The COVID-19 pandemic has seriously affected the daily lives of the global population, heavily compromising the physical and psychological well-being of the whole world and placing a strong burden on Public Health Care (1–3). Recent psychological and psychoanalytic studies on the emotional effects of COVID-19 (4–8) show that living with the pandemic has led to tiredness and uncertainty, derived from not being able to count on the usual certainties based on an order that guarantees the predictable and certain functioning of a series of organizational and contextual components. In addition, the loss of confidence in the health system and a loss of credibility concerning the regulations issued by the institutions has generated a serious sense of anomie. The various pandemic waves have undoubtedly caused a pervasive feeling of anxiety about being infected, and the drastic reduction in socialization experiences due to virus containment measures have certainly increased the risk factors for mental distress in the general population, as well as in people from the most fragile sections of society, such as those with pre-existing psychiatric diagnoses or those suffering from relational and behavioral disorders (3, 5, 9–11).

Recent scientific papers show that psychiatric and emotional disorders were significant risk factors during the pandemic in terms of physical and mental health (5, 11); people suffering from psychiatric disorders seem to be at high risk of Infection due to pre-existing disorders, unhealthy lifestyle, cognitive deficiency or reduced level of consciousness of the risk (5, 10, 12). Data on access to mental health services suggest a significant increase in mental health consultations (including telephone consultations and e-consultations) (13, 14), an increase (15) certainly attributable to a rise in the number of cases of acute crisis in old and new users as a consequence of the experiences of anguish and isolation resulting from the pandemic (9, 16), and of the weakening of community mental health care networks.

Regarding the use of mandatory psychiatric treatments during the first year of COVID-19 pandemic, early studies (17, 18) indicate a reduction in the number of compulsory psychiatric treatments during the first wave of the pandemic, unlike in the second, when they increased again. A slight decrease of treatments are not clearly attributable to a reduction in acute crises, notwithstanding contextual variables including a greater tolerance on the part of family members who preferred not to report acute cases to avoid referrals to hospital structures for fear of exposing themselves to the risk of infection from the health care or paramedic staff, and the temporary closure of psychiatric hospital wards in certain countries (especially in Latin America) most affected by the pandemic, or unprepared to face it. Data also indicate an increase in the average length of hospital stay during the period from March to June 2020 compared to the previous year, probably due to the difficulty in guaranteeing a “safe” return home for the patients (17, 19) a condition that in some cases violates the principles of brevity and transience that characterize compulsory treatments. The studies carried out so far on the progress of compulsory psychiatric treatments during the pandemic (17–26) have been the first appreciable attempt by scholars and mental health professionals to monitor and make sense of what they witnessed in terms of the mental health of the population while the pandemic was ongoing and gradually advancing around the world.

The results of the qualitative study are condensed into four key themes. These are: (a) the culture of psychiatric care services, (b) the effect of the pandemic on involuntary admissions, (c) exceptional management of hospitalization in order to reduce the spread of infection, and (d) policies for more inclusive mental health care. The themes are presented and argued below. For each theme, a table with the most relevant sentences (quotations) extracted from the interviews with the key characters is has been added to support the discussion and the interpretation of results.

The research has highlighted some key aspects of the use of mandatory psychiatric treatments during the COVID-19 pandemic. The interviewees provided some details on the health policies in force in the areas they belong to and, in other cases, information on the field about their direct experience in the psychiatric services of the national health system. This has made it possible to trace the boundaries and the socio-cultural framework within which psychiatric intervention and the treatment of patients in critical situations have been conceived and implemented in an unprecedented anomic condition, such as the spread of the COVID-19 Pandemic.

First of all, we saw a decrease in involuntary treatments during the first months of the pandemic; this is transversal data confirmed by all the interviewees. This phenomenon should not be read superficially. It is possible that during a period of hard lockdown, families were more tolerant of the mental illness of one of their family members, for fear of getting infected by coming into contact with health personnel or while gaining access to hospitals. In fact, the fear of coming into contact with the health system led to a reduction in psychiatric hospitalizations in general in the months of March and April, and consequently also involuntary hospitalizations. The decision not to hospitalize people who had previously suffered from mental illness was a choice of both families and health personnel to reduce the risk of contagion among the population. It is also probable that disadvantaged people could still count on their own resources, not yet drained by the exhausting prolongation of the pandemic. In the following months, starting from summer 2020, the trend seemed to return to the levels prior to the pandemic. In Greece, we are told a slight increase in involuntary hospitalizations has been registered when compared to those of 2019. This is most likely due to an easing of safety measures and less fear of contagion.

