brasil MAA. Implementation of a telemental health service for medical students during the COVID-19 pandemic. Rev Bras Educ Med 2021; 45(4):e202.. They still reinforce that the therapeutic welcoming space telecare offered is essential for mental health care.

The discussion about digital accessibility was also relevant. Guan et.al (2021) highlight the difficulty with which people who used mental health services had in obtaining technological/digital resources¹⁴14 Guan I, Kirwan N, Beder M, Levy M, Law S. Adaptations and innovations to minimize service disruption for patients with severe mental illness during COVID-19: perspectives and reflections from an assertive community psychiatry program. Community Ment Health J 2021; 57(1):10-17.. The authors point out that they could offer electronic devices to users with the help of the Canadian government.

In addition to this lack of resources, difficulties occur in the use of virtual tools. Ferrari et.al (2021) point out that, in the Brazilian reality, measures by digital technologies have faced accessibility barriers due to access inequalities and platforms that are difficult to use²⁹29 Ferrari SML, Pywell SD, Costa ALB, Marcolino TQ. Grupos de terapia ocupacional em telessaúde na pandemia de Covid-19: perspectivas de um Hospital-Dia de Saúde Mental. Cad Bras Ter Ocup 2022; 30:e3019.. These considerations about accessibility and use of digital equipment also challenge the national health system.

Finally, only half of the digital measures were integrated into the public health network¹⁶16 Moon KJ, Montiel GI, Cantero PJ, Nawaz S. Addressing emotional wellness during the COVID-19 pandemic: the role of promotores in delivering integrated mental health care and social services. Prev Chronic Dis 2021; 18:E53.^,1717 Hamoda HM, Chiumento A, Alonge O, Hamdani SU, Saeed K, Wissow L, Rahman A. Addressing the consequences of the COVID-19 lockdown for children's mental health: investing in school mental health programs. Psychiatr Serv 2021; 72(6):729-731.^,1919 Albott CS, Wozniak JR, McGlinch BP, Wall MH, Gold BS, Vinogradov S. Battle buddies: rapid deployment of a psychological resilience intervention for health care workers during the COVID-19 pandemic. Anesth Analg 2020; 131(1):43-54.. This volume, which must be considered, enables us to inquire about the continuity of care these measures produced, as well as who were, in fact, the populations that had access to the necessary resources to be remotely aided.

In-person model

A smaller number of publications evinced this measure format, but it should be noted that it was the most used for healthcare providers and populations that already used mental health services¹⁰10 Bröcker E, Louw KA, Hewett M, Burger H, Felix R, De Koker P, Rossouw J, Seedat S. A collaborative and evolving response to the needs of frontline workers, patients and families during the COVID-19 pandemic at Tygerberg Hospital, Western Cape Province, South Africa. S Afr Med J 2021; 111(5):405-408.^,1313 Rahul P, Chander KR, Murugesan M, Anjappa AA, Parthasarathy R, Manjunatha N, Kumar CN, Math SB. Accredited Social Health Activist (ASHA) and Her Role in District Mental Health Program: Learnings from the COVID 19 Pandemic. Community Ment Health J 2021; 57(3):442-445.^,3838 Beauchamp MR, Hulteen RM, Ruissen GR, Liu Y, Rhodes RE, Wierts CM, Waldhauser KJ, Harden SH, Puterman E. Online-delivered group and personal exercise programs to support low active older adults' mental health during the COVID-19 pandemic: randomized controlled trial. J Med Internet Res 2021; 23(7):e30709.^,4040 Orui M, Saeki S, Harada S, Hayashi M. Practical report of disaster-related mental health interventions following the great east japan earthquake during the COVID-19 pandemic: potential for suicide prevention. Int J Environ Res Public Health 2021; 18(19):10424.. Some studies have shown measures that allow for mental health management of professionals in the workplace itself, which became a hostile environment amid the fear propagated throughout the pandemic²⁰20 Noal DS, Freitas CM, Passos MFD, Serpeloni F, Melo BD, Kadri MRAE, Pereira DR, Souza MS, Magrin NP, Kabad JF, Meneses SS, Lima CC, Rezende MJ. Capacitação nacional emergencial em Saúde Mental e Atenção Psicossocial na Covid-19: um relato de experiência. Saude Debate 2020; 44(Esp. 4):293-305.^,3939 Roberts C, Darroch F, Giles A, van Bruggen R. Plan A, Plan B, and Plan C-OVID-19: adaptations for fly-in and fly-out mental health providers during COVID-19. Int J Circumpolar Health 2021; 80(1):1935133.. Pine et.al (2021) reiterate the importance of mental health strategies to reduce anxiety, stress, and depression in frontline nurses⁵¹51 Pinho L, Correia T, Sampaio F, Sequeira C, Teixeira L, Lopes M, Fonseca C. The use of mental health promotion strategies by nurses to reduce anxiety, stress, and depression during the COVID-19 outbreak: a prospective cohort study. Environ Res 2021; 195:110828..

