COVID-19 and Mental Health

Introduction

A health care worker takes a break outside the Brooklyn Hospital Center in New York City in April as coronavirus cases peaked in the city. Anxiety and depression have spiked among Americans during the pandemic, especially among health care workers and first responders. (Getty Images/Andolu Agency/Tayfun Coskun)

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Overview

Katharine Hartleb was studying psychology at the University of South Carolina in Columbia when the COVID-19 pandemic hit. The 21-year-old junior had a history of depression and anxiety but had been doing so well she had recently stopped seeing a therapist.

Due to the virus, the state locked down and her university shifted to online classes. Hartleb — who thrives on social engagement and activity — was largely confined to her apartment, with only her roommate for company. After a couple of weeks of social isolation, she says she felt some of her past symptoms “start to creep back in.”

Grieving family members embrace during the funeral service for Santos A. Rivas at Woodlawn Cemetery in Everett, Mass., in April, as friends and relatives, maintaining social distance, observe from their cars. Some 150,000 Americans had died from coronavirus as of July 29, adding to the grief and anxiety caused by the pandemic. (Getty Images/The Boston Globe/Jessica Rinaldi)

To make it through the rest of the semester, Hartleb used meditation apps, talked with friends and family and counseled herself: “I gave myself some grace, that it was OK to feel like this during an uncertain time and not to freak out that this was going to send me into another suicidal episode.” (Hartleb says she had experienced suicidal thoughts, but had not attempted the act, while in high school and in her first year of college.) When school ended, she moved home with family and has felt better, though she has to consciously focus on not worrying about catching the virus, either now or when she returns to school this fall.

As of July 29, the coronavirus pandemic had killed some 150,000 Americans and infected more than 4 million since January.1 The damage it has wrought on mental health is harder to track. While each person experiences the pandemic differently, experts see common patterns of anxiety, depression and stress brought on by grief, uncertainty, economic pain, isolation and fear. The problem has been compounded by a chronically underfunded mental health system, gaps in insurance and access to care and a shortage of mental health professionals, according to experts.

To make matters worse, the virus began to spike again in June and July, just as some states started to reopen their economies, and another wave of infection could be looming in the fall.2

Mental health professionals worry that the United States is not prepared for what may lie ahead.

“We are bracing for the next pandemic — [one] of mental health crises in children and adults,” says Dr. Ujjwal Ramtekkar, a child and adolescent psychiatrist and associate medical director of behavioral health in the Partners for Kids program at Nationwide Children's Hospital in Columbus, Ohio. Many of his patients' chronic symptoms have been aggravated or patients have lost ground while in isolation; and some have conditions, such as eating disorders or obsessive-compulsive disorder, that are difficult to treat without hands-on group care.

“Mental trauma is the deadly undertow of the pandemic's first wave,” Karen Lynch, executive vice president at CVS Health, said in May. CVS had seen a 200 percent increase in virtual mental health visits since March 1, compared to 2019, she said.3

Indeed, COVID-19's impact on the economy could trigger between 27,644 and 154,037 “deaths of despair” — suicides and deaths from drug and alcohol misuse — according to the Meadows Mental Health Policy Institute, a think tank in Texas, with 75,000 deaths being most likely.4

Based on recent surveys and research, warning signs of the coming crisis include:

• About 30 percent of U.S. adults report symptoms of generalized anxiety disorder and 24 percent of major depression, according to a U.S. Census survey conducted in May. About half of respondents reported having a depressed mood, about double the 2013-14 rate. The survey showed the highest symptoms of anxiety (42 percent) and depression (36 percent) in those ages 18 to 29.5

• More than 25,000 people said they had thought about suicide or self-harm during more than half of the days during one week in June (up from 4,205 in January), according to online screening data collected by Mental Health America, a nonprofit advocacy group in Alexandria, Va. Also, an increasing number of site visitors scored in the positive range for depression and anxiety.6 The majority of respondents who said they'd thought about suicide were under age 25, an especially high-risk group for suicide, says Debbie Plotnick, vice president for state and federal advocacy for the group. She attributes the new numbers, the highest in the past two years, to “COVID and current events, and how they combine to increase isolation and bring up past trauma.”

• Nearly 40 percent of adults in May said worry or stress over the coronavirus was harming their mental health, according to a Kaiser Family Foundation survey. Women reported more harmful effects than men (46 percent vs. 33 percent), while those who had experienced income or job loss in their households also reported high rates of mental health suffering (46 percent).7

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More than 42 million Americans had lost jobs by June, as the nation officially entered its first recession since 2009.8 Even for those who have jobs, “the financial concerns that people have just exacerbate all the mental health issues that normally would come up from dealing with an unknown disease,” says Lisa Brown, a psychologist and director of the Trauma Program and the Risk and Resilience Research Lab at Palo Alto University in Palo Alto, Calif.

Health care workers have been among those most affected by the pandemic — even to the point of committing suicide. For example, Dr. Lorna M. Breen, 49, an emergency room physician at New York-Presbyterian Allen Hospital, killed herself in April, after treating an overwhelming influx of COVID-19 patients. Shortly before her death, Breen — who had contracted the virus herself — described her working situation as “like Armageddon.”9

Callers in need of emergency mental health services can use this crisis hotline on the Rio Grande Gorge Bridge near Taos, N.M., where 115 suicides have occurred over the past 20 years. Experts say suicide rates have spiked during the pandemic. (Getty Images/Corbis/Steven Clevenger)

Dr. Dennis S. Charney, dean of the Icahn School of Medicine at Mount Sinai in New York, said that based on research on post-traumatic stress disorder (PTSD) among 9/11 responders, about 25 to 40 percent of first responders and health care workers are likely to be affected by PTSD as a result of the pandemic. The hard-hit Mount Sinai hospital system has surveyed its own staffers and found evidence of stress and trauma, says Dr. Deborah Marin, director of a new center at the hospital aimed at helping workers experiencing mental health issues.10

“Now with people expecting a second wave, we're very worried about the well-being of our staff,” she says.

Luana Marques, a psychologist and president of the Anxiety and Depression Association of America, a nonprofit organization based in Silver Spring, Md., says that even 10 years after 9/11, about 10 percent of those who responded to the attacks still suffered from PTSD. Many of the nation's 18 million first responders could develop pandemic-related PTSD and suffer its effects a decade from now, she says.

