As psychiatrists who have worked on the front lines of the pandemic, we’ve seen firsthand how the COVID-19 outbreak has ruthlessly tested the limits of our health-care system. Just as the pandemic seemed to be momentarily abating, the country began reckoning with another public health crisis—that of anti-Black racism and police violence. Data show that COVID disproportionately affects minority communities, likely resulting from racism’s downstream effects on socioeconomic opportunities, health outcomes and insurance coverage.
With widespread social isolation, high unemployment and unprecedented levels of stress, we are witnessing an impending mental health crisis. Although these events have painfully unearthed the weaknesses of our system, we as psychiatrists see one hopeful prospect: recognition and improvement of mental health care in the U.S. Here are five ways that we believe COVID could drive mental health innovation forward to create a more equitable system of care for Americans.
The Power of Telehealth
Mental health clinics across the country shut down in-person services at the start of the pandemic, leading to a huge rise in utilization of telemedicine solutions. Remarkably, patients and clinicians alike have discovered that this form of clinical interaction can work and may even be preferable in some scenarios. Telehealth practice solutions such as Doxy.Me and Zoom For Healthcare, as well as start-ups such as Teladoc and Talkspace, have seen dramatic increases in demand.
Fueling the transition is the loosening of telehealth regulations. The Centers for Medicare and Medicaid Services (CMS) began temporarily reimbursing telehealth at the same rate as in-person treatment. “Originating site requirements,” which require patients to be located at a health-care facility to participate in telehealth visits, were suspended in 2020. States also eased licensure requirements so that physicians could practice across state lines. An increasing number of telephonic visits are being reimbursed as well, and HIPAA enforcement is being relaxed so physicians can videoconference with their patients without excess worry.
Although telehealth reimbursement may begin to decrease as in-person visits resume, we predict that some regulations will stay loosened as its prominence increases. In fact, some telehealth coverage was made permanent at the end of 2020. The Medicare originating site requirement, considered overly restrictive by many, may be dropped permanently. As patients and clinicians alike see the value of telehealth, its steadily increasing market share may be the easiest trend to spot in mental health care.
Substance Use Resources
People with substance use disorders (SUDs) are especially suffering from disruption to their treatment. Mainstays, including peer support groups, counseling sessions and periodic toxicology screens, are all severely interrupted. During the 2008 Great Recession, social isolation and economic depression led to a wave of opioid and illicit drug use that fueled the opioid epidemic. As we navigate another recession, many health-care professionals are particularly worried about their clients relapsing or increasing their use.
Thankfully, technology has enabled in-home access to substance use supports. Peer support groups such as AA and Smart Recovery are operating nearly all of their groups through video, and methadone clinics are now able to dispense weeks of methadone to clients. Buprenorphine, another medication-assisted therapy for opiate use disorder, can now initially be prescribed online. Online substance use programs, such as Lionrock Recovery, have seen demand rise by more than 40 percent. Even as some communities reopen clinical services, there will still be intense market pressure for comprehensive home-based solutions to substance use treatment.
Continuum of Care
A huge problem in U.S. behavioral health care is the lack of intermediate care options. In the continuum of care, treatment resources cluster around outpatient treatment, such as weekly therapy with a counselor, and inpatient treatment, such as admission to a psychiatric hospital. Intermediate care options such as intensive outpatient programs (IOPs) and partial hospital programs (PHPs) offer a way for patients to be engaged in intensive therapy, medication management and group support, but they do not require patients to be admitted for a costly hospitalization.
Across the country many IOPs and PHPs have converted to telehealth because of COVID. In New York State, strict billing requirements that were associated with PHPs and prevented their widespread availability have been loosened. We believe that online intermediate care models should continue outside of this pandemic, especially for patients in rural states where access to such care traditionally lagged. The demand for intermediate care options that increase outpatient support and prevent hospital admissions will expand the menu of treatment options past simple weekly therapy.
To place someone in the appropriate treatment option, we must be able to quantify a person’s risk and needs. Mental health providers are traditionally bad at predicting or quantifying risk, including suicide risk. Part of this inability to assess risk has been the historical struggle with the implementation of measurement-based care, defined as the ability to quantify symptoms of patients with mental illness. The COVID-19 crisis and the increasing utilization of digital tools can help researchers discover new markers of impending decompensation. We can also better understand the types of digital tools that people find effective for their mental health treatment. We hope that this information will help us to develop risk-informed treatment plans and more precise delivery of care.
Introducing Public Mental Health
Public mental health focuses on preventing mental illness instead of simply treating it. Because COVID can be classified as a collective trauma, Americans are at risk of developing post-traumatic stress from the pandemic. Compounded with the inequitable outcomes we are seeing across Black and brown communities, we may be worsening our existing mental health disparities. The mental health consequences of COVID could lead to long-term losses in well-being, diminished economic productivity and increasing health-care costs. Unfortunately, the existing U.S. mental health system is sorely lacking a public focus: it engages largely with those who are already mentally ill and often only those who are able to pay for treatment.
We believe that to reduce long-term economic and social impact, payers and government will need to increase funding of public mental health programs that prevent illness and increase treatment access. To be effective, these programs must offer access to those without financial resources or with serious mental illness and commit to best practices when treating underserved populations. Tech-enabled services that can assist with risk stratification, offer support before illness develops, or connect people with accessible mental health treatment are slowly arriving, joining those such as NYC Well, which offers a “front door” to support services for New Yorkers in mental duress. For tech-enabled solutions to soar, however, structural change that closes the gaps in funding and infrastructure must occur.
In the midst of the devastation, we remain hopeful that mental health care will transform. As the U.S. confronts a calamitous loss of life, widespread isolation and deep social fractures, there will be an even greater need for mental health services. A functioning mental health-care system will be critical in supporting our communities.