The second surge – how the COVID-19 pandemic is exacerbating America’s behavioral health crisis.

Vic Siclovan, Director, and Hanna Helms, Manager, Medicaid Challenges, AVIA

The immediate impact of COVID-19 and the resulting long-term consequences are creating significant demand for historically scarce behavioral health services. 

Living through a pandemic is stressful and anxiety-inducing. The stay-at-home measures put in place to contain the spread of COVID-19 are compounding this stress, resulting in social isolation and unprecedented economic hardship, including mass layoffs and loss of health coverage. These factors will likely worsen the conditions driving suicide and substance-related deaths, the “deaths of despair” that claimed 158,000 lives in 2017 and contributed to a three-year decline in US life expectancy among adults of all racial groups. The economists Angus Deaton and Anne Case, whose influential 2015 paper popularized the term, argue that business cycle fluctuations do not drive deaths of despair in the short term; however, they do believe that the coronavirus will likely worsen the long-term conditions that are responsible for these deaths.

Even before the emergence and spread of COVID-19, the US was experiencing a behavioral health treatment crisis: 2018 data showed that only 43% of adults with mental health needs, 10% of individuals with SUD, and 7% of individuals with co-occuring conditions were able to receive services for all necessary conditions. In 2019, to improve behavioral health access and outcomes and address addiction, we launched the Behavioral Health Initiative and Substance Use Disorder Initiative with 30 health systems as part of the Medicaid Transformation Project. Together, these systems committed to building comprehensive behavioral health strategies with innovative digital tools and clinical best practices to help more people who struggle with untreated depression, anxiety disorders, post-traumatic stress disorder (PTSD), and substance use disorder (SUD).

This work is more important than ever. A concerted public and private effort is needed to redouble investment in behavioral health during and after the pandemic. Otherwise the all-consuming nature of the COVID-19 surge response will leave the US healthcare system even more poorly equipped to address the behavioral health crisis that has already exacted great human cost.

A pandemic tests everyone’s mental health and wellbeing. Different populations will be impacted in different ways, but there are meaningful and market-facing solutions that can help each segment.

  • General population: As has been widely reported, the pandemic is causing a rise in stress and anxiety in the general population:
    • A recent KFF survey reported more than four in ten individuals feel that worry and stress related to coronavirus has had a negative impact on their mental health. Of those indicating negative mental health impacts, one in five say the impact is major. Importantly, the highest groups reporting a major impact on mental health are women (24%), Hispanic adults (24%), and black adults (24%).
    • Further, one pharmacy benefit manager reported a 21% increase in prescriptions filled per week for antidepressant, anti-anxiety, and anti-insomnia medications between February 16 and March 15.

Solution: Deploy digital solutions that expand access to low-acuity behavioral health services and connect socially isolated individuals to peers and online communities that can prevent exacerbation of behavioral health concerns.

  • Health system employees and their families: Healthcare workers and their families are experiencing extreme levels of stress, anxiety, and trauma. Many have also been self-isolating to prevent potential transmission and, consequently, have been cut off from their families and communities. As COVID-19 spreads, the need for ongoing, easily accessible behavioral health resources for the healthcare workforce will only grow.

Solution: Provide immediate (and free) access to behavioral health services to employees and their families, including therapists, psychiatrists, and online resources. UCSF is one example of how to do this well.

  • Newly financially insecure and un/under-employed: Recession, and attendant unemployment and financial hardship, precipitates and exacerbates behavioral health issues. These circumstances are associated with increased income inequality, increased substance use, and risk of suicide. Unemployment can lead to loss of employer-sponsored healthcare coverage and inability to pay rent, access nutritious food, and provide childcare.

Solution: Connect individuals experiencing financial insecurity to financial assistance programs, social care services, and behavioral health resources.

  • Individuals with pre-existing BH conditions: Individuals with pre-existing behavioral health needs already face immense access challenges, as previously indicated. Note – these same challenges extend to the pediatric population: only 20% of children with behavioral and developmental disorders receive care from a specialist. Adding fuel to the fire, COVID-19 has disrupted access to many behavioral health services, including face-to-face interactions with providers, peer recovery services, and social support networks, risking negative outcomes like medication non-adherence, recovery disruptions, and increased suicide risk, among others.

Solution: Expand access to behavioral health services through digital modalities to support continuity of care in the midst of potential in-person service disruptions.

  • High-acuity, high-need individuals: Although everyone will be impacted by the pandemic in some way, certain populations demand special attention, including the frail, home-bound elderly; individuals with disabilities; individuals experiencing homelessness; and victims of domestic violence. These groups already faced significant and unique barriers to receiving appropriate care, and shelter-in-place orders put these groups in even greater need of behavioral health resources. There are a few considerations in caring for these populations in a COVID-19 world:
    • First, medically fragile individuals, for whom Medicaid is the primary payer, often require high-touch, in-person care. Stay-at-home orders and an overwhelmed healthcare workforce make caring for these patients more challenging. Extra caution must be taken to ensure the safety of those requiring high-touch care and the professionals who care for them.

Solution: Implement robust screening practices and updated care protocols that take into account not only COVID-19 considerations but also the unique needs of complex, high-risk populations.

  • Stay-at-home orders have also created new barriers to providing social services, like transportation, food, and shelter. For example, the social distancing practices that have kept many safe at home are virtually impossible to observe for individuals who rely on homeless shelters.

Solution: Provide temporary, isolated housing (e.g., renting out hotel rooms), testing at shelter sites, and easily accessible community behavioral health resources.

  • Finally, a shelter-in-place order can mean greater risk of physical harm or even death for individuals experiencing domestic violence.

Solution: Form partnerships with local organizations well-versed in supporting individuals experiencing domestic violence, as healthcare organizations may not have these capabilities in-house.


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