The impact of Covid-19 on Belgian mental health care: A Delphi study among psychosocial health professionals, patients, and informal caretakers

The study addresses how the Covid-19 pandemic—managed predominantly through a biomedical lens—affects psychosocial health and the organization and delivery of psychosocial care in Belgium. It argues that a biopsychosocial approach is necessary, as psychosocial health influences adherence to measures and outcomes of the outbreak, and the chronic nature of Covid-19 measures places sustained strain on societal resilience. Prior outbreaks and emerging Covid-19 evidence suggest significant psychosocial impacts, especially for vulnerable groups. While the biomedical system’s reorganization during the pandemic is well documented, the specific impact on psychosocial care systems is less understood. The research aims to develop a consensus on these effects, focusing on daily practice, service provision, and implications for patients and informal caregivers, to inform preservation and enhancement of psychosocial remediation capacities within a biopsychosocial pandemic approach.

Background literature cited underscores the absence of psychosocial dimensions in many pandemic plans and highlights the need for a biopsychosocial framework (e.g., Brewin et al., 2020; Cullen et al., 2020; Stuart et al., 2020; Wainwright and Low, 2020). Evidence from WHO and OECD shows widespread reallocation of biomedical resources, affecting continuity of care for non-Covid conditions (WHO, 2020; OECD, 2020). Primary care disruptions and delayed care risk increased morbidity and mortality (Gray and Sanders, 2020; Rawaf et al., 2020; Verhoeven et al., 2020; Czeisler et al., 2020). Literature also notes potential psychosocial consequences (Bojdani et al., 2020; Guessoum et al., 2020; Chevance et al., 2020) and concerns about telehealth access and equity (Hashiguchi, 2020; Salari et al., 2020; Talevi et al., 2020). Broader findings link pandemic stressors to anxiety, depression, insomnia, and adherence challenges (Vindegaard and Benros, 2020; Rajkumar, 2020; Pappa et al., 2020; IASC, 2020; WHO, 2020).

Design: Three-round Delphi consensus study with psychosocial experts (professionals, patient representatives, informal caregivers) coordinated via the Belgian Superior Health Council. - Round 1: Open-ended questionnaire tailored by stakeholder group to elicit experiences of Covid-19’s impact on psychosocial care (question sets included items on professional changes, target population consequences, vulnerable groups, difficulties, resources, unmet needs, and innovations). Four researchers conducted independent ethnographic content analyses and collaboratively synthesized responses into 23 statements across seven thematic subdomains and two lists (vulnerable groups; helpful resources). Two independent researchers reviewed for methodological consistency. - Round 2: Individualized survey presenting the 23 statements and two lists; respondents rated statements on a 7-point Likert scale (strongly disagree to strongly agree). Consensus threshold: mean score ≥5/7 (≈≥70% agreement) and interquartile range (IQR) ≤2. - Round 3: Feedback of group results; participants could revise scores or add comments; no changes were made; a fourth round was deemed unnecessary. Panel recruitment and sample: - Invitation sent via Superior Health Council database (N=3,752); 221 expressed interest; 195 participated in Round 1. Not all provided contact information, yielding a core group of 148 for subsequent rounds. - Composition of 195 Round 1 participants: 149 psychosocial care professionals (45 mental health facility; 36 independent; 13 network directors; 25 preventive services; 11 academic researchers; 5 unspecified) and 46 representatives of patient organizations/informal caregivers. Linguistic distribution: French and Flemish speakers across groups. Participation and attrition: - Round 2: 113/148 completed (76% response rate). - Round 3: 50 responded (44.25% response rate); none altered prior ratings. Analysis: Group averages and IQRs computed per statement to assess consensus. Items and themes organized to support judgment and identify omissions. Attrition was within expected Delphi ranges and evenly distributed across expert categories.

