This paper reviews the existing literature on burden attributed to mental health in the Eastern DRC and summarizes the suggestive means of amelioration of integration of mental health into PHC. Although developed countries have implemented guidelines to cope with the increasing health challenges during armed conflict or natural disasters, few efforts have been done in developing countries to cover the burden of psychological distress and mental disorder during pandemics [20].

We found that mental health services are not integrated into PHC across the eastern part of the country, despite the wide recognition of its contribution to the health system. In fact, there is less attention regarding the application of mental health legislation during public health emergencies. To date, less than 10% of individuals with mental illness have access to needed healthcare services in DRC [6]. Additionally, a recent study revealed high rates of relapse among adolescent patients living in these armed conflict and EVD outbreak settings in DRC [21]. In most cases, the majority of Congolese population travel a distance of more than 10 km before attending mental health facilities [22]. Mental health care is frequently provided at the health facility level, mainly for individuals with high educational and socioeconomic status [6].

There is strong evidence that outbreaks and armed conflict impeded the quality of life. A recent study demonstrated that 28.0% of the global population experienced depression; 26.9% of cases showed anxiety; 24.1% of cases presented the symptoms of post-traumatic stress disorder; and sleep-related problems were seen in 27.6% of cases during COVID-19 [23]. Mental health problems during outbreaks and armed conflict are not fully treated due to lack of health workers or stigma. There is an urgent need for a strong mental health system, centered on improving the provision of mental health services into PHC and communities. This may increase access to mental healthcare services to affected individuals. Wakida and colleagues suggested that the achievement of good outcomes during the management of mental illness requires adaptation of national guidelines regarding mental health into the local context of health care [24]. Therefore, the integration of mental healthcare into PHC remains the best alternative to the provision of mental healthcare at both community and health facilities levels.

The eastern part of DRC has a large range of risk factors that can result in an explosion of mental disorders. While mental health is not fully integrated into health care among people living in armed conflict and outbreaks, except for the survivors of gender-based violence; mental illness is a major concern of public health [25]. New policies based on the extension of emergency response to the existing health system are required regarding the promotion of guidelines on how to handle mental health challenges due to outbreaks. Amelioration of mental health services into PHC requires appropriate planning, continuous monitoring, and measurement of performance as well as their recruitment among and into the concerned communities [8]. Our analysis of existing evidence regarding mental illness in the DRC highlights the importance of the implementation of a new model of providing mental healthcare services.

As a result of the analysis of available evidence; a model based on the implementation of mhGAP at community level of the health system is actually proposed by this review. This model should aim to ameliorate mental healthcare services via the community engagement [26]. Active encouragement toward the adoption and diffusion of the mhGAP services sets up a basis of providing mental health of quality across individual communities.

To ensure that access to mental health services has improved, social workers and community health workers should be skilled and supported to reach all households at least weekly for collecting and addressing mental health problems [4]. Also important skills are needed by the health zone monitors and workers to implement the mental healthcare services at community levels. Additionally, even if the mental health department is implemented at the Ministry of Health of DRC and has established the mental health legislation [6], its priority should ensure that the success of the mhGAP in complex humanitarian setting of DRC helps to achieve universal health coverage in regions affected by armed conflict and health emergencies regarding the mental health. Mental health promotion and the establishment of a close relationship between modern mental healthcares with community, traditional and religious healers could improve the mental health of Congolese.

First, raising the awareness of mhGAP programs during outbreaks and armed conflict needs important reforms of mental health legislation [27]. Secondly, the public emergency response against the tenth and twelfth EVD outbreaks in DRC demonstrated an important delay to overcome community resistance, triggered by psychological and mental background of the affected community [3], despite the involvement of experts to cover the gap of mental health workers in the local context [2]. Prioritization of community mental health support for direct and indirect victims of natural disasters highlights the implementation of mental wellness check-ups of vulnerable individuals and continuous monitoring [4]. This could be shifted from the short-term period, commonly used to, long-term mental health programs. Therefore, these trained health workers should be prioritized as part of the mental health task force for the implementation of community mental health into the health system in the aftermath of outbreaks.

Thirdly, the implementation of mental health services at PHC requires the development of standardized approaches to use in outbreak and conflict zones settings. Furthermore, this implementation highlights the change of support provided to PHC workers and health communication regarding community mental health and psychosocial support. Mental health could be included in the national country’s health communication systems, and a need for developing specific screening psychological tools useful by health care providers and policymakers at the provincial, operational, and community levels to strengthen mental capacity building.

To ensure the integration of the mental health model into PHC in the aftermath of armed conflict and outbreaks; there is a need of implementation research study related to the mhGAP in three provinces of eastern DRC, namely South Kivu, North Kivu, and Ituri. This research will aim to identify the barriers and facilitators to scaling up mhGAP interventions and the integration of mental health services into PHC. This study will target to improve the uptake of the findings research for effective development of new policy in DRC. Furthermore, this study will address the following objectives: i) to identify operational strategies, implementation challenges, and gaps of the mhGAP interventions in conflict settings, and propose solutions with a potential influence of policies and practices of mental healthcare services in the three above-mentioned provinces; ii) to explore the factors influencing the proposed model to contribute to the promotion of mental health and well-being of individuals living in armed conflict concerned with EVD outbreaks; iii) to identify lessons about the implementation of a mhGAP regarding the prevention and management of mental illness as well as the promotion of mental health; iv) to propose feasible solutions able to determine the sustainability of the community mental health and psychosocial support model proposed by this paper.

A multilevel strategy will be performed for an in-depth understanding of the process of integration of mental health services into PHC. A mixed approach using qualitative and quantitative will be used to collect data. Measurement will concern the evolution of common mental illnesses over time; the access to mental health facilities, as well as the involvement of all the relevant stakeholders in the provision of mental healthcare into PHC. Desk review, in-depth interviews and focus group discussions associated with consultation and brainstorming will be used to collect data that will have the potential to influence the control and promotion of mental health and well-being at the community level. Recommendations of this study will offer insight to all the relevant stakeholders including the Ministry of Health on the barriers and facilitators to scaling up mhGAP interventions and the integration of mental health services into PHC. However, these recommendations have to be read in DRC context.