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

Figures & data

Table 1. Evaluation criteria.

Criteria	Inclusion	Exclusion
Language	Publications written in the English language.	Publications not written in the English language.
Scope of Study	Studies that explore mental health services and systems, or factors relating to mental health services and systems. This includes studies that explore the experiences of service providers treating mental health conditions within the community, and service users’ or groups of service users’ challenges and/or experiences within community mental health systems.	Studies that focus on biological determinants of mental health. Studies that focus on developmental disorders (e.g., Autism Spectrum Disorders), intellectual disorders, neurological disorders (e.g., Alzheimer’s and Dementia) only. Studies that examine substance use, where the studies do not make an explicit and distinguishable reference to root-cause mental health issues. Studies that look broadly at health systems and/or non-communicable diseases without specifically examining mental health services, systems and/or conditions. Studies that focus on individuals’ experiences without contextualizing them within a system or service (e.g., experimental studies that test specific interventions in an experimental setting).
Study Period	Data collected during the early stages of the COVID-19 response (i.e., from 2020 to 2021).	Data collected pre-COVID-19, or after the pandemic’s response phase (i.e., during and after 2022).
Population Groups Studied	Studies that examine the mental health issues of all users of community mental health services will be included. To clarify, this study does not specifically examine the mental health of health care workers during COVID-19. Health care workers’ mental health issues will be assessed in the same way as all other members of the population, unless their mental health issues relate to issues arising in their service of community mental health services or systems.	Studies that consider niche population groups who access health care services that are not part of the general health care system. For instance, inmates (who are seen by prison psychiatric services), seafarers (who may have access to extraterritorial mental health services), or users of fly-in-fly-out mental health services.
Publication Date	Manuscripts published during or after the start of the COVID-19 pandemic (i.e., January 2020).	Manuscripts published before January 2020.
Publication Type	Primary studies published in peer-reviewed academic journals.	Books, Book Chapters, Conference Proceedings, Editorials, Opinion Pieces, Protocols, Reviews, Systematic Reviews.
Research Methods Used	Studies that contain a qualitative component. Publications that report qualitative primary data.	Studies that involve quantitative methods. Publications that involve qualitative methods but do not report qualitative primary data.

Figure 1. PRISMA chart.

Table 2. Study characteristics.