Survivors of the virus also are at risk. A recent study of 714 COVID-19 patients quarantined in temporary hospitals in Wuhan, China, where the disease first surfaced last year, found that 96.2 percent of them reported PTSD symptoms. Being put on a ventilator alone raises the risk of developing PTSD, according to a 2013 Johns Hopkins University study.11

Those with pre-existing mental health conditions also are at risk. “People who are seriously mentally ill are having more trouble,” says Dr. Ken Duckworth, chief medical officer for the National Alliance on Mental Illness, a national advocacy organization in Arlington, Va.

Marques says her patients with a history of anxiety, depression or trauma are “a little more on edge, a little more irritated. They find themselves having trouble focusing, difficulty sleeping.”

In addition, she says, “Many people who didn't have mental health challenges are experiencing anxiety that is clinically significant.”

People of color face additional challenges, largely due to a lack of access to care.12 “Race is a huge determinant here,” says Marques. “You're seeing an increase in anxiety and depression more so in Black and Hispanic Americans, compared to white Americans.” This comes on top of the overall toll that racism exacts on the mental health of minority populations, a growing subject of exploration by mental health professionals.13

Depending where people live, it can be difficult to find a mental health provider. Researchers estimate 113 million Americans live in areas without enough clinicians. Meanwhile, already cash-strapped federally funded community behavioral health organizations (which treat both mental health and substance use disorders) are in danger of failing due to additional pandemic-related costs, such as for personal protective equipment. About two-thirds of such clinics reported in April that they could only survive three months under current conditions. Many have canceled programs and cut staff.14

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Telehealth has emerged as a partial solution, allowing patients to see clinicians despite lockdown and distancing policies. Patients are meeting with counselors over apps such as Zoom or Facetime, sometimes participating in sessions on their smartphones while sitting in their cars — the only private place some can find to talk, says Mary Alvord, a psychologist in private practice in Maryland who specializes in resilience.

Virtual therapy sessions are allowed now after the federal government temporarily waived rules governing telemedicine, such as making it easier for providers to treat patients across state lines. Medicare and Medicaid also expanded reimbursement for telecare. But the waivers were issued for the pandemic emergency, and providers do not know whether they will be made permanent once the crisis eases. (See Pro/Con.)

It is just one more uncertainty, in a time when so much about the virus is unknown and unpredictable.

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Background

Suicide Spikes

Pandemics have ravaged populations for centuries, with the earliest on record occurring in 430 B.C., when a form of typhoid fever hit parts of Africa, Egypt and Greece. In 1918, the Spanish flu killed 20 million to 50 million people worldwide, including 675,000 Americans — among them, President Trump's grandfather.15

More recently, the severe acute respiratory syndrome (SARS) pandemic struck in 2003, infecting more than 8,000 in 29 countries and leaving about 800 dead. Both SARS, a type of coronavirus, and the Spanish flu led to subsequent spikes in suicide, according to researchers.16

The current SARS-CoV-2 pandemic likely began in Wuhan, which reported an outbreak of pneumonia (later identified as being caused by the virus) to the World Health Organization on Dec. 31, 2019. More than 4,600 people reportedly died in China as of July 25, mostly in the Wuhan area, where the virus was largely contained by April. Since then, studies have shown that the pandemic left anxiety, depression and PTSD in its wake among health workers, survivors and young people (ages 14-35).17

The United States recorded its first COVID-19 case on Jan. 20 near Seattle; 11 days later, the U.S. government declared a national emergency. Widespread shutdown orders began in many states in March, closing all but essential businesses; many people began practicing social distancing and avoiding in-person, nonemergency medical visits.18

Also in March, U.S. government agencies began waiving regulations on telehealth, enabling people to be treated without physical contact.19

However, sometimes providers receive lower payments for telehealth sessions than for in-person care. That can cause financial hardship for facilities, such as community-based health care centers that receive federal funds to provide physical and mental health care to underserved areas, says Mei Kwong, executive director of the Center for Connected Health Policy, a telehealth advocacy group. The revenue gap could put them out of business, she says, and often such facilities “are the only game in town” in small, rural areas.

New York City firefighters respond to the terrorist attack on the World Trade Center on Sept. 11, 2001. About 10 percent of first responders were still experiencing symptoms of post-traumatic stress disorder 10 years after the attack, according to experts. (Getty Images/Universal History Archive/Universal Images Group)

This comes just as demand for mental and behavioral health care is on the rise, particularly among young people. Even before the pandemic, youth suicide rates were at 20-year highs, making it the second-leading cause of death for those ages 10-24.20

Adult depression has been increasing as well. Among those ages 35-64 with private health insurance, 5.8 percent had been diagnosed with major depression in 2016, up from approximately 4.7 percent in 2013, according to a Blue Cross Blue Shield report. Depression also went up in all other age groups. Experts suggest that stress, lack of community, excessive time spent on smartphones and computers, other medical problems and genetics may have contributed to the spike. In addition, about 38 percent of adults in 2017 battled an illicit drug use disorder.21

Opioid-related deaths are up this year in more than 35 states, according to the American Medical Association, and public health officials nationwide fear that the pandemic — with its associated joblessness, stress and isolation — has refueled the opioid epidemic.

“The number of opioid overdoses is skyrocketing,” said Dr. Mike Brumage, former director of the West Virginia office of drug control policy.22

Ramtekkar, of the Partners for Kids program, also says he fears “an uptick in cases of domestic violence and child abuse.” For instance, Chicago police reported a 12 percent rise in calls related to domestic violence from January through mid-April, compared to 2019. But some cities say such calls are declining, leading authorities to surmise that people confined with their abusers do not feel safe enough to call for help. Also, children and teens are not being seen by teachers, coaches and other adults who are required by law to report signs of abuse.23

In addition, since the COVID-19 crisis began, gun sales have jumped 85 percent, with 2.6 million sold in March — raising concerns that increased gun ownership could lead to more deaths by suicide.24

Despite the greater need, funding for mental health care remains a problem. “Mental health has been forever underfunded,” says Plotnick, of Mental Health America. Insurers also are not paying for mental health services at rates equivalent to physical health, despite mental health parity laws, one study found.25

The $2 trillion Coronavirus Aid, Relief and Economic Security (Cares) Act, enacted in late March, provided $425 million to the federal government's Substance Abuse and Mental Health Services Administration (SAMSHA), including $250 million for community behavioral health clinics and $50 million for suicide prevention efforts.26

Advocates said this amount was not nearly enough to meet the demand. In early April, a dozen leading mental health organizations petitioned Congress for $38 billion more for mental health infrastructure and $10 billion to meet anticipated COVID-19-related mental health and addiction care needs.27

States will be forced to cut their budgets as they lose tax revenues from coronavirus-related business closures and job losses, analysts say.28 Typically, mental health services are “first on the chopping block” when states make cuts, says Plotnick, raising fears that people with mental illnesses may again slip through the cracks of care.