Other studies show actions that had to be developed to try to ensure access to and continuity of mental health care to prevent the spread of the new coronavirus¹⁹19 Albott CS, Wozniak JR, McGlinch BP, Wall MH, Gold BS, Vinogradov S. Battle buddies: rapid deployment of a psychological resilience intervention for health care workers during the COVID-19 pandemic. Anesth Analg 2020; 131(1):43-54.^,3333 Boldt K, Coenen M, Movsisyan A, Voss S, Rehfuess E, Kunzler AM, Lieb K, Jung-Sievers C. Interventions to ameliorate the psychosocial Effects of the COVID-19 pandemic on children-a systematic review. Int J Environ Res Public Health 2021; 18(5):2361.^,4141 Ortega AC, Valtierra E, Rodríguez-Cuevas FG, Aranda Z, Preciado G, Mohar S. Protecting vulnerable communities and health professionals from COVID-19 associated mental health distress: a comprehensive approach led by a public-civil partnership in rural Chiapas, Mexico. Glob Health Action; 14(1):1997410.. Sousa (2021) emphasizes that access and adaptation to activities that were carried out prior to the pandemic were as important for the mental health of older adults as the sanitary measures to prevent COVID-19¹⁸18 Sousa JG. Atividades socioculturais como interface de bem-estar emocional e de prevenção da transmissão da Covid-19 em estruturas residenciais para pessoas idosas. Interface (Botucatu) 2021; 25(Supl. 1):e200576.. It is also worth highlighting the importance of interpersonal exchanges between co-workers, neighbors, and acquaintances from different environments in in-person measures.

The in-person modality also highlighted the measures aimed at self-care, such as meditation, physical activities, and personal protection against the virus³³33 Boldt K, Coenen M, Movsisyan A, Voss S, Rehfuess E, Kunzler AM, Lieb K, Jung-Sievers C. Interventions to ameliorate the psychosocial Effects of the COVID-19 pandemic on children-a systematic review. Int J Environ Res Public Health 2021; 18(5):2361.. Beauchamp et.al (2021) emphasize that these alternative care practices benefit mental health, which can be done at home and the implementation of which involve fewer financial resources³⁸38 Beauchamp MR, Hulteen RM, Ruissen GR, Liu Y, Rhodes RE, Wierts CM, Waldhauser KJ, Harden SH, Puterman E. Online-delivered group and personal exercise programs to support low active older adults' mental health during the COVID-19 pandemic: randomized controlled trial. J Med Internet Res 2021; 23(7):e30709..

Integration with the health network

An important finding of this research refers to most measures developed in-person (66%) being integrated with health networks, especially in primary and specialized care.

The integration of measures with the network could guarantee the continuity and longitude of health care, ensuring promotion, prevention, and rehabilitation throughout the stages of life⁵²52 Arantes P. O ódio às universidades públicas [Internet]. 2021. [acessado 2023 jun 11]. Disponível em: https://souciencia.unifesp.br/opiniao/o-odio-as-universidades-publicas
https://souciencia.unifesp.br/opiniao/o-... . Therefore, it becomes necessary in the production and debate of this article.

Considering that most measures were digital, the concern with their integration into the public health network enables us to reflect on the continuity of care projects²⁸28 Mattos EBT, Francisco IC, Pereira GC, Novelli MMPC. Grupo virtual de apoio aos cuidadores familiares de idosos com deme^ncia no contexto da COVID-19. Cad Bras Ter Ocup 2021; 29:e2882.^,4646 Amaral GG, Silva LS, Oliveira JV de, Machado NM, Teixeira JS, Passos HR. Suporte ético-emocional à profissionais de enfermagem frente à pandemia de COVID-19: relato de experiência. Esc Anna Nery 2022; 26(Esp.):e20210234.. Most of the measures that were integrated with the network were in specialized/outpatient care⁴³43 Liberati E, Richards N, Parker J, Willars J, Scott D, Boydell N, Pinfold V, Martin G, Dixon-Woods M, Jones P. Remote care for mental health: qualitative study with service users, carers and staff during the COVID-19 pandemic. BMJ Open 2021; 11(4):e049210.^,4848 Hopkins L, Pedwell G. The COVID PIVOT - re-orienting child and youth mental health care in the light of pandemic restrictions. Psychiatr Q 2021; 92(3):1259-1270..