Authors	Country	Publication Year (Study Period)	Study Aims	CMH Service/System Studied	Methods of Data Collection	Population	Qualitative Methods of Analysis
1. Adams, E. A., et al.	England	2022 (Feb–May 2021)	Explore access to CMH and substance use support for people experiencing homelessness during COVID-19	Community-based mental health and substance use support for people experiencing homelessness	Semi-structured interviews (SSIs)	26 adults self-identifying as experiencing homelessness	Inductive reflexive thematic analysis (RTA), participatory approaches
2. Ali, N., et al.	Pakistan (Karachi)	2021 (May–Jun 2020)	Explore perceptions and attitudes of community members toward their mental well-being during COVID-19	Ad-hoc programs initiated by community leaders and volunteers (e.g., talks, building awareness of CMH)	SSIs	12 young adults, 8 middle-aged adults, 7 older adults in Karachi	Thematic analysis
3. Bhome, R., et al.	England	2021 (Apr–May 2020)	Examine staff perspectives on challenges/innovations for delivery of older adults mental health care in COVID-19	Older adult CMH teams	Open-ended survey questions	158 participants working in community/inpatient settings from various professional disciplines	Descriptive content analysis
4. Bornheimer, L., et al.	USA (Midwest)	2022 (Nov–Dec 2020)	Explore mental health provider perspectives of client challenges in service utilization and provider challenges in service delivery and treatment of psychosis	CMH facilities in northern mid-western United States	Qualitative questions, platform not stipulated	12 social work mental health providers in CMH setting	Not specified
5. Bower, M., et al.	Australia (several states)	2022 (Jul–Dec 2020; Mar–Jun 2021)	Investigate effects of COVID-19 on mental health in Australia	CMH services utilized by members of the Australian community (e.g., counseling, psychiatric services)	Open-ended optional questions	1037 participants in mixed-methods longitudinal study on mental health/substance use	Thematic analysis
6. Burton, L., Wall, A., & Perkins, E.	England	2022(Jun–Jul 2020)	Examine experiences of community-based frontline staff of impact of leadership on delivery of community care in COVID-19	One CMH team in North-west England	SSIs	21 staff from a CMH Team	Constant comparative thematic analysis
7. Cheng, L., et al.	People’s Republic of China (Hong Kong)	2023 (Jan 2020–Jan 2021)	Explore perspectives of elderly and caregivers toward mental health, treatments and challenges underlying telemedicine adoption	Telemedicine for elderly CMH care	Semi-structured focus groups	57 elderly users of tele-medicine products and caregivers	Not specified
8. Culleton, B.	Ireland	2022 (Sep–Oct 2020)	Explore experiences of occupational therapists (OTs) working in community and rehabilitation mental health settings during COVID-19	Occupational Therapy in community and rehabilitation mental health services	Phenomenological research, SSIs	10 OTs working with Health Service Executive rehabilitation and CMH services	RTA
9. Daly, K., et al.	Ireland	2022 (Aug 2020)	Examine service users’ experience of community-based OT tele-mental health interventions during COVID-19	Mental health telehealth occupational therapy services	Focus groups and individual SSIs	5 users of OT tele-mental health service	RTA
10. Darwin, Z., et al.	England	2022 (Date unmentioned)	Understand key factors that enable/hinder access to perinatal mental health (PMH) care for women from minority groups, and how these have been affected by COVID-19	Perinatal mental health services in one region of northern England	SSIs	19 women from ethnic minority and/or socio-economically deprived backgrounds who had PMH difficulties, 12 key informants from voluntary/community sector workforce	Framework method
11. Duden, G. S., et al.	Germany (Leipzig)	2022 (Mar–May, Jul 2021)	Explore changes in psychosocial and psychiatric services during COVID-19	City-level psychosocial and psychiatric services	SSIs	11 professionals from various mental health services in Leipzig	Thematic analysis
12. Garbutt, J., et al.	USA	2022 (May 2021)	Describe pediatric primary care providers’ experience of meeting mental health patients’ needs during COVID-19, identify opportunities to optimize care	Pediatric mental health services	SSIs	19 Pediatricians and 2 nurse practitioners within a community-based pediatric PCP	Not specified
13. Garcini, L., et al.	USA (South Texas)	2022 (Date unmentioned)	Examine barriers faced by community health workers in assisting historically underserved communities with mental health needs, training needs required to deliver CMH services	Community-based mental health services in historically underserved U.S. Latino communities	Survey and Focus groups	43 CHWs in communities near US-Mexico border	Not specified
14. Gillard, S., et al.	England	2021 (May–Jul 2020)	Examine experiences of people with existing mental health conditions during COVID-19	Community-based mental health services utilized by individuals with preexisting mental health conditions	Interviews and community participatory approaches	49 individuals with preexisting mental health conditions	Not specified