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Current Situation

Congressional Action

Mental health advocates say more funding is needed to care for people with problems brought on or exacerbated by the pandemic. The $3 trillion Health and Economic Recovery Omnibus Emergency Solutions (Heroes) Act, which the U.S. House passed on May 15, would provide $3 billion for SAMSHA programs and $100 billion for health care providers.29

However, critics said the $3 billion earmarked for mental health care in the Heroes Act was insufficient to meet rising needs. Instead, it would take $38.5 billion “to prevent the looming collapse of our behavioral health care system,” said Chuck Ingoglia, president of the National Council for Behavioral Health, a mental health advocacy organization.30

The Heroes Act is unlikely to pass in its current form in the Senate, where Majority Leader Mitch McConnell, a Republican from Kentucky, has called it a “parade of absurdities that can hardly be taken seriously.” President Trump also opposes the measure. McConnell has suggested a scaled-back version, with a $1 trillion price tag.31

Another, narrower measure affecting mental health services could be more likely to pass: A new, three-digit, nationwide phone number (988) to call for suicide prevention. The number would be akin to 911, but for mental health crises only. The bipartisan measure unanimously passed the Senate in May and is under consideration in the House.32

Access to Care

Federal and state governments also will need to decide whether to make the waivers for virtual doctor visits permanent. The waivers allowed such visits when physicians' offices were closed. Now, with many states lifting restrictions and liberalizing social distancing policies, the waivers could expire, says Kwong, of the Center for Connected Health Policy.

A gun shop in Manassas, Va., displays its wares. Gun and ammunition sales in the United States have jumped 85 percent since the coronavirus pandemic began, which experts say is one sign of a nation gripped by fear and anxiety. (Getty Images/Anadolu Agency/Yasin Ozturk)

The changes made it easier for doctors to treat patients in other states and to write prescriptions for controlled substances without first seeing patients in person; waived privacy rules so visits could be conducted using apps such as Zoom or Facetime; and allowed Medicare and Medicaid to reimburse providers for video and audio telehealth services.33

Although some states established different rules, the temporary measures helped open up telemedicine, allowing many patients and doctors to try it for the first time — and to discover it worked for them.

“Now it's going to be very hard to take it away from those people,” says Kwong.

A host of advocacy groups, such as the American Psychiatric Association and the American Medical Association, have lobbied for these rule changes to be made permanent, or at least extended. On May 21, a bipartisan group of about 30 legislators asked that Congress extend the telehealth exemptions for mental health care.34

Others advise caution, with one government official warning of potential fraud. “There are unscrupulous providers out there, and they have much greater reach with telehealth,” said Mike Cohen, an operations officer with the Health and Human Services Department's inspector general's office.35

Julie Carter, a senior federal policy associate at the Medicare Rights Center, a nonprofit advocacy organization with offices in New York and Washington, says her group fears some changes could lead to telemedicine being the only choice available in some communities.

Experts say access to mental health care could also be affected by President Trump's continued opposition to the Affordable Care Act, also known as Obamacare. The law requires that mental health conditions be covered on a par with physical ailments and prohibits insurance companies from rejecting coverage for a patient due to pre-existing conditions. The law provides health insurance for 11.4 million Americans through state health insurance exchanges, plus 12.5 million receive subsidized insurance through expanded Medicaid coverage.36

The U.S. Supreme Court is scheduled to hear a challenge to the Affordable Care Act during its fall term, which starts in October. The case was brought by a coalition of Republican-led states that have argued the law is unconstitutional; the U.S. Justice Department has declined to defend the act.37

“Obamacare is a disaster,” Trump said. “What we want to do is terminate it and give great health care.”38

About 12.7 million Americans have lost their employer-based health care coverage due to the COVID-19 crisis, and the Urban Institute, a Washington-based think tank, estimates that the figure could rise to 25 million or more.39

“Do we just let all these people not have any income and no health care?” asks Maryland psychologist Alvord. “I wish as a country we would think about our country and learn from each other and work together; we're all in this together.”

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Outlook

A Second Wave?

The future course of the pandemic is impossible to predict. But if a second wave does strike, will the nation accept another lockdown?

Dr. Elinor McCance-Katz, a psychiatrist and the U.S. assistant secretary of health and human services for mental health and substance abuse, recently said this should be avoided, due to the severe mental health effects caused by such measures.40 Alvord would like to see creative alternatives to lockdowns.

More widespread use of virtual therapies is likely, especially “now that everyone's given telehealth a test drive” and found that it works, says Duckworth of the National Alliance on Mental Illness. Geoffrey Boyce, the CEO of InSight + Regroup, a telepsychiatry provider, thinks most regulatory barriers will remain lifted but some services will require in-person treatment. Alvord predicts that about 30 to 40 percent of her clients eventually will use telehealth but says some services, such as group therapy for teens, are more difficult to provide virtually.

Even if telehealth becomes more common, it cannot solve the national shortage of mental health clinicians, says Marques, of the Anxiety and Depression Association of America. She would like to see the workforce reinvented, with paraprofessionals trained in such duties as teaching patients cognitive behavioral therapy skills, a practical, goal-oriented form of psychotherapy, to help manage their symptoms.

The pandemic likely will cause long-lasting mental health consequences for a segment of Americans, says Palo Alto University's Brown. “They are going to be devastated and never recover in their lifetimes,” she says. While another segment of the population will emerge relatively unscathed, she says, the “vast majority” of those affected will recover but will have “ups and downs, good days and bad.”

Alvord says that “for the most part we're resilient as humans.” But she adds: “It depends on how many adversities you face. The more you face, the harder it is.”

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Pro/Con

Should the telemedicine rule changes made during the pandemic be made permanent?

