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Research Article

Roles and Dynamics within Community Mental Health Systems During the COVID-19 Pandemic: A Qualitative Systematic Review and Meta-Ethnography

Cheryl Su Ling Sima Saw Swee Hock School of Public Health, National University of Singapore, Singapore, SingaporeView further author information
,
PV Asharanib Department of Research Division, Institute of Mental Health, Singapore, SingaporeView further author information
,
Mythily Subramaniamb Department of Research Division, Institute of Mental Health, Singapore, SingaporeView further author information
&
Huso Yia Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore;c National University Health System, Singapore, SingaporeCorrespondence[email protected]
ORCID Iconhttps://orcid.org/0000-0003-4724-5235View further author information
ORCID Icon
Article: 2314525 | Received 27 Sep 2023, Accepted 01 Feb 2024, Published online: 10 Apr 2024

ABSTRACT

Globally, COVID-19 had an immense impact on mental health systems, but research on how community mental health (CMH) systems and services contributed to the pandemic mental health response is limited. We conducted a systematic review and meta-ethnography to understand the roles of CMH services, determinants of the quality of CMH care, and dynamics within CMH systems during COVID-19. We searched and screened across five databases and appraised study quality using the CASP tool, which yielded 27 qualitative studies. Our meta-ethnographic process used Noblit and Hare’s approach for synthesizing findings and applying interpretive analysis to original research. This identified several key themes. Firstly, CMH systems played the valuable pandemic role of safety nets and networks for the broader mental health ecosystem, while CMH service providers offered a continuous relationship of trust to service users amidst pandemic disruptions. Secondly, we found that the determinants of quality CMH care during COVID-19 included resourcing and capacity, connections across service providers, customized care options, ease of access, and human connection. Finally, we observed that power dynamics across the CMH landscape disproportionately excluded marginalized groups from mainstream CMH systems and services. Our findings suggest that while the pandemic role of CMH was clear, effectiveness was driven by the efforts of individual service providers to meet demand and service users’ needs. To reprise its pandemic role in the future, a concerted effort is needed to make CMH systems a valuable part of countries’ disaster mental health response and to invest in quality care, particularly for marginalized groups.

Introduction

The impact of the COVID-19 pandemic on mental health systems and service delivery was immense. The disruption of mental health services, coupled with a rise in pandemic-driven mental illness caseloads, created unprecedented systemic strain in many countries.Citation1,Citation2 Mental health systems are no stranger to capacity issues in peacetime,Citation3–5 but capacity management becomes essential during disasters like infectious disease outbreaks, and continuous mental health care in the community is a crucial feature of disaster responses to prevent mental health crises.Citation6–8

Prior literature has discussed the utility of community collaboration in a country’s mental health response.Citation9–12 For example, research in disaster responses recommends addressing capacity shortages by employing a range of public health professionals, not just mental health specialists, to deliver mental health services to the community during disasters.Citation13,Citation14 The American Psychological Association (APA) adopts a similarly broad definition in peacetime and considers all activities that promote mental health in the community, instead of in institutional settings (e.g., hospitals), as part of community mental health (CMH).Citation15

Notably, the contemporary theoretical discourse on CMH posits the inevitability of this broad-based definition of CMH systems, as “many laymen are becoming involved as the system, claiming an insatiable need for personnel, begs for volunteers … (and) many community mental health workers stress the equality of these paramedical and nonmedical participants as therapeutically competent ‘case managers’.”Citation16(p100) Such a definition also allows researchers to consider the value and roles of various stakeholders, including families, informal and formal social networks, communities and organizations that surround people with mental illnesses,Citation17 in catering to a broad base of service users’ care needs.Citation18 With a broad definition of CMH, ecological and network approaches should be employed to study CMH systems,Citation19–21 as should organizational studies of network effectiveness.Citation22–24 For example, studies reported that stable top leadership, powerful lead agencies, and system integration were important in facilitating outcomes for CMH systems.Citation24

Primary research on CMH systems’ contributions to COVID-19 mental health service delivery is limited. Community-based literature in the early stages of COVID-19 focuses on reporting and evaluating community-based interventions.Citation25–28 The literature also favors insights from healthcare professionals,Citation25 academic and policy documents,Citation26 and reviews of secondary quantitative data, such as randomized controlled trials.Citation27 In contrast, much like the peacetime literature,Citation29–32 few primary studies examine the role of CMH systems and services in relation to the broader mental health response. In addition, studies that examine the reality of operations and dynamics within CMH systems and those that amplify the voices of CMH service users during the pandemic are limited.Citation33 Studies also focus on operations and dynamics within specific countries, demographic groups, or CMH systems and service modalities, which are difficult to generalize to a wider population without losing contextual nuance.