15. Hynie, M., et al.	Canada (4 states)	2022 (Nov 2020–May 2021)	Examine different aspects of access to virtual mental health care for refugees during COVID-19	Virtual mental health care for refugee newcomers	Structured and SSIs	8 community leaders, 37 refugee clients, 63 mental health or service providers and managers	Not specified
16. Kourgiantakis, T., et al.	Canada (Ontario)	2022 (Mar–Jul 2021)	Explore experiences of youth with mental health and/or addiction concerns and their families during COVID-19, and adequacy/equitability of mental health services	Community-based mental health services for youth	SSIs	15 service users, 10 service providers	Thematic analysis
17. Leeming, D., et al.	England	2022 (Sep–Oct 2020, Jan–Feb 2021)	Examine experiences of people with long-term mental health issues (previously supported by third-sector organizations) with lockdowns and remote service access	Third sector organizations (e.g., health and social care, charities) catering to individuals with long-term mental health problems	SSIs	15 people with long-term mental health problems, supported by third-sector organizations before COVID-19	Template analysis
18. Liberati, E., et al.	England	2021 (Jun–Aug 2020)	Investigate experiences of those working in English NHS secondary mental health services during first wave of COVID-19	NHS secondary CMH services, including older adults CMH teams, CMH psychiatric support and early intervention psychosis services	SSIs	35 members of clinical staff from NHS secondary mental health services	Constant comparative method
19. Newbronner, E., et al.	England	2022 (Oct 2021–Jan 2021)	Explore effects of pandemic restrictions on people with serious mental illness, including perceptions of how/why physical/mental health changed in COVID-19	Community-based mental health services utilized by individuals with severe mental illness	Interviews	18 participants recruited to England’s Optimising Well-being in Self-Isolation Study	Thematic analysis
20. O’Donnell, S., et al.	Ireland	2023 (Mar–Aug 2021)	Examine work-related experiences of consultant psychiatrists in Ireland during COVID-19	Psychiatric consultancy services in a community-based setting	Interviews	18 CPs across geographical locations and sub-specialties	Inductive thematic analysis
21. Palinkas, L., et al.	USA (21 states)	2021 (Nov 2020–May 2021)	Examine impact of COVID-19 on implementation of policy and practice by State Mental Health Authorities for preventing/treating mental health problems in children and adolescents	CMH services run by State Mental Health Authorities, including but not limited to: services for youth, mobile crisis teams, trauma CBT, crisis lines and other tele-health services	SSIs	29 representatives of SMHA from 21states	Protocol based on Rapid Assessment Procedures Informed Community Ethnography
22. Shah, P., et al.	England	2022 (Sep–Oct 2020)	Examine experiences of people with preexisting mental health conditions during COVID-19	Community-based mental health services utilized by individuals with preexisting mental health conditions	SSIs, co-participatory approaches	44 people with mental health conditions and service use	Thematic analysis principles
23. Sheikh, Y., et al.	England	2023 (Apr–May 2021)	Examine psychiatrists’ and GPs’ perceptions of benefits/challenges of video consultations for diagnosis and follow-up of adult CMH during COVID-19	Video consultations for mental health in community care	Open-ended questions with flexible interview guide	11 Psychiatrists and 12 GPs in NHS CMH settings	Thematic analysis
24. Thompson, K. V., et al.	USA (New York)	2022 May–Aug 2020)	Explore trauma and resilience demonstrated by callers to using an emotional support helpline service	State-run COVID-19 Emotional Support Helpline	Archival data collected by agents of a helpline	251 calls to NY State’s COVID-19 Emotional Support Helpline	Thematic analysis
25. Tyler, N., et al.	England	2021 (May–Jun 2020)	Understand stakeholder perspectives about changes in mental health transitions in COVID-19, impact on health care quality and safety	Mental healthcare for individuals making transitions from acute mental health services to the community	SSIs	14 participants with experience of discharge from acute mental health services, 6 patients, 7 carers and 7 key informants	Thematic analysis
26. Venville, A., et al.	Australia (Victoria)	2021 (Aug–Nov 2020)	Explore user and worker experiences in tele psychosocial support during COVID-19	Telehealth for Psychosocial Support offered by community-managed organization, Neami National	SSIs	20 service users and 8 workers across different Neami sites	Thematic analysis
27. White, J., et al.	England	2022 (Date unmentioned)	Explore users with personality disorder experiencing remote therapy through a CMH service during COVID-19	Virtual/telephone therapy offered through a community forensic mental health service	SSIs	9 Community Service Users accessing virtual/telephone therapy through a forensic CMH service	Thematic analysis

