Nine months have elapsed since the first case of COVID-19 was detected in Mexico and six since the transition to a new reality after two months of lockdown. Still, over half the states in the country are on high or maximum alert, with a spike in new cases. In Mexico we have not achieved the significant decrease reached in other regions. We are still lacking effective preventive medication and being uncertain about the availability or length of effectiveness of a vaccine.

During this long period, our emotional stability has undoubtedly been put to test. We have been affected by the proximity of death in multiple spheres such as that of relatives and others close to us, or through us through the vicarious experience of what is happening in Mexico, one of the five countries with the highest mortality rate in the world and through the media. It has also been affected by exposure to the difficult experiences of people dying alone in hospitals and their families who experience a great uncertainty and are unable to honor the lives of their loved ones with the rituals that mitigate grief.

The pandemic has also highlighted the enormous inequality existing in the country. Populations in vulnerable conditions have not been able to comply with health recommendations because they lack running water at home, and are unable to shelter in place because they have to go out to work to feed their families. Most of those who die come from the most disadvantaged sectors and states where health services are less available.

In addition, fear is prevalent among a large sector of the population, particularly those who have been exposed to contagion or have had to be hospitalized. The situation is compounded by the distrust of those who do not believe in the existence of the virus and thus fail to observe measures that have proven to be effective in reducing the risk of infection. There has also been an increase in the risk of emotional imbalance and mental illness associated with the consequences of lockdown measures such as reduced incomes, unemployment, loss of the mechanisms many families once had to obtain resources, violence, information overload and fake news, mistrust, and uncertainty.

The most common outcomes are health worries, acute stress, anxiety crises, insomnia, substance abuse, and exhaustion. Many experience grief, which in some cases will be prolonged. This discomfort will exceed some individuals’ ability to handle it and will progress from acute stress disorder to depression and anxiety disorders including post-traumatic stress disorder. We have found that these disorders affect at least a third of the population, and that they may be more common among those who have experienced the crisis closely or are in the first line of care. Also, those who had pre-existing conditions may suffer imbalances and be at higher risk of becoming ill from COVID-19, while those who survive may suffer severe neuropsychiatric sequelae.

Among children, an increase in behavioral problems, emotional symptoms, sleep problems, difficulty to engage in playing, and psychosomatic problems have been observed. High stress levels can hinder brain development, which can lead in turn to long-term problems. When children do not attend school, they are less physically active and spend more time watching television. They have irregular sleep patterns and less healthy diets, gaining weight and losing cardio-respiratory fitness. They are also more frequently victims of abuse and witnesses of violence at home.

This increase in the need for care faces a system in which a significant treatment lag already existed. Before the pandemic, the burden of mental disorders was already high, accounting for 16% of all days lived without health adjusted for disability for any condition, eight times higher than the proportion of health spending it receives. Four out of five people who fell ill did not receive care. During the pandemic, people with chronic illnesses −including those with mental illnesses− have experienced an impairment in their treatment.

Investment in care for mental disorders is even more urgent now. However, treatment of these disorders will not suffice: we must incorporate successful models to address their social determinants. These include the reduction of gender violence, child abuse, and discrimination in the demographic sphere; resource transfers, the reduction of income inequality, improvements in employment and the economic sphere, home improvements and safe neighborhoods in the immediate environment; the reduction of violence, early response to environmental events and the protection of ecosystems in the environmental realm; and the strengthening of education, support networks, and social capital.

Together with these difficult experiences, during this period we have undeniably learned a great deal about the coronavirus and its mode of contagion, in which approximately half of all cases are asymptomatic. Hospitals have been successfully reconverted to deal with it and drugs capable of reducing the severity of those that have been infected have been discovered and used with good results −provided people are treated in a timely fashion− and a smaller proportion have required intubation.

In addition, research has been strengthened through innovations in data-collection strategies, and editorial policy has been broadened. Mexico´s Ministry of Health has set up effective mechanisms to provide care during the crisis, which include organizing voluntary work, establishing civil society organizations and public institutions, and increasing the installed capacity to address the challenges posed by the pandemic by combining mental health and addictions care. Mental health care specialists have successfully transitioned from face-to-face care to distance care. In this respect, the impact of the closure of institutions has been less than it has been for other professions, without overlooking the fact that people with fewer resources have not benefited from this transition.

Although we do not know how long it will be before we can resume our daily activities, we do know that the prevalence of mental disorders will increase. The way we deal with them and make provisions for their ongoing care will determine the well-being of many generations. We need to advance the transition from hopelessness to resilience; from loneliness to new ways of relating; from fear to health care; from anger to solutions for change making the best of the crisis to emerge as better versions of ourselves; from self-care to taking care of others. This is the only these attitudes will enable us to survive. Our challenge is to make these solutions available to the population as a whole.

Among the paths that have been outlined is the restructuring of the Health System to guarantee long-term, person-centered care, with a community care platform and primary health care and the general hospital as its axis. Tertiary-level hospitals must be strengthened so they are able to care for the most severe, resistant cases. People with serious disorders must be given guarantees to enable them to live in the community. This requires free treatment coverage, sheltered homes, and reasonable adjustments in workplaces and education centers adapted to the needs of people who become ill, as well as campaigns against stigma and the promotion of care-seeking skills. The voices of people with lived experience must be incorporated, together with those of their families and other community resources. Greater use must be made of technology, and steps taken to evaluate its impact.

Just as has been the case at other times of crisis, research will have to support a reform based on the recognition of the need for mental health care. That is why this issue of Salud Mental (Mental Health) on COVID-19 is extremely welcome. It incorporates original research on behavioral aspects of adherence to measures to prevent contagion, including perceived risk and the adaptability to social distancing; the socioemotional skills recommended to prevent emotional malaise in young people; the management of complex conditions such as delirium; the medical conditions of and psychological impact on elderly adults; and the special needs of frontline health personnel. This information will undoubtedly help us to strengthen the response to the challenge of the pandemic for the benefit of the population.