To address the gap in the literature while retaining sensitivity to contextual factors and service users’ perspectives, we conduct a meta-ethnography to draw on insights from 27 qualitative studies conducted during the early stages of the COVID-19 pandemic. We focus specifically on qualitative studies. While quantitative studies focus on prevalence and the relationships between variables and outcomes (e.g., correlation and prediction), qualitative studies critically describe contextual determinants and the complexities of system dynamics. This accords with our goal, which is to understand the contextual and human factors behind system-level responses to the pandemic.

The three aims of the systematic review are to understand the (1) roles of CMH services, (2) determinants of the quality of CMH care, and (3) dynamics within CMH systems during COVID-19. We hope to draw these insights from service providers’ and users’ first-hand perspectives on how the load of mental health care was divided across the field,Citation34 and the factors that shaped CMH service delivery during the early stages of COVID-19. This would offer valuable insights into how CMH systems and services can help safeguard communities’ mental health needs in disaster contexts or other capacity shortages.

Materials and Methods

We used Noblit and Hare’s seven-step approach for qualitative evidence synthesis and reporting guidelines from Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ), commonly used in qualitative systematic reviews.Citation35,Citation36 To optimize reporting quality, criteria provided by the meta-ethnography reporting guide (eMERGe) were also applied (Supplementary Table S1).Citation37 The study’s systematic review protocol is registered (PROSPERO: CRD42023425133) on the International Prospective Register of Systematic Reviews.

Inclusion and Exclusion Criteria

Our screening process adopted the following Inclusion Criteria:

  1. Language. Publications written in the English language.

  2. Scope. Studies focused on mental health systems and services and the experiences of community-based service providers and service users navigating these systems. The APA’s abovementioned definition of CMH was used: community-based service providers were included even if they were not mental health specialists.Citation15 In contrast, studies with a limited exploration of mental health systems and services were excluded, such as studies that focused on:

    1. biomedical determinants of mental health and interventions at the individual level that did not consider the context of a CMH system or service.

    2. neurodevelopmental disorders with no explicit reference to psychiatric disorders. The Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD) clearly distinguish between neurological and psychiatric disorders.Citation38,Citation39 One relevant difference is that many neurological disorders are detected early in an individual’s life,Citation40,Citation41 which impacts the nature of therapeutic relationships and patterns of mental health service utilization. To be clear, this study does not exclude the experiences of individuals with both neurological and psychiatric disorders; indeed, the two are often co-morbid.Citation42,Citation43

    3. substance use with no explicit and distinguishable reference to co-morbid mental health issues.

    4. health services, systems and/or conditions with no specific examination of mental health services, systems and/or conditions.

    5. individuals’ experiences that were not contextualized within a system or service. For example, experimental studies that test interventions within a clinical setting.

  3. Study Period. To focus on the impact of CMH systems and services during the early stages of the COVID-19 response, only studies conducted from 2020 to 2021 were considered; studies based on data before 2020 or during and after 2022 were excluded. To note, by 31 December 2021, the World Health Organization’s target to fully vaccinate at least 70% of the population had been met by many developed countries,Citation44,Citation45 signaling the move toward the transition phase of a pandemic: from response to recovery.Citation46

  4. Population Group(s). The experiences of all CMH service providers and users were examined equally, without prioritizing specific population groups (e.g., health care workers). However, studies of population groups that did not use the same mental health services as the general population (e.g., users of prison psychiatric services, extraterritorial, or fly-in and fly-out mental health services) were excluded.Citation47,Citation48

  5. Publication Date. Only manuscripts published during or after the start of the COVID-19 pandemic (i.e., January 2020) were included.

  6. Publication Type. Only primary studies published in peer-reviewed academic journals were included. Books, book chapters, conference proceedings, editorials, opinion pieces, protocols, reviews, and systematic reviews were excluded.

  7. Research Methods. Only publications involving studies with a qualitative component and that reported qualitative primary data were included. Studies with insufficient qualitative findings (e.g., only reporting interpretations of primary data) were excluded.

The full Evaluation Criteria are presented in .

Table 1. Evaluation criteria.

