LeiP#netz 2.0: mapping COVID-19-related changes in mental health services in the German city of Leipzig

Which changes did the MHS and FBM-functions experience due to the COVID-19-pandemic and associated restrictive measures?

Participants were professionals who worked in MHC institutions in the city of Leipzig (see Table 1). For the qualitative part, 11 professionals were interviewed. For the quantitative part, 81 people started the survey (including those who clicked ‘Start’ but provided no or minimal data) and 45 got to the end. We report results for participants who completed at least 3 of the 16 pages of the online survey. This produced a sample of 50, which in its totality represented all of the 16 functions of the FBM.

Ethical approval was obtained from the Ethics Committee at the Medical Faculty of the University of Leipzig (Reference number: 044/21-ek) and the Ethics Committee at the Saxon State Medical Association (Reference number: EK-BR-9/21-1). Participants signed an informed consent sheet and data were anonymised and stored securely in accordance with data protection laws.

Participants were recruited by contacting all MHS emanating from the pilot project LeiP#netz 1.0 and additional services identified in public registers resulting in a total number of 77 institutions. Data were collected from March 16 to May 21 2021. During this time, the online survey was administered to all participants and 11 participants additionally took part in semi-structured interviews via Skype, Zoom or MS Teams. Interviews were transcribed verbatim in German language with all identifiers removed. Back-translation to English was used for the interview verbatim extracts presented here. After the first round of data analysis, a network meeting was held in July 2021 with the purpose of providing an additional feedback loop and actively involving participants in the research process. Following a participatory action research approach [30], the meeting offered a space for discussion of preliminary results and for connecting participants among each other.

Quantitative Data Descriptive statistics were produced using JASP [31] to summarise relevant aspects of the quantitative data.

Qualitative Data We used thematic analysis [32] and the program MAXQDA [33] to analyse the interview transcripts. Two independent coders identified codes (most basic units of meaning in the transcripts) and grouped them into a hierarchical structure (coding tree) consisting of subthemes and themes. Subsequently, the coders compared their codings and coding trees. Levels of agreement between the two coders for randomly selected transcripts were 90%. Disagreements were resolved through consensus discussion. The findings were adjusted in accordance to the additional feedback given by participants at the network meeting.

The most reported changes on the structural level concerned digitalisation and telemental health. In the quantitative analysis, 68% indicated an increase in digital services, and 86% in telephonic services caused by the pandemic.

In the qualitative part, on the one hand, positive consequences of the digitalisation were described. These included better and quicker access to services for service users, benefits for people with social anxieties, and professionals overcoming a reluctance to use technologies: “I could never have imagined doing online therapy. And now I think it's a really great medium.” [210504]. On the other hand, professionals voiced concerns regarding digitalisation, such as users’ difficulties to employ digital tools, and exhaustion of employees due to increasingly blurry boundaries between work and home. In addition, some professionals felt that digital work would never be able to replace face-to-face services.

Results demonstrated a discontinuation of MHS due to the pandemic with 78% of survey participants indicating a decrease in face-to-face services, of which 4% reported a complete hold of these services. 30% of services indicated the complete suspension of group activities for MHC users, and 50% that group offers were reduced. Meanwhile, quantitative results also showed that on average, the overall services utilisation, the proportion of users with severe mental illness, as well as the provision of individual settings did not change (Table 2).

Qualitative results explicated that the disruption of MHS particularly concerned psychosocial groups, work involving relatives of users and volunteers, and services focussed on workplace integration and leisure time activity. Meanwhile, participants also indicated MHC continuity with inpatient services, home visits, and social psychiatric services remaining open and functioning.

A change in access to MHS was reported by 46% of survey participants (Table 3). 34% described that now pre-registration was necessary to access services, and 26% indicated an increase in waitlist times. At the same time, 38% reported that newly introduced digital services allowed a new way to access services.

Qualitative results confirmed the findings regarding newly introduced pre-registration of users and increase in waitlist times due to the restrictive measures and remote work of employees. Ad hoc consultation was not possible anymore.

The pandemic resulted in financial issues and augmentation in administration efforts in MHC. For the majority of services (76%, Table 3), there were no changes in funding. Meanwhile, for 32%, it was unclear who would cover the costs of the safety equipment needed due to the pandemic.

Similarly, interview participants reported that the budget of services did not foresee the extra costs of hygiene measures (masks, tests) and some experienced a decrease in financial donations.

