The COVID Depression: A New Deal for Mental Health

We are learning to understand, manage and live with COVID-19. In response to the crisis caused by the pandemic the U.S, government moved swiftly to provide economic relief. In time, we will reach a new economic equilibrium. But if we don’t invest rapidly and effectively to provide immediate mental health support we will lose much more-lives robbed by suicide, impaired by mental illness, or shortened by the interplay of mental health and chronic disease. Ramifications impact generations-today and for years to come.

In the 1930s, to reassure citizens, stabilize the economy and secure the future, the New Deal provided economic relief, launched major public works to support recovery, and advanced reforms and regulations. To bring our country back to life and back to work, today’s leaders must follow that example, providing relief, recovery and reform in the area of mental health.

The already poor state of mental health in the U.S. is rapidly worsening.

Pre-pandemic mental illnesses cost were among the most costly and common illnesses in the U.S. and cost an estimated $200 billion in lost earnings per year and, costing more than $100 billion in health care costs. Presenteeism (defined as being unable or unwilling to function at work while physically being at work) was rampant. Low-income groups were twice as likely U.S. average to develop depression and eight times as likely to be schizophrenic. Diagnoses among children and teenagers are at all-time high.

The combination of a health disaster of unknown magnitude, a supply and demand shock akin to war time conditions, suspension of freedom of assembly and social distancing are worsening underlying conditions. They are also preventing many from physically accessing either inpatient or outpatient care. In addition, because many Americans depend on their employment for health insurance, unemployment is disconnecting them with access to care. Even if employees are able to access mental health services through employer-sponsored plans, a broad swath of society will lose those services. The economic uncertainty amid the pandemic fuels mental anguish. Most of us have lost essential elements of well-being: the chance to succeed, control over our lives, and for many financial security, time spent on social interaction, self-care (fitness, diet, and sleep) and community. It is clear that COVID-19 is negatively impacting the lives of many and will continue to do so, until we approach something close to normal way of life.

Like many economic indicators, mental health indicators lag but they are already alarming In mid-April, nearly half of Americans polled said that their mental health had worsened since February 2020. Between February 16 and March 15, 2020 Express Scripts reported a 21% increase in anti-depressant, anxiety and insomnia prescriptions. Some Americans with such symptoms find it hard to access therapists and physicians to help them cope, as calls to telehealth providers have outstripped the supply of therapists and physicians, and strained those providers’ technical infrastructure.

Mood disorders and substance use are skyrocketing. Because 2/3 of gun deaths in the U.S. are from suicide, rising gun sales are also worrisome. Many of us are going through the stages of grief, showing signs of burnout and in more extreme cases experiencing PTSD. The pandemic worsens existing illnesses. Patients with now untreated chronic diseases might also experience greater mental disorders.

The pandemic, from a mental health standpoint, has multiple targets. Those of us with preexisting mental illnesses or with a proclivity for depression; but even those without prior episodes of mental illness are at risk. We can further segment the level of risk by the degree of proximity to COVID-19. Experiencing COVID-19 as a patient, healthcare provider, loved one or caregiver is terrifying and heartbreaking. Judging by the experience of SARS in 2003 and H1N1 in 2009 in China, those COVID-19 patients who survive will be at significant risk for mental illness. Already, extubated patients are showing signs of “ICU delirium,” which can occur in patients on ventilators and sedation for a long period of time. This form of confusion and inattention can be transient, but in some instances it brings dementia and higher risk for mental health issues such as anxiety, depression and PTSD, according to a 2013 study in the New England Journal of Medicine.

In COVID-19 the most vulnerable are most at risk on every dimension. Research out of the University of Miami on distress caused by COVID-19 suggests that psychological distress is more likely among the less educated. Blacks, Hispanics and Latinos are overrepresented among COVID-19 victims, since they tend to fill more service jobs and perform more “essential work,” rely more on public transportation, have denser living situations, and have more preexisting health conditions. Domestic abuse reports are also increasing and children are being exposed to more abuse at home because of the new stress, economic distress, and substance abuse at home.

We are now in a state of emergency, especially for high risk populations. Children with acute mental conditions cannot be cared for at home and are being brought to emergency rooms around the country. Patients in rehabilitation centers have been sent home. Therapists and psychologists are seeing patients with masks, or over the phone, which create barriers, muffles the exchange, and lowers the potential efficacy of treatment. Drug tests can no longer be conducted to ensure that patients are properly dosing.

Access to medical care and support for mental health was inadequate pre-pandemic.

The first deterrent to treatment for mental illness is under-diagnosis. The second is stigma — shame of being in ill health and unable to control one’s state of well-being and function. The third is finding the right medical provider and resources, and fourth is the inability to afford them, both in terms of time and financial resources, for the necessary duration (oftentimes, recovering from mental illness and/or learning to manage it requires time off work or studies. Some college students, although more open to treatment, put off seeking care.).

