We used the SPICE (Sample; Phenomenon of interest; Context; Emphasis or focus) framework to define the research question and structuring the study design [15] (in Appendix). Additionally, we followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [16] to structure and format the paper and to ensure comprehensive reporting of qualitative method and findings (in Appendix). Our methodology is consistent with the WHO‐recognized guidelines [17] outlining a four-step process of identification, classification, assessment, and engagement.

We adopted a stakeholder dialogue methodology grounded in participatory research principles to explore stakeholders’ perspectives on MH needs and service gaps in southern Switzerland while gathering factual and qualitative data. Stakeholder engagement, as an extension of stakeholder theory (Freeman, 1984; Freeman et al., 2010) encompasses “all activities aimed at fostering dialogue between an organization and its stakeholders, with the goal of providing a well-informed foundation for decision-making” [18]. This method fosters collaboration among individuals leading to shared understanding and the co-production of recommendations. The methodology also aligns with the analytic-deliberative process devised by Deverka et. al., (2012), a framework used to examine the perspectives of multiple stakeholders by combining (1.) Analysis i.e., gathering stakeholders’ perspectives, preferences, and values; (2.) Deliberation i.e., engaging stakeholders in open dialogue to explore options and implications on the issue; (3.) Synthesis and decision-making i.e., integrating stakeholders’ input into decision-making processes, with mechanisms for feedback and iteration. Overall, the analytic-deliberative process ensures that diverse perspectives and values are thoroughly considered, thereby enhancing the transparency, legitimacy and effectiveness of decisions [19].

The identification and selection of local stakeholders was an important aspect of this study. This was completed with input and guidance from the senior author (MM) and after a careful mapping activity (Figure 1). The objective of this mapping phase was to identify and categorize all relevant actors systematically to ensure comprehensive representation throughout the dialogue and to identify potential gaps in the existing networks. Figure 1 presents a conceptual overview of all stakeholder categories identified in our mapping exercise, not the actual dialogue roster. Four actor groups are displayed: government, service providers, institutional actors, and social actors, each derived by inductive clustering and the prior knowledge of the researchers. Following, participants were selected based on their level of power (i.e., the ability to influence decisions, outcomes, and direction given by factors such as authority, expertise, resources), and their level of interest in the specific subject (i.e., the degree to which stakeholders are affected by or concerned about the issue) using the power versus interest grid [20]. This grid allows for the prioritization of stakeholders’ participation, ensuring that the most influential and affected individuals are actively involved: stakeholders with high power have significant control or authority over the issue, while those with low power have minimal influence. Similarly, stakeholders with high interest are directly impacted by the initiative or have a vested interest in its outcomes. Conversely, those with low interest may have little or no concern about the initiative’s progress or results [21].

Plotting stakeholders in the grid permits to prioritize their engagement and tailor communication strategies to build positive relationships and support through the initiative. In addition, we purposively selected stakeholders working in different settings (e.g., inpatient, outpatient, community care), in different sectors (i.e., public, non-profit, private), and in urban and rural regions of southern Switzerland. We tried to maximize inter-professionalism and to ensure different background and seniority. Selected stakeholders were contacted by email and informed about the initiative and its aim. Of the 45 stakeholders contacted 32 agreed to participate (71%). Lack of time or prior-planned commitments were amongst the reasons for declining participation.

The investigator (CS) led the data collection with support of an observer who did not intervene in the dialogue and took notes of non-verbal communication among participants (MB). In April 2024, two distinct 2-h dialogues were conducted, each engaging different stakeholders: the first dialogue was held online (via MS Teams), the second took place in a dedicated meeting room at the Universita’ della Svizzera Italiana (USI). Both dialogues were conducted in a quiet and respectful atmosphere, facilitating interactions among participants without interruptions. The dialogues were conducted in Italian (the local language), and were audio recorded and transcribed verbatim by CS. Before conducting the dialogues, stakeholders were provided with a dialogue guide in form of a policy brief (PB) illustrating contextual information, the issue and preliminary evidence-based recommendations to tackle it [22]. In the dialogues, we asked stakeholders to share their experiences and perspectives on how the pandemic affected patients’ MH and the use of related services within their work contexts. Besides, we asked them to engage in discussion and agree on key PH recommendations for addressing unmet MH needs. Finally, we asked them to identify barriers and facilitators to the implementation of the recommendations. Discussions continued until no new arguments were mentioned.

