Luana Marques has had a busy few months. Since March, the Boston-based researcher and clinician estimates that she has done about 40 webinars to help individuals process the stress of the coronavirus pandemic. “There’s a lot more need for support,” Marques says. “People in the communities I work with have been a lot more distressed, more anxious, especially after some of the police brutality.”
So in her webinars, she wanted to give people the tools to start to process those feelings. “I started saying, ‘It’s OK not to be OK. Right now, biologically, it’s OK to have that response, it’s natural.’ It’s that permission to understand that sometimes you hit a wall—that it’s biology,” she says. “That’s when I’ve seen people’s eyes light up. That instead of avoiding the feelings, they [start to] welcome the feelings.”
All over the world, people are trying to cope with similar distress—and existing mental health care systems are not always equipped to help them. In China, where the pandemic started, government officials flagged the potential for an acute need for mental health care back in January; in the months since, universities and nonprofit organizations have set up hotlines to field calls from depressed and anxious citizens. In India, where the rate of suicide had been increasing for years before Covid-19 arrived, calls to improve the mental healthcare system have been getting louder.
Experts in countries from France to Brazil, from Ethiopia to the United Kingdom, are calling attention to what they anticipate could be a huge influx of patients in need of mental health care, with needs far greater than the countries’ existing systems can handle.
“It is now crystal clear that mental health needs must be treated as a core element of our response to and recovery from the Covid-19 pandemic,” Tedros Adhanom Ghebreyesus, the director of the World Health Organization (WHO), said according to a May press release from the UN. “A failure to take people’s emotional wellbeing seriously will lead to long-term social and economic costs to society.”
This is certainly a concern for the US, which has seen more cases of Covid-19 per capita than any other country and whose citizens had higher rates of unmet mental health needs than many other countries. “In many ways there’s a lot of red tape around who is qualified to do what,” Marques says—that is, there are restrictions around which medical professionals can perform particular aspects of care.
Months after the start of the first lockdown orders, experts are still working to understand whether the WHO’s dire predictions have come to pass. It may take several more months or years to know for sure. But in the US and elsewhere, this moment could present an opportunity to shape mental health care systems into what they always should have been.
A broken system
An estimated 20% of Americans suffer from a mental health condition. Treatments vary depending on the individual and the disorder, but many people choose some combination of talk or behavioral therapy (cognitive behavioral therapy, or CBT, is a popular type) and pharmaceuticals like selective serotonin reuptake inhibitors (SSRIs). Over the past decade, increased access to services, along with growing awareness around mental illness, were leading greater numbers of patients to seek diagnosis and treatment in the US.
But even before the pandemic, many of these patients couldn’t get the treatment they needed. In 2018, only 43% of US-based adults with mental illness received treatment for their condition. Among them, it was mostly the wealthy and insured who had access to therapists and psychiatrists to diagnose and help them manage their conditions.
To make matters worse, many of those who are lucky enough to have access to prescription SSRIs never find one that works for them; research into new drugs has stalled out in the past decade. Those who cannot or do not seek treatment may find their conditions spiral into a mental health crisis, whose response can involve hospitals, hotlines, or even police. In the absence of a strong medical safety net, these patients resort to a loosely-woven patchwork of last resorts.
“The gap in access to care is like the Grand Canyon. Any uptick is going to crush it,” says Marques, who is the director and founder of the Community Psychiatry Program for Research in Implementation and Dissemination of Evidence Based Treatments (PRIDE) at Massachusetts General Hospital.
The pandemic seems to have provided just that kind of uptick. Roxane Cohen Silver, a psychology researcher at the University of California, Irvine, has spent decades studying how individuals respond to disasters both human-made (terrorist attacks, mass shootings) and natural (hurricanes, wildfires). The Covid-19 crisis is similar to an event like 9/11 in that it affects a large proportion of the US population, Silver says, but it’s different in that it’s slow-moving and it’s not clear when it will end, making it more challenging for people to rally and pick up the pieces mentally. The losses are many: the death of a family member, the loss of financial security, the disappointment of a milestone deferred.
Dealing with those losses can be difficult, Silver says, made even more difficult by the fact that our usual ways of coping—getting dinner with friends after we’ve been laid off, or gathering with loved ones at a relative’s funeral—have been cut off or altered because of the pandemic, leaving more people feeling isolated. “I know that there are many losses, both real and symbolic, that might make it difficult for people to cope with the consequences of the pandemic,” Silver says. “As it continues, if it escalates further, if we have a second wave, if the restrictions are re-imposed, we could have all sorts of potential ongoing psychological challenges.” Though Silver’s comments pertain to the particular dynamic in the US, many people worldwide are likely having similar reactions.
Some groups were already at high risk. A portion of the US population (about 4%) has severe mental health conditions, such as schizophrenia or severe bipolar disorder, that weren’t under control even before the pandemic, often leaving them unemployed or homeless. For others previously diagnosed with a psychiatric condition but who had found a treatment that worked to keep it under control, the stresses of the pandemic may increase the risk that the illness will once again inhibit the patient’s life.
“Individuals with preexisting mental health challenges are at greatest risk for mental health difficulties in response to an event like this,” Silver says.
The pandemic is making things worse
Some experts see early signs of increasing demand for mental health services. Among 1,226 US-based adults, 45% said concern about the virus had negatively affected their mental health, according to a survey conducted by the Kaiser Family Foundation published in April. Other surveys have indicated that feelings of fear and anxiety, as well as more formal symptoms of mental health conditions, are already higher than pre-pandemic levels, according to Richard Frank, a professor of health economics at Harvard Medical School.