Pro Debbie F. Plotnick Vice President of State and Federal Advocacy, Mental Health America. Written for CQ Researcher, July 2020 Telemental health has long held the promise of extending a limited workforce, overcoming transportation barriers, reducing the number of people that miss appointments, improving people's ability to get help when they need it and accessing services before crises. At Mental Health America, we call that addressing mental health B4Stage4. Since the emergence of the COVID-19 pandemic, the need for mental health services has increased, and many regulatory barriers have eased. The federal agency that oversees Medicaid and Medicare has encouraged states to amend their Medicaid rules to reduce barriers to telemental health. And Medicare has removed the requirement for an in-person first visit and now allows for telephone-only mental health care. Employer-provided private insurance and Affordable Care Act health insurance policies also have allowed (and encouraged) people to use telehealth — including telemental health. While schools are closed due to the pandemic, school-based mental health services for students have moved to telemental health. There are still some issues regarding telemental health services for some employer-funded plans that come under the Employee Retirement Income Security Act (ERISA) of 1974, the federal law governing most voluntarily established private retirement and health plans. Although such policies should cover telemental health if other types of telehealth services are covered, sometimes employers need to inform the insurance administrator to add telemental health. By all accounts, telemental health services are working well. People like accessing care from their homes, students are still being served, and seniors and those without internet service are getting help by telephone. Providers also are adding new clients. Peer support services have gone online, and nonemergency help lines are available and are growing in number. Most of this expanded access is happening because of the national emergency declared due to the COVID-19 pandemic. Without legislative action these expansions are expected to only be in place during the emergency. What about after the state of emergency? Some states, such as Idaho and Colorado, have made permanent changes in state regulations, and bills are pending in Congress to extend telehealth expansion beyond the emergency. Regulations and legislation to allow telemental health expansion should remain in place long-term. I have adopted a new mantra: “Telemental health now and from now on.” Our elected officials and regulators need to hear that message. There is no reason that telemental health should not be here to stay.

Con Ateev Mehrotra Associate Professor of Health Care Policy, Harvard Medical School. Written for CQ Researcher, July 2020 Medicare and many other payers have implemented temporary changes that increase the use of telemedicine. Many people think those should be permanent: “Oh, what a stupid rule, making people go to the doctor's office — why don't they just let them have it at home?” I understand that perspective, but some of these regulations are necessary. When Medicare or other health plans regulate telemedicine, they are trying to balance improving access with costs. By forcing patients to go to a local clinic, Medicare is trying to ensure that patients use the service only if they think the visit is really important. If they can just dial up a telemedicine doctor at home, they may make visits that are not that necessary, driving up costs without health benefits. Another temporary rule change made it easier for patients with an opioid use disorder to obtain medications prescribed by doctors they see online. The federal Ryan Haight Act, which requires in-person visits before doctors can issue prescriptions for controlled substances in order to prevent abuse, has been waived for now. While there are advantages to treating patients with opioid use disorders in their homes, such as having them avoid travel, there are also potential disadvantages. It may be ill-suited for some high-risk patients with unstable housing or co-occurring mental illness; it requires a patient to have a computer or smartphone and Internet access; and it presents privacy concerns when family members may overhear or interrupt therapy sessions. How effective is telemedicine for treating opioid use disorder? We don't know, so we need to carefully evaluate. As we move forward, there are two principles that need to be considered. First, we need to stop thinking of telemedicine as a monolithic type of care. Just as we do not have a single policy for all drugs, we need to have a nuanced policy for telemedicine. Regulations and payment policy will likely vary based on the type of condition being treated, the type of telemedicine and type of patient. Second, the lens by which we decide on the regulation or payment policy is value: Is this telemedicine visit improving health for a reasonable sum compared to another form of medicine? Although many more clinicians are using telemedicine health due to the COVID-19 pandemic and the temporary rule changes, it is unclear what may happen when the pandemic is over. A lot will depend on what payers do regarding telemedicine regulations after the pandemic.

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Short Features

Digital Tools Ease Pandemic's Adverse Mental Health Effects

The 300-plus residents at the Illinois Veterans Home in Quincy, Ill., are restricted to their facility due to the coronavirus pandemic. Yet some have biked the Golden Gate Bridge, gone skydiving in Brazil, toured Okinawa, Japan, and — in one case — checked out a granddaughter's new home in Kansas.

How? Through virtual reality (VR) technology, which uses 360-degree cameras, special headsets and immersive technology to create “you are there” experiences. The technology can help ease the loneliness, boredom and stress caused by social isolation, conditions that can lead to physical and mental health problems.

“The residents have just loved having this,” says Sara Colgrove, the facility's director of volunteer services and activities. “VR is just amazing. To see smiles and fascination on the residents' faces when they are watching the videos…. it gives them their moment of joy.” It also has helped ease social isolation and depression, something that is critical during a time when seniors, who are especially vulnerable to the coronavirus, cannot see family members or travel, she says.

Residents in groups of six wear headsets (donated by a local American Legion chapter) and enjoy sharing the virtual travel and other experiences together, which can spark memories or other meaningful conversations, says Colgrove. The equipment, from manufacturer Rendever, also includes games. In one recent event, residents at senior facilities across the country joined to participate in a travel-and-quiz get-together.

VR can also allow family members who have headsets to communicate with loved ones in senior facilities, even doing activities — such as movie-watching — together, while speaking to each other via an avatar. That technology is not being used yet by the Quincy facility but is being studied by researchers from Rendever and the University of California, Santa Barbara, and funded by the National Institutes of Health.1

Other digital tools also can help counter some of the negative mental health effects of the coronavirus pandemic.

For example, the U.S. Department of Veterans Affairs has developed a free app, available to vets and nonvets alike, called COVID Coach. It offers resilience training and stress-relief tips, mood-trackers and graphs to track your progress, along with education about coping during the pandemic. It is similar to other apps the department has produced in the past, such as PTSD Coach, designed to help cope with post-traumatic stress disorder.2

Stephen Schueller, an assistant professor of psychological science at the University of California, Irvine, is the executive director of One Mind PsyberGuide, a nonprofit web service that reviews popular and scientifically validated mental health apps. The reviews focus on how well the app is supported by research, how user-friendly it is and how well it guards privacy.