Search Strategy

The search process was conducted by two independent reviewers (CS and a research assistant) across five databases—CINAHL, PsychINFO via Ovid, PubMed, Science Direct, and Web of Science. The following MESH terms were used: “COVID-19,” “community,” “mental health*,” and “qualitative,” connected using boolean operators (AND, OR, NOT). Filters were set to restrict the search to publications in and after 2020 and research articles published in English. The full search terms and filters are presented in the supporting documents (Supplementary Table S2). The reviewers also conducted reference tracking of the articles from the database search to identify relevant articles that might have been missed. The search process yielded 781 articles.

Screening

Search results were imported into EndNote; duplicates and undesired publication types were removed. The two reviewers then independently screened articles by title and abstract against the Evaluation Criteria (per ). Discordant assessments were cross-checked and addressed if a simple consensus was reached; where a simple consensus was not reached, the articles were retained for full-text analysis and discussion with two other reviewers (AP and HY). In three studies where further clarification was needed on the methods used, authors were contacted to provide more details. After this process, 78 records remained for full-text screening.

Following full-text screening against the Evaluation Criteria, it was deemed that 32 studies involved limited exploration of mental health services and systems; 14 studies’ findings conflated (a) data arising from mental health conditions with data arising from other conditions (e.g., substance abuse), (b) data obtained from CMH settings with data obtained from non-community settings, or (c) data gathered during COVID-19 with data gathered before COVID-19; 3 studies had insufficient qualitative findings and/or use of qualitative research methods. As a result, 29 articles were included in the quality appraisal. The full search and screening process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses’ (PRISMA’s) four-phase flow diagram in .Citation49

Figure 1. PRISMA chart.

Figure 1. PRISMA chart.

Quality Appraisal and Final Set of Studies

Information on the 29 included articles was independently extracted by two coauthors (CS, AP) into a spreadsheet with standardized headings: author, title, country focus, publication year, study aims, qualitative methods of data collection, population, and methods of analysis. The Critical Appraisal Skill Program (CASP) tool for the appraisal of health-specific qualitative evidence synthesis was used to evaluate selected articles.Citation50 Each article was allocated a risk rating against the ten CASP criteria. Per best practice, the strength of evidence was weighted against the strength of methodological approaches.Citation51 In two studies, clarification was needed on the methods used, and authors were contacted. The articles were independently scored, and the appraisal was confirmed collaboratively. Consequently, two high-risk studies were removed, yielding the final set of 27 studies presented in .

Table 2. Study characteristics.

Data Extraction, Translation and Synthesis

Reciprocal Translational Analysis (RTA) guided the interpretive data synthesis process.Citation35,Citation52 All papers were read closely by two coauthors (CS and HY), with relevant primary data (i.e., direct quotations) extracted and coded independently using NVivo 12. Using the extracted data, the studies were categorized based on whether they offered insights on (a) CMH service providers, (b) CMH service users, and/or (c) others. Within each sub-category, further analysis was conducted on the populations and types of CMH systems or services being studied to determine how the studies were related.Citation53

All studies were then reviewed to identify first-order concepts from the primary data. To practice reflexivity and ensure analytical rigor, all studies were thoroughly and repeatedly read, with thematic interpretations discussed to check underlying assumptions. Thirty-four first-order concepts were identified from the primary data.

To develop second-order themes (SOTs), findings from comparable first-order concepts were iteratively translated into each other to capture the spirit and language of the original studies in question.Citation35,Citation54 Where there were contrasting first-order concepts, fundamental or operational reasons for the differences were analyzed, articulated, and preserved in developing SOTs.Citation55 Some first-order concepts were insufficiently substantiated and were excluded from the development of SOTs. Eventually, 13 SOTs were developed.

To ascertain confidence in the SOTs, a GRADE-CERQual assessment was conducted by two coauthors (CS, AP) to assess the methodological limitations, relevance, coherence, and adequacy of data.Citation56 Three SOTs received a CERQual assessment of “low confidence,” and were excluded. The CERQual assessment of SOTs is presented in .

Table 3. CERQual analysis.

The overarching concepts or metaphors from the remaining SOTs were then synthesized as responses to the study’s originating research questions,Citation57 expressed via four third-order themes (TOTs). The four TOTs were finally synthesized into a single line of argument and contextualized to explain the state of CMH services during COVID-19.Citation57,Citation58 Collectively, the TOTs and line of argument represent the outcomes of the meta-ethnography. The initial TOTs were developed by the first author (CS) and reviewed with senior authors (HY, MS) to reach a consensus on the TOTs and line of argument.

