Johnson et al¹ provide a comprehensive account of the different service models aimed to address mental health crises, focusing on assessment and immediate management of the crisis, intensive treatment following crisis, further perspectives on crisis care including prevention, and crisis care in low- and middle-income countries. They conclude that a variety of options exist, but also that the evidence based on robust studies is scarce, and that most studies and policies reflect a clinician rather than a patient or consumer perspective.

Generations of mental health care providers and consumers have strived to improve management of mental health crises, and the extensive synopsis of these efforts is striking in many ways. On the one hand, it illustrates the complexity of the issue; on the other, it shows the creativity needed in trying to address it. However, the plethora of models that the authors describe also reflects the general inadequacy of the services available and the failure of experts and service users alike to identify effective solutions. In addition, complex systems tend to be ineffective, complicating the pathways to care, increasing the time for a patient to receive adequate support, and increasing direct and indirect mental health costs.

The COVID-19 pandemic has introduc­ed many new challenges to our societies, especially affecting the most vulnerable populations, including people with mental illness. While the united efforts of scientists worldwide have yielded the unprecedentedly rapid development of immunization strategies, health care service delivery in general, and mental health care delivery in particular, have suffered². As an unintentional global stress test for health care systems, COVID-19 has revealed structural weaknesses in our acute mental health care services.

COVID-19 infection itself causes acute mental health disturbances as well as long-lasting neurological and psychiatric sequelae. In addition, the forced reduction in social contacts and activities during lockdowns, anxiety and stress in the face of impending economic hardship, and uncertainty during a global crisis have exposed previously undetected mental health problems, led to increased rates of relapse of existing psychiatric illness, and induced new psychiatric problems. This increase in psychiatric morbidity has led to a surge in service use, for which most mental health systems were not prepared³.

Mental health care workers and admin­istrators alike are struggling to uphold mental health care provision, resorting to creative measures, including new e-health solutions. Despite these efforts, it is proving impossible in many cases – and especially in institutional settings – to sustain services at pre-pandemic levels, leading to a degradation of the therapeutic alliance, one of the most critical success factors in psychiatric treatment⁴. The mental health crisis within the pandemic crisis has exposed a lack of robust policies backing the interventions needed to help people with mental illness, and can be taken as an indicator for the fragility of mental health care delivery.

In addition, as Johnson et al¹ describe in their review, patient or consumer access to acute psychiatric care is often characterized by a loss of autonomy and self-de­termination. Aggressive behavior and vio­lence in psychiatric patients are used to jus­tify more restrictive settings in inpatient fa­cilities, in the interest of maintaining safe­ty when dealing with patients who might otherwise harm themselves or be a danger to the community. However, recent evidence points in another direction: more open and empowering treatment approaches promoting reduction of coercion are able to reduce aggression and violence in emergency psychiatric settings⁵, suggesting that it is feasible to implement and uphold services with a minimum use of coercion and maximal patient autonomy.

However, this is a demanding and long-term effort. Again, the COVID-19 pandemic shows how easily this progress can be lost. In times of a pandemic crisis, the level of involuntary admissions and coercive mea­sures increases⁶. This is not necessarily caused by an increase in psychopathology, but also due to an increased need for safety of the population and mental health care workers during times of uncertainty⁷. Normative attitudes outweigh moral doubts in times of crises and may lead mental health care workers to use more coercion in treatment settings.

Lastly, the COVID-19 pandemic reminds us of the importance to focus not only on interventions for mental health crises, but also to help prevent these crises if possible. The mental health system should provide interventions to promote resilience and well-being, to facilitate self-care, and to support informal care. As the topic of Johnson et al¹ is acute psychiatric care, they understandably only give a short overview of secondary and tertiary prevention efforts. However, the importance of prevention cannot be underestimated in its value to counteract the development of mental health crises, thereby reducing the suffering of the affected persons as well as the strain on the mental health care system and health care costs.

We agree with the authors that new research and policies need to be promoted and that integrated local crisis care systems should be created to address the diverse needs of people with mental health crises. It is crucial to include people who use services, their families, communities and staff in all relevant sectors of mental health care delivery to design service systems that address the specific needs of patients and consumers. The COVID-19 pandemic has demonstrated the demand for better and more enduring service structures for people with mental illness. To achieve this goal, it is paramount to focus on the empowerment and de-stigmatization of service users⁸.

In order to counter the structural stigmatization of mental health, politicians and policy makers need to be challenged and held accountable to include mental health care provision specifically in pandemic policies. The focus must shift from a fragmented, complex service system, including multiple crisis service models and leading to service gaps and unmet medical and psychiatric needs, toward a full continuum of psychiatric care⁹. Governments and agencies need to support and fund the development of comprehensive continua of mental health care, from inpatient beds in psychiatric institutions to low-threshold services, based on evidence-based public policies and practices on a national level. International research groups, including scientists and service users from low- and middle-income countries, are the key to the collection and timely dissemination of data on the best models and practices, with the goal to provide the evidence for sustainable acute psychiatric care delivery.

