Challenges facing mental health systems arising from the COVID-19 pandemic: Evidence from 14 European and North American countries

We assessed challenges that the COVID-19 pandemic presented for mental health systems and the responses to these challenges in 14 countries in Europe and North America. Experts from each country filled out a structured questionnaire with closed- and open-ended questions between January and June 2021. We conducted thematic analysis to investigate the qualitative responses to open-ended questions, and we summarized the responses to closed-ended survey items on changes in telemental health policies and regulations. Findings revealed that many countries grappled with the rising demand for mental health services against a backdrop of mental health provider shortages and challenges responding to workforce stress and burnout. All countries in our sample implemented new policies or initiatives to strengthen mental health service delivery - with more than two-thirds investing to bolster their specialized mental health care sector. There was a universal shift to telehealth to deliver a larger portion of mental health services in all 14 countries, which was facilitated by changes in national regulations and policies; 11 of the 14 participating countries relaxed regulations and 10 of 14 countries made changes to reimbursement policies to facilitate telemental health care. These findings provide a first step to assess the long-term challenges and re-organizational effect of the COVID-19 pandemic on mental health systems in Europe and North America.

A comparison of health system responses to COVID-19 in Bulgaria, Croatia and Romania in 2020

This article compares the health system responses to COVID-19 in Bulgaria, Croatia and Romania from February 2020 until the end of 2020. It explores similarities and differences between the three countries, building primarily on the methodology and content compiled in the COVID-19 Health System Response Monitor (HSRM). We find that all three countries entered the COVID-19 crisis with common problems, including workforce shortages and underdeveloped and underutilized preventive and primary care. The countries reacted swiftly to the first wave of the COVID-19 pandemic, declaring a state of emergency in March 2020 and setting up new governance mechanisms. The initial response benefited from a centralized approach and high levels of public trust but proved to be only a short-term solution. Over time, governance became dominated by political and economic considerations, communication to the public became contradictory, and levels of public trust declined dramatically. The three countries created additional bed capacity for the treatment of COVID-19 patients in the first wave, but a greater challenge was to ensure a sufficient supply of qualified health workers. New digital and remote tools for the provision of non-COVID-19 health services were introduced or used more widely, with an increase in telephone or online consultations and a simplification of administrative procedures. However, the provision and uptake of non-COVID-19 health services was still affected negatively by the pandemic. Overall, the COVID-19 pandemic has exposed pre-existing health system and governance challenges in the three countries, leading to a large number of preventable deaths.

Balancing financial incentives during COVID-19: A comparison of provider payment adjustments across 20 countries

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries.

We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff.

We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care.

Interventions to reduce stress, anxiety and depression symptoms in teenagers – a systematic review

Introduction

Stress, anxiety and depression symptoms are frequent in teenagers. Objectives: To identify the interventions effectively able to prevent or reduce anxiety, depression and psychological stress in adolescents; to assess the effectiveness, feasibility and transferability of the interventions.

Methods

Comprehensive systematic review was performed. Three steps searching strategy using the databases: PsycINFO, PubMed, SCOPUS, Cochrane Library, and Google Scholar identified 679 studies and reviews. Critical appraisal was performed by 2 reviewers, data extraction performed on finally selected 59 reviews, RCT, cohort studies focused on sample size, geographical context, setting, description of intervention, measures of primary and secondary outcomes.

Results

The considered interventions are: Internet-based multifaceted cognitive bias modification training (CBM), Internet (iCBT) or school-based cognitive behavioral group training (CBT), Social skills training (SST), Metacognitive therapy, Psychosocial Support Intervention, organized sports participation and voluntary outdoor play, school-based resilience-focused intervention, assertiveness group training, short-term psychoanalytic psychotherapy (STPP), brief psychosocial intervention (BPI), Guided Parent-Delivered Cognitive Behaviour Therapy (GPD-CBT), Internet-based self-support method.