While Schueller thinks COVID Coach “is cool,” he also says, “it's an open question whether products being developed to meet [COVID-related] needs … are effective.” At this point, he says, most are too new to have been studied.

In a pre-COVID meta-analysis published in The Lancet medical journal in January, Australian researchers found that self-guided suicide prevention apps were effective, particularly those that specifically targeted what is known as suicidal ideation — having thoughts about or planning suicide. The researchers called for more digital interventions, especially where clinicians are in short supply.3

At PsyberGuide — both before the pandemic and currently — the most popular apps are meditation- and mindfulness-based, such as Calm and Headspace, Schueller says. Visitors also are interested in chatbot apps such as Youper and Woebot, which allow people “to sort of have a conversation with a virtual agent” about stress or other concerns, using an artificial intelligence system, he says.

Some innovative apps also can help track people's mental health, and even intervene if they sense problems, says Schueller. One is Mindstrong, which notes how fast someone is typing or scrolling on their phone and uses this data to predict the person's mental state. If necessary, it can then send an alert to a therapist, suggesting a personal check-in.4

Some apps do not protect privacy and security as well as they should, Schueller says. But he says that is less due to malevolent intent than to well-intended amateur developers not realizing what security standards are needed. He recommends users check to see that apps are associated with credible academic institutions and that they are updated regularly.

Staff members push telemedicine carts into the Benioff Children's Hospital in San Francisco in March. As a result of the coronavirus outbreak, physicians increasingly are conducting patient visits remotely in order to keep both health care workers and patients safe. (Getty Images/Smith Collection/Gado)

A new wellness app has been developed by the Mount Sinai Health System's new Center for Stress, Resilience and Personal Growth. The app allows staffers to see anonymously how their patients are doing and whether they need help, says Dr. Deborah Marin, director of the center, which is based in New York City.

The center is studying other technologies as well, she says. One smartphone app, for example, measures heart-rate variability, an indicator of stress and anxiety. Such wearable devices can provide biofeedback, helping people see their own bodily stress reactions in order to calm themselves.5

Geoffrey Boyce, who heads InSight + Regroup, a telehealth provider, says he is excited by the potential of tools such as artificial intelligence and online cognitive behavioral therapy, a practical, goal-oriented form of psychotherapy, especially given the shortage of clinicians. But he is concerned when people propose digital technologies as a replacement — not a supplement — to in-person treatment.

“There is something very important in the personal connection between a clinician and their client that will not be replaced by any technology any time soon,” he says.

— Lorna Collier

[1] “Rendever Receives NIH Grant to Study VR-based Virtual Family Engagement With Seniors Experiencing Cognitive Decline and Their Adult Children Across Distances,” press release, PR Web, Sept. 18, 2019, https://tinyurl.com/y2ywja6v.

[2] “COVID Coach,” U.S. Department of Veterans Affairs, https://tinyurl.com/yxojl24a.

[3] Michelle Torok et al., “Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials,” The Lancet, Vol. 2, Issue 1, Jan. 1, 2020, https://tinyurl.com/y4z29eq7.

[4] “Managing Coronavirus Anxiety,” Mindstrong, https://tinyurl.com/y64pugkb.

[5] John F. Hunter et al., “Effect of Brief Biofeedback via a Smartphone App on Stress Recovery: Randomized Experimental Study,” JMIR Serious Games, Nov. 26, 2019, https://tinyurl.com/y4dumdty.

Bibliography

Books

Kelly, Brendan , Coping With Coronavirus: How to Stay Calm and Protect Your Mental Health — A Psychological Tool Kit , Merrion Press, 2020. An Irish psychiatrist and Psychology Today blogger provides strategies for recognizing and dealing with COVID-19's risks while diminishing unnecessary panic.

Articles

Bender, Ruth, and Rachel Pannett , “Coronavirus Pandemic Takes Toll on Mental Health,” The Wall Street Journal, April 9, 2020, https://tinyurl.com/y4exavh4. Lockdowns, isolation and calls for increased hygiene can aggravate pre-existing mental health conditions, such as anxiety, depression and obsessive-compulsive disorders.

Davis, Dominic-Madori , “The State of Gen Z: How the youngest Americans are dealing with a world in crisis and a future that's been put on hold,” Business Insider, June 14, 2020, https://tinyurl.com/y63tokjb. Studies show younger Americans (those under 24) are experiencing mental health problems due to coronavirus-related stressors, such as schools switching to online instruction, disappearing jobs and financial uncertainty.

Falzone, Diana , “‘It Is Harrowing. It Is Daunting. It Is Overwhelming’: The Mental Toll of Coronavirus Is Crushing Medical Workers,” Vanity Fair, April 19, 2020, https://tinyurl.com/y2jd9ukj. Health care workers face trauma when COVID-19 spikes, and many are likely to suffer from post-traumatic stress disorder (PTSD) in the coming months.

Noori, Sofia, and Isobel Rosenthal , “Mental Health after COVID-19,” Scientific American, June 17, 2020, https://tinyurl.com/y9tnbku6. Those suffering from loss, isolation and trauma are likely to need more mental health care in the pandemic's wake. Increased use of telehealth and other technologies are helping.

Stern, Jacob , “This Is Not a Normal Mental-Health Disaster,” The Atlantic, July 7, 2020, https://tinyurl.com/y85m3fte. Coronavirus is likely to cause Americans to experience the same aftereffects suffered by survivors of the three-month-long SARS epidemic in 2003, more than 40 percent of whom had psychiatric illness, such as PTSD or depression.

Wan, William , “The coronavirus pandemic is pushing America into a mental health crisis,” The Washington Post, May 4, 2020, https://tinyurl.com/yct4l5ru. The U.S. mental health system is underprepared and insufficiently resourced to deal with the influx of people needing help due to anxiety, depression and other conditions caused by the pandemic.

Reports and Studies

“Covid-19 and the Need for Action on Mental Health,” Office of the Secretary-General, United Nations, May 21, 2020, https://tinyurl.com/y4cpaqw3. A U.N. policy brief recommends actions countries can take to address citizens' mental health needs during the COVID-19 pandemic, such as ensuring widespread availability of emergency mental health and psychosocial support.

“Mental Health and Substance Use Disorder Impacts of a COVID-19 Economic Recession,” Meadows Mental Health Policy Institute, April 21, 2020, https://tinyurl.com/yxb67y6h. Depression and addiction, along with the risk of suicide, are likely to rise as unemployment increases due to the COVID-19 pandemic.