Results

Study Characteristics

Per the inclusion criteria, all included studies were conducted in the early stages of the pandemic, between 2020–2021. Twelve studies were from England, seven from North America, three from Ireland, two from Australia, and one each from Germany, Hong Kong, and Pakistan.

In terms of services studied, nine studies examined a full range of CMH services available to a specific geographical region (e.g., city-level) or demographic group (e.g., older adults). Six involved tele-mental health services, virtual mental health services, or hotlines. Five studied specialist mental health service providers (e.g., pediatric or perinatal mental health). Five examined services provided by specific organizations (e.g., the National Health Services in the UK, the State Mental Health Authorities in the USA) and/or CMH teams. One study focused on transitions from acute to community-based mental health care and one on ad-hoc mental health activities in the community. Most studies focused on services catering to the general population. Three focused exclusively on children and adolescents, two on older adults, and one each on: women, Latino communities, homeless individuals, and refugees. Sixteen studies examined the service providers’ perspectives, while 15 studies examined service users or members of the general community.

With respect to methods, 21 studies used interviews, three open-ended survey questions, three focus groups, three community participatory methods, and one archival data analysis. Most analyses were guided by thematic analysis.Citation59 All study characteristics are detailed in above.

Themes

The study’s thematic findings are presented in . Four TOTs were identified: (a) the role of CMH systems as safety nets and networks in the broader mental health ecosystem during COVID-19; (b) the role of CMH service providers in offering a continuous relationship of trust to individual service users amidst pandemic disruptions; (c) the determinants of quality of CMH care during COVID-19; and (d) the power dynamics within the CMH landscape during COVID-19, where mainstream CMH systems and services tended to disproportionately exclude marginalized groups.

Table 4. Thematic interpretations.

Role of CMH Systems as Safety Nets and Networks

The first theme explores the role that CMH systems played as safety nets and networks in the broader mental health ecosystem during COVID-19. Across the wider mental health system, capacity shortages were rife. Institutional mental health services may have been shut down or restructured due to official policy to “protect … core service(s)”Citation49(p6) or to cater to priority cases. As a result, many service users were unable to access institution-based service providers or may even have been discharged by institutions to providers in the community “(although) they shouldn’t have been discharged”Citation60(p4), or “without (having received) psychiatric care.”Citation61(p4)

In many cases, CMH service providers stretched their personal capacity to meet this new demand despite manpower shortagesCitation49,Citation62–65 or restructured their operations to serve new clients or crisis functions,Citation65 due to a lack of capacity elsewhere in the system:

There’s three … really high-risk patients that are waiting to go in for inpatient, they have a mental health act framework in place, but because there is not a single bed available, we’re trying to manage these risky patients in the community which is increasing a lot of kind of staff pressure and stress.Citation64(p8)

This approach sometimes required CMH services to work around policy guidelines to meet ground-level constraints: “if you need to take one or two shortcuts … so long as everything’s safe, then get on with it, you know? You’ve got to think generally, it’s the service user at the end of the day that needs the support.”Citation64(p7) Indeed, the client-centricity of individual CMH practitioners was a common factor driving system-level adaptability, allowing CMH systems to be uniquely effective as a safety net for patients.

CMH systems were also able to be responsive and flexible to find new modes of operation within these pandemic restrictions.Citation49,Citation62,Citation64,Citation66–69 For example, some CMH services moved their existing services onto telehealth and online platforms during the initial stages of the pandemic,Citation62,Citation69 while others tapped into community connections to find pandemic-friendly physical locations: “A community garden service approached us and said to set it up and we jumped at it … we can all maintain social distance (…) my service users … are really happy to come to it.”Citation67(p6)

One feature that enabled CMH services to be responsive was that they could cater to individual-level constraints in a way that institutions might not have been able to. For example, if clients did not have digital devices, CMH service providers might “assist with facilitation of telehealth services by seeing them with a tablet.”Citation66(p7) Some CMH service providers “found other ways of tracking progress,”Citation67(p5) such as by conversing with regular service users using e-mail and photographs to set progress goals.

An additional role of CMH systems was providing referrals to a network of other services, therapeutic or otherwise.Citation49,Citation68,Citation70–72 The effectiveness of referrals was enhanced by long-term relationships between CMH providers and service users, as the former were familiar with the latter’s recurring mental health conditions. For example, a service user said: “I phoned my doctor about something else, completely different … and she said ‘ah that sounds a bit like your weird thoughts that you had 4 years ago. I think we should talk to a psychiatrist.’”Citation71(p4) However, these referrals could eventually reach a “dead end”Citation72(p4) due to a lack of operational capacity in other parts of the mental health system.Citation49 Some CMH service providers attributed this to a lack of “joined-up thinking”Citation62(p4) across the wider system to manage capacity across the board.