Most of the measures that were integrated with the health networks aimed at mental health care with short responses, i.e., emergency lines, telemonitoring, and mental health diagnoses and/or for COVID-19 cases²¹21 Abdullah H, Lynch S, Aftab S, Shahar S, Klepacz L, Cristofano P, Rahmat S, Save-Mundra J, Dornbush R, Lerman A, Berger K, Bartell A, Ferrando SJ. Characteristics of calls to a COVID-19 mental health hotline in the first wave of the pandemic in New York. Community Ment Health J 2021; 57(7):1252-1254.^,2323 Chevance A, Gourion D, Hoertel N, Llorca PM, Thomas P, Bocher R, Moro MR, Laprévote V, Benyamina A, Fossati P, Masson M, Leaune E, Leboyer M, Gaillard R. Ensuring mental health care during the SARS-CoV-2 epidemic in France: a narrative review. Encephale 2020; 46(3):193-201.^,2525 Nascimento RB, Arau´jo IFL, Vieira ES, Oliveira ACA, Arau´jo RLMS. Estrate´gias de enfrentamento para manutenc¸a~o da sau´de mental do trabalhador em tempos de Covid-19: uma revisa~o integrativa. Rev Psicol Divers Saude 2021; 10(1):181-197.. Some studies considered this support from the mental health network, which existed before the pandemic, as necessary to refer recurrent demands⁴⁶46 Amaral GG, Silva LS, Oliveira JV de, Machado NM, Teixeira JS, Passos HR. Suporte ético-emocional à profissionais de enfermagem frente à pandemia de COVID-19: relato de experiência. Esc Anna Nery 2022; 26(Esp.):e20210234..

In addition to monitoring and referring to a network, the measures that relied on this integration could also expand care beyond the health sector, associating it with school interventions and even with social work, ensuring a more comprehensive view of the mental health of populations¹⁶16 Moon KJ, Montiel GI, Cantero PJ, Nawaz S. Addressing emotional wellness during the COVID-19 pandemic: the role of promotores in delivering integrated mental health care and social services. Prev Chronic Dis 2021; 18:E53.^,1717 Hamoda HM, Chiumento A, Alonge O, Hamdani SU, Saeed K, Wissow L, Rahman A. Addressing the consequences of the COVID-19 lockdown for children's mental health: investing in school mental health programs. Psychiatr Serv 2021; 72(6):729-731..

Measures with community participation

Few studies considered measures with community participation in their execution and/or implementation, although all targeted populations and communities in general. In total, seven articles described measures with community participation. All were carried out with integration into the health network, and most were designed in the first year of the pandemic (2020), mainly focusing on the therapeutic purpose.

The measures built by the communities refers to the ones that most included specific populations within each proposal, namely: frontline healthcare providers, older adults in therapeutic housing, vulnerable populations, children, and mental health users (prior to the pandemic). Guan et.al (2021), for example, refer to measures that included services, healthcare providers, and the general population¹⁴14 Guan I, Kirwan N, Beder M, Levy M, Law S. Adaptations and innovations to minimize service disruption for patients with severe mental illness during COVID-19: perspectives and reflections from an assertive community psychiatry program. Community Ment Health J 2021; 57(1):10-17.. Thus, the measures that had community participation in their elaboration met the needs of the specific populations, who helped to constitute the measures themselves.

Community participation enabled greater accessibility in health, providing greater universal and comprehensive care in the places where it was implemented¹⁴14 Guan I, Kirwan N, Beder M, Levy M, Law S. Adaptations and innovations to minimize service disruption for patients with severe mental illness during COVID-19: perspectives and reflections from an assertive community psychiatry program. Community Ment Health J 2021; 57(1):10-17.^,1717 Hamoda HM, Chiumento A, Alonge O, Hamdani SU, Saeed K, Wissow L, Rahman A. Addressing the consequences of the COVID-19 lockdown for children's mental health: investing in school mental health programs. Psychiatr Serv 2021; 72(6):729-731.^,2020 Noal DS, Freitas CM, Passos MFD, Serpeloni F, Melo BD, Kadri MRAE, Pereira DR, Souza MS, Magrin NP, Kabad JF, Meneses SS, Lima CC, Rezende MJ. Capacitação nacional emergencial em Saúde Mental e Atenção Psicossocial na Covid-19: um relato de experiência. Saude Debate 2020; 44(Esp. 4):293-305.^,2323 Chevance A, Gourion D, Hoertel N, Llorca PM, Thomas P, Bocher R, Moro MR, Laprévote V, Benyamina A, Fossati P, Masson M, Leaune E, Leboyer M, Gaillard R. Ensuring mental health care during the SARS-CoV-2 epidemic in France: a narrative review. Encephale 2020; 46(3):193-201.. These measures were also associated with models to prevent and cope with the most common mental health conditions in pandemics (anxiety, stress, and depression)¹⁶16 Moon KJ, Montiel GI, Cantero PJ, Nawaz S. Addressing emotional wellness during the COVID-19 pandemic: the role of promotores in delivering integrated mental health care and social services. Prev Chronic Dis 2021; 18:E53.^,2323 Chevance A, Gourion D, Hoertel N, Llorca PM, Thomas P, Bocher R, Moro MR, Laprévote V, Benyamina A, Fossati P, Masson M, Leaune E, Leboyer M, Gaillard R. Ensuring mental health care during the SARS-CoV-2 epidemic in France: a narrative review. Encephale 2020; 46(3):193-201..

