Public Health Policy Analysis (PHPA) Paper

AJPH COVID-19

COVID-19 Exposes the Cracks in Our Already Fragile Mental Health System

See also Morabia, p. 923, Tarantola et al., p. 925, and the AJPH COVID-19 section, pp. 939–977.

The coronavirus pandemic has caused enormous concern among many people. Every morning, we are met with an increasing deluge of dire news about the most recent number of people to contract COVID-19 and to die from it, decreases in the stock market, and countries implementing broad travel re- strictions and stay-at-home or- ders.1,2 The current state of affairs is having a negative effect on the mental well-being of our coun- try’s residents. It also highlights the policy gaps in our current system that inhibit the vital conditions for well-being and resiliency.3 Although the pri- mary focus has rightfully been on stopping the spread of COVID-19, we should also quickly prepare to address the mental toll the pandemic is taking on individuals and communities across the country.

Those involved in past emergency responses have cited the elevation of anxiety among the general public as well as the heightening of symptoms among those who have a preexisting mental health or substance use disorder diagnosis. The former health commissioner of Boston (J. A.), who led the city’s health response during the months after 9/11, reported the city’s need for mental health professionals who could offer counseling and make referrals to those who called the

city hotline. Similar needs arose with the H1N1 outbreak and the Haitian earthquake.

The current state of affairs could exacerbate the conditions of those seeking or receiving mental health care, and current regulations may further impede access to care. Right now, 112 million Americans live in mental health professional shortage areas, and roughly 50% of those who do receive care have to travel more than one hour round trip.4.5 In- creasing the number of mental health workers, putting them in the right places, and training them to work in these settings will remain a challenge for the foreseeable future. To augment onsite services, mental health telecare services are being used in primary care settings, nursing homes, and correctional facili- ties, where it may be difficult to find a local clinician. Sadly, these efforts have been stymied by a lack of access to technology, fi- nancial mechanisms to support delivery, and underenforcement of mental health parity laws, which affect all access to mental health services. Should an indi- vidual need to self-quarantine, or if a clinician restricts the hours of access to medications, as with treatment of an opioid use dis- order, this could add yet another problem, making access and consultation to clinicians even more burdensome.6

Recently, the Substance Use and Mental Health Services Administration issued guidance for opioid treatment programs regarding COVID-19.7 The guidance refers providers to their state opioid treatment authority to develop and implement a disaster plan to address various contingencies, including con- tinuing medication-assisted treatment.7 Although it is com- mendable of federal leadership to issue such guidelines quickly, pushing the decision down to states could create a patchwork of policies that could enable the easy continuation of treatment in one state while creating compli- cations in others. Complicating this, the guidance came shortly before an inspector general re- port finding that the Substance Abuse and Mental Health Ser- vices Administration’s oversight of opioid treatment programs did not comply with some federal requirements (https://bit.ly/ 33Ib2k3).

The elevated need for mental health services also exacerbates the already problematic gaps in culturally and linguistically

appropriate care (https://bit.ly/ 39iadQ3). The mental health workforce, particularly for highly trained providers such as psy- chologists, is less diverse than is the general population (https:// bit.ly/39j06dy). In past emer- gencies, these inadequacies meant unequal access to care, made even more complicated by lower rates of insurance cov- erage among the same pop- ulations (https://bit.ly/3br1vAt). There are even greater compli- cations for immigrants who fear that seeking care might risk their immigration status (https:// bit.ly/2xmG58P).

For many, the fear of getting ill is not new but has been aggra- vated by the novel coronavirus. According to the Bureau of La- bor Statistics, 71% of private in- dustry workers have paid sick leave benefits, but on average receive seven paid sick days (https://bit.ly/2WIw9Bl). For those exposed to COVID-19, self-quarantine and social dis- tancing can be recommended for 14 days, creating a possible shortfall. Anyone who cannot afford to take time off sick is faced with a Faustian choice that can create tremendous stress: should they continue to work while sick to make ends meet, or should they take the necessary time to recover—even if that means they might be unable to pay rent or buy enough food for their family.

ABOUT THE AUTHORS John Auerbach is the president and CEO of Trust for America’s Health, Washington, DC. Benjamin F. Miller is the chief strategy officer of Well Being Trust, Oakland, CA.

Correspondence should be sent to John Auerbach, Trust for America’s Health, 1730 M Street NW, Washington, DC 20036 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

This editorial was accepted March 28, 2020. doi: 10.2105/AJPH.2020.305699

July 2020, Vol 110, No. 7 AJPH Auerbach and Miller Editorial 969

Furthermore, many older adults, caregivers, and individuals with chronic medical conditions who are at higher risk of serious complications from COVID-19 are facing the double uncertainty of a new disease with many unknown variables and the unknown duration of this dan- ger. Nursing homes and long- term care facilities, which have emerged as the highest risk areas, are taking prudent measures to address these dangers by limiting visitors and increasing screenings (https://bit.ly/3bsx8cG). Older adults who already suffer from social isolation may have even greater isolation as they are discouraged from traveling or attending events with large numbers of people.