The main investigator (CS) conducted data analysis with supervision by MB as thematic content analysis to identify and interpret patterns within the dialogues [23] he transcriptions of the dialogues were analysed in the original language and excerpts were translated only for the purpose of this study. The coding process was conducted as follows: first, the investigator carefully read the transcription to familiarize with the content. A first level of analysis was done by assigning codes to text segments that captured relevant aspects of the issue. Following this, codes with similar patterns were grouped into themes (i.e., working context, recommendation) and related subthemes (i.e., core element, barrier, facilitator). These themes and subthemes were then reviewed, combined, or divided, ensuring internal consistency and mutual exclusivity [24]. Finally, the themes and subthemes to retain were discussed with senior authors (EA, MB, MM).

A total of 32 stakeholders, representing various public and private organization in southern Switzerland (e.g., hospitals and clinics, nursing homes, long-term and community care centres, pharmaceutical companies, and health insurance) took part in the dialogue. The stakeholders were either directly or indirectly involved in MH care, and worked in different settings (e.g., inpatient, outpatient, community care), in both urban and rural areas in southern Switzerland (Table 1).

When referring to their working contexts in the aftermath of the COVID-19, stakeholders described increasing psychiatric visits and psychiatric hospitalizations, especially among children and adolescents, together with a growing demand for psychological therapy among young adults. Increasing urgent care interventions for MH problems from the ambulance services were also reported. Stakeholders observed that, the MH profile of patients and care users had evolved over time diversifying clinical expression, symptomatology, and complexity. Evolving profiles included: 1. Multimorbidity, such as common mental disorder combined with substance use disorder diagnosis. 2. Onset of psychological distress at an increasingly younger age. 3. Increased urgent psychiatric care. They deliberated that the process of profile evolution likely started several years before but that the COVID-19 pandemic exacerbated and accelerated it. Most physicians reported difficulties facing the emerging clinical expressions of psychological distress, and they reported uncertainty in clinical decisions about treatment and follow-up care, which contributed to greater referral of patients to specialists. Emerging changes and complexity required outpatient care services to ensure the provision of a multidisciplinary equipe comprising psychiatric nurses, social workers, and HC assistant. Finally, the psychotherapist perceived massive increase in requests of psychotherapy, difficulties in coping with the demand for consultations and long waiting lists.

Our study has some limitations. The qualitative design generated rich and multi-perspective information, but potential selection bias cannot be excluded in that we contacted a somewhat convenient sample of stakeholders that were easy to reach and that possibly know each other. While this may have contributed to reduce possible conflicts, opposing and diverging stances may have been less likely. Finally, no systematic independent coding of the dialogues was made but one researcher worked in autonomy, this is common in qualitative research that applies standard methods not prone to subjectivity.

The impact that COVID-19 has had on the population’s MH and access to services is a widely recognized issue at the international level [39]. Our project can offer models and lessons that can inform tailored approaches in other regions facing similar demographic or socio-economic challenges. Conducting research at the local level in Switzerland remains valuable internationally, as Switzerland is a high-income country with one of the most advanced HC systems in the world in terms of quality and accessibility [40]. Hence, Switzerland’s experience can serve as a valuable example, offering insights to inform and improve HC policies and practices in diverse contexts, particularly for policymakers aiming to improve and develop their systems at both the European and international levels. Besides, southern Switzerland has peculiarities that make it an interesting case study at the international level: it hosts a demographically older population, and its spatial and functional proximity to Northern Italy contributed to it being one of the first regions in Europe severely affected by the pandemic [41]. It also hosts a significant number of cross-border HC professionals [42].

When analysing techniques for implementing recommendations, it is important to consider aspects related with policy materialization, securing funding, preparing organizational conditions necessary for success, negotiating resources, and executing the policy recommendation [43]. Paying attention to these aspects permits to identify and possibly anticipate potential underlying causes of policy implementation failures or delays [43, 44]. Finally, attention should be paid to the critical issues to policy implementation such as resource diversion, goal misalignment arising from the engagement of multiple stakeholders, resistance to control over the dynamics and effectiveness of bureaucratic and administrative systems [45].

The COVID-19 pandemic highlighted the necessity for PH responses to meet new and established MH needs of the population while also addressing the long-standing issue of scarce, unequal, and inefficient resources [8]. The study offers novel perspectives on MH needs gaps recognized by local HC professionals in the aftermath of the pandemic. Engaging local stakeholders turned up as an effective strategy to derive PH recommendations to improve MH prevention and promotion along with the access and use of related services. The PH recommendations were directly incorporated into political decision-making; in fact, they were included in a policy brief, which was subsequently disseminated by the SLHS to support the development and integration of research-based solutions addressing current challenges [22]. A better understanding of the issue from the experiences and perspectives of local stakeholders provides insights on how the Swiss MH care system is addressing the repercussion of the pandemic. Further, it revealed aspects and guidelines to health policy making at the local level.