Amidst Multiple Crises, NIMH Pursues Research to Improve Outcomes

CONFERENCE REPORTER

Singularly, natural disasters and traumas have the potential for long-term mental health implications, noted Joshua A. Gordon, MD, PhD, National Institute of Mental Health (NIMH) Director, so it is no surprise that the simultaneous nationwide crises of 2020 posed significant threats to mental health. Fortunately, lessons learned from previous events and preliminary research point to a relatively positive outlook, he told attendees of the 2021 American Psychiatric Association Annual Meeting.

The past year presented a dangerous pandemic, with unprecedented morbidity and mortality numbers and mitigation strategies that resulted in isolation and economic strife. On top of that, the United States saw natural disasters and a reckoning around the systemic racial injustice that has plagued this country for years. Individually, each crisis had the possibility of a negative impact on mental health; together, they had the potential to be catastrophic.

Fortunately, lessons from previous traumas have found most individuals (90%) who are exposed to trauma improve within a year or so. However, there is a significant minority who may have long-term or chronic experiences with mental illness, Gordon explained. Specifically, studies have shown there are 4 trajectories following trauma.¹ The first group consists of individuals whose levels of symptomology following the trauma are low and remain low; they generally do not require clinical attention. The second and third groups have either immediate (within 1 to 3 months following trauma) or delayed (between 3 and 6 months post-trauma) increased symptomology, but usually recover. The final group has a sustained or chronic time course, and symptoms last beyond 6 months.

Although improvement is often due to treatment, Gordon noted other factors often predict recovery versus negative outcomes. Risk factors for long-term or chronic experiences include: few social supports, a history of trauma or mental illness, direct exposure to death or injuries, severe acute reactions to disaster, and ongoing stressors such occupational and financial strain. Having these risk factors does not equate to long-term issues, Gordon explained, but increases the risk of such. He added that having multiple factors further increases the risk of chronic symptoms.

Study after study has indicated that meeting immediate needs after a trauma helps to reduce the long-term impact, Gordon explained. For instance, after a hurricane, it is important to make sure victims have a safe place to stay and food. Similarly, treating new or worsening mental illness is very important, he said. After Hurricane Katrina, half the residents met criteria for a diagnosable DSM condition, Gordon shared, but only half received treatment and even less received evidence-based treatment. “We put people at risk when we don’t identify that they have symptoms, and don’t help them cope or get them treatment,” Gordon explained.

COVID-19 Impacts on Mental Health

There is already data on the COVID-19 pandemic, Gordon reported. Building on previous traumas and risk factors, it was not a surprise that contracting COVID-19 increased the risk for long-term mental health issues. Individuals with preexisting psychiatric disorders, especially schizophrenia, were found at higher risk for developing trauma-related mental health issues.² The same study found the likelihood of new onset psychiatric disorders following COVID-19 infection was 6%, which is 2 to 3 times the rate as that with the flu. The incidence of any psychiatric diagnosis within the first 3 months after infection rose to 18% when including those with previous psychiatric disorders. The majority of the new onset symptoms were mood or anxiety-related. Gordon said the NIMH is embarking on a multi-institute study to further explore these data.

Similarly, the pandemic affected individuals who did not contract the virus, Gordon added. Data from the Centers for Disease Control and Prevention indicated that most adults had some symptoms, including mood, substance use, and suicide ideation. Rates of suicidal ideation was disturbingly high among young adults, he said, with about 18% noting they seriously considered suicide in the previous 30 days, double the number than would be normally expected.³ Gordon cautioned, however, that this data is a result of self-reports of mental illness, not diagnosed illnesses. Still, he said he would not be surprised if future studies found an increased rate of psychiatric diagnoses during the pandemic.

Yet, the picture is not all bleak, Gordon said. He referred to unpublished data from the Mental Health Research Network, which consists of a number of managed care organizations, that looked at electronic health records. In each system, the number of visits for self-harm diagnosis (including self-injurious behavior and suicide attempt) remained steady over time, even through the pandemic.

Addressing Inequities

The pandemic also illuminated the inequities of health care in the United States, with certain minorities at increased risk of adverse events associated with COVID-19, Gordon said. Of great concern was the shift to telehealth in the early days of the pandemic, and the possibility of telehealth exacerbating access to care issues for vulnerable populations.

The Mental Health Research Network looked at the number of mental health visits in person, via phone, and via video both before and during the pandemic, and the data revealed some promising news. The numbers of visits among White non-Hispanic patients, African-American patients, and Hispanic patients were similar, with a huge drop in in-person visits at the beginning of the pandemic, when a slow upward shift was found for voice and video visits, Gordon reported. Although there were fewer visits during the pandemic, the rates were similar among all groups. Gordon said more research is needed across wider swaths of populations to confirm these findings, but he believes the increased popularity and availability of smartphones helped forestall access issues.

Unfortunately, Gordon noted not all the news was good: There was a dramatic increase in suicide rates among Black youth. Blacks have been relatively protected against suicide when compared with Whites in the United States, he noted, although it is not quite certain why. For some reason, he added, that is changing in Black youth, especially males, and that is troubling.

Gordon added that the NIMH is addressing the growing awareness of broad systemic racism on 2 fronts: an increase in diversity in the workforce and an increase focus in disparity research. For instance, Gordon discussed the April 21, 2020, webinar cohosted with SAMHSA, “Responding to the Alarm Addressing Black Youth Suicide.”

On a broader scale, the NIMH has taken the lead with a number of NIH organizations to further explore, measure, and address the social and economic impacts of COVID-19 on mental health, especially among vulnerable populations (eg, older adults, frontline workers, racial and ethnic minorities, etc). To date, the NIMH and working group members have funded 28 longitudinal studies, 15 digital health studies, and 9 community health studies looking at substance use and other mental health outcomes as well as public health mitigation impact and adherence. Gordon expects the information learned from these studies will not only help address issues from the pandemic, but also inform future disaster response.

Fostering Resiliency

In terms of the pandemic, there are still many uncertainties, which continues the risk of new and exacerbated mental health issues, Gordon warned. “We don’t know when it will end, there is increased exposure to morbidity and mortality (at this point we all know someone who has had COVID-19), there is continued social economic vulnerability, and preexisting mental health problems,” all of which are risk factors for poor outcomes, he explained.

Still, research shows there are ways to foster resiliency and prevent negative outcomes, and Gordon encouraged attendees to focus on those endeavors. Psychiatrists can help patients focus on the hope for the future and remind patients they have some control over their situations. They can encourage patients to find ways to meet their immediate needs. And, they can inspire healthy coping habits.

References

1. deRoon-Cassini TA, Mancini AD, Rusch MD, Bonanno GA. Psychopathology and resilience following traumatic injury: a latent growth mixture model analysis. Rehabil Psychol. 2010;55(1):1-11.

2. Taquet M, Luciano S, Geddes JR, Harrison PJ. Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA. Lancet Psychiatry. 2021;8(2):130-140. Erratum in: Lancet Psychiatry. 2021;8(1):e1.

3. Czeisler MÉ , Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1049-1057.