As a result, pre-pandemic, more than about half of the individuals affected by mental illness received treatment in the U.S. And about 40% of those did not have insurance or were on public insurance. Many therapists do not take patients whose insurance does not reimburse at their desired billing rates, and many others are at capacity already. In fact, patients with private insurance have a similarly low chance of finding an available specialist to patients on Medicaid. Waiting lists are months long, and the problem are compounding. When therapists are at capacity, care needs to come from providers with less experience or the wrong specialization. Some patients need to be sent to other states for critical care. And measuring the effectiveness and long term impact of therapies can be challenging, with a significant number of patients giving up on treatment due to the lack of measurable goals.

Finally, telehealth does not work for every patient (especially the elderly, children and patients in small houses, those who privacy, are in abusive relationships, etc.) or for every pathology. It is safer and more effective if the therapist knows the patient before going remote. In addition physical exams are harder to conduct remotely.

Managing increased demand requires a Mental Health Strategy.

The goals of a national mental health strategy should parallel those of the pandemic response: treat the affected; limit the spread, and protect us in the future. The first step is to acknowledge and elevate the issue by appointing a medical officer (ideally a psychiatric epidemiologist) to address mental health issues and put together the mental health New Deal plan. Below are some suggestions.

Immediately: Treat the affected

- Expand access to hotline and telehealth resources. Many healthcare workers will have access to PTSD resources, and so should the rest of the population, perhaps in the form of sponsored tele-therapy apps (some are around $25/week but cheaper than 45-minute therapy that can range from $30 to $250 and more per session). Expand access to telehealth more generally and make it more affordable; CARES liberated telehealth and made it easier for doctors to bill for those services. Accessibility and awareness are key; the technology is there and young people know how to use it. What is also needed is internet access for all.

- Support part of a psychologist / recovery coach / outplacement experts fee as part of recovery effort — an equivalent of a stimulus check for mental health.

- Ensure that psychologists/coaches who can no longer see their patients sustain their practices (tax deductions, insurance…). In-patient programs are also at risk and will be in great demand when they reopen.

- Launch an education campaign about self-care, focus on important protective and preventive measures to increase everyone’s overall health baseline. The communication should acknowledge fears and feelings and remind us all that we are not alone.

Short-term: Limit the spread

- Incorporate prevention into reimbursement schemes. Medicaid and State health plans should establish premium deductions or co-pay exemptions based on preventive medicine actions taken by plan holders. Similarly, assess the impact of interventions.

- Assess the risk of accelerating the graduation/accreditation of service providers / revisit role of PAs and psychologists in dispensing medicine (as some states have done with nursing and medical school students).

- Develop targetted program for at risk children to ensure that the will be treated and not become victims of Adverse Childhood Event Syndrome (ACES).

- Enroll the displaced into becoming part of the larger solution and economic recovery. The first New Deal took those economically displaced and gave them a working role in the solution (build bridges, roads, public facilities, etc.). In this situation, we might need an army of temporary contact tracers, public health support workers, etc.

Medium-term: Protect the future

- Key regulations may need to be updated, including:

• The ADA protects individuals with mental illness from firing because of their disability but does not protect the time they need to access treatment in the case of a mental disability. For example, for most employees, attending treatment or seeing a therapist does not qualify for paid time off. Trading off urgently needed income for eventual healing leads to undertreatment and a worsening of the illness, until the underlying condition makes it impossible for individuals to perform their work.
• The 2010 Patient Protection and Affordable Care Act Mental Health secured mental health parity, building on the 2008 Mental Health Parity and Addiction Equity Act. However, not all healthcare plans were subject to this act and plans provide different levels of deductibles, out of pocket maximums and co-insurance; they also define differently what disorders fall under mental health and many set a maximum number of mental days insurance. Review options to enable individuals who can’t afford expensive / private insurance to access mental health services.

Our leaders were quick to react to the economic carnage of the pandemic. Let us make sure they (and we) do the same to alleviate the mental pain that will come in its wake. As an individual, check your plans and make to understand your needs. As employer, review the provisions of your company’s plans, accommodations and leave policies. As parents, make sure that mental, physical and social health are part of the curriculum. And as citizens contact your elected officials to lobby for combination of reforms, capital, innovation and new technology, and the political courage, to care for a deeply traumatized nation. In the promise we can work to create an America that guarantees that everyone have equitable access to quality mental health care.

Note from the authors: Carin-Isabel Knoop (Harvard Business School) & John A. Quelch (University of Miami), authors of Compassionate Management of Mental Health in the Modern Workplace (2018). We welcome feedback and input as we all learn together.

Originally published at https://www.linkedin.com.