Flattening The Mental Health Curve: Three Strategies for Medical and Psychiatric Care During the COVID-19 Pandemic (6/15, Stanford, UCSF)

Jimmy J. Qian, Stanford University School of Medicine, Khashayar Nattagh, University of California San Francisco School of Medicine, and Robert Pearl, MD, Stanford University School of Medicine and Graduate School of Business, Stanford University

Contact: jimmyqian@stanford.edu

Mental Health Also Requires A Flatter Curve

Throughout the COVID-19 pandemic, physicians and policymakers have focused efforts on “flattening the curve.” This approach spreads the number of infected patients over a longer time interval to prevent overwhelming hospitals and critical care capacity. Much attention has been given to flattening the curve for the respiratory illnesses caused by SARS-CoV2.

By contrast, relatively little has been done about the mental health crisis and the urgent need to flatten the curve for the psychiatric burden of this pandemic. In some ways, flattening one curve can do the opposite to the other: social distancing can save lives from SARS-CoV2 infection while prolonging and worsening mental health issues.

COVID-19 Is Exacerbating the Mental Health Crisis In The U.S.

The United States already had a mental health crisis prior to the pandemic, with nearly 20% of Americans living with a mental health condition and nearly 50,000 suicides in the US each year [1]. A pre-pandemic shortage of mental health providers has also been well-documented. During and after COVID-19, it is expected that the mental health crisis will be exacerbated by a sharp rise in depression, anxiety, and post-traumatic stress disorder.

In addition to the deaths and suffering caused by the coronavirus itself, economic factors and social isolation have negatively impacted people’s mental well-being. Unemployment, which has been shown to correlate with suicide rates, has affected millions of workers as many families struggle to pay rent or buy critical food and supplies [2]. In one study, nearly half of U.S. adults reported that their mental health had been negatively affected by the pandemic [3].

Demand for therapy has skyrocketed, while research has shown after major events like natural disasters and economic downturns, rates of suicide, overdose deaths, and substance use disorders go up [4]. Indeed, rates of depression, domestic violence, alcoholism, overdoses, and suicides have already increased [2].

Three Solutions to Flatten the Mental Health Curve

The American healthcare system must brace for heightened demand for mental health services this year and for several more to come. Yet little funding and attention has been allocated for this purpose and no additional trainees are in the training pipeline. We argue that elected officials and healthcare leaders must devote themselves to flattening the mental health curve just as they did for coronavirus-associated medical illnesses.

Unlike a viral infection, there is no vaccine or curative therapeutic for psychiatric conditions. The US healthcare system must pursue a coordinated effort to proactively address these problems, rather than once again addressing a crisis too late. To this end, we propose three specific solutions.

Screen: First, we should screen for mental health conditions when people get tested for SARS-CoV2 infection or resulting antibodies. In the same way that patients may not realize they have the coronavirus, they may be unaware of mental health issues. A unique opportunity to achieve population-scale mental health screening arises from the tremendous effort dedicated to testing for viral spread.

The Patient Health Questionnaire-2 (PHQ-2) with an additional question on suicidality could work well: the PHQ-2 questionnaire is rapid and has been validated as a depression screening tool [5]. Because it does not very reliably detect suicidality, an extra question about suicidal ideation would be helpful and simple to add. This concise mental health screen can be directly added to any patient-facing paperwork or digital interface associated with the viral infection test.

In addition to being able to help individuals, widespread mental health screening will allow the medical community to quantitatively understand the country’s state of mental health during this pandemic in the same way we study transmissibility and lethality of the coronavirus itself. An additional screening question could also help identify individuals who might not feel safe in their shelter-in-place locations due to domestic violence or other factors.

Workflow innovation: Second, leaders must design novel workflows and incentives to meet the increased demand for mental health care. The United States has a shortage of mental health personnel.

Just as the healthcare system has embraced technology, virtual care, and novel infrastructures for COVID-related medical illnesses, it must do the same for psychiatric conditions. For instance, both asynchronous and synchronous virtual psychiatric care expands capacity and increases efficiency.