Role of CMH Service Providers in Offering Continuous Relationships of Trust

The second emergent theme from the studies relates to the role of CMH service providers in providing a continuous relationship of trust with individual service users amidst the disruptiveness of the pandemic.Citation62,Citation68–70,Citation73,Citation74 The continuation of pre-pandemic therapeutic alliances was a particular source of assurance. One service user said: “I still had her with me, talking me through the treatment plan, that was the best thing about it … Just knowing that I could still access her.”Citation69(p69) Another echoed that: “the family navigator, (the only one) with whom I was speaking, saved my life.”Citation62(p812)

Indeed, where conventional methods of therapeutic support were disrupted by pandemic constraints, the trust established with long-term service providers enabled service users to adopt unfamiliar therapeutic interventions (e.g., telehealth).Citation68,Citation69 Where therapeutic relationships were nascent, CMH service providers sought to build trust over time while transitioning patients to new and unfamiliar platforms.Citation73 However, due to the pandemic, capacity shortages still meant that some CMH service users were “unable to see the same provider more than once or twice,”Citation75(p10) which meant that they had to go through the process of repeatedly rebuilding trust with new service providers again.Citation62,Citation73,Citation75,Citation76

The long-term trust established between CMH service providers and service users was not only built through therapeutic support but also support with pandemic-related challenges,Citation70 practical needs,Citation70 and social inclusion (“We got a parcel sent to everyone … a card to say that they’re missing us”Citation68(p1303)). While service users preferred long-term service providers to offer them therapeutic support, episodic practical and social needs were effectively met by short-term CMH services, such as hotlines,Citation70 community programs, and forums.Citation77,Citation78

Determinants of Quality of CMH Care

A third theme in the studies relates to determinants of the quality of CMH care during COVID-19. The most frequently mentioned determinant of quality of care during COVID-19 was resourcing and capacity,Citation49,Citation60–63,Citation65,Citation72,Citation75,Citation76,Citation78,Citation79 sometimes directly attributable to the extent of Government funding.Citation75,Citation77 In all cases, resources were limited, a problem with CMH systems that existed before COVID-19.Citation62,Citation72 Shortages resulted in significant delays in service delivery or a reduced frequency of scheduled in-person treatments.Citation78,Citation79 For example, one service user did not receive an appointment for three months because their panic attacks were not “bad enough to see anyone.”Citation75(p11) Some who needed specialized treatment could not find appropriate services in operation.Citation62,Citation75 Others were prematurely discharged into the community as the available services were not equipped to manage their cases.Citation60,Citation62,Citation78

A second determinant of the quality of CMH care is related to the strength of connections across service providers within the CMH system.Citation61,Citation67,Citation72,Citation75 Across these studies, COVID-19 brought out the value of closer cooperation across service providers, institutions, and authorities for more effective referrals and access to support: “I think the more the NHS … work with community organizations like us who build up that trust … the more that will build up confidence … quite a lot of these (barriers for accessing support) stem from a lack of confidence.”Citation61(p15) Both service users and providers reflected on the importance of such cooperation: to ensure that sensitive case information would be transmitted across multiple service providers where necessary, enhancing the trust between clinicians and service users,Citation75 and to prevent clients from falling through cracks during follow-up.Citation61 While most service users observed that cooperation was weak, some noted that COVID-19 offered a catalyst for communication across providers who were not connected before, opening up more opportunities for conversation and cooperation despite teething frustrations.Citation61,Citation67

The availability of customized care was the third widely cited determinant of care quality.Citation60,Citation61,Citation74,Citation76,Citation79–83 A lack of diversity and genuine choice in CMH care was observed by many, with CMH care options tending to be one-size-fits-all in several ways. First, the virtual modalities adopted during COVID-19 catered to some mental health conditions (e.g., depression and anxiety) but not to others (e.g., paranoia and psychosis).Citation60,Citation74,Citation79,Citation80,Citation82 Second, mainstream therapeutic practices did not cater for users’ ethnic or cultural beliefs.Citation74,Citation81 Third, few diverse and genuine treatment options were available to service users,Citation61,Citation81 which made them feel “coerced”Citation61(p10) into treatment decisions. A wider range of accessible treatment options—ranging from community groups to peer support and crisis lines—would have helped CMH service users exercise agency in their treatment plans.Citation61