Conclusions

Interventions for promoting mental health in adolescents have to combine parenting programs with leisure activities and balanced curriculum; various approaches (physical activity, music, sports participation) should be tailored into the national, community and school contexts. Resilience factors (relationship with parents, communications with peers), development of help-seeking behaviours and available self-help programs could support early detection and assistance. Most interventions showed positive effects on short and medium term and potential transferability.

Key messages

Regular screening for childhood adversities and traumas and screening of symptoms as feeling sad, hopeless, worried should be performed in adolescents as they get older. Besides mental health risk factors, interventions should target developmental risk factors in transitional stages from childhood to adolescence and from adolescence to young adulthood.

Appropriate approaches for improving health promotion literacy in adolescents – a systematic review

Background

Adolescents are exposed to various risks for their health: substance use, Internet overuse, video game addiction, unhealthy diet (reduced intake of fruits and vegetables, fast food culture), low physical activity, overweight, stress, violence, unsafe sexual behaviours, self-medication. Health literacy is defined as the knowledge, motivation and competence to access, understand, appraise and apply right information to make decisions in terms of healthcare, disease prevention and health promotion. Despite the advancement of theoretical models, many national and international health promotion programs, the percentage of unhealthy behaviours still persist in young age. Objective: Current review proposes to assess the implementation and effectiveness of various interventions in order to identify possible success or failure factors.

Methods

Comprehensive Systematic review was performed. After three steps data searching (in PubMed, SCOPUS, Cochrane, PsycINFO, Google Scholar) and critical appraisal, 63 studies out of 739 were fully retrieved.

Results

Implementation aspects as intervention types (single or combined targeted risk factors), type of audience (students, parents, school staff, communities), settings (home, school or outdoor), type of organization (face to face, groups, online), professional or peer-led, communication type (written materials as brochures, posters or videoconferencing) or effectiveness measures were extracted and synthesized. Important features of context such as funding, European or government programs were used for clustering the studies.

Conclusions

Health literacy interventions in adolescents need the involvement of education staff and parents participation. Health literacy for adolescents has to take into account cultural context, language, psychological features of each age; either digital or non-digital interventions cannot elude face to face communication between adolescents and their parents, academics or peers.

Key messages

Health literacy school-based interventions are effective but the content for adolescents audience should rely on guidelines provided by interdisciplinary teams of experts. Health Literacy interventions in adolescents should be age-appropriate and do-not-harm precautions must always be taken in order to avoid prejudices, body-image or self-esteem concerns.

Romania: Health System Review

This analysis of the Romanian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. The Romanian health care system is a social health insurance system that has remained highly centralized despite recent efforts to decentralize some regulatory functions. It provides a comprehensive benefits package to the 85% of the population that is covered, with the remaining population having access to a minimum package of benefits. While every insured person has access to the same health care benefits regardless of their socioeconomic situation, there are inequities in access to health care across many dimensions, such as rural versus urban, and health outcomes also differ across these dimensions. The Romanian population has seen increasing life expectancy and declining mortality rates but both remain among the worst in the European Union. Some unfavourable trends have been observed, including increasing numbers of new HIV/AIDS diagnoses and falling immunization rates. Public sources account for over 80% of total health financing. However, that leaves considerable out-of-pocket payments covering almost a fifth of total expenditure. The share of informal payments also seems to be substantial, but precise figures are unknown. In 2014, Romania had the lowest health expenditure as a share of gross domestic product (GDP) among the EU Member States. In line with the government's objective of strengthening the role of primary care, the total number of hospital beds has been decreasing. However, health care provision remains characterized by underprovision of primary and community care and inappropriate use of inpatient and specialized outpatient care, including care in hospital emergency departments. The numbers of physicians and nurses are relatively low in Romania compared to EU averages. This has mainly been attributed to the high rates of workers emigrating abroad over the past decade, exacerbated by Romania's EU accession and the reduction of public sector salaries due to the economic crisis. Reform in the Romanian health system has been both constant and yet frequently ineffective, due in part to the high degree of political instability. Recent reforms have focused mainly on introducing cost-saving measures, for example, by attempting to shift some of the health care costs to drug manufacturers by claw-back and to the population through co-payments, and on improving the monitoring of health care expenditure.