The COVID-19 pandemic: The ‘black swan’ for mental health
care and a turning point for e-health
Tim R. Wind, Marleen Rijkeboer, Gerhard Andersson, Heleen
Reference: INVENT 100317
To appear in: Internet Interventions
Received date: 17 March 2020
Revised date: 18 March 2020
Accepted date: 18 March 2020
Please cite this article as: T.R. Wind, M. Rijkeboer, G. Andersson, et al., The COVID-19
pandemic: The ‘black swan’ for mental health care and a turning point for e-health,
Internet Interventions (2020), https://doi.org/10.1016/j.invent.2020.100317
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The COVID-19 pandemic: The „black swan‟ for mental health care and a turning point for e-
Tim R. Wind, PhD1, Marleen Rijkeboer, PhD2 Gerhard Andersson, PhD3, & Heleen Riper,
PhD 4 5
1Foundation Centrum '45, Oegstgeest, The Netherlands | partner in Arq Psychotrauma Expert
Group, Nienoord 5, 1112 XE Diemen, The Netherlands
2Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience,
Maastricht University, The Netherlands
3Department of Behavioural Science and Learning, Linköping University, Linköping, Sweden
and Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
4Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit,
Amsterdam, The Netherlands
5 Department of Research and Innovation, GGZ in Geest/Amsterdam University Medical
Center, VU University Medical Center, Amsterdam, Netherlands
In February 2020, Duan and Zhu (2020) stressed the need for a solid Chinese evidence-based
mental health care system in times of public health emergencies such as the outbreak of the
Coronavirus disease-2019 (COVID-19). That would enable treatment of people who suffer
from mental health problems in relation to the epidemic. The WHO has meanwhile labelled
the Coronavirus a pandemic, and it is now hitting Europe, the USA, and Australia hard as
well. In an attempt to reduce the risk of infections, many mental health care providers in
afflicted countries are currently closing their doors for patients who need ambulatory face-to-
face therapy. They are simultaneously trying to replace some of these contacts with digital
therapies. Most probably, European mental health care institutions have yet to experience the
full impact of the coronavirus crisis. At the same time, the demand for mental health care
among infected patients and their relatives is expected to rise (Blumenstyk, 2020). Levels of
anxiety will increase, both through direct causes including fears of contamination, stress,
grief, and depression triggered by exposure to the virus, and through influences from the
consequences of the social and economic mayhem that is occurring on individual and societal
levels. We expect that this "black swan" moment (Blumenstyk, 2020) - an unforeseen event
that changes everything - will lead to a partly, though robust, shift in mental health care
provision towards online prevention, treatment, and care in the near future. We also need to
consider the role of psychological processes and fear that may cause further harm on top of
the pandemic (Asmundson, & Taylor, 2020).
The obvious solution to continue mental health care within a pandemic is to provide mental
health care at a „warm‟ distance by video-conferencing psychotherapy and internet
interventions. A systematic review showed that videoconferencing psychotherapy show
promising results for anxiety and mood disorders (Berryhill et al., 2019), and the evidence-
base for therapist-guided internet interventions is even stronger (Andersson, 2016; ). Yet,
despite two decades of evidence-based e-mental health services, numerous barriers have
stalled the overall implementation in routine care thus far (Vis et al., 2018; Tuerk et al.,
2019). One of the most important barriers highlighted, however, has been that e-mental health
has not been integrated as a normal part of routine care practice due to the lack of acceptance
by health professionals themselves (Topocoo et al., 2017). Myths on telehealth such as “the
therapeutic alliance can only be established face-to-face” have dominated the field, in spite of
research showing the opposite (Berger, 2017). In that sense, learning curves in the adoption of
new e-mental health technologies by both patients and psychologists have progressed far
more slowly than initially expected, thus tallying with the estimate that it takes on average16
years for a health care innovation to be implemented (Rogers et al., 2017). There are however
exceptions in the world but progress is still slow.
In the Netherlands and elsewhere, we are now witnessing a phenomenon whereby the
outbreak of COVID-19 is hastening managers, ICT-staff, and clinicians to overcome all such
barriers overnight, from a pragmatic standpoint seldom seen before. The virus seems a
greater catalyst for the implementation of online therapy and e-health tools in routine practice
than two decades of many brilliant, but failed, attempts in this domain (Mohr et al., 2018).
After all, since predictions about COVID-19 are largely unclear as of yet, it is now time to
create a longer-term solution to the problem of heterogeneous patient populations, such as
those still active in the community and those that are house-bound or isolated in hospitals.
Videoconferencing and internet interventions could therefore be very helpful in mental health
care, as well as in physical care and can be easily upscaled to serve isolated regions and reach
Thus, the “black swan virus” has already enabled wide-scale acceptance of videoconferencing
by health professionals and patients alike – creating a win-win situation for both. We should
stress that e-mental health applications hold value far beyond the provision of
videoconferencing psychotherapy in the current situation of crisis. Countries hit by the
Corona virus may also consider adopting a wider public e-mental health approach, which
would focus additionally on prevention and on reaching people at risk for mental health
disorders. In this respect, not only guided but also fully self-guided interventions, such as self-
help apps or online therapeutic modules, could also be applied in settings and countries with
scarce mental health resources (Christiani & Setiawan, 2018). We should also consider the
need for treatment development (for the psychological problems caused by corona virus
isolation), which is by far more rapid in the field of internet interventions than in traditional
psychotherapy (Andersson et al., 2019).
It is likely that the response to this emergency will be more than a temporary increase in
online work (Blumenstyk, 2020). Once mental health care institutions have developed the
capabilities of serving their patients via videoconferencing and other digital technologies,
there is little reason for them to give these up, in view of the many advantages (Blumenstyk,
2020; Tuerk et al., 2019).This black swan should be a call for action by encouraging providers
to move more rapidly towards blended care models (van der Vaart et al., 2014; Kooistra et al
2019). Agility, flexibility, and resilience are essential skills for 21-st-century institutions,
particularly when unforeseen disruptive viruses and devastating events driven by climate
change are likely to be increasingly common (Blumenstyk, 2020). We urge practitioners to
promptly start adopting e-mental health care applications, both as methods to continue their
care to current patients in need and as interventions to cope with the imminent upsurge in
mental health symptoms due to the coronavirus.
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