The quantitative results also showed that professional training was considerably impaired by the pandemic. For 10%, professional training was completely suspended and 74% reported its (considerable) reduction (Table 2). At the same time, professionals wished for more specialised training in a crisis situation, particularly regarding topics such as self-care and coping with strain for employees (64%), providing support for users afflicted by the crisis (60%) and digital service provision (48%).

Qualitative data confirmed these findings and indicated that if professional training took place, it happened almost exclusively within the organisation and only due to the initiative of engaged employees.

In the survey, 42% of participants reported a decline in daily service users, 2% an increase, and 32% indicated that numbers remained unchanged. 30% saw particularly people with chronic illnesses, 26% single parents and 24% users older than 51 years as strongly impaired by the COVID-19-pandemic in using MHS. 30% reported that users’ concerns had changed due to the pandemic (see Table 3).

Qualitative data confirmed that due to the pandemic concerns changed. Particularly coping with the COVID-19-pandemic itself became a new topic in therapeutic spaces, and partially hindered the therapeutic work on any other topic: “It was really about the here and now, […] and how to deal with it. But therapy was out of the question.” [210315]. While interview participants mostly reported a decline in users’ numbers, they expected a surge in mental health problems caused by the pandemic in the future. Especially the reduction in social contacts and the prohibition of visitors in inpatient care were seen to negatively affect users’ well-being.

The survey revealed changes in team climate and teamwork dynamics. 70% reported a transformation in teamwork and team climate, with 62% indicating that face-to-face team meetings had stopped completely or were reduced, 22% stating that digital meetings were newly introduced, and 42% noting that individual work had increased. Figure 1 shows which aspects of the team climate were affected. In particular, 48% reported a negative impact of the pandemic on employees’ well-being and the team atmosphere, and 58% an increase in the strain of work.

Interview participants also reported that the team atmosphere worsened and exchange of informal information declined. Meanwhile, some described an “atmosphere of pioneers” [210503]—a feeling that they had to stick together as a team to meet the new challenges. For instance, professionals embraced communicating with politics as new tasks of their job, as they became aware of the direct effects policies had on their services and users. In the qualitative data too, participants reported on high levels of strain among employees, particularly due to quickly changing rules and processes: “all kinds of information, today the decision is like this, the day after tomorrow like that, which regulation applies to me now, depending on where I live and work, what do I have to pay attention to, now something is different again—so the nerves are on edge.” [210318]. Furthermore, for some professionals having to take care of and home-school their own children constituted additional strain.

The quantitative analysis showed that for 54% cooperations with the local MHS network changed due to the pandemic (Table 3). Of these, 77% reported having less contact with other members of the network, and 96% indicated that personal meetings involving professionals from other services were reduced or cancelled. Pandemic-related restrictions and the closure of some services were stated as the main reasons for decreasing network activities. 64% of survey participants wished for improving cooperations in the future.

Interview participants reported that the COVID-19-pandemic became an obstacle to a functioning network of services. Cooperations and communication with each other was placed on hold, network meetings cancelled, other demands increased, and spontaneous and personal encounters stalled. However, the importance of having a network of the MHS in the city was highlighted throughout the interviews.

As problematic issues, in the survey, the deficiencies in available digital equipment for users (70%) and services (58%), and a lack of digital competencies among staff (64%) became apparent, as well was missing attention for MHS in the COVID-19 regulations (54%).

Similarly, interview participants also remarked on the deficiencies in digital infrastructure and on the lack of attention for MHS during the pandemic. As services were not mentioned explicitly in the COVID-regulations, managers were responsible for deciding if services remained open. Interview participants felt that the “stay at home policy” did not work well for people with mental health problems. Furthermore, they uttered criticism especially concerning the equivocality of COVID-19 regulations, the permanent changes of these regulations and the consequential high level of uncertainty among professionals: “…basic requirements were missing. What was allowed, what was not allowed? For example, could we have done a group with five people or could we not have done it if we had had a room that was big enough?” [210319]. The uncertainty resulted in chaotic and ever-changing work procedures, unclear responsibilities, stress among employees and leaders. Professionals criticised that flow of information within and among institutions was defective and that particularly the communication with authorities was impaired. Participants reported that the already existing problems intensified during COVID-19, such as a general lack of specialised professionals.

