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A Behavioral Health Pandemic is Emerging

August 26, 2020
Ron Manderscheid
By Ron Manderscheid, Executive Director, NACBHDD and NARMH
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The opinions expressed by Psychiatry & Behavioral Health Learning Network bloggers and those providing comments are theirs alone and are not meant to reflect the opinions of the publication.

Previous natural and person-generated disasters, such as Hurricane Katrina and the 9/11 tragedy, taught us that such events always are followed by a spike in behavioral health conditions. Thus, the new findings reported last week in the CDC Morbidity and Mortality Weekly Report are not surprising. However, the severity and extensiveness of the behavioral health conditions reported actually are shocking.

Based on a national probability survey conducted this past June, a total of 40.9% of American adults, more than 100 million persons, reported having experienced at least one adverse mental or behavioral consequence as a result of the COVID-19 pandemic. This contrasts with the 25% of adults who reported diagnosable behavioral health conditions in previous national surveys conducted during periods without a disaster.

The problems reported in June include very high levels of anxiety or depression (30.9%), significant trauma or stress reactions (26.3%) increased substance use (13.3%), and contemplation of suicide (10.7%).

The fine-grained results are even more disconcerting. Almost one-third of unpaid caregivers (30.7%) and more than a quarter of those between 18 and 24 (25.5%) actually contemplated suicide. Very large numbers of essential health workers (21.7%), Hispanics (18.6%), and Blacks (15.1%) also experienced this extreme risk.

The prevalence of those who reported at least one symptom was exceptionally high: age 18 to 24 (74.9%); 25 to 44 (51.9%); Hispanics (52.1%), less than high school (66.2%), essential workers (54.0%); and unpaid caregivers (61.6%).

These exceptionally high rates must be contrasted with our current capacity to deliver care. At the present time, about 6% of the U.S. adult population receives specialty behavioral health services, and 7 to 8% receives these services from primary care providers. Because of overlap between the two groups, one can reasonably conclude that the total actually served is about 12% of the adult population. Clearly, we do not have the capacity to double this effort (expand to 24%) or even to increase it by half (18%).

A word should be said about essential health workers and unpaid caregivers. Both groups are exceptionally important. Should we give such persons priority for receiving behavioral healthcare services? If so, how would this be accomplished?

Similarly, racial and ethnic minorities obviously have been disproportionately affected by COVID-19. What must we do to address these disparities?  

Some persons have experienced these behavioral health effects because of fears, anxieties and traumas directly attributable to the pandemic itself. Others have developed these reactions as a result of the mitigation efforts put in place to contain the pandemic, e.g. stay-at-home mandates. This distinction is very important. When mitigation efforts are eased, some of their behavioral health consequences also can be expected to ease. However, we also can anticipate that the pandemic will endure for an extended period, thus continuing the risk of developing or worsening behavioral health conditions for many persons.

It is important to note that we are in a situation with many unknowns: Will the behavioral health spike continue to climb? What would be the effect of a very protracted pandemic that extends for one or two years?  Can behavioral health coping skills be improved significantly in the face of a long-term continuing threat?

Yet, the fundamental equation remains one of high unmet need and little additional care capacity. Thus, we must develop alternatives. Virtual care can help to improve availability and access. Similarly, many new apps are now arriving in the care space. Once demonstrated, these also can help to address unmet need. However, we still will require a good, operational, national plan for expanding the behavioral healthcare workforce. This must include training for new providers, as well as modifications to present laws and procedures that shackle our current providers.

Exceptional crises demand exceptional solutions. Now is the time to act.

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