Dear Editor
The World Health Organization (WHO)declared the COVID-19 outbreak a public health emergency in January 2020 and identified it as a pandemic in March 2020 [1]. Following the official announcement of COVID cases in Iran and in response to a request from the Ministry of Health, the 4030 Call System was launched on February 27, 2020, to provide medical services addressing COVID-19-related needs. The system had several sections that answered people’s questions regarding symptoms, progression, prevention, treatment, and news related to COVID-19. One of these sections specifically addressed inquiries about mental health, allowing anyone to call the system for advice from a mental health professional. These professionals were 562 volunteers with master’s degrees in psychology who had completed a short training course to prepare them for work in the system. During this course, they learned how to apply guidelines prepared by the Ministry of Health in collaboration with the Iranian Psychiatric Association and several Iranian universities. They were selected by the Ministry of Health from across Iran to ensure familiarity with the subcultures of each region of the country. After a relative decline in the epidemic, the number of people contacting the system decreased, and after a few months, the number of psychologists working in the system was reduced to about three hundred.
A group consisting of individuals with PhDs in psychology, psychiatrists, and professors of psychology and psychiatry also participated in this system as supervisors. The supervisors were available to support the frontline staff (senior psychologists), allowing them to ask questions or refer urgent cases, such as potential suicides, to the supervisors. The supervisors had a private Internet line to contact users and reached out to the referred individuals, interviewing them for as long as necessary. Cases that required more effective interventions, longer-term follow-up, or those who were unable to receive help were referred to local mental health centers. The system operated 16 hours a day, from 8 a.m. to midnight.
All frontline staff and supervisors could submit questions and issues in a large WhatsApp group. The group included a senior manager (a psychiatrist and a representative from the Ministry of Health) who worked to resolve the problems of group members and followed up on difficult or urgent phone calls throughout the referral process.
To evaluate the mental health section of the 4030 Call System, a study was conducted in August 2020, supported by the WHO and commissioned by the Ministry of Health. This study was led by the first author of this paper and involved collaboration with the second, third, and fifth authors [2]. In this project, the views, attitudes, and suggestions of individuals involved in the system—including senior managers, supervisors, managers of university mental health departments, and service providers—were examined through in-depth interviews.
The findings indicated that the number of phone calls made to the system could serve as evidence of the society’s mental health status, as the number of daily calls answered was positively correlated with the number of daily deaths announced on that day (Pearson correlation coefficient=0.24; P=0.006).
Based on the findings of this study, the establishment of the psychological counseling section within the 4030 Call System was a successful experience, and the system enhanced the community’s existing screening system and access to services. The study showed that people were generally satisfied with the services provided by the system. Given the stigma associated with psychiatric disorders, one of the major barriers to individuals trusting and utilizing mental health services is the fear of disclosure [3]. The anonymity of users and the absence of stigma created an opportunity to build public trust in the services offered by the 4030 call system. Additionally, the continuous presence of specialists serving as supervisors for the activities of frontline experts was a strength of the system [2]. However, the findings revealed that: 1. The system’s infrastructure has serious problems, 2. The number of service providers needs to be increased and they require more training, 3. The referral system needs to be completed, 4. Inter-agency cooperation needs improvement, and 5. There is a need for greater public awareness about the system.
Considering the level of public access to services, people’s needs, and their acceptance of this type of service, the continued provision of public services through the 4030 Call System could have played an effective role in improving the society’s  mental health.
Unfortunately, the service provided by the 4030 Call System did not continue in its original form, and now, several years after the initial implementation of the system, people’s questions and requests are addressed by only a handful of psychologists within this system. Although the COVID-19 epidemic has subsided and is no longer considered a health problem in Iran, it is necessary to assess the current situation and the trajectory of people’s mental health in the country to determine the need for the continuation of the 4030 call system:
The annual prevalence of psychiatric disorders in Iran was estimated at 24% in a large epidemiological study conducted in 2011 [4], with some estimates suggesting that this rate is on the rise [5, 6]. On the other hand, Iran is vulnerable to natural hazards such as earthquakes and floods, with high susceptibility according to the World Risk Report 2023 criteria [7]. For example, the flood that impacted a large part of Iran in early 2019 significantly increased the rate of psychiatric disorders for at least five months following the disaster [8, 9]. Additionally, there is substantial information about suicide in Iran [10-12], and it is estimated that the suicide rate in Iran is also increasing [13]. In this context, the economic recession and the declining trend of social capital indices [14] should also be considered as factors affecting the mental health of Iranians.
Therefore, it is suggested that the country’s mental health authorities, specifically the Ministry of Health, take steps to improve public service delivery by utilizing existing research data and involving experts in revitalizing and upgrading available facilities with documented cost-effectiveness, such as the 4030 call system.



References

1. World Health Organization (WHO). Archived: WHO timeline - COVID-19. 2020 [Update 2020 April 27]. Available from: [Link]
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