While the negative consequences of the pandemic prevailed in the data, professionals also indicated positive implications. In the questionnaire, 76% reported that the digital competencies of professionals were strengthened, 58% saw a bettering in crisis management of the institution, and 46% an extension of telehealth services as positive consequences of the pandemic.

In the interviews, professionals perceived a high flexibility and capacity to adapt to the new situation particularly in outpatient care. They stressed how important it was to keep MHS running in such an emergency situation and to evaluate closely which security measures were helpful for their users. Professionals highlighted how the pandemic caused rapid improvements. For instance, digital and telemental health services were extended and their funding secured by health insurances. Interview participants reported on several learning effects evoked by the pandemic: the importance of being flexible as a professional, of managers communicating quickly and clearly, the potential of home treatment, and the need to keep service websites up-to-date. Furthermore, professionals described that due to the pandemic there was an increased awareness for uncontrollable life events in the general population and thus, an improved comprehension for people suffering from mental illnesses. Finally, participants emphasised the capacity to deal with crisis situations and resistance of service users as a positive experience during the pandemic.

In line with the finding that digital infrastructures were insufficient, the quantitative data showed that participants felt improvements in digitalisation for users (76%) and services (70%) were needed. Furthermore, 64% wished for more staff in MHC, and 70% for ongoing vocational training. 54% indicated the need for more stable funding of their services, and for more clarity in funding of emergency equipment.

In the interviews, participants highlighted the need to take service users and relatives’ experiences into consideration when reacting to emergency situations and to focus measures on vulnerable groups, such as children. They wished for consistent and clearer communication from the policy level and that mental health would be taken into account when developing pandemic guidelines. Professionals recommended guaranteeing the financial support of MHC, improving and maintaining low-threshold access to services, and wished for more therapeutic facilities. Professionals felt that reflection was needed on how to maintain MHS, and in particular therapeutic groups, functioning in such a crisis situation. Finally, they highlighted the necessity to invest in outpatient care as the way forward, as outpatient care proved more flexible in exceptional circumstances than inpatient settings.

In the interviews, professionals stressed that they had experienced different phases of change during the pandemic. The first phase which encompassed the first “lockdown” in Germany from March to May 2020 was described as a phase of shock, great uncertainty, and of rigid measures: “The first phase was quite shocking and quite frightening for us, namely because […] there was the general regulation, the regulation for the residential facilities, the regulation for the workshops, the regulation for care and the like. I always had to read three or four regulations every time something new was published on Friday afternoon. That went into effect on Monday, of course.” [210505] The second phase was perceived as the summer of 2020 (May until November 2020), during which restrictive measures were reduced, services successively opened up again and the feeling of returning to “normality” emerged. The third phase referred to the increasing restrictions and “lockdown” in November 2020 until March 2021, during which professionals saw a “COVID-19 fatigue” happening with high levels of stress, fear and strain. The fourth phase from April 2021 onwards started with the beginning of the vaccination and the re-uptake of services leading to feelings of relief.

Given the unprecedented situation, velocity and impact of changes due to the COVID-19-pandemic, we aimed to gain a broad overview of experiences, but much detail has likely been missed. The survey was an ad hoc developed and not yet validated instrument. Our sample may over-represent professionals who are particularly engaged in working towards change and who have many concerns about the current situation. We managed to include a range of professions and work settings, but did not recruit professionals working in private practise. Further efforts to engage and form partnerships are likely to be needed here too. Finally, Leipzig also appears to have many functional MHS and networks in place and rural areas may face very distinctive challenges. Future research could benefit from comparisons of different types of regions (e.g. urban vs. rural) to better understand the effects of the pandemic on MHS. Service user should also be taken into consideration. As further data become available, future research could measure impacts on the mental health system more systematically and making international comparisons.

In terms of implications, the present study raises attention about the importance of clear communication in policies and infection-control measures, whereby people’s mental health as well as MHS should play an explicit role. Budgets for crisis situations should be established that can cover additional costs for implemented measure and, if needed, extra staff. This, as well as maintaining vocational training and providing adequate supervision for staff is likely to support professionals’ well-being.

The COVID-19-pandemic has shown that community and outpatient services are particularly adaptive to crisis situations [37, 38]. Efforts should be made to foster this specific type of MHC which has also been reported to hold higher responsiveness than inpatient care [49]. Furthermore, this study has shed light on the importance of well-established networks among services. In the future, it will become essential to sustain such networks by creating positions for professional network coordinators and by providing up-to-date overviews of available services for professionals and service users.