“The Other COVID-19 Crisis: Mental Health,” Qualtrics, April 14, 2020, https://tinyurl.com/y2v4mk9o. An international survey of more than 2,000 people finds that about 66 percent report they feel stressed due to the pandemic, 57 percent are experiencing heightened anxiety and 50 percent increased irritability.

“State Data and Policy Actions to Address Coronavirus,” Kaiser Family Foundation, June 12, 2020, https://tinyurl.com/yyux7kz4. This continually updated Web page provides coronavirus-related data and policies adopted by states.

Conrad, Rachel , et al., “Expanding Telemental Health in Response to the COVID-19 Pandemic,” Psychiatric Times, April 7, 2020, https://tinyurl.com/y23w3v9x. Many states and the federal government have temporarily eased regulations in order to allow insurance companies to cover telemental health care during the pandemic, but the rules have focused mostly on Medicare or Medicaid rather than on private payers.

Lwin, May Oo , et al., “Global Sentiments Surrounding the COVID-19 Pandemic on Twitter: Analysis of Twitter Trends,” JMIR Public Health Publications, April 17, 2020, https://tinyurl.com/y5tvkrck. A study by Singapore researchers of global Twitter trends suggests people are shifting from fear to anger in their response to COVID-19.

Uscher-Pines, Lori , et al., “Suddenly Becoming a ‘Virtual Doctor’: Experiences of Psychiatrists Transitioning to Telemedicine During the COVID-19 Pandemic,” Psychiatric Services, 2020, https://tinyurl.com/y5vbk346. A study of the experiences of 20 psychiatrists providing telemental health services during the COVID-19 pandemic finds that while they experienced some negative effects in the early weeks, the transition eventually went more smoothly than anticipated.

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The Next Step

Government Action

Bote, Joshua , “FCC unanimously approves 988 as new three-digit suicide prevention hotline,” USA Today, July 16, 2020, https://tinyurl.com/y6jdruls. Months after the initial proposal was introduced, the Federal Communications Commission approved a new three-digit telephone number for a suicide prevention hotline.

Cummings, Caroline , “Iowa's mental health regions welcome federal boost, but say long-term funding is essential,” CBS-2 Iowa, July 8, 2020, https://tinyurl.com/y3ol3l9v. Iowa Gov. Kim Reynolds allocated $50 million in federal money for mental health services, but health professionals say a longer-term state funding boost is needed because Iowa's mental health system has been ranked one of the worst in the country.

Holman, Gregory J. , “Parson administration announces new agriculture, mental health funding to address pandemic,” Springfield News-Leader, July 22, 2020, https://tinyurl.com/y4cqqoxk. Missouri Gov. Mike Parson directed $10 million in federal funds from the Cares Act to help health care providers address mental health and substance abuse problems.

Health Care Workers

Kehres, Elle , “NC Launches Mental Health App ‘Heroes Health’ to Support Frontline Workers,” Chapelboro.com, July 16, 2020, https://tinyurl.com/y3649xwq. A new app developed at the University of North Carolina sends weekly surveys to health care workers to monitor their mental health.

Kent, Kandra , “Portland doctor pens op-ed about COVID-19's mental toll on frontline healthcare workers,” Fox 12-Oregon, July 21, 2020, https://tinyurl.com/y5zhmc5y. A Portland emergency physician spoke out about mental health struggles medical professionals are experiencing during the pandemic and how seeking treatment could have professional consequences.

Steinberg, Jake , “As Arizona cases surge, health care workers suffer ‘emotional exhaustion,’” Arizona Public Media, July 1, 2020, https://tinyurl.com/y44pnolb. Some health care professionals say they are facing lower levels of trust from the public due to political debates over pandemic mitigation measures, and such attitudes may be aggravating the workers' emotional exhaustion.

Post-Traumatic Stress Disorder

Kupfer, Dina , “Pandemic PTSD: Tips To Manage Stress Brought On By Coronavirus Pandemic,” CBS13 Sacramento, https://tinyurl.com/y4k3hgxk. The pandemic could bring past traumas back to the surface for those struggling with post-traumatic stress disorder (PTSD).

Triggle, Nick , “Coronavirus: Survivors ‘at risk of PTSD,’” BBC, June 29, 2020, https://tinyurl.com/y2y7ueo2. A group of British medical experts has recommended that patients hospitalized for coronavirus be regularly screened for PTSD.

Wayland, Michael , “‘I still have nightmares every night’ — health workers struggle with PTSD symptoms as coronavirus takes toll,” CNBC, June 27, 2020, https://tinyurl.com/ybsoh32b. Some physicians report PTSD-like symptoms after having to make life-or-death decisions while feeling overwhelmed with patients.

Technology

Marek, Matt , “With National Crises Harming Mental Health, Technology Provides Hope,” Milwaukee Community Journal, July 8, 2020, https://tinyurl.com/yybwhwa9. Internet support groups can help people feeling isolated during the pandemic by allowing them to connect with others who are experiencing similar struggles.

Ohlheiser, Abby , “The online battle for the mental health of service workers,” Technology Review, July 16, 2020, https://tinyurl.com/ycoqo7xj. Service workers support each other and try to overcome work-related stress on TikTok and Facebook, sharing stories and videos of belligerent customers, many of whom refuse to wear masks in public.

Ovide, Shira , “Health Care Comes to Us,” The New York Times, July 22, 2020, https://tinyurl.com/y3ps9e4t. The transition to virtual appointments has made mental health care more accessible than ever, but those without good internet access may still struggle.

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Contacts

Anxiety and Depression Association of America
8701 Georgia Ave., Suite 412, Silver Spring, MD 20910
240-485-1001
adaa.org
Organization representing 1,800 mental health providers; focuses on research into the prevention and treatment of mental health disorders and provides education and training.

Center for Connected Health Policy
2520 Venture Oaks Way, Suite 180, Sacramento, CA 95833
877-707-7172
cchpca.org
Nonprofit that seeks to integrate telehealth into the health care system; provides technical assistance to a dozen federally funded regional Telehealth Resource Centers, as well as to state and federal policymakers, health care providers and the public.

