The development and dissemination of effective COVID-19 vaccines gives us hope for an end to the pandemic that has upended our lives. But vaccines will not end the mental health crisis that is emerging and likely worsening, particularly during the isolating winter months. The stress of the pandemic is leading to substantial mental health issues across the country. In June 2020, the Centers for Disease Control and Prevention (CDC) estimated that four in 10 Americans were struggling with mental health or substance use. Another 11 percent reported having seriously considered suicide in the past month. Coupled with grief and loss from being separated from loved ones, losing people to the virus, high levels of uncertainty, balancing work and caregiving, and loss of opportunities or jobs, this pandemic has created a perfect storm for psychological distress.
Although containment efforts are clearly necessary, the mental health effects of isolation and potentially lowered social support must be addressed. Based on our public mental health experience and research on previous pandemics, we anticipate that this long-lasting storm will widen already massive mental health disparities among marginalized populations.
If our country is to fully recover from this pandemic, the Biden-Harris administration and the new Congress must invest as much in combating the short- and long-term mental health effects of COVID-19 as they invest in developing and distributing vaccines. A true recovery cannot exist without focusing on both mental and physical health. The long-term consequences of poor population mental health can be devastating, and, without a coordinated public health approach, they are imminent.
A Public Health Approach To Mental Health
Mental health is not just an individual problem. It also demands a comprehensive public health pandemic strategy, including universal screenings, anti-stigma campaigns, and health equity–focused access to mental health care with specific efforts focused on the needs of high-risk populations. We urge the Biden-Harris administration to focus in its first 100 days on five key areas:
Invest In Public Health Media Campaigns
Distress may disproportionately affect individuals with previous mental health problems, but there are also alarming rates of depression even among those who have not been given a mental health diagnosis previously. Even in the best of times, those who need mental health care do not always seek it due to financial obstacles, difficulty finding care, and stigma. During a pandemic, accessing care may be even more difficult. Federal and state leaders must invest in public health campaigns that normalize distress, destigmatize mental health concerns, promote self-care, communicate effective prevention and treatment strategies, and help people access mental health services. Public health campaigns aimed at educating the public about the signs and symptoms of distress should also raise awareness of the different ways distress may manifest in children and young adults depending on age and developmental stage.
Rapidly Expand Mental Health Screening
Given how common psychological distress has become during the pandemic, wide-scale mental health screening should be initiated immediately. Vaccine administration provides an ideal universal setting; our public health approach aims to vaccinate 70–90 percent of the population, providing unusual access to a large proportion of the US population. Return to work and return to school protocols could also initiate mental health screening. Such screening is quick given available brief validated instruments that identify anxiety and depressive symptoms.
Screening is also important for specific high-risk groups. Not surprisingly, the mental health effects are falling hardest on people of color, LGBTQ communities, frontline workers, those with low incomes, and people who are more socially isolated—the same groups that are disproportionately impacted by COVID-19. Screening strategies thus need to include a focus on high-risk populations and must include those who are more isolated or are in underresourced settings and who may have high need and high obstacles to obtaining care.
To implement such an approach, public officials must fund the necessary workforce and remove financial and other obstacles to accessing social workers, psychiatric nurse practitioners, mental health counselors, and other trained mental health care providers.
Furthermore, a recent Lancet study suggests that COVID-19 presentation may include mental health challenges both acutely and after recovery; screening of COVID-19 patients is an important tool for addressing the mental health aspects of their illness. Also, those who already have mental health conditions may be at higher risk of becoming ill with COVID-19 or exacerbation of their psychological distress due to the pandemic. The field of public mental health understands that mental and physical health are inextricably tied together, and this pandemic is further demonstration of this and of the need for an integrated physical/mental health strategy to combat the pandemic’s effects.
Finally, screening and referral systems must be put in place for children and adolescents. According to the CDC, visits to the emergency department by children younger than age 18 for mental health issues increased by more than 40 percent when comparing the period from March to October 2020 to that same period in 2019. In a national study, more than half of young adults (ages 18–24) surveyed at the end of June 2020 reported depression, and one-quarter reported having seriously considered suicide in the past month. Officials should leverage existing infrastructure such as federally funded health centers and rural health clinics, primary care and pediatricians’ offices, and importantly, schools, to dramatically increase support for screening, education, and referrals.
Target Key Interventions
A third component of a public mental health approach involves population-level efforts to reduce distress, build resilience, and provide specialized supports for those at highest risk of distress. Evidence from previous pandemics suggests that psychological distress may extend months—or even years—after the virus dissipates. Although it is difficult to predict how prolonged and severe stress may be, rates of chronic and delayed distress after previous pandemics such as Ebola and SARS have ranged from 15 percent to an alarming 65 percent. The COVID-19 pandemic is more widespread and longer lasting. Thus, it will likely require an unparalleled national effort, including public mental health interventions. Early interventions with long-term follow-up can help prevent protracted or deteriorated symptoms.
Targeted interventions are critical for health care providers, others on the front lines, and essential workers. This includes employer-based programs to treat current distress and prevent exacerbation of symptoms. Individual-level treatments are also critical and are currently limited by one’s ability to afford mental health treatment via insurance coverage or out-of-pocket expenses, contributing to sizable unmet needs for mental health care, even prior to the pandemic. Policy makers must take steps to improve access including the continuation of policies implemented during the pandemic, such as insurance coverage for telehealth, copayment waivers, and license reciprocity to enable telehealth across state lines.
The mental health care system was already struggling to meet Americans’ mental health needs prior to this pandemic. We must now invest in expanding our social worker, psychiatric nurse practitioner, psychologist, master’s-level therapist, psychiatrist, and peer counselor workforces.
Research suggests that health disparities may be reduced when people from marginalized groups receive care from people who look like them or share some key identities and experiences. Recruitment and retention of underrepresented students and reductions in financial barriers to advanced degrees in mental health educational programs is one way to diversify the pipeline of mental health professionals, improving cultural competence and health outcomes. We must also consider peer-based strategies and coverage for these services. Continued insurance coverage for telehealth and license reciprocity also have positive workforce benefits as these allow providers to more easily reach underserved populations and provide care in rural areas.
Prioritize Mental Health Surveillance And Research
This pandemic is unlike others, and it is unknown exactly how the mental health implications will manifest over time. To identify risks and understand the longer-term trajectories of distress and resilience, we must prioritize real-time population mental health monitoring and the collection of high-quality longitudinal and representative data. Such an approach will allow us to identify the highest-risk individuals and communities and guide our dissemination of resources to best mitigate those risks. Other areas of public health have benefited from similarly data-driven approaches, but the unique mental health demands of this pandemic require renewed infrastructure and additional resources—financial and otherwise.
Ongoing research should evaluate communication efforts; screening programs; systems of care workforce development; and new and existing interventions at the population-, organization-, and individual-levels. This evidence—in particular, on the integration of mental and physical health care during and after the pandemic—must inform our responses to future crises. We hope to never see a large-scale disaster such as this one again; but we must prepare and make informed decisions.
An Extraordinary Approach To An Urgent Crisis
We urge the Biden-Harris administration to include mental health in its “plan to beat COVID-19” and to appoint a mental health czar to demonstrate the urgency of this crisis, ensuring an immediate and sustained public health commitment. We also urge the administration to increase funding for mental health research funding through the CDC and the National Institutes of Health. Enacting our recommendations will require a coordinated, universal, financially accessible, and compassionate public mental health approach. Such an extraordinary approach to public mental health is essential for improving health and hastening a national recovery that will benefit all in the short and long term.