Analysis of the measures in Brazilian studies

Considering that COVID-19 was an unprecedented health event for the Brazilian Unified Health System (SUS) and that services and territories had to modify their routine and ways of life to face the pandemic, we seek to highlight the studies produced in Brazil.

All selected national studies were conducted in 2020 (the first year of the pandemic) in a reality in which vaccination was yet to be an alternative for care in the country. Moreover, most articles included experience reports, giving visibility to the initiatives of services and their connection with academic production, even in the face of a government that threatened public universities⁵³53 Costa AM, Chioro A, Laguardia J, Flauzino RF. Ainda tem pandemia, mas há esperança. Saude Debate 2022; 46(Esp. 1):5-14..

Most measures were public and covered the mental health of frontline professionals, mostly by the digital model. The most pointed out digital innovations referred to the creation of telephone lines and applications to meet the demands of this population²⁹29 Ferrari SML, Pywell SD, Costa ALB, Marcolino TQ. Grupos de terapia ocupacional em telessaúde na pandemia de Covid-19: perspectivas de um Hospital-Dia de Saúde Mental. Cad Bras Ter Ocup 2022; 30:e3019.^,3131 Alavi Z, Haque R, Felzer-Kim IT, Lewicki T, Haque A, Mormann M. Implementing COVID-19 mitigation in the community mental health setting: march 2020 and lessons learned. Community Ment Health J 2021; 57(1):57-63.^,4747 Calvetti PU, Vazquez ACS, Silveira LMOB. Teleatendimento psicológico em universidade pública da saúde no enfrentamento da pandemia: da gestão com pessoas à telepsicologia. Rev Bras Psicoter 2021; 23(1):31-43..

The main purpose of these measures related to therapeutic activities aimed at supporting and coping with mental health demands due to the pandemic²⁹29 Ferrari SML, Pywell SD, Costa ALB, Marcolino TQ. Grupos de terapia ocupacional em telessaúde na pandemia de Covid-19: perspectivas de um Hospital-Dia de Saúde Mental. Cad Bras Ter Ocup 2022; 30:e3019.^,3030 Liberal SP, Bordiano G, Lovisi GM, Abelha L, Dias FM, Carvalho CO, Morais LRN, Brasil MAA. Implementation of a telemental health service for medical students during the COVID-19 pandemic. Rev Bras Educ Med 2021; 45(4):e202.^,3333 Boldt K, Coenen M, Movsisyan A, Voss S, Rehfuess E, Kunzler AM, Lieb K, Jung-Sievers C. Interventions to ameliorate the psychosocial Effects of the COVID-19 pandemic on children-a systematic review. Int J Environ Res Public Health 2021; 18(5):2361.. Since the pandemic increased mental health demands, the predominance of this therapeutic purpose is justified.