Johnson 等人¹全面介绍了旨在解决心理健康危机的不同服务模式，重点是危机的评估和即时管理、危机后的强化治疗、包括预防在内的危机护理的进一步观点，以及低收入和低收入人群的危机护理。中等收入国家。他们得出的结论是，存在多种选择，但基于稳健研究的证据很少，大多数研究和政策反映的是临床医生而不是患者或消费者的观点。

几代精神卫生保健提供者和消费者一直在努力改善对精神卫生危机的管理，这些努力的广泛概要在许多方面都令人震惊。一方面，它说明了问题的复杂性；另一方面，它显示了解决这个问题所需的创造力。然而，作者描述的过多模型也反映了可用服务的普遍不足以及专家和服务用户都未能确定有效的解决方案。此外，复杂的系统往往效率低下，使护理途径复杂化，增加了患者获得足够支持的时间，并增加了直接和间接的心理健康成本。

COVID-19 大流行给我们的社会带来了许多新的挑战，尤其是影响到最脆弱的人群，包括患有精神疾病的人。尽管全世界科学家的共同努力使免疫战略取得了空前的快速发展，但总体而言，医疗保健服务的提供，特别是精神卫生保健的提供却受到了影响²。作为对卫生保健系统的无意全球压力测试，COVID-19 揭示了我们急性精神卫生保健服务的结构性弱点。

COVID-19 感染本身会导致急性心理健康障碍以及长期的神经和精神后遗症。此外，在封锁期间被迫减少社交接触和活动，面对迫在眉睫的经济困难时的焦虑和压力，以及全球危机期间的不确定性，暴露了以前未被发现的心理健康问题，导致现有精神疾病的复发率增加，并引发新的精神问题。精神疾病发病率的增加导致服务使用激增，而大多数精神卫生系统并未为此做好准备³。

精神卫生保健工作者和管理人员都在努力维护精神卫生保健的提供，采取创造性措施，包括新的电子卫生解决方案。尽管做出了这些努力，但事实证明，在许多情况下——尤其是在机构环境中——不可能将服务维持在大流行前的水平，从而导致治疗联盟的退化，这是精神科治疗中最关键的成功因素之一⁴。大流行危机中的精神健康危机暴露了缺乏强有力的政策来支持帮助精神疾病患者所需的干预措施，并且可以作为精神卫生保健服务脆弱性的指标。

此外，正如 Johnson 等人¹在他们的评论中所描述的，患者或消费者获得急性精神科护理的特点通常是丧失自主权和自决权。精神病患者的攻击性行为和暴力被用来证明在住院设施中设置更严格的设置是合理的，以便在与可能伤害自己或对社区构成危险的患者打交道时保持安全。然而，最近的证据指向另一个方向：促进减少胁迫的更开放和赋权的治疗方法能够减少紧急精神科环境中的攻击和暴力⁵，这表明实施和维护服务是可行的患者自主权。

然而，这是一项艰巨的长期努力。再次，COVID-19 大流行表明这种进展是多么容易失去。在大流行危机时期，非自愿入院和强制措施的水平会增加⁶。这不一定是由于精神病理学的增加，而是由于在不确定时期对人口和精神卫生保健工作者安全的需求增加⁷。在危机时期，规范态度胜过道德怀疑，并可能导致精神卫生保健工作者在治疗环境中使用更多强制手段。

最后，COVID-19 大流行提醒我们，不仅要关注心理健康危机的干预措施，还要尽可能帮助预防这些危机。精神卫生系统应提供干预措施，以促进复原力和幸福感，促进自我保健，并支持非正式护理。由于 Johnson 等人¹的主题是急性精神科护理，因此可以理解的是，他们只简要概述了二级和三级预防工作。然而，预防的重要性不可低估，因为它可以抵消精神卫生危机的发展，从而减少受影响者的痛苦以及精神卫生保健系统的压力和卫生保健费用。

我们同意作者的观点，即需要促进新的研究和政策，并且应该建立综合的地方危机护理系统来解决精神健康危机患者的多样化需求。将使用服务的人、他们的家人、社区和精神卫生保健提供的所有相关部门的工作人员包括在内，以设计满足患者和消费者特定需求的服务系统至关重要。COVID-19 大流行表明需要为精神疾病患者提供更好、更持久的服务结构。为实现这一目标，最重要的是关注服务用户的赋权和消除污名化⁸。

为了对抗对精神卫生的结构性污名化，政治家和政策制定者需要接受挑战并承担责任，将精神卫生保健的提供具体纳入流行病政策。重点必须从分散、复杂的服务系统（包括多种危机服务模式并导致服务缺口和未满足的医疗和精神科需求）转向完整连续的精神科护理⁹. 政府和机构需要根据国家层面的循证公共政策和实践，支持和资助从精神病院的住院病床到低门槛服务的全面连续性精神卫生保健的发展。国际研究团体，包括来自低收入和中等收入国家的科学家和服务用户，是收集和及时传播最佳模型和实践数据的关键，旨在为可持续的急性精神科护理提供证据。