Mental Health Care Innovation and the COVID-19 Pandemic

We know anecdotally that our country is in a mental health crisis. Now, the data is piling up. Earlier this month, the CDC reported that between August 2020 and February 2021, the percentage of adults with recent symptoms of an anxiety or depressive disorder increased from 36.4% to 41.5%. Historical data has demonstrated that less than half of that number (~20%) typically experience a mental health condition over their lifetimes. In addition, Mental Health America’s (MHA) aggregated findings of mental health screenings over the past 12 months found that one-third of people who took a diagnostic test were experiencing depression. MHA found hundreds of thousands more were experiencing anxiety or psychosis.

This national mental health crisis importantly shines a light on the prevalence and burden of these mental health conditions. With this surge came public acknowledgment and action. This spotlight on mental health helped reduce stigma and encourage open dialogue. Now mental illnesses like depression and anxiety are becoming more common topics of discussion.

But what about the people living with serious mental illnesses (SMI), such as schizophrenia, major depressive disorder, or bipolar disease? This community has been equally, if not more significantly, affected than people who may have developed a mental health condition during the pandemic.

According to a Schizophrenia Research study published in August 2020, the COVID-19 pandemic may be a catalyst for new onset of psychosis or an exacerbation of symptoms in individuals living with serious mental illnesses. In some cases, social distancing guidelines led to poor psychiatric outcomes, such as social isolation and loneliness, which are already common in these individuals. Loneliness has long been associated with lower quality of life, depression, paranoid thinking, and suicide ideation. Social distancing can bring about significant emotional distress, causing a relapse of psychotic symptoms and leading to increased risk of rehospitalization in this population.

Earlier this year, researchers found schizophrenia was second only to old age as the greatest risk factor for COVID-19 death. Those with the disorder were nearly 3x more likely to die of coronavirus than those without. This higher risk is likely attributed to the increased likelihood of comorbidities within the patient population based on lifestyle factors.

Still, the pandemic-related mental health challenges most commonly discussed are those that pertain to anxiety and depression...even though nearly 1 in 25 adults in America lives with an SMI. This could be partly due to the negative perception we have of these illnesses, largely based on false narratives created by the media and the public. To best acknowledge and advocate for these communities, we must work to raises awareness and reduce the stigma around these illnesses. Media, industry, mental health advocates, and the medical community, including myself and fellow physicians should lead the charge in educating about these diseases and advocating for people to have access to treatment and support. With a more collective understanding and acceptance of mental illness, we can break down barriers together.

This heightened attention to our collective mental wellbeing and an increased focus on the need for mental health support has spurred innovation. When access to care and in-person visits were disrupted by the pandemic, telehealth, expanded insurance coverage, access to medication, and more allowed for continuity of care and helped meet the challenges of this mental health crisis, especially for those with an SMI.

Innovations Prevented an Even Greater Mental Health Crisis

The mental health ecosystem has responded rapidly to ensure people living with mental illnesses and SMIs continue to receive the services, support, and care they need.

The accelerated implementation and adoption of telehealth — specifically telepsychiatry — has been an incredible benefit in treating individuals with SMIs. This service allowed providers to continue our work with patients and even allowed us to gain insight, often for the first time, into our patients’ home life. Telepsychiatry also removes barriers to care, such as transportation and resistance to coming to the office. Studies have shown that some patients avoid treatment due to the stigma of going to a mental health professional’s office. The pandemic yanked off the training wheels from telepsychiatry and forced us to innovate nearly overnight. Providers are now integrating virtual platforms with screen sharing and group video chat capabilities, expanding hiring efforts to include bilingual clinicians — resources that were not available before and that has reimagined the concept of true patient-centric care. We went from telepsychiatry use in mostly rural areas and prisons to a practice that is now the norm, rather than the exception.

In recognition of telepsychiatry’s dramatic rise and success, policymakers, insurers, and health systems have sought ways to deliver care to patients in their homes. The federal government loosened restrictions on telehealth in Medicare, HHS waived enforcement of HIPAA for telemedicine and the DEA loosened requirements on e-prescribing of controlled substances. On a state level, telehealth has been expanded in Medicaid programs, and restrictions on provider licensing, online prescribing, and written consent have been relaxed. Many states are also mandating equal coverage and reimbursement for telemedicine services.