Table 3. CERQual analysis.

Summary of review finding	Relevant Studies (as listed in Table 2)	CERQual confidence assessment	Methodological limitations	Relevance	Coherence	Adequacy
1: Responding to Pandemic Needs.	2, 4, 6, 7, 8, 9, 12, 13, 14, 15, 16, 17, 18, 20, 21, 25	High	16 studies, minor-moderate limitations	Data from 7 countries, range of service-provider/user views.	No concerns	No concerns
2: Adapting to Pandemic Constraints.	4, 6, 10, 12, 14, 18, 19, 21, 26, 27	Moderate	10 studies, minor-moderate limitations	Data from 3 countries, range of service-provider/user views.	No concerns	Minor concerns, data Western-centric
3: Making Referrals to Other Services.	9, 10, 16, 17, 18, 19, 24	Moderate	7 studies, minor-moderate limitations	Data from 3 countries	Minor concerns due to differing views on referrals	Minor concerns, data Western-centric
4: Holistic Support for Mental Health.	2, 3, 8, 9, 10, 13, 14, 15, 17, 18, 19, 22, 24, 26	High	14 studies, minor-moderate limitations	Data from 6 countries, range of service-provider/user views.	No concerns	No concerns
5: Pandemic Meaning-Making.	2, 13, 24	Low	3 studies, minor-moderate limitations	Limited data from 2 countries (US-New York/Texas-and Pakistan).	Minor concerns but limited data available	Serious concerns, limited data
6: Resourcing and Capacity.	1, 2, 4, 5, 6, 10, 12, 14, 16, 17, 18, 20, 21, 22, 25	High	15 studies, minor-moderate limitations	Data from 6 countries, wide range of service-provider/user views.	No concerns	No concerns
7: Connection Across Providers.	1, 5, 8, 9, 10, 11, 12, 13, 25, 26	Moderate	10 studies, minor-moderate limitations	Data from 5 countries, findings specific to niche sub-populations.	Minor concerns due to differing views on pandemic as opportunity for connection	Minor concerns, data focused on niche sub-populations
8: Customization of Care.	2, 3, 4, 7, 9, 10, 12, 13, 14, 15, 16, 17, 21, 22, 23, 25, 26, 27	High	18 studies, minor-moderate limitations	Data from 7 countries, wide range of service-provider/user views.	No concerns	No concerns
9: Ease of Access.	1, 4, 5, 10, 12, 13, 14, 15, 16, 21, 22, 23	Moderate	12 studies, minor-moderate limitations	Data from 4 countries, findings specific to niche sub-populations.	Minor concerns due to differing views on factors that improved or interfered with access	Minor concerns, data focused on niche sub-populations
10: Human Connection.	4, 6, 8, 9, 15, 16, 17, 18, 20, 23, 25, 26, 27	Moderate	13 studies, minor-moderate limitations	Data from 5 countries, wide range of service-provider/user perspectives.	Minor concerns due to differing preferences for human connection	No concerns
11: CMH solutions entrenching position of marginalized.	1, 2, 3, 4, 5, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 21, 22, 23	High	18 studies, minor-moderate limitations	Data from 3 countries, wide range of service-provider/user views.	No concerns	Minor concerns, data Western-centric
12: CMH services and service providers deprioritised compared to other services.	6, 10, 12, 18, 20	Low	5 studies, minor-moderate limitations	Limited data from 3 countries.	No concerns	Moderate concerns, limited data
13: CMH systems dependent on other policies.	6, 7, 13, 22	Low	4 studies, minor-moderate limitations	Limited data from 3 countries.	Minor concerns but limited data available	Moderate concerns, limited data