Notably, the measures integrated with the SUS aimed at promoting mental health via health education, professional training, and self-care²⁰20 Noal DS, Freitas CM, Passos MFD, Serpeloni F, Melo BD, Kadri MRAE, Pereira DR, Souza MS, Magrin NP, Kabad JF, Meneses SS, Lima CC, Rezende MJ. Capacitação nacional emergencial em Saúde Mental e Atenção Psicossocial na Covid-19: um relato de experiência. Saude Debate 2020; 44(Esp. 4):293-305.^,2222 Fukuti P, Uchôa CLM, Mazzoco MF, Cruz IDGD, Echegaray MVF, Humes EC, Silveira JB, Santi TD, Miguel EC, Corchs F; COMVC-19 program; Fatori D, Campello G, Oliveira GM, Argolo FC, Ferreira FM, Machado G, Argeu A, Oliveira GMR, Serafim AP, Siqueira LL, Rossi L, Rios IC, Oliveira TR, Antoniazzi LCK, Gagliotti DAM, Abelama Neto E, Oliveira Junior PN, Correia AV, Gonçalves LS, Tortato LS, Busato WMM, Guimarães-Fernandes F, Alves M, Leite Netto OF, Schoueri PCL, Roque MA, Merlin SS, Boer GCM, Sallet PC, Malbergier A, Spedo MA, Kamitsuji CS, Faria E, Moreira MVG, Kaufman A, Abdo C, Scanavino MT, Lancman S, Tavares H, Polanczyk G, Brunoni AR, Forlenza OV, Barros-Filho TEP. COMVC-19: a program to protect healthcare workers' mental health during the COVID-19 Pandemic. What we have learned. Clinics (Sao Paulo) 2021; 76:e2631.^,4747 Calvetti PU, Vazquez ACS, Silveira LMOB. Teleatendimento psicológico em universidade pública da saúde no enfrentamento da pandemia: da gestão com pessoas à telepsicologia. Rev Bras Psicoter 2021; 23(1):31-43.. Since these national studies dated to the beginning of the pandemic, none analyzed how the produced measures contributed to maintaining free and anti-asylum care in Brazil.

Despite the history of defunding SUS faced prior to the pandemic, it still showed great resilience⁵⁴. Accordingly, half of the measures are integrated into the public health network, which reiterates the importance of the Brazilian health system.

For Caponi (2020), the absence of central actions and coordination by the federal government and the stimulus toward the dissemination of fake news configured negative factors that determined the construction of the fight against the pandemic in Brazil⁵⁵. Half of the Brazilian studies offered health education measures, reiterating the fight against misinformation and the role of SUS in the accessibility of current knowledge about the pandemic²¹21 Abdullah H, Lynch S, Aftab S, Shahar S, Klepacz L, Cristofano P, Rahmat S, Save-Mundra J, Dornbush R, Lerman A, Berger K, Bartell A, Ferrando SJ. Characteristics of calls to a COVID-19 mental health hotline in the first wave of the pandemic in New York. Community Ment Health J 2021; 57(7):1252-1254.^,2323 Chevance A, Gourion D, Hoertel N, Llorca PM, Thomas P, Bocher R, Moro MR, Laprévote V, Benyamina A, Fossati P, Masson M, Leaune E, Leboyer M, Gaillard R. Ensuring mental health care during the SARS-CoV-2 epidemic in France: a narrative review. Encephale 2020; 46(3):193-201.^,4747 Calvetti PU, Vazquez ACS, Silveira LMOB. Teleatendimento psicológico em universidade pública da saúde no enfrentamento da pandemia: da gestão com pessoas à telepsicologia. Rev Bras Psicoter 2021; 23(1):31-43.. The author also highlights the importance of community organizations and territories in the production of life and mental health. From this perspective, considering the relevance of community articulations to build coping tools, only one study reported a measure with community participation²³23 Chevance A, Gourion D, Hoertel N, Llorca PM, Thomas P, Bocher R, Moro MR, Laprévote V, Benyamina A, Fossati P, Masson M, Leaune E, Leboyer M, Gaillard R. Ensuring mental health care during the SARS-CoV-2 epidemic in France: a narrative review. Encephale 2020; 46(3):193-201.. Thus, the production of mental health care that is more integrated with the communities in the territories is still a challenge for SUS.

The limitations of this research include this review being conducted in early 2022 to evaluate the two previous years to understand actions carried out since the beginning of the pandemic. However, the difficulties in production and the long time between the submission and publication of articles in the scientific community may have been one of the reasons for the lower number of publications in 2021.

Final considerations

This review analyzed the measures and inventions for mental health care in the fight against COVID-19, pointing to the digital medium and remote health productions as one of the main inventions in the response to the COVID-19 pandemic.

The possibilities of mental health care have grown, including different populations, but they always focus on the problems due to health emergency situations. Whether as a tool for self-and/or collective care, mental health measures have changed and adapted to this new reality.

The analyses of the measures in Brazil reiterated the importance of SUS in the daily lives of populations by actions that ranged from the welcoming of frontline healthcare providers to health education activities. SUS once again showed its strength during the pandemic.

The challenges for the Brazilian health system point to the integration with territories and communities, which can expand the scope of people cared for by the produced measures.

Another indication that can ground future research refers to investigating its developments and the sustainability and continuity of their measures. Moreover, this study recommends investigating the populations accessed by the measures to understand whether they were universal and of broader access, including for populations in vulnerable situations, which will require other methodological approaches.

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