The COVID-19 pandemic reveals existing weaknesses in the mental health system, but also presents opportunities for reform.
Our mental health system is facing something of a perfect storm. The stress of the COVID-19 contagion, the civil strife and social disruption, and economic insecurity is causing an increased demand for mental health treatment.1 Yet, government agencies and health care institutions are incurring budget deficits, and without government funding to cover these losses, existing treatment programs are in jeopardy. California, Colorado, and Virginia have already announced reductions in mental health care funding, and other states are expected to follow.2-4
The simultaneous increased demand and decrease in available services could generate a second phase of the COVID-19 crisis. This is particularly true for racial and ethnic minorities and those in lower socioeconomic groups, who faced an increased risk of psychiatric disorders before the pandemic and have been hardest hit by the virus.5 For children, the situation is more dire. Mental health services were deficient for this patient population prior to COVID-19 and are now worse. In the context of the pandemic, the rates of mental illness can be expected to rise precipitously.
This country has been struggling with mental health care problems even before COVID-19. Deaths from suicide, drug overdose, and alcohol-related liver disease, eclipsed the combined mortality of all infectious diseases combined in the United States.6,7 According to recent projections, we can expect up to 75,000 excess deaths from suicide and addiction as a result of COVID’s ripple effects without additional interventions.8
We were caught unawares by the COVID-19 pandemic, and we are suffering the consequences. We cannot afford a repeat failure.
The good news is that there are evidence based, cost-effective interventions to address public mental health needs.9,10 But let us start with what we should not do. We should not—as we repeatedly do out of habit—continue talking about our “mental health system.” The truth is that we do not have a system but rather a patchwork or mosaic that is far from comprehensive and not close to being adequate. The same is true for all of health care; there are many systems, organizations, clinics, and practices delivering mental health services under many auspices (from governments to nonprofits to for profit investor-owned). However, these neither meet all health care needs nor provide the requisite evidence-based services or ensure uniform quality of care. Given the wide range of stakeholders and the lack of leadership and political will, it is doubtful we will see one system emerge from the COVID-19 crisis. Yet, we can use this opportunity to accelerate the coordination of services for communities, including adequate mental health services that will provide a template for post-COVID care.
Accountable care organizations, medical homes, and Medicaid waivers have all inched coordinated care forward. We have also seen expanded use of telehealth due to the elimination of regulatory and reimbursement barriers. Virtually overnight, this resulted in unfettered adoption of online mental health treatment. We can do the same for coordinated care by removing regulatory barriers and offering payments that incentivize hospitals and their services, community-based organizations, and local primary care providers to create a no-wrong door, seamless continuum of mental health and substance abuse services.
This is our vision for the Northern Manhattan Mental Health Initiative, targeting one of the most severely affected areas by the COVID-19 virus. It gives health care providers and communities the opportunity to strengthen existing relationships, build new partnerships, and create a safety net for patients.
Other systemic problems can be addressed to meet the increasing demand for mental health care. For example, there are too few inpatient psychiatric beds.11 The inpatient bed is the ICU of mental health care: for the most severe cases, it can be the difference between life and death. Well-meaning but flawed deinstitutionalization policies in the second half of the 20th century left many people with serious mental illness on the streets, in homeless shelters, or incarcerated. Deinstitutionalization policies, compounded by relatively low reimbursement rates, incentivized hospitals to close inpatient units and created a critical bed shortage.12 As a result, patients can wait in emergency departments for days—or sometimes weeks—for an inpatient bed.13
In the midst of this pandemic, many inpatient beds, including those in our institution, have been converted to medical units to meet the deluge of patients with COVID-19, and it is unclear when or how they will return.
While such developments are regrettable, they are incentivized by the health care financing system that provides far higher reimbursements for procedural interventions than for preventative health measures like mental health. For example, according to the Centers for Medicare & Medicaid Services Physician Fee Schedule, payment for an emergency hour-long session by a psychiatrist with a patient who is acutely suicidal, homicidal, or floridly psychotic is only $147, while a 10 minute skin biopsy and 20 minute cataract surgery are reimbursed at rates of $150 and $765, respectively.14 These disparities are 1 reason there are so many surgery centers with an average profit of $2 million profit per year are popping up, while nearly half of patients with mental health disorders go without treatment.15,16 Leveling the playing field with reimbursement will incentivize health systems to emphasize mental health treatment.
Of course, mental health, like physical health, does not exist in a vacuum. When people’s basic needs are met, they are healthier in mind and body. The previously noted interventions will be most effective if we do all we can to address social determinants of health, including nutrition, housing, education, community safety, and employment. Being poor is bad for your health. This certainly holds true in New York City, where black and Latinx people are disproportionately vulnerable to the coronavirus.