Center for the Study of Traumatic Stress
Department of Psychiatry, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814-4799
301-295-2470 (director)
cstsonline.org
Academic organization dedicated to advancing research and training on the treatment of people exposed to trauma; provides COVID-19 resources for health care workers, families and others.

Centers for Disease Control and Prevention
1600 Clifton Road, Atlanta, GA 30329-4027
800-232-4636
cdc.gov
Federal agency dedicated to the study of health, safety and disease-related security threats; provides research and policy guidance concerning COVID-19.

Mental Health America
500 Montgomery St., Suite 820, Alexandria, VA 22314
703-684-7722, 800-969-6642
mhanational.org
Mental health advocacy organization with 200-plus affiliates and associates nationwide.

National Alliance on Mental Illness
4301 Wilson Blvd., Suite 300, Arlington, VA 22203
703-524-7600, 800-950-6264
nami.org
Nonprofit group that advocates for mental health policies, organizes support groups and provides peer training and community education.

National Center for PTSD
U.S. Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC 20420
802-296-6300
ptsd.va.gov
Research and educational center that focuses on multidisciplinary initiatives to investigate the causes, diagnosis and treatment of post-traumatic stress disorder; offers COVID-19 resources for managing stress.

National Council for Behavioral Health
1400 K St., N.W., Suite 400, Washington, DC 20005
202-684-7457
thenationalcouncil.org
Association focused on treatment of mental health and addiction, with 3,326 member organizations serving more than 10 million people.

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Footnotes

[1] “COVID-19 Dashboard by the Center for Systems Science and Engineering,” Johns Hopkins University, accessed July 29, 2020, https://tinyurl.com/rnjqnnh.

[2] Lazaro Gamio, “How Coronavirus Cases Have Risen Since States Reopened,” The New York Times, July 9, 2020, https://tinyurl.com/yb2tb78c; Louis Jacobson, “Is A Second Wave of Coronavirus Coming?” Kaiser Health News, June 23, 2020, https://tinyurl.com/y6sp9r5c.

[3] “CVS Health commits to flattening the second curve of the COVID-19 pandemic,” press release, CVS Health, May 4, 2020, https://tinyurl.com/yynrhk2m.

[4] “New WBT & Robert Graham Center Analysis: The COVID Pandemic Could Lead to 75,000 Additional Deaths from Alcohol and Drug Misuse,” Well Being Trust, May 8, 2020, https://tinyurl.com/yyzwha3v.

[5] Alyssa Fowers and William Wan, “A third of Americans now show signs of clinical anxiety or depression, Census Bureau finds amid coronavirus pandemic,” The Washington Post, May 26, 2020, https://tinyurl.com/y28zxarf.

[6] “More Than 169,000 People Screen Positive For Depression Or Anxiety Since The Start Of The Pandemic,” Mental Health America, July 17, 2020, https://tinyurl.com/y4uuqu9f.

[7] Liz Hamel et al., “KFF Health Tracking Poll — May 2020,” Kaiser Family Foundation, https://tinyurl.com/y7m2h5xb.

[8] Brian Cheung, “The U.S. Economy is Officially in Recession,” Yahoo Finance, June 8, 2020, https://tinyurl.com/y9zx6g69.

[9] Gina Vivinetto and Scott Stump, “Family of New York ER doctor who died by suicide: Getting COVID ‘altered her brain,’” Today, April 30, 2020, https://tinyurl.com/yxrgrygp; Ali Watkins et al., “Top E.R. Doctor Who Treated Virus Patients Dies by Suicide,” The New York Times, April 27, 2020, https://tinyurl.com/yccsmzr6.

[10] “Mount Sinai Takes On Mental Health Impact of COVID-19 Crisis Among Health Workers,” NBC4 New York, April 30, 2020, https://tinyurl.com/y6dumdhb.

[11] James Fisher, “Are COVID-19 Patients at Risk for PTSD?” Psychology Today, April 4, 2020, https://tinyurl.com/yxtdjmvu; “PTSD Symptoms Common Among ICU Survivors,” press release, Johns Hopkins Medicine, Feb. 26, 2013, https://tinyurl.com/y2oepzuv.

[12] “Double Jeopardy: COVID-19 and Behavioral Health Disparities for Black and Latino Communities in the U.S.,” Office of Behavioral Health Equity, Substance Abuse and Mental Health Services Administration, undated, https://tinyurl.com/yyuyj82j.

[13] Cordilia James and Andrea Petersen, “A Growing Push to Treat Racism's Impact on Mental Health,” The Wall Street Journal, July 20, 2020, https://tinyurl.com/y4xxvdxw.

[14] Jesse C. Baumgartner, Gabriella N. Aboulafia and Audrey McIntosh, “The ACA at 10: How Has It Impacted Mental Health Care?” Commonwealth Fund blog, April 3, 2020, https://tinyurl.com/y275qjky; Sophia Majlessi, “Behavioral Health Crisis in America Getting Worse as COVID-19 Forces Community Behavioral Health Care Organizations to Cut Back,” National Council for Behavioral Health, April 16, 2020, https://tinyurl.com/y435c9ql.

[15] “How pandemics change society,” The Week, May 24, 2020, https://tinyurl.com/yxbvtyua; Evan Andrews, “Why Was it Called ‘The Spanish Flu?’” History, March 27, 2020, https://tinyurl.com/rmv6v9x; and Gillian Brockell, “Trump ‘didn't know people died from the flu.’ It killed his grandfather,” The Washington Post, March 7, 2020, https://tinyurl.com/r7e5c2r.

[16] Shawn Radcliffe, “Can We Learn Anything from the SARS Outbreak to Fight COVID-19?” Healthline, March 11, 2020, https://tinyurl.com/r4nh6b6; Knute Berger, “Seattle struggled with suicide in later stages of the 1918 flu,” Crosscut, May 7, 2020, https://tinyurl.com/yx8wo98v; and David Gunnell et al., “Suicide risk and prevention during the COVID-19 pandemic,” The Lancet, Vol. 7, Issue 6, June 1, 2020, https://tinyurl.com/y7d3ueh9.