Another interesting topic concerns the causes of hospitalization. Here, differences emerge between the countries and the local realities to which the interviewees belong. In Greece and Chile, for example, our interviewees reported that the people who were involuntarily hospitalized were those suffering from severe psychiatric disorders, such as schizophrenia and paranoid and bipolar personality disorders. There was no difference between before and after the pandemic, as only people suffering from severe mental illness, very often already known to family members or local health personnel, are involuntarily admitted. In these countries, the emergence of new psychopathologies and other causes during the pandemic is not highlighted. The consideration that derives from this is that, in this conception, mental distress coincides with a severe psychopathology that affects the body and mind of a person, and the person is identified with his or her own psychopathology. On the other hand, the two psychiatrists interviewed in Italy speak of the use of compulsory involuntary treatments not in relation to a severe psychopathology of a person, but of critical events in general which then triggered the use of hospitalization. These events include the discomfort of living all together with the family during the lockdown which, for people who were not used to sharing close family relationships in confined spaces, during the pandemic resulted in attacks of violence against themselves and members of the family or community. This difference between Italy, Greece and Chile speaks to us of the differences in the conception of mental illness between the different countries. In Chile and Greece, the psychiatric reform has not yet been completed, so a conception of mental distress as a psychopathology persists; a concept of mental distress as a failure of the relationship between contextual dimensions, social relations and the individual is still developing. Italy, on the other hand, has been the protagonist since the 1970s of a very profound reform of both the national psychiatric system, which has led to the complete closure of asylums, and the concept of psychiatric discomfort, which has moved from an organicistic dimension to a dimension of psycho-socio-relational. In Italy, it was possible to identify a new discomfort that emerged during the pandemic, a discomfort that seems to have affected the youth segment of the population, who saw themselves deprived of their future, their relationships with peers, and their chance to attend school or university. A conflict has emerged between youth culture and family culture, experienced by the young people in an obligatory and asphyxiated way during this period. Another issue concerns the management of patients who are involuntarily hospitalized in psychiatric structures. In Italy, there were no psychiatric wards for people affected by COVID-19. Rather, in each ward, distinct spaces of isolation were organized for the first days of hospitalization to find out the outcome of COVID tests. In other contexts, such as in Chile and Greece, some specific areas of psychiatric hospitals were used as COVID-19 wards, where infected people spent part of their hospital stay if positive. In these last two cases, the segregation of psychiatric patients who were separated within the psychiatric structure was certainly greater. On the other hand, in all the situations analysed, there was a lack of staff to manage the admission and hospitalization of patients.

At the end of the interviews, the participants were asked to indicate the objectives that, in their opinion, the psychiatric services of their country should pursue to improve the management of mental distress and reduce the number of people having mandatory psychiatric treatments. It was interesting to note that each reality was expressed differently, but their wishes were similar: to increase the number of psychiatric structures, to increase the number of professional staff within the psychiatric system, and to increase financing of mental health.

Another central point that can guide the development of the psychiatric systems analyzed concerns the models through which mental distress is read and interpreted. Without a model that understands the emergence of mental suffering within relationships, we are destined to make mental illness chronic. Reform of the psychiatric system should concern the possibility of intervening in specific contexts and reducing the risk for vulnerable groups of the population, such as immigrants, the poor, and young people. In conclusion, we would like to make a final reflection on the subject of compulsory psychiatric treatments. One wonders whether intervening in these cases necessarily corresponds to a forced hospitalization in a psychiatric facility or if it is possible to carry out other types of treatment, for example by carrying out a home intervention over a medium-short period (days or a few weeks). Forced hospitalization is a violent tool for those who are subjected to it, and often the patient’s rehabilitation measures do not allow them to find a home with their family that can accommodate them once hospitalization is over (49–51) The hope for the future is to be to be able to nourish and nurture a global model of community mental health intervention (52) by training professional staff in a holistic conception of mental distress and social stigma (53–55), also educating society to request and integrate psychiatric and psychosocial interventions (56) with support from the third sector, ensuring the continuity of care in the family and community after discharge from hospitals.

This research certainly has important limitations, of which the reader should be aware. The first limit certainly concerns the small number of participants, it was not easy to find participants during the sampling period, many universities were closed, many professionals were difficult to find internationally via email, although efforts in this direction have been made. The second limitation concerns the difficulty of finding professional personnel in the field of mental health in China, despite our great interest, we have not received further interest from mental health professionals to join this study in that moment; in fact it was difficult to finds personal information of professionals through the web due to language barriers. Unfortunately, local scientific literature is still scarce (57–59), there are no studies or data on mandatory psychiatric treatments in China or that collect experiences of mental health professionals. Another limitation concerns the fact that this exploratory study does not specifically concern mental health in childhood or adolescence (56). Another limitation concerns the generalizability of the data, the results of this study are to be understood exclusively in relation to a specific non-replicable historical moment and that the experiences of the key people involved are to be considered as subjective narratives not attributable in general to universal contexts. Finally, another limit concerns the choice of countries to compare, a choice dictated by availability within the acquaintance of the authors and the desire to compare different continents (Europe, Asia and South America), with great divergence on the treatment of mental illness and in the advancement of a territorial reform of mental health treatment; this choice could certainly have concerned other National contexts.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Ethics Committee of LSE - London School of Economics and Political Sciences (Ref. 28888 - 2021). The patients/participants provided their written informed consent to participate in this study.

AC and MK contributed to conception and design of the study. AC organized the database, performed the analysis, and wrote the first draft of the manuscript. MK supervised the manuscript. All authors contributed to the article and approved the submitted version.

This work was founded by CPEC at Department of Health Policy of London School of Economics and Political Sciences.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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