Healthcare systems and payers must move quickly: they should rapidly scale their virtual mental health services if they have the capability to do so in-house. If not, they can collaborate with digital health companies that can offer virtual mental health care at scale.

Payers must also expand coverage of mental health services to beneficiaries, ensuring widespread access and coverage during the pandemic and also for the years to come. Restrictions such as caps on the number of covered therapy sessions should be abrogated, and provider reimbursement must increase.

Many healthcare systems showed immense speed innovating in care delivery for coronavirus-induced respiratory illness and comorbidities. This is the time for them to do the same for psychiatric care.

Multiple stakeholders: Third, just as medical care has taken an all-hands-on-deck approach during the pandemic, psychiatric care should also utilize a variety of stakeholders to meet increased patient demand. An approach that works particularly well with virtual mental health care is the use of peer counseling and patient communities, allowing people with similar experiences to support one another online. Group counseling has been shown to achieve similar results to individual sessions and is a way to rapidly increase access.

Another useful strategy is to utilize the collaborative care model (CCM), a clinical protocol that has been shown through randomized controlled trials to consistently improve mental health outcomes [6]. CCM allows primary care providers to provide mental health care in conjunction with a psychiatric consultant and a behavioral health manager. This leveraged model allows mental health care providers to care for more patients, alleviating the psychiatric provider shortage. Research has shown that telemedicine-based CCM yields better outcomes than on-site CCM [7], making CCM an even more attractive model in the setting of the pandemic.

Looking Forward

COVID-19 has exacerbated the American mental health crisis. The best way to combat this pandemic-induced psychiatric burden is to adopt three strategies similar to those used for the outbreak’s medical burden. First, we must implement mental health screenings at-scale in conjunction with viral detection and serology tests. Second, we must leverage rapid adoption of novel technologies and infrastructures for mental health care delivery, such as expanded use of telemedicine. Third, just as overwhelmed healthcare systems enlisted residents, various medical specialists, and mid-level providers to help treat respiratory illness, so mental healthcare systems can use peer-to-peer support and collaborative care models to meet demand.

We must flatten the curve – both for medical and psychiatric care – to save lives and help patients.

 

Acknowledgements

Financial support and sponsorship: none

Conflicts of interest: none

 

References

1. Statistics. Mental Health Information, National Institute of Mental Health. Accessed May 22, 2020. https://www.nimh.nih.gov/health/statistics/index.shtml
2. Pearl R. How the 80/20 Rule Can Save Your Life During the Coronavirus Reopening. Forbes. Published May 26, 2020. Accessed May 27, 2020. https://www.forbes.com/sites/robertpearl/2020/05/26/the-80-20-rule/#58b7ec0627f8
3. Panchal N, Kamal R, Orgera K, Cox C, Garfield R, Hamel L, Munana C, Chidambaram P. The Implications of COVID-19 for Mental Health and Substance Use. Kaiser Family Foundation. Published April 21, 2020. Accessed May 22, 2020. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
4. Wan W. The coronavirus pandemic is pushing America into a mental health crisis. The Washington Post. Published May 4, 2020. Accessed May 22, 2020. https://www.washingtonpost.com/health/2020/05/04/mental-health-coronavirus/
5. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):1284‐1292. doi:10.1097/01.MLR.0000093487.78664.3C
6. Woltmann E, Grogan-Kaylor A, Perron B, Georges H, Kilbourne AM, Bauer MS. Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: systematic review and meta-analysis. American Journal of Psychiatry. 2012 Aug;169(8):790-804. doi: 10.1176/appi.ajp.2012.11111616
7. Fortney JC, Pyne JM, Mouden SB, et al. Practice-based versus telemedicine-based collaborative care for depression in rural federally qualified health centers: a pragmatic randomized comparative effectiveness trial. Am J Psychiatry. 2013;170(4):414‐425. doi:10.1176/appi.ajp.2012.12050696