[17] “WHO Timeline — COVID-19,” World Health Organization, April 27, 2020, https://tinyurl.com/y9q7q5pr; Bill Chappell, “Wuhan Reports New COVID-19 Cases — The City's 1st in More Than a Month,” NPR, May 11, 2020, https://tinyurl.com/ydx4nkv5; “COVID-19 Coronavirus Pandemic,” Worldometer, https://tinyurl.com/ub9gvyc; Jillian Mock, “Psychological Trauma Is the Next Crisis for Coronavirus Health Workers,” Scientific American, June 1, 2020, https://tinyurl.com/ybsbqxf5; Beth Ellwood, “Chinese youth show heightened symptoms of PTSD following coronavirus outbreak,” PsyPost, May 20, 2020, https://tinyurl.com/y5gtkao8; and “COVID-19 Dashboard by the Center for Systems Science and Engineering,” op. cit., accessed July 25, 2020.

[18] Alan J. Stein, “First confirmed case of COVID-19 in the United States is diagnosed in Snohomish County on Jan. 20, 2020,” HistoryLink, April 20, 2020, https://tinyurl.com/y5sa97g5; “Secretary Azar Declares Public Health Emergency for United States for 2019 Novel Coronavirus,” press release, U.S. Department of Health and Human Services, Jan. 31, 2020, https://tinyurl.com/y8qu5r2r; and Suzanne Rowan Kelleher, “45 U.S. States Shut Down And Counting — State By State Travel Restrictions,” Forbes, March 28, 2020, https://tinyurl.com/yy74ck6u.

[19] “Secretary Azar Announces Historic Expansion of Telehealth Access to Combat COVID-19,” press release, U.S. Department of Health and Human Services, March 17, 2020, https://tinyurl.com/y5cosn6e.

[20] Dennis Thompson, “U.S. Youth Suicide Rate Reaches 20-Year High,” US News, June 18, 2019, https://tinyurl.com/y4r42oyb; Linda Carroll, “Suicides and homicides on the rise in young people,” NBC News, Oct. 17, 2019, https://tinyurl.com/y6jnxqqy.

[21] Maggie Fox, “Major depression on the rise among everyone, new data shows,” NBC News, May 10, 2018, https://tinyurl.com/yyf98guy; “Alcohol and Drug Abuse Statistics,” American Addiction Centers, updated June 1, 2020, https://tinyurl.com/y6agblcp; and Nora D. Volkow, “Collision of the COVID-19 and Addiction Epidemics,” Annals of Internal Medicine, April 2, 2020, https://tinyurl.com/y28wq4w8.

[22] Chris McGreal, “‘Opioid overdoses are skyrocketing’: As Covid-19 sweeps across US an old epidemic returns,” The Guardian, July 9, 2020, https://tinyurl.com/y7czyzw8; “Issue brief: Reports of increases in opioid-related overdose and other concerns during COVID pandemic,” American Medical Association, July 20, 2020, https://tinyurl.com/y3plktgu.

[23] Julie Bosman, “Domestic Violence Calls Mount as Restrictions Linger: ‘No One Can Leave,’” The New York Times, May 15, 2020, https://tinyurl.com/y7tl9fpm.

[24] Alexandra Villarreal, “Surge in US gun sales and online searches raises fears of rise in suicides,” The Guardian, April 28, 2020, https://tinyurl.com/y5bjjrzd.

[25] Patrick J. Kennedy, “Mental health and addiction care are poorly covered by insurance networks,” Stat News, Dec. 10, 2019, https://tinyurl.com/rwecb6g.

[26] “Information On The CARES Act For People With Mental Illness,” National Alliance on Mental Illness, March 27, 2020, https://tinyurl.com/y4oomymf.

[27] “NAMI Calls On Congress To Respond To The Mental Health And Addiction Crisis Caused By The COVID-19 Pandemic,” National Alliance on Mental Illness, April 8, 2020, https://tinyurl.com/y532mdq9.

[28] “States Grappling With Hit to Tax Collections,” Center on Budget and Policy Priorities, June 4, 2020, https://tinyurl.com/y76s43pn.

[29] Shelley Starkey, “House Unveils COVID-19 Response Proposal,” National Council for Behavioral Health, May 15, 2020, https://tinyurl.com/yxma8zou.

[30] Ibid., “House Passes HEROES Act as Part of COVID-19 Response,” National Council for Behavioral Health, https://tinyurl.com/y6ksll97.

[31] Ramsay Touchberry, “House Democrats Narrowly Pass Another Massive Stimulus Worth $3 Trillion,” Newsweek, May 15, 2020, https://tinyurl.com/y92bcqu6; Jacob Jarvis, “Nancy Pelosi Criticizes Mitch McConnell's Call to Delay Second Stimulus: ‘Tell That to the Virus,’” Newsweek, May 29, 2020, https://tinyurl.com/y4wbb22z.

[32] Heather Poltrock, “Senate unanimously passes Sen. Baldwin's Suicide Hotline Bill,” WSAW Fox 7, May 14, 2020, https://tinyurl.com/yxckrx6f.

[33] Joyce Frieden, “COVID-19 Changes to Telehealth Rules Should Stick, Senator Says,” MedPage Today, June 17, 2020, https://tinyurl.com/y6jeq6lk.

[34] “Emmer Leads Bipartisan Letter to Leadership Requesting Extension of Mental Telehealth Care,” press release, office of Rep. Tom Emmer, U.S. House of Representatives, May 21, 2020, https://tinyurl.com/y468z5dq.

[35] Fred Schulte, “Coronavirus fuels explosive growth in telehealth — and concern about fraud,” Modern Healthcare, April 22, 2020, https://tinyurl.com/y2dmkw9e.

[36] Alison Durkee, “Trump Still Wants to Kill Obamacare, Pandemic Be Damned,” Vanity Fair, May 7, 2020, https://tinyurl.com/y3wvmjjz.

[37] Tami Luhby and Joan Biskupic,“Obamacare, Trump and the Supreme Court, explained,” CNN.com , May 6, 2020, https://tinyurl.com/yavhs5kh.

[38] Durkee, op. cit.

[39] Ibid.

[40] Douglas Belkin, “Nation's Top Mental-Health Official Warns Against a Second Lockdown,” The Wall Street Journal, May 21, 2020, https://tinyurl.com/y9vdlzx4.

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About the Author

Lorna Collier has written about mental health and other health-related topics for the American Psychological Association, the Chicago Tribune, Healthgrades.com , Chicago Health magazine, PBS Next Avenue, Discover.com , AARP Bulletin and many others.

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