Overall: Robust consensus for all but three statements (7, 12, 23). No significant differences by expert type or language. Strongest agreements (Likert means and IQRs from Round 2): - Social inequality: Covid-19 increased social inequalities, elevating risk of long-term psychosocial problems (Statement 18: 6.07; IQR 2). - Mental strain: Fear of infection/transmission creates constant emotional pressure (Statement 10: 5.95; IQR 2). - Strategic vision gap: Lack of strategic vision and underestimation of psychosocial health in society (Statement 3: 5.92; IQR 2). General population impact: - Current impact situated in adaptation problems and emotional strain (Statement 11: 5.84; IQR 1). - Long-term rise in psychosocial problems anticipated (Statement 14: 5.89; IQR 2). - Duration of measures more challenging than the measures themselves (Statement 15: 5.48; IQR 2). - Need for workplace flexibility acknowledging psychosocial burden (Statement 13: 5.35; IQR 1). - Lower agreement: impact predominantly on the work floor (Statement 12: 3.94; IQR 2) — not supported. Vulnerable groups and inequality: - Increased severity/number of psychosocial problems among those with pre-existing vulnerabilities (Statement 17: 5.71; IQR 2). - Decision-makers insufficiently attend to vulnerable/underrepresented groups (Statement 19: 5.57; IQR 2). - Perceived reduction in social cohesion/solidarity (Statement 16: 5.27; IQR 2). - Rated vulnerable groups (mean; IQR): elderly (6.18; 1), lower socioeconomic status (6.14; 1), pre-existing conditions (5.90; 2), family of victims (5.88; 2), children/youth (5.77; 2), self-employed (5.72; 2), Covid survivors (5.68; 2), informal caregivers (5.67; 1), frontline healthcare workers (5.65; 2), incarcerated people (5.44; 3). Psychosocial care system impacts: - Preventive measures negatively affected therapeutic relationships (Statement 6: 5.18; IQR 1.5). - Service closures/reductions harmed psychosocial health (Statement 5: 5.81; IQR 2). - Insufficient governmental support for needed resources (Statement 4: 5.49; IQR 1.5). - Sector was under structural pressure pre-Covid, reducing preparedness (Statement 2: 5.84; IQR 2). - Need for a coupling/dispatching (stepped care) system to triage/refer rapidly and ensure continuity (Statement 21: 5.50; IQR 2). - Need for better linkage and overview of existing psychosocial impact data (Statement 22: 5.83; IQR 2). - Lower agreement with innovation claims: Teleconsultations opened access (Statement 7: 3.99; IQR 2) and innovations improving access in second wave (Statement 23: 4.84; IQR 2) — not supported. Unmet needs and resources: - Unmet needs: clear communication/guidelines (Statement 8: 5.35; IQR 2); possibilities to “recharge” constrained by measures (Statement 9: 5.75; IQR 2). - Helpful resources to develop (mean; IQR): clear information (6.36; 1), healthy lifestyle supports (6.18; 1), financial security (6.18; 1), clear vision/purpose (5.97; 2), flexible/innovative management (5.81; 2), physical social contact (5.78; 2), sense of purpose (5.70; 2), campaigns/prevention (5.38; 2), knowledge sharing (5.13; 3), digital social contact (4.82; 2), collective social initiatives (4.44; 1). Temporal aspects: - Higher psychosocial impact during the second wave than the first (Statement 20: 5.69; IQR 2).

Findings directly address how Covid-19 and biomedically oriented policies affected psychosocial health and care delivery. Experts report that insufficient attention to psychosocial dimensions—combined with preventive measures—has strained therapeutic relationships, reduced care continuity through closures, and exacerbated pre-existing system weaknesses. Consensus indicates broad, diffuse mental strain across the population with likely long-term consequences, alongside disproportionate burdens on vulnerable groups and reduced social cohesion. The results underscore the need for a strategic psychosocial vision, stronger resource support, and a stepped/matched care model to maintain continuity and rapidly respond to shifting needs. Telehealth and other innovations showed mixed value in this context, with concerns about access, quality, and equity, particularly for vulnerable populations. Experts call for improved communication strategies and better integration of psychosocial impact data to rebalance the dominant biomedical discourse toward a biopsychosocial approach. These insights are relevant for policy planning and preparedness to mitigate ongoing and future psychosocial harms.

The study achieved expert consensus on most statements, concluding that the psychosocial impact of Covid-19 in Belgium has been underrecognized, with adverse effects on both population wellbeing and the psychosocial care system. Key contributions include identifying: (1) heightened social inequalities and generalized mental strain; (2) system-level challenges—resource shortages, service disruptions, and weakened therapeutic relationships—exacerbated by pre-existing structural deficits; (3) unmet needs in communication and opportunities for recovery; and (4) priority resources (clear information, financial security, healthy lifestyle supports, purpose, and flexible management). The authors advocate incorporating psychosocial prevention, detection, and treatment into pandemic planning on par with biomedical preparedness and implementing stepped/matched care models to ensure access and continuity. Future research should strengthen data linkage on psychosocial impacts, address representation of vulnerable groups, and evaluate the effectiveness and equity of telehealth and blended care modalities under adequate sector support.