But the innovation didn’t stop there. Because providers cannot see patients in-person as often, the “doctor’s office” has changed, with many providers offering creative solutions for medication delivery. With offices closed or limited appointments available, pharmacists, nurses, and primary care doctors are offering services to treat those with mental illnesses. For instance, in Houston, Texas, a local pharmacist has been home-delivering medications, and, in some cases, providing injections for those whose medication is administered intravenously. Especially with local pharmacies and practices, providers established new ways to continue and/or create those personal relationships with their patients. Primary care doctors are seeing more patients for mental health and referring patients to psychiatrists after an initial evaluation, sometimes that same day.

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I’m also encouraging my patients to consider all medication options — particularly for those who are living with schizophrenia — including long-acting injectables (LAIs), during this time where in-person visits are limited. LAIs were recently recommended by the American Psychiatric Association (APA) and Substance Abuse and Mental Health Services Administration (SAMHSA) for their role in supporting medication adherence. At a time when in-person visits are limited, LAIs can offer some people support for continuity of care and peace of mind to physicians, patients, and their caregivers. The recommendations of LAIs along with proven treatment throughout the pandemic has helped reduce some of the preexisting perceptions around, and hesitancy toward, antipsychotic injectables.

Instead of accepting the pitfalls brought on by the pandemic, our health system has responded to support those with first-onset illnesses and continuity of care for those with existing serious mental illnesses. These innovations must continue — we cannot consider these new developments as short-term solutions, but opportunities to change the landscape for the long-term.

How Do We Move Forward?

Instead of reverting back to the standard of care, policymakers, insurers, and health systems should evaluate this past year’s successes to create lasting systemic solutions.

1. We must continue to advocate for mental health and normalize the conversation around seeking treatment. The effects of mental illness won’t disappear as the pandemic comes to an end. Especially for those with preexisting serious illnesses, continuing to educate the public on the patient experience will be critical to destigmatize, which can encourage long-term treatment adherence.
2. In the case of telepsychiatry, a hybrid solution should be implemented moving forward. I found success with patients I met with in-person prior to transitioning to telepsych. These in-person meetings established trust and built a foundation for the provider-patient relationship, and transitioning to telepsych allowed for continuity of care. One of the greatest benefits of telepsych that helped ensure continuity of care was its flexibility. Instead of having to take time off from work or hire a babysitter to watch their kids to come into the office, people were able to save time and effort and schedule virtual meetings that didn’t interfere with their everyday life. This is an even bigger deal for those in rural communities who had to dedicate a full day for a session at the office. And as society starts opening up, schedules will only get busier. Telehealth’s success post-pandemic is dependent on policymakers and the payer community. Some providers, such as Blue Cross Blue Shield of Massachusetts, have already committed to continuing to support and cover telehealth. In general, we are seeing that the entire industry has been freed of many regulatory issues that had been a barrier to accessing care.
3. Finally, continuing to encourage camaraderie within the health care community is essential as we look to expand mental health care for patients. As we saw with frontline workers, there was an “all hands on deck” attitude, with health care professionals from different medical backgrounds stepping in to help their fellow physicians. This collaborative spirit was vital to the mental health care space as well. Psychiatrists were supported by pharmacists, primary care doctors, ER nurses, and many others to address the influx of mental health cases. Continuing this work across the health care space provides new perspectives and learnings that will enhance the patient experience and expand access. The pandemic highlighted the need and efficiency of adapting to a more comprehensive multispecialty team-based care approach to mental health.

As many people around the world start to resume life, the lingering effects of mental illness, whether brought on by the pandemic’s stresses or for those with preexisting illnesses, will very much remain a public health crisis and in need of attention. The innovations put forth over the past year provide an opportunity to improve how we treat those with mental illnesses not just for the months following the pandemic, but for years to come.