Given our awareness of the looming mental health repercussions of the COVID-19 pandemic, we cannot remain idle in the anticipation of 75,000 excess deaths from the complications of mental disorders. It is morally wrong to condemn those who have the least to suffer the most, and it is irresponsible for us not to plan for a public mental health initiative to stem this imminent crisis.
Dr Magoon is a resident in psychiatry at the New York Presbyterian Hospital, Columbia University Irving Medical Center. Ms Rosenberg is assistant professor of medical sociology at Columbia University Vagelos College of Physicians and Surgeons and past president of the National Council for Behavioral Health. Dr Lieberman is chairman of psychiatry at Columbia University Vagelos College of Physicians and Surgeons, past president of the American Psychiatric Association, and the author of Shrinks: The Untold Story of Psychiatry.
1. Wan W. The coronavirus pandemic is pushing America into a mental health crisis. The Washington Post. May 4, 2020. Accessed August 25, 2020. https://www.washingtonpost.com/health/2020/05/04/mental-health-coronavirus/
2. Dembosky A. Doctors urge governor to reconsider cuts to maternal mental health care. KQED. May 15, 2020. Accessed August 25, 2020. https://www.kqed.org/news/11818800/doctors-urge-governor-to-reconsider-cuts-to-maternal-mental-health-care
3. Some mental health resources could be cut from Colorado's budget because of COVID-19. 9news.com. May 15, 2020. Accessed August 25, 2020. https://www.9news.com/video/news/local/next/some-mental-health-resources-could-be-cut-from-colorados-budget-because-of-covid-19/73-cb8ab247-76d7-46d2-a371-7a0d17284e64
4. Ress D. Budget cuts to hit schools, colleges, mental health services hard. Daily Press. April 23, 2020. Accessed August 25, 2020. https://www.dailypress.com/government/local/dp-nw-budget-20200423-u3puda5or5cl3dwyrh6f4qynu4-story.html
5. Kivimäki M, Batty GD, Pentti J, et al. Association between socioeconomic status and the development of mental and physical health conditions in adulthood: a multi-cohort study “Deaths of despair”: The deadly epidemic that predated coronavirus. Lancet Public Health. 2020 Mar;5(3):e140-e149. Accessed August 25, 2020. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(19)30248-8/fulltext
6. Karma R. “Deaths of despair”: The deadly epidemic that predated coronavirus. Vox. April 15, 2020. Accessed August 25, 2020. https://www.vox.com/2020/4/15/21214734/deaths-of-despair-coronavirus-covid-19-angus-deaton-anne-case-americans-deaths
7. Kunzmann K. Deaths from infectious diseases drop in United States. Pharmacy Times. March 30, 2018. Accessed August 25, 2020. https://www.pharmacytimes.com/news/deaths-from-infectious-diseases-drop-in-united-states
8. Well Being Trust. The COVID pandemic could lead to 75,000 additional deaths from alcohol and drug misuse and suicide. Accessed August 25, 2020. https://wellbeingtrust.org/areas-of-focus/policy-and-advocacy/reports/projected-deaths-of-despair-during-covid-19/
9. WHO. Draft menu of cost-effective interventions for mental health. September 2, 2019. Accessed August 25, 2020. https://www.who.int/mental_health/WHO_Discussion_Paper_Draft_Menu_of_cost-effective_interventions_for_mental_health.pdf?ua=1
10. Arango C, Díaz-Caneja CM, McGorry PD, et al. Preventive strategies for mental health.Lancet Psychiatry. 2018;5(7):591-604. Accessed August 25, 2020. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30057-9/fulltext
11. Raphelson S. How the loss of U.S. psychiatric hospitals led to a mental health crisis. NPR.
November 30, 2017. Accessed August 25, 2020.https://www.npr.org/2017/11/30/567477160/how-the-loss-of-u-s-psychiatric-hospitals-led-to-a-mental-health-crisis
12. National Council for Behavioral Health. The psychiatric shortage: causes ad solutions. National Council Medical Director Institute. March 28, 2017. Accessed August 25, 2020. https://www.thenationalcouncil.org/wp-content/uploads/2017/03/Psychiatric-Shortage_National-Council-.pdf?daf=375ateTbd56
13. Hlavinka E. Teenager in psych crisis waits 25 days in ED for admission. MedPageToday. January 7, 2020. Accessed August 25, 2020. https://www.medpagetoday.com/special-reports/exclusives/84236
14. CMS. Physician Fee Schedule Search. Accessed August 26, 2020. https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx
15. 100 Surgery Center Benchmarks. Becker’s Hospital Review. Accessed August 26, 2020. https://www.beckershospitalreview.com/asc-turnarounds/100-surgery-center-benchmarks.html
16. Christidis P, Lin L, Stamm K. An unmet need for mental health services. American Psychological Association Monitor. April;49(4). Accessed August 26, 2020. https://www.apa.org/monitor/2018/04/datapoint