MHPSS and COVID-19: Considerations for cross-sectoral coordination and integration from Italy

Dr Anita Marini is an Executive Psychologist within the Italian Public Health System based in the Emilia-Romagna region (Romagna subregion). This region is ranked second in Italy for the highest numbers of positive COVID-19 cases and deaths. In this post, she describes the challenges of integrating mental health and psychosocial support (MHPSS) considerations across sectors in the emergency pandemic response. 

Key messages: Innovations:
Integrate MHPSS considerations across sectors at the policy and decision-making levels  Ongoing and on-the-job training for MHPSS staff about core principles and approaches of MHPSS in emergency
Strengthen coordination mechanisms at national, regional and local levels involving MHPSS actors from public and private sectors Dedicated phone lines for the general population and social and health workers                                                                              
Find ways to reach vulnerable groups that cannot access e-resources  Targeted calls to older adults and people positive with COVID-19

Italy was not very familiar with MHPSS principles and guidelines for emergency settings as it had not been exposed to a national emergency of this scale in decades. When it comes to MHPSS, one frequently hears about “trauma” and clinical interventions to support “traumatised populations” rather than recommended frameworks, such as those  developed by IASC and Sphere. The outbreak in Italy occurred right after China, and there was limited time for preparation and necessary assessments to inform service organisation and capacity development.

Each day presents new challenges and sudden unexpected demands. As a clinician, I have seen increased anxiety about death, being infected and affecting others as well as anger and high level of distress. Discrepancies between the information delivered and restriction measures adopted causes mistrust and confusion. There is also intense guilt when a person knows they have transferred the virus to someone who has died and in some cases blame occurs. People positive with COVID-19 feel afraid, sad, abandoned and stigmatised. Additionally, heavy financial losses cause fear, anxiety and irritability. On top of all this, there has been an escalation in gender-based and domestic violence.

Shortages of personal protective equipment (PPE) and inconsistent information and instructions leave health care workers feeling frustrated, unsupported and distressed. All the uncertainty and insecurity brings up overwhelming feelings of clinical responsibility. It is a heavy burden managing sudden changes in patients who seemed stable and then having to communicate unexpected deaths to family members. 

Without investment in coordination mechanisms, initiatives may duplicate services and create needs gaps, poor referral outcomes and confusion regarding how to navigate the system.

While it is amazing that there are many organisations and agencies eager to provide mental health and psychosocial support, there has been poor coordination between the public health system, the private sector and NGOs and also between national and regional levels. Without investment in coordination mechanisms, initiatives may duplicate services and create needs gaps, poor referral outcomes and confusion regarding how to navigate the system.

Another major challenge is integrating MHPSS considerations horizontally at decision-making levels. They are often seen and requested as standalone, vertical (and sometimes a bit magical!) interventions to be provided to individuals struggling to cope with all the challenges posed by COVID-19. Less frequent are requests to integrate MHPSS considerations within a department or health unit in order to support and promote the wellbeing of all workers and teams.

 Intervention pyramid for mental health and psychosocial support (IASC Interim Briefing Note)

The public health system of Emilia-Romagna subregion organised the MHPSS response to the pandemic based on the IASC briefing note with a multi-layered response - starting with the community and on to primary care and specialised care. It is challenging, however, to adapt the IASC pyramid given required social distancing measures and the need for remote interventions. The system and the communities may not have been ready to transition to working remotely both in terms of culture and equipment. Group activities are particularly challenging on digital platforms (Zoom, Webex, etc) as the platforms do not always perform very well. 

Nevertheless, we already see opportunities for “Building Back Better”, For example, institutionalising innovative e-interventions that are proving to be more effective in reaching and engaging some target populations compared to face-to-face interventions.

Finally, there is the need to adjust the response continuously, adapting to changing restriction measures, the phase of the emergency and the needs of the population. It is an on-going learning experience that poses challenges and opportunities. 

In Emilia-Romagna, we have implemented the following main interventions:  

  • On-the-job and on-going capacity building of MHPSS staff on principles, approaches and interventions of IASC MHPSS in emergency settings
  • Psychoeducational materials developed and provided to different target populations in accordance with IASC and WHO guidance 
  • Remote phone and video call MHPSS services with face-to-face contact only for urgent and severe cases
  • Plans to support GPs and paediatricians in integrating MHPSS in their interventions and refer when needed
  • Training sessions for health care workers on providing psychoeducation and simple stress management tools
  • Post-graduate Psychology students trained to call elderly people over 65 to identify needs and activate available resources if necessary
  • Psychologists call all people affected by COVID-19 using a semi-structured interview format, a psychological screening tool with consent and follow up if requested (this is coordinated by the Ministry of Health, Department of Public Health)
  • Dedicated phone line and email for people directly or indirectly affected by COVID-19
  • Dedicated phone line and email for health and social workers
  • Tablets for some hospital units to enable video calls with psychologists and family members
  • Specific projects to assist elderly and adults with and without cognitive impairments and disabilities in residential institutions who have been affected by severe COVID-19 outbreaks
  • Specialised mental health services and outreach for more vulnerable cases
  • Basic M&E Activities

So far we have received 888 contacts in one month: 96% by phone and 4% by email. Eighteen percent requested follow up. Sixty percent are women and only 12% are health workers. We have also conducted a study on the mental health effects of the pandemic, and preliminary results will be available soon.

The COVID-19 pandemic and resulting lockdown measures have highlighted the relevance of the social determinants of mental health. Addressing social determinants requires strengthening public health systems and integrating MHPSS considerations across sectors, not just in emergency health responses. Fortunately, Italy uses a community-based mental health system so people do not live in large psychiatric institutions where outbreaks would be detrimental. However, we need to protect people living in nursing homes and other residential institutions as they are particularly vulnerable and at increased risk if exposed.

Key Resources:

  • Briefing note: Addressing Mental Health and Psychosocial Aspects of COVID-19 Outbreak (IASC)​ [Link]
  • Building Back Better: Sustainable mental health care after emergencies (WHO)​ [Link]
  • Mental health and psychosocial considerations during the COVID-19 outbreak (WHO) [Link]

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Region: 
Europe
Population: 
Maternal and neonatal health
Children and adolescents
Adults
Older adults
Families and carers
Minority populations
Non-communicable diseases (e.g. cancer, diabetes, stroke)
Disability
Setting: 
Community
Primary care
Specialist care
Approach: 
Policy and legislation
Treatment, care and rehabilitation
Training, education and capacity building
Disorder: 
All disorders
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