Table 4. Thematic interpretations.

Third Order Themes	Second Order Themes	First Order Concepts (Sample Primary Data)
1: CMH Systems: Mental Health Safety Net and Network	1: Responding to Pandemic Needs	1. Responsiveness to New Opportunities “A community garden service approached us and said to set it up and we jumped at it … we can all maintain social distance … (service users) are really happy to come to it.” (P1) [Culleton]^Citation67
		2. Pivoting to New Roles “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.” [Burton]^Citation64
		3. Stretching to Meet New Demand “I’m effectively working seven days a week, at the moment, because of increased demand, because of the pandemic. And this has been flagged to management, time and time again … we’ve applied for additional resources and we haven’t got them.” (Roisin, urban area) [O’Donnell et al.]^Citation63
	2: Adapting to Pandemic Constraints	4. Working within System-level Constraints “So the entire of the service was geared towards (crisis) … traffic-lighting everyone … that then would dictate how frequently a mental state was performed on risk. The focus of the organisation changed overnight pretty much.” (Trainee Psychiatrist, Community mental health service) [Liberati et al.]^Citation84
		5. Working within Policy Constraints “We’re … doing the best that we can with limited resources and limited capability. There’s a lot of stuff that we’re not supposed to be doing, we get the guidelines, we do our best to follow them … if you need to take one or two shortcuts, for instance, so long as everything’s safe, then get on with it … it’s the service user at the end of the day that needs the support.” (Respondent 006) [Burton et al.]^Citation64
		6. Working within Client’s Constraints “In most circumstances, clients are needing telehealth and virtual services to facilitate medication reviews, and many clients don’t have phones or devices for telehealth, which means I assist with facilitation of telehealth services by seeing them with a tablet.” (Provider 12) [Bornheimer et al.]^Citation66
	3: Making Referrals to Other Services.	7. Via Primary Care Providers “So from the first lockdown after about 2 months I was starting to get hallucinations … so I phoned my doctor about something else, completely different and she said, how are you otherwise? And I said, well I lost something today and I thought someone, you know, broke in to steal it 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.” (Aaliya) [Newbronner et al.]^Citation71
		8. Via Community Health Service Providers “In terms of perinatal mental health specific services we don’t provide counseling or anything like that but what we do is we signpost and work with other local organizations … if there is that joined-up thinking right from the ground upwards then it means … that kind of filtration system is there.” (VCS KI9) [Darwin et al.]^Citation61
		9. Via Helplines z “I also explored her interest in speaking to someone for therapy on a regular basis for emotional support and human connection. Caller was interested in seeing a therapist.” [Thompson et al.]^Citation70
2: CMH Service Providers: Continuity of Therapeutic Care and Social Support	4: Holistic Support for Mental Health	10. Therapeutic Support “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.” (Participant A) [Daly et al.]^Citation69
		11. Social Support “I’ve had [worker from Organisation A] ringing me up, asking me if I’m alright … we got a parcel sent to everyone at [Organisation A], with a jig-saw in, quizbook, workbook, a cup, a card to say that they’re missing us … it’s nice.” (Naomi, P1) [Leeming et al.]^Citation68
	5: Pandemic Meaning-Making	12. Pandemic Meaning-Making [Dropped]
		13. Practical needs [Dropped]
3: Determinants of Quality of CMH Care	6: Resourcing and Capacity	14. Responsiveness to Needs “I need to be speaking to somebody … once every two weeks, and I’m not getting that … I need to see the psychiatrist, and not for it to be open- ended, when the next appointment is, or if I’m even getting another appointment. It needs to be structured.” (P9) [Shah et al.]^Citation78
		15. Availability of Appropriate Treatment “A lot of the groups that were referred to me … hardly any of them were OCD-specific, and that was really frustrating.” (P21, SU-Y) [Kourgiantakis et al.]^Citation62
		16. Premature Discharge “So you’ve got a whole load of service users who have basically been booted out of the hospital early … who have just been abandoned.” (Carer, G3) [Tyler et al.]^Citation60
	7: Connection Across Providers	17. Service User experience “Once they felt I was okay to be discharged they just discharged me … but after that there’s been no follow-up from my GP, from my midwife, or any of the services, I haven’t heard anything really.” [Darwin et al.]^Citation61
		18. Service Provider collaboration “I think the more the NHS or, you know, [specialist service] … work with community organizations like us who build up that trust and see that yeah, we’re working with the NHS … the more that will build up confidence … a lot of these (barriers for accessing support) stem from a lack of confidence.” (VCS KI9) [Darwin et al.]^Citation61
	8: Customization of Care	19. Agency and Empowerment “Creating spaces where people can have their voices heard, where they can say what they need and what they want and not necessarily what professionals think are best for them … people need something different … to feel more empowered in their care and their treatment.” (VCS KI10) [Darwin et al.]^Citation61
		20. Sensitivity “I … work with clients that have [indigenous] background … we need skills to help understand different cultural beliefs and views of mental illness and how [people] reacted in the past or how [people] deal with it now are needed so that we can better help them.” [Garcini et al.]^Citation74
		21. Effectiveness “Paranoid patients, people with psychosis, can get paranoid thoughts that somebody is trying to record them [during virtual calls].” (02 GP) [Sheikh et al.]^Citation80
	9: Ease of Access	22.Geography “ … there is only one bulk billing psychiatrist in my area and none in the nearby two large towns” [Bower et al.]^Citation75
		23. Cost “The biggest [challenge] is finding counseling no matter what their insurance is … it’s just almost just a crapshoot trying to figure out who’s gonna take their insurance and who isn’t.” (1004) [Garbutt et al.]^Citation72
		24. Digital Access “ … patients who are isolated, who barely even open the post, forget you know having access to anything technical or being tech savvy in any way. So the majority don’t have smartphones” (02 CP) [Sheikh et al.]^Citation80
	10: Human Connection	25. Diagnosis and Assessment “It’s been a big change in our practice, you know, trying to assess people over the phone … It’s not easy in psychiatry because … you’re not getting any kind of feel for the patient” (Orla, rural area) [O’Donnell et al.]
		26. Rapport “Sometimes it’s that reassurance that you’re seeing a professional … you don’t see the person and you kind of lose that human contact, even in video.” (09 GP) [Sheikh et al.]^Citation80
		27. Professional Validation “It’s been a more isolating time or period as a doctor, the camaraderie that’s normally there with junior doctors has gone entirely, because there’s no gatherings for teaching, it’s all virtual and anonymous … I find that quite difficult.” (Trainee Psychiatrist, Older Adults CMHT) [Liberati et al.]^Citation84
4: Power Dynamics Across CMH landscape	11: CMH systems and services disproportionately excluding marginalized groups	28. Low-income Groups “They [patients] have said there’s no money for even a call, for them to call us” (03 GP) [Sheikh et al.]^Citation80
		29. Racial or Ethnic Minorities “It’s hard enough to engage some families and then, when you put in the connectivity, on top of it, I think it is exacerbating kind of the racial and ethnic disparities … in really problematic ways and so it’s much harder to engage families and especially over Telehealth.” [Palinkas et al.]^Citation65
		30. Poorly Educated or Illiterate “opt-in letters … are an enormous barrier for marginalized groups … 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.” (HCP9, universal service, GP) [Darwin et al.]^Citation61
		31. Individuals in Vulnerable Living Conditions “People fear seeking help because of their immigration status … immigration is a big factor … many people don’t want to give their information in the agencies databases.” [Garcini et al.]^Citation74
	12: CMH services and service providers deprioritised compared to other services	32. Services [Dropped]
		33. Service Providers [Dropped]
	13: CMH systems dependent on other policies	34. Policies and Politics [Dropped]

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Data Availability Statement

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