Issues of loneliness and isola- tion are serious concerns across the entire population, but espe- cially for older adults. Rates of loneliness are at an all-time high, and the impact of loneliness on our health is profound (https:// bit.ly/33Jw5Tj). We must not overlook ways to address loneli- ness and isolation in the time of a pandemic. Alongside loneli- ness, underlying mental health and substance misuse needs re- quire thoughtful attention to evidence-based solutions as well as technological advances that connect even the most isolated people to care and caregivers (https://bit.ly/2Jk8YFf).

Disruptions to everyday life have been widespread. Many college students returned from spring break only to be notified that they must leave their dorms and that any summer plans they had, like studying aboard or work–study programs, are up in the air (https://wapo.st/ 2QJPAWi). K–12 students are also experiencing cancellations or postponements of school plays and fieldtrips, and, in some areas, they are experiencing school

closures (https://bit.ly/2xkzD2i, https://bit.ly/2UBOkpn). Al- though these decisions have been made to ensure the safety of students, policymakers should also prepare to address any mental health ailments that may result (https://bit.ly/39oDp8c). Men- tal health resources for both children and adults have been developed by the Centers for Disease Control and Prevention and should be reviewed by all parties (https://bit.ly/39hwQ7f, https://bit.ly/33KVCLK).

We have reached the tipping point at which the phenomena surrounding COVID-19 have affected most people in some way. The time has arrived to bolster supports for our fellow Ameri- cans. On March 6, the president signed into law a bill to fund re- sponse efforts to mitigate the spread of COVID-19 (https:// bit.ly/3dtfwiW). Following this, the Congress passed the Families First Coronavirus Response Act, which includes provisions for free coronavirus testing, paid emer- gency sick leave, enhanced un- employment insurance, and increased funding for Medicaid (https://bit.ly/2UgjaFi).

Conversations about future legislative efforts to address the effects of COVID-19 continue. Any future legislation to address COVID-19 should include social policies that alleviate many of Americans’ current concerns. These include establishing clear contingencies for those in need of or currently receiving mental health care, including expand- ing mental health teleservices, strengthening the integration of mental and physical health ser- vices, and incorporating mental health first aid and supports into broader recovery strategies. They also include expanding immedi- ate crisis supports such as the Disaster Distress Helpline and National Suicide Prevention

Lifeline. In an evolving situation with many unknown factors, we should focus on proven policies that, if implemented right now, will address present and future fears. We don’t have time to waste.

John Auerbach, MBA Benjamin F. Miller, PsyD

CONTRIBUTORS The authors contributed equally to the content and preparation of the editorial.

ACKNOWLEDGMENTS The authors thank the Well Being Trust for its support.

CONFLICTS OF INTEREST The authors have no conflicts of interest to declare.

REFERENCES 1. New York Times. Coronavirus turmoil in 5 charts, 10 quotes, 5 photos and 1 map. 2020. Available at: https://www.nytimes. com/2020/03/10/business/dealbook/ coronavirus-markets-oil.html. Accessed March 25, 2020.

2. USA Today. Coronavirus: all of Italy placed on lockdown; state department to limits services there. 2020. Available at: https://www.usatoday.com/story/ travel/destinations/2020/03/09/italy- imposes-nationwide-restrictions- contain-coronavirus/5004545002. Accessed March 25, 2020.

3. Well Being Trust. Healing the nation: a policy guide. Available at: https:// healingthenation.wellbeingtrust.org. Accessed March 25, 2020.

4. Henry J. Kaiser Family Foundation. Mental health care health professional shortage areas (HPSAs). 2019. Available at: https://www.kff.org/other/state- indicator/mental-health-care-health- professional-shortage-areas-hpsas/? currentTimeframe=0&sortModel= {”colId”:”Location”,”sort”:”asc”}. Accessed March 25, 2020.

5. National Council for Behavioral Health. New study reveals lack of access as root cause for mental health crisis in America. Available at: https://www. thenationalcouncil.org/press-releases/ new-study-reveals-lack-of-access-as- root-cause-for-mental-health-crisis-in- america. Accessed March 25, 2020.

6. Wicklund E; mHealthIntelligence. ATA releases 2019 update of state-by-state telehealth report cards. 2019. Available at: https://mhealthintelligence.com/news/ ata-releases-2019-update-of-state-by- state-telehealth-report-cards. Accessed March 25, 2020.

7. Substance Abuse and Mental Health Services Administration. Medication- assisted treatment (MAT). 2020. Avail- able at: https://www.samhsa.gov/ medication-assisted-treatment. Accessed March 25, 2020.

AJPH COVID-19

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