Ease of access was a fourth determinant of the quality of CMH care. Due to physical distancing policies in place during COVID-19, several study respondents focused on how virtual platforms created greater access to therapeutic solutions to circumvent typical barriers of geography or scheduling.Citation65,Citation78,Citation81,Citation82 For example, “If they have to go in person, it could be a challenge. We have to arrange for interpretation. We have to arrange for transportation … but with virtual services they can even reach out to mental health therapist in [different cities].”Citation81(p8) Yet, virtual services limited access for others for reasons including digital exclusion,Citation61,Citation66,Citation73,Citation74,Citation76,Citation80,Citation81 distrust in the system,Citation61,Citation73,Citation81 and prohibitive individual health conditions and preferences.Citation61,Citation73,Citation74,Citation79,Citation80 Ultimately, as one service provider acknowledged: “It depends on the individual or even the group. I know that we’ve had a lot of issues with [a group of service users] just because they are so distrustful because of their trauma.”Citation81(p9) Such variability underscores the importance of customized care; there will not be a single solution to make CMH accessible to all.

A final determinant of quality of care was the value of human connection. Both service providers and users agreed that virtual platforms were no substitute for in-person appointments.Citation63,Citation66,Citation67,Citation69,Citation80–82 Providers lacked the ability to accurately diagnose and assess mental health conditions or detect service users’ feelings via a screen: “It’s not easy in psychiatry because you don’t kind of get a look at the person to … get any kind of feel for the patient.”Citation63(p3) It was also difficult to develop “therapeutic rapport”Citation80(p7) online. Yet, there were respondents for whom virtual platforms lowered social pressure, freeing them to “open up” more,Citation82(p318) while others were simply grateful for a platform to connect.Citation68,Citation69,Citation81,Citation82

Mainstream CMH Systems and Services Disproportionately Excluding Marginalized Groups

The final theme relates to power dynamics within the CMH landscape during COVID-19. A repeated finding was that individuals who were vulnerable or marginalized pre-pandemic also experienced marginalization during COVID-19, particularly in terms of navigating mainstream CMH systems and treatment pathways, which disproportionately excluded groups that were “most at risk.”Citation63(p4)

Four patterns of disparities were salient. First, low-income groups could not access a wide range of CMH services during COVID-19 due to poor access to technology (e.g., smartphones with an internet connection) or digital literacy.Citation61,Citation65,Citation66,Citation71,Citation74–76,Citation79,Citation81 Examples of digital exclusion included “ … patients who are isolated, who barely even open the post, forget … having access to anything technical or being tech savvy in any way … the majority don’t have smartphones.” Citation80(p5) Income also impacted the affordability of mental health services,Citation61,Citation71,Citation75,Citation78 or even more fundamental services like the cost of a phone call or public transportation to see a therapist.Citation61

Second, racial or ethnic minorities were less likely to engage with the CMH system during the pandemic.Citation61–63,Citation65,Citation79 Telehealth and other virtual platforms often required an element of trust in the system or service providers, which was lacking among minority groups with a history of “feeling discrimination, of not developing a trusting relationship with the healthcare system, but developing one where they feel blamed, excluded and not represented.”Citation62(p813) As one state mental health representative described: “the professionals in the system are largely white … (but the state is) about 40% people of color (…) COVID is just exacerbating that dynamic as well in really problematic ways … so it’s much harder to engage families and especially over Telehealth.”Citation65(p13) This phenomenon may have been further reinforced during the pandemic, as some services during COVID-19 were not equipped to cater to cultural minorities.Citation61,Citation62,Citation74,Citation79,Citation81 The impact of this was as one service user described: “They didn’t have cultural training, wasn’t their fault, but it felt alien to me … we live in a multi-cultural [country] … there should be more representation in services.”Citation79(p1453)

Third, a handful of studies found that CMH system was not designed to include the poorly educated and illiterate during COVID-19. This was above and beyond the issue of digital literacy, though the two may not be mutually exclusive; individuals struggling with literacy issues found it challenging to even understand the resources available to them, let alone navigate new modes of service delivery.Citation61,Citation81,Citation83 For example, one General Practitioner observed how the CMH system introduced a form of health inequity premised on one’s level of literacy:

Opt-in letters … are an enormous barrier for marginalized groups. They mean that the most proactive patients with best literacy and best ability to seek help end up using all the resources and getting a better service, and those who struggle to read, struggle to accept that they have a problem, or don’t speak much English, or don’t like making phone calls simply don’t get any access to secondary care MH services.Citation61(p15)

Some studies found that language minorities were also excluded to a certain degree, as language barriers could hinder communication with service providers.Citation61,Citation81 For instance, a service user who was a refugee noted that “When it comes to a phone call … we may have language barrier (…) you may be talking with strong tone, which might seem that even if you are talking good words, they may feel you are yelling … this is because … you cannot express everything you want to say.”Citation81(p10)

Fourth, CMH systems were not sensitive to individuals in vulnerable living conditions.Citation61,Citation65,Citation69,Citation73,Citation74,Citation76,Citation79,Citation81 Several studies found that vulnerable migrants were less trusting of the mental health system to begin with: “they worry they may be sent to a detention centre and so then the support will stop”Citation61(p10) and might avoid seeking CMH services because “many people don’t want to give their information in the agencies databases.”Citation74(p6) Multiple studies found that virtual CMH services were inaccessible to individuals in were not living in safe or private spaces, as they had no venue to share their concerns openly with service providers.Citation61,Citation65,Citation69,Citation73,Citation74,Citation76,Citation79,Citation81 More broadly, a deep understanding of individual trauma and how it affects mental health service utilization was lacking, and necessary to reverse the powerlessness of marginalized individuals within the mainstream CMH system: “ … if we don’t work in a trauma informed way our services are not accessible.”Citation61(p15)

A small number of studies noted a parallel power dynamic at the systems level. CMH systems were largely deprioritized during the pandemic relative to other policy priorities or health care services.Citation49,Citation63,Citation64,Citation84 At the systems level, the government’s frequent policy changes during the pandemic were not disseminated to CMH systems before they were announced to the public. This eroded CMH service providers’ credibility with service users: “We would tell people [policy] at lunch time and then the Prime Minister would deliver his briefing … the very next morning we would have to contradict our message … that undermined [people’s] confidence in us”Citation64(p5)

CMH systems were also deprioritized compared to other health care services in the amount of operational support their programs and staff received. In some cases, staff were redeployed from CMH settings to staff crisis services.Citation49 This had an impact on morale:

Our own service was put way down the list … I had an apoplectic fit … and said, “you cannot do this (…) these patients are the most vulnerable, the most at risk, and you know, most likely to die from COVID, so to say that we’re not going to provide services, it’s just absolutely outrageous.”Citation63(p4)

In other cases, there was a perception that CMH teams’ safety and well-being were not prioritized due to a slow rollout of COVID-19 testingCitation64 and vaccinationCitation63 among CMH teams compared with staff in hospital settings, despite the front-line nature of CMH work. These created the perception among CMH teams that “we were probably bottom of the chain”.Citation64(p6) These short-term pandemic reprioritizations reflect an underestimation of the need for and value of CMH at the mental health systems level, which reinforced the powerlessness of already-vulnerable individuals navigating mainstream CMH systems and services.

Line of Argument

The “implementation story”Citation54,Citation57,Citation85 of our findings is that the role of CMH systems and service providers in COVID-19 was clear, but its effectiveness was largely driven by efforts of individual CMH service providers to meet pandemic demand and service users’ needs. It remains to be seen if this role can be reprised in future pandemics without a concerted effort to make CMH systems a valuable part of a country’s disaster mental health response. To do this, policy makers should invest in key determinants of quality CMH care, particularly for marginalized groups, during a pandemic.

Discussion

In the aftermath of COVID-19, health systems across the world have begun to recognize the value of building pandemic-resilient health systems.Citation86,Citation87 There is an acknowledgment that this process must begin in peacetime, as enhancing resilience to future disease outbreaks requires long-term work to create high-quality health systems and build trust.Citation86 Indeed, in the mental health space, there have been long-standing peacetime recommendations to invest in resourcing and capacity-building for CMH,Citation88,Citation89 stronger cooperation across mental health service providers,Citation90–92 and accessible and person-centered care,Citation93,Citation94 particularly through strong therapeutic alliances.Citation95,Citation96

While empirical studies on CMH systems and services mostly focus on outcome-based evaluation research, our meta-ethnography highlights the importance of understanding the complex attributes of CMH systems and services during public health disasters. Our findings suggest that it is crucial to examine the positionality and functions of CMH services in a large network of institutional health and societal systems. The conceptual and operational definitions and therapeutic boundaries of CMH systems need further investigation for better-coordinated health care delivery in collaboration with social welfare sectors.

