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What Comes After the Acute Phase of COVID19: Is a Mental Health Pandemic Inevitable?

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The COVID19 crisis has brought to light, often in very personal and immediate terms, the inequities of the healthcare marketplace.  From difficulties in getting third party insurors and the Centers for Medicare and Medicaid Services (CMS) to pay for telepsychology (including therapy conducted via telephone, which just earlier this month CMS allowed with retroactive billing to March 1), to uncertainties about the personal safety of patients and colleagues when dealing with the virus, the pandemic has vividly highlighted the shortcomings of the American healthcare delivery system.  In a finding that is entirely predictable, minority patients are both suffering the brunt of the viral illness and are also facing some of the highest costs – which may not be covered by third party insurors. Complicating the already severely stressed healthcare delivery system is the possibility that a mental health pandemic will occur in the wake of the viral pandemic.  In this column I will address the probability of a post-virus mental health pandemic.  In my next column I will offer some suggestions about how to rectify the vulnerabilities in our healthcare system that the virus has exposed.

Can we expect a mental health pandemic to follow the infectious phase of the pandemic?  While it is wise to prepare for such an eventuality, prior pandemics provide only limited predictive knowledge.  On the positive side of the ledger, we have few earlier pandemics to guide our planning. Although pandemic illness has, of course, been a part of the human landscape for millennia, in times past we did not consider the mental health consequences of mass illness in mental health planning.  Recent changes to the geopolitical landscape brought about by pandemic illness have incorporated more systemic mental health responses.  Here we have the experience from regional pandemics involving SARS, Ebola, and various strains of influenza as well as human caused disasters such as 9/11.  Human-caused disasters have resulted in surges in demand for mental health services, as have conflicts such as the Long War in Iraq and Afghanistan, but in general the mental health response to mass illness seems different than that to crises of human origin.

In broad terms, history seems to tell us that mental health sequelae of natural or human caused disasters tend to be limited both in terms of scope and geography.  First responders can be overwhelmed by dealing with high mortality and morbidity and can develop acute stress responses including anxiety and depression.  Medical and rescue personnel are highest risk for development of mental illness both during the acute and the recovery phases of crises, particularly nurses whose contact with ill patients is often prolonged.  Insomnia is a common complaint and may be a leading indicator for development of more significant symptoms, and suicide is a rare but present threat when acute stress reactions occur.  But syndromic responses such as a major depressive episode or brief reactive psychosis are rare, and while estimates vary, only a minority of first responders display severe psychological symptoms.  Such symptoms appear to be most prevalent in the midst of a response, though data from the SARS regional pandemic suggest that post-disaster symptoms persisted in a significant number of first responders who developed symptoms in the acute response period. A widely reported but poorly studied consequence of disaster intervention is the phenomenon of vicarious traumatization or compassion fatigue.  Although this term has achieved currency among first-line responders and psychotherapists and the concept has some appeal, research into vicarious traumatization is uneven.  Unsurprisingly, it is perhaps best studied in nurses, but estimates of prevalence and risk are difficult to determine, though reports of vicarious traumatization in COVID nurses have already appeared in the literature.  

While an epidemic of mental illness is, in my judgment, unlikely, our colleague Ben Miller has also raised an alarm that we may be facing a wave of “deaths of despair” in the wake of the acute phase of the pandemic. Noting that such deaths increased in the wake of the Great Recession, Miller and his co-authors suggested we might anticipate an additional 75,000 deaths in the coming decade from suicide, drug and alcohol abuse among those who are economically and psychologically affected by the virus, with highest risks associated with unemployment, isolation and uncertainty.   

Other soft indicators suggest that mental health planners would be wise to be prepared for an increased incidence of mental health issues in the months following the acute phase of the pandemic, even though a mental health pandemic seems improbable.  A recent survey from a large pharmacy benefits manager (ExpressScripts) found a 21% increase in new prescriptions for antidepressants, anxiolytics and sleep medications in the first month of the pandemic.  Strikingly, 78% of these prescriptions were for patients who had not been prescribed such agents in the past.

These data should be interpreted with caution.  A prescription for an anxiolytic or antidepressant does not mean that the patient has an established depressive or anxiety spectrum disorder.  Such medications, like sedatives, are likely being prescribed for acute stress responses, perhaps because access to mental health providers was particularly constrained early in the pandemic and medication was more expedient to obtain.

Nevertheless, mental health providers should be sensitive to the development of symptoms, particularly among those who are first responders or who have suffered losses due to coronavirus.  As Miller warns, those who have suffered the effects of uncertainty, economic loss and isolation may be the most vulnerable.

According to the Kaiser Family Foundation, over half of all individuals surveyed reported at least one new mental health symptom since the pandemic began. Symptoms include insomnia, increased alcohol use or eating problems and increased worry or stress, particularly among healthcare workers. 

This poll, conducted in late April, reports that over half of Americans who were employed on February 1 have subsequently lost a job or have seen their hours reduced, making it difficult for them to pay credit card bills or medical expenses.  This scenario creates a near term catastrophe for many families -wage-earners have lost their source of income, and, since most health insurance in this country is tied to employment, they are at high risk of losing health insurance as well. 

In brief, we anticipate that there is likely to be a hierarchy of symptomatic responses to COVID19 that roughly corresponds to the level of involvement in the acute phase.  First responders and direct healthcare personnel are most likely to express a syndromic response either immediately or after a period of time.  Patients and those close to patients or the deceased are also at risk.  Those who suffer non-medical consequences, such as loss of livelihood or income, may be at risk for symptoms of despair.  Psychologists should be aware of this likely hierarchy, and while we anticipate that most coronavirius mental health symptoms are situational and will resolve spontaneously, we can also predict that a significant minority will develop into full-blown syndromes requiring intervention. 

But if a family has lost its health insurance, how are we to provide?  As a profession, we should call upon policy makers to compel third-party payors to make available low or no cost-mental health services to those most likely to be affected – minority workers, low income wage earners, and those who have been directly affected via illness, personal loss, or the effects of isolation.  Extension of job-related healthcare coverage for those newly unemployed should be mandated.  Copays and out of network billing should be suspended.  Insurors should invest in public awareness campaigns regarding COVID related suicide and substance abuse, and treatment for substance abuse should be expanded as should screening for all mental health, particularly in community health centers and other centers serving the unemployed and disadvantaged.  As Ben Miller reminds us, despair is a killer, and even though patients may not display symptoms consistent with diagnosable disorders, each of us should be aware of the insidious effects of unemployment, isolation, and loss. 

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