The COVID-19 Impact on Our Mental Health System

May 04, 2020 | Julia Wunder, Janet Oputa, Kat Patterson

As we commemorate Mental Health Month in May, state health departments are tasked with a monumental public health crisis that includes the impact of COVID-19 on mental health and suicide. The U.S. experienced a 19 percent increase in screening for clinical anxiety at the beginning of February and a 12 percent increase at the beginning of March. Children, the elderly, frontline healthcare workers, and people with preexisting mental health and substance use disorders are particularly vulnerable.

Stress and distress reactions are normal during and after a traumatic event, and can include fear, anxiety, guilt, sadness, frustration, and helplessness. A pandemic can exacerbate these feelings, particularly since there is uncertainty of the pandemic’s length, misinformation, information overload, economic stress, and fear of contagion. Physical distancing can also contribute to higher levels of anxiety, depression, loneliness, and stress.

The demand for mental health services, the system is strained, according to a survey conducted by the National Council for Behavioral Health. In April, they found:

• Almost 61 percent of behavioral health organizations closed at least one program.
• Almost 83 percent do not have enough personal protective equipment (PPE) for two months of operation.
• 62 percent believe they can continue operations for only three or fewer months under current conditions.

States can take action to protect the mental health of U.S. individuals through specific strategies that support the mental health organizations and systems that serve them.

Telebehavioral Health

COVID-19 has accelerated the transition to providing mental healthcare virtually in both federal and state governments. Telebehavioral health is an effective and convenient strategy to deliver mental health services using communication technologies like live videoconferencing. The Centers for Medicaid & Medicare Services (CMS) issued temporary regulatory waivers and new rules to promote flexibility around and expansion of telehealth services. CMS will allow Medicare enrollees to access telehealth services from the home, which could reduce stigma and shame individuals can face when attending in-person mental health visits. Depending on the state, Medicare and Medicaid will also reimburse for telephone encounters. To make telehealth more widely available and affordable, several private insurers—such as Blue Cross Blue Shield and Aetna, among others—have agreed to temporarily expand telehealth coverage options and/or waive service fees during this time period.

States are also implementing educational programs, such as Project ECHO, to share best practices, build provider capacity, and develop competencies to treat mental health conditions. Ohio's Project ECHO, operating out of the Northeast Ohio Medical University, offers weekly pop-up ECHO sessions and trainings that address issues such as heightened anxiety and loneliness among providers and patients. New Jersey’s Project ECHO program provides telehealth implementation tips for beginners and mental health strategies that address social isolation, addiction, and long-lasting mental health effects of the pandemic. These programs can be useful for learning best practices from their peers and building the ability to deliver quality telebehavioral health services.

Crisis Call Lines

In March 2020, the Substance Abuse and Mental Health Services Administration (SAMSHA) “Disaster Distress Helpline” saw an 891 percent increase in call volume from March 2019 and a 338 percent increase from February 2020. These call lines are well-established across state, federal, and local governments to provide individuals in distress with free, confidential support and prevention and crisis resources. “Warmlines” are used to prevent crises by providing emotional support and early intervention, and “hotlines” are resources for individuals experiencing emotional distress, suicidal ideation, or a mental health crisis. The National Suicide Prevention Lifeline is accessible 24/7 and its website has specific resources for disaster, loss, and suicide attempt survivors.

Though not new, states are also increasing the accessibility and visibility to crisis hotlines through workforce development and educational campaigns. On March 25, Gov. Andrew Cuomo announced the launch of New York’s Emotional Support Helpline. The Helpline is staffed by at least 6,000 volunteer mental health professionals, whose free and confidential support is a powerful resource for the general public, essential workers, and first responders. In late April, Maine launched the “FrontLine WarmLine” to provide health care workers and first responders with emotional support between 8 a.m. and 8 p.m. daily. Maine also developed the Everyday Survival Guide educational campaign to accompany their crisis hotline, which provides individuals with a guide and resources to assess mental health symptoms.

Changes in Prescribing Practices

It’s important to continue a regular medication schedule during a pandemic, especially for individuals with preexisting mental and behavioral health disorders. To make this easier, the Drug Enforcement Agency (DEA) added an exception to the Ryan Haight Act which allows registered practitioners to issue prescriptions for controlled substances, excluding methadone, to patients using live-video telehealth. It also temporarily eliminates the requirement for in-person visits if certain conditions are met.

Arizona has also revised and relaxed rules surrounding prescribing practices with Executive Order 2020-20, which allows pharmacists to dispense emergency refills of maintenance medications for a 90-day supply. The Executive Order excludes controlled substances. The law also extends the time limit by when providers must follow up with paper prescriptions from seven to fifteen days and allows for phone-in prescriptions to be sent by fax, scan, or photo. Furthermore, to prevent drug shortages, Arizona pharmacies can obtain pharmaceuticals from an unpermitted wholesaler, third-party logistics provider, or manufacturer located in another state or country.

Mental Health Moving Forward

Federal and state governments are taking action to reduce the heightened risk of mental health symptoms, disorders, and suicide associated with the COVID-19 pandemic through expanded telebehavioral health, crisis call lines, and prescribing practices. However, many of the telebehavioral health services and prescribing authorities associated with COVID-19 are made possible through temporary policy changes. Policymakers at both the state and federal levels should assess the success of these policy changes and continue efforts to improve the mental health system in the U.S. both during and after the pandemic.