Our review illustrates how CMH services were adaptive and transformative, perhaps more than primary health care systems, to address the needs of served populations. Such a system’s adaptability is strengthened by patient-centered care and organizational and personal commitment to social determinants of mental health and health equity. Further research on the individual and collective agency of service providers and users will further elucidate the dynamics of response and resilience in CMH systems.

Policy Implications

Our meta-ethnography also indicates research themes and topics for policy development. Our study’s findings underscore the findings in the existing literature on health system resilience,Citation86,Citation87 and the importance of investing in the determinants of quality CMH care,Citation88–96 to prepare mental health systems for future pandemics and potentially other crises. Beyond advocating for increased funding for CMH systems and services, advocating for government resources that align with CMH priorities (e.g., digital infrastructure) could also have a knock-on benefit to CMH systems and services. This is because developments in CMH tend to be sensitive to developments in other public health services or operations; mental health services “normally rely heavily on public-funded medical resources.”Citation83(p8) A deeper understanding of how CMH systems and services respond to infectious disease outbreaks compared to systemic shocks due to other disasters (e.g., natural disasters) would be necessary to consider the extent to which these findings can contribute to the vast disaster literature.

In addition to investing in quality CMH care in peacetime, it is also important to formulate continuity plans to ensure that quality CMH care is not short-changed during crises and that CMH systems are allocated sufficient capacity to absorb, adapt, and transform.Citation86 Such policy development requires further research on the organizational networks of mental health systems and how they coordinate, cooperate, consult, and communicate.Citation97 It also requires psychiatric epidemiological knowledge of the effects of CMH services on mental health outcomes and factors of service utilization. Implementation studies will verify the findings from this synthesis in a post-pandemic era. Integrating evidence from this meta-ethnography with insights from future studies could advance theory and practice for CMH systems.

Fundamentally, a mindset shift is also necessary: acknowledging the essential role of public mental health in a country’s pandemic response; identifying CMH systems as an integral part of the mental health landscape; and embracing person-centered care in the design of CMH services, paying particular attention to people on the margins of the mainstream CMH system. This shift is necessary to create an equitable CMH system for all.

Limitations

The scope of our review was defined to qualitatively examine CMH systems and services during the COVID-19 pandemic. There were several limitations to this approach. Our focus on qualitative studies limits our understanding of the quantitative (including the moderating and mediating) impacts that CMH services have on mental health outcomes. Studies included were mostly in the Western context and therefore limited in their geographical representativeness and usefulness in spotlighting socio-cultural influences of CMH systems and pandemic responses in non-Western regions. This was reinforced by the inclusion of only English-language studies. The topic of our review was specific, yielding a modest number of articles (N=27), which might have limited detailed comparisons and corroborations within and across large categories of data in mental health systems. To address this, an extensive and thorough preliminary search was conducted to ensure that all relevant articles were included to facilitate comprehensive coverage of the topic. Several review assessment tools (e.g., CASP and GRADE-CERQual) were used to ascertain the trustworthiness of sources and confidence of the findings.

The adoption of RTA as a tool for synthesis had strengths and limitations. The tool was appropriate given the well-defined and small set of papers within the study scope.Citation52,Citation58 However, while the tool facilitates interpretive synthesis, it provides little guidance on how to move from a summary of responses to an interpretative synthesis of concepts. Thus, the resultant themes may be anchored by the original primary data and, therefore, conservative.

Conclusions

Community mental health systems are well-placed to serve a valuable role as safety nets and networks for pandemic mental health needs, adapting and responding to new pandemic-related demands. CMH service providers offer continuity in the provision of trusted therapeutic care and social support amidst pandemic disruptions. To effectively fulfill these important roles in countries’ future pandemic mental health responses, policymakers should explore investments in determinants of quality of CMH care before future pandemics—resourcing and capacity, connections across mental health service providers, customized care options, ease of access, and human connection—catering in particular to those at the margins who are often disproportionately excluded from mainstream CMH systems and services.

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Acknowledgments

We thank Marc Yeo for his invaluable assistance with the search and screening processes for this study.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Data Availability Statement

The datasets used and/or analyzed for the review study are available from the corresponding author upon reasonable request.

Supplementary Data

Supplemental material for this article can be accessed online at https://doi.org/10.1080/23288604.2024.2314525

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

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