The use of alcohol is increasing, as is the use of opioids and the number of overdose deaths. The Disaster Distress Helpline, intended to emotionally support Americans suffering from the effects of disasters, saw a 47% increase in call volume from April to May, and an increase in calls from the same month the year prior, according to a spokesperson. “All of those are sort of hints that things are going awry,” Frank adds.
Crisis facilities in some of the hardest-hit states are feeling it, too. Paul Galdys, the deputy CEO of RI International, a mental health services provider in five US states, says that a number of their facilities saw a lower volume of patients at the beginning of the lockdown orders. “Early isolation led to lower volume,” he says—but by late June, facilities in Arizona and California were receiving record numbers of patients.
“We’re seeing a higher volume in crisis facilities than we’ve ever seen in those locations,” Galdys says. And he anticipates the trend will continue. “I can only expect that we’ll still find people who are continuing to isolate and who we don’t know are struggling as much as they are,” Galdys says.
The greatest stress on the mental health care system will likely come from people who were never diagnosed with a disorder but whose symptoms reach diagnosable levels. This might include elderly people who can’t receive visitors, young people who relied on school-based resources, frontline workers dealing with trauma of treating Covid-19 patients, or those patients themselves.
Add the stress of confronting systemic racism and growing awareness of police brutality brought on by the protests in the wake of George Floyd’s killing, and we’re seeing Black and Latinx people with above-average incidences of anxiety and depression.
“Those who are experiencing mental health issues, who may or may not have a diagnosed disorder and are unstable, whose symptoms are likely to be exacerbated as a result of the pandemic—those are the individuals at the highest level of risk,” says Adam Haim, the chief of the Treatment And Preventive Intervention Research Branch at the National Institute of Mental Health.
Finding adequate treatment for all of these people could literally be a matter of life and death. “If we can’t treat them, we’ll see ever-rising suicide rates. We’ll see people whose job might come back, but they’re unable to work because they’re too depressed or are having cognitive symptoms that no one is working up,” says Steve Hyman, the director of the Stanley Center for Psychiatric Research at the Broad Institute.
“Some people expect a tsunami of mental health crisis, and I think that’s right,” Galdys adds.
What to do about it
Experts still don’t know that the anticipated uptick in mental health needs will in fact come to pass. They might not know for years. After other traumatic events, experts might look at admissions to emergency rooms or prescriptions of psychological medication to gauge a growing need for mental health services, Silver says. “Those data might not be valuable right now. People didn’t go to emergency rooms because of fear about coronavirus,” she says; since an estimated 27 million Americans lost their health insurance due to the economic downturn, it’s hard to know whether there were increased needs since they may not be able to afford care, she adds.
That’s part of the reason Marques is trying to arm people with the tools of therapy techniques like CBT, even without a therapist. PRIDE’s training institute has trained hundreds of frontline professionals (like teachers and community health workers doing contact tracing) to start teaching those they work with to use CBT strategies to improve their mental health. They can ask distressed people questions that help them reframe the narrative in their heads or “flex their thinking,” as Marques calls it. Though this program existed before the pandemic—and the idea has been around for a few years in the world of global health—it’s particularly important now. “In our training institute, we are clear—we teach skills, not therapy,” Marques says. “The hope is to do as much of this as possible.”
Marques is not alone in wanting to expand the kinds of professionals who can help address mental health issues. The US suffers from a shortage of psychiatrists, reducing patient access to critical facets of care. Some experts have called for other mental health care professionals, such as nurse practitioners, to be allowed to perform some of the same duties.
Peers, too, can help care for those in crisis. Far too often, people in mental health crises end up in interactions with the police; one 2017 review study showed that 12% of people with mental disorders have police involved in their path to treatment. “If you send the police, you’re pushing people to jail or emergency departments, and it’s just not OK. We’re aware of some of the adverse reactions when you send law enforcement,” Galdys says. (RI International’s facility in Peoria, Arizona receives 400 law enforcement drop offs every month, he notes). RI International certifies peers to help deliver services, and staffs its facilities with them—a model that, studies have shown, can be more effective for patients than hospitalization. As communities question the role of police, programs that allow certified peers to help those in crisis could become more common or better funded.
Another change that could help patients: Simplifying the way they get connected with services. Before the crisis, insurance typically required that a general practitioner refer a patient to a psychologist or psychiatrist. Something like a hotline for mental health support (different than the existing suicide hotline) could act as an “easy onramp,” as Frank calls it, to connect patients to services whether or not they’re in crisis. The Federal Communications Commission will vote in July whether to make 988 the nationwide phone number to reach the National Suicide Prevention Hotline.
Telehealth has already been one of the great successes of the pandemic. As lockdown orders prevented in-person visits, psychologist appointments have moved online. For some, online appointments are actually more accessible; long distances or other health conditions can make physical visits a challenge. Though telehealth has been around for years, providers are still working out some of the logistics, such as how insurers will pay for it and inter-state licensing.
As countries around the world consider similar measures, some may help address the short-term mental health crisis. But to improve care for patients into the future, the world will need more science to find new treatments and effective models. Investments from pharmaceutical companies, governments, and public health foundations will need to revive the search for antidepressant drugs and to evaluate treatments that seem promising. We’ll need more research into the genetic underpinnings of mental health conditions to find biomarkers that can indicate patients’ susceptibility for disorders and what kinds of treatments would work best. And people will need to work to reduce stigma around mental illness, a major hurdle for people seeking services.
Marques is confident that the US’s mental health care system will emerge stronger once the pandemic is behind it. “I think mental health now is part of the conversation more than ever… To me that destigmatizes it a little bit. Mental health is brain health,“ she says. “Somehow we forgot that.”
If you or someone you know is in crisis, in the US you can call the National Suicide Prevention Lifeline, 24/7, for confidential support at 1-800-273-8255. For hotlines in other countries, click here.