Much of our national attention has been focused on the COVID-19 pandemic and factors such as positivity rates, ICU capacities, in-person schooling, and potential vaccines. However, we are overlooking a mounting concern regarding the state of mental health.
Since the beginning of the COVID-19 pandemic (March 2020), mental health needs have grown. In June 2020, the Centers for Disease Control and Prevention (CDC) conducted a national survey focused on mental health in the U.S. and found that 40.9% of adults had mental health symptoms.[i] The majority of these identified adults reported depression or anxiety (30.9%); however, they also reported significant increases in trauma and stress due to COVID-19 (26.3%). Substance use also seems to have increased significantly given that 13.3% of adults reported that they either started or increased their substance use to cope with the stress of COVID-19.[i]
To help us better assess trends in mental health during the pandemic, the U.S. Census Bureau launched the Household Pulse Survey.[ii] This study is showing significant increases in the number of adults needing counseling and behavioral health medications. For example, in 2019, 15.8% of adults reported that they use mental health medications compared to August 2020 when that percentage increased to 19.4%. It further increased to 20.8% in November 2020.[ii]
For youth, the data is much less robust, but it seems to point to an even greater level of concern. For example, the proportion of Emergency Department visits due to a mental health condition has grown by 24% for 5-11 year olds and by 31% for 12-17 year olds.[iii] Probably the most concerning issue is that we as a nation have been losing a battle against youth suicide. Prior to 2007, youth suicide rates remained low and fairly stable. Between 2007 and 2017, however, those rates increased by 56%. Most concerning is the trend that youth suicide rates have been rising at a 7% year-over-year increase since 2013.[iv] Now, during the pandemic, it is very unclear whether the rate is continuing to increase, or even worse, growing completely out of control.
While mental health challenges have grown during the pandemic, healthcare practice has gone through a rapid transformation. Prior to March 19, 2020, the vast majority of services were delivered in person; now, only a small percentage is delivered in person. This pivot to telehealth was shockingly quick and, as a result, we have no idea how it is working or how this massive practice redesign has impacted efficacy, access or utilization. Fortunately, we can have some peace of mind from previous research. One large meta-analysis[v] covering all empirical research prior to 2013 showed strong outcomes for improved access, utilization, adherence, and notable cost benefits to behavioral health care delivered via telehealth. This study, as well as others, also suggested that the individual behavioral health outcomes were equal to in-person services. However, there were many limitations to this previous research, not the least of which point to a need to explore variations in outcomes by different populations and levels of care.
Unfortunately, even though the practice of mental health attempted to keep up with the current demands through telehealth practice re-designs, these efforts are falling short. For example, the Household Pulse Survey[ii] is showing that the need for therapy services is increasing month by month with the reported need in 2019 being as low as 4.3% compared to the jump to 11.2% in November 2020.
This is not to say that telehealth isn’t working; rather, one of two issues (and possibly both) is happening. Either the demand/need for care is increasing faster than it was prior to COVID-19 or the resources available for behavioral health are decreasing. In the case of the latter, we have no idea how many practices survived the pivot to telehealth. Fortunately, many are still thriving, and that is primarily due to impressive policy efforts that have helped keep mental health practices alive. These initiatives include the CARES Act which provided money to support telehealth infrastructure as well as multiple executive orders that pushed parity for telehealth and allowed certain levels of mental healthcare to operate utilizing telehealth.
The result of all of these policy efforts has kept the mental healthcare infrastructure going and, in many ways, improved the future of care especially in regards to access and utilization of behavioral health care nationally. However, these gains can be lost quickly if we don’t look forward starting now.
Although a lot has changed and changed for the better long term, we need to evaluate what is happening and retain what is working. To do this well, we need to immediately begin tracking access and utilization as well as population effectiveness variations. Having said this, we do know that our national practice design is providing better access and utilization across the board. Therefore, some of the executive orders should become actual law through Congressional action. If we don’t take this step now, we will force a large portion of the field to invest in practice re-design again and, in the process, cripple smaller agencies, losing opportunities for increasing access to mental health care.
Brian Distelberg, PhD
Dr. Distelberg is the Director of Research at the Behavioral Medical Center and is also a Professor of Counseling and Family Sciences for the School of Behavioral Health. His research interests include behavioral health integration, community and organizational systems, multivariate analysis, community-based research, and social and behavioral health.
- [i] Czeisler MÉ , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049–1057. DOI: https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm?s_cid=mm6932a1_w
- [ii] U.S. Census Bureau. Household Pulse Survey.2020. https://www.census.gov/data/experimental-data-products/household-pulse-survey.html
- [iii] Leeb RT, Bitsko RH, Radhakrishnan L, Martinez P, Njai R, Holland KM. Mental Health–Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic — United States, January 1–October 17, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1675–1680. DOI: http://dx.doi.org/10.15585/mmwr.mm6945a3
- [iv] Curtin SC, Heron M. Death rates due to suicide and homicide among persons aged 10–24: United States, 2000–2017. NCHS Data Brief, no 352. Hyattsville, MD: National Center for Health Statistics. 2019. https://www.cdc.gov/nchs/products/databriefs/db352.htm
- [v] Hilty, D. M., Ferrer, D. C., Parish, M. B., Johnston, B., Callahan, E. J., & Yellowlees, P. M. (2013). The effectiveness of telemental health: a 2013 review. Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 19(6), 444–454. https://doi.org/10.1089/tmj.2013.0075