LAUSR

The COVID-19 pandemic has put tremendous strain on health care systems all over the world and has particularly challenged mental health services. During the first wave of the pandemic, for reasons of both infection control and resource allocation, many mental health services have been downsized or even closed worldwide. A rapid assessment of 130 World Health Organization member states revealed that more than 60% of countries fully or partially closed community-based mental health services, and more than 40% fully or partially closed inpatient services for substance use disorders. At the same time, it has been widely recognized that the pandemic increases the burden on people with mental illness and puts many healthy people at risk of developing mental health problems. Maintaining adequate mental health services and adapting the way mental health care is delivered during the pandemic is thus of tremendous importance. Previous population studies have shown that mental disorders enjoy low standing in the public opinion when it comes to allocation of financial resources, so there is reason to suspect that the current shortage of health care resources puts people with mental disorders at risk of structural discrimination. In this study, we examined how public priorities on health care spending have evolved from 2001 through 2011 to 2020. From July to September 2020, a representative face-to-face survey was carried out among the adult population in Germany (N=1,200, response rate: 57%). The survey was a methodologically identical replication of surveys in 2001 (N=5,025, response rate: 65%) and 2011 (N=1,232, response rate: 64%). In 2020, respondents were asked: “In order to have sufficient resources for the care of patients with the coronavirus disease, it may become necessary to cut budgets for the care of people with other diseases. Please choose from the following list those three conditions where, in your opinion, it would by no means be acceptable to reduce funding for patient care” . They were then presented with a list of nine diseases, including physical conditions such as diabetes, rheumatism, cancer, AIDS and cardiovascular diseases, as well as mental disorders such as Alzheimer’s disease, alcoholism, depression and schizophrenia. In 2001 and 2011, the question had been posed similarly, only with the first sentence being framed in more general terms: “There is an increasing shortage of financial resources within the health care system. Please choose from the following list...” In 2020, depression ranked fourth – after cancer (84%), cardiovascular diseases (60%) and diabetes (41%) – among conditions for which funding should by no means be reduced, with 25% of the respondents selecting it to be spared from budget cuts. Its rise from the 8th position in 2001 and 6th position in 2011 mostly reflected two developments: a growing share of respondents indicating a funding preference for depression (up from 6% in 2001 and 21% in 2011), and a declining share of people giving priority to the funding of AIDS care, which started at 47% in 2001 and went down to 35% in 2011 and 20% in 2020. Schizophrenia, although remaining on the 8th position in the list, was nevertheless chosen by 17% to be spared from financial cuts in 2020, about doubling its share from 9% in 2001 and 8% in 2011. Alcoholism, in contrast, remained firmly at the bottom of the list, chosen by 5% in 2001, 8% in 2011, and 6% in 2020. Our results show that, under the unprecedented pressure of the coronavirus pandemic on our health care systems, resources for the treatment of people with mental disorders have solid support among the general public, at least in Germany. Probably, this reflects the extensive coverage of the mental health consequences of the pandemic both in the public media and medical journals, and possibly also the personal experience of psychological vulnerability during the crisis. Comparing our recent survey with those from 2001 and 2011, there is evidence for a trend of growing support for mental health care funding, especially for the treatment of depression. It is striking, however, that alcoholism remains firmly excluded from this supportive public sentiment, despite evidence for an increased burden due to substance use during the pandemic. Our findings are thus reassuring with respect to funding priorities for depression and schizophrenia, with little indication of public support for structural discrimination of people with these disorders. They are worrying, however, with regard to alcohol use disorders. Despite their high prevalence, considerable burden, and available treatment options, people with these latter conditions remain at particular danger to be neglected when competing for Dana Tzur Bitan Department of Behavioral Sciences, Ariel University, Ariel, Israel; Shalvata Mental Health Center, Hod Hasharon, Israel