By Peggy Johnson, MD, VP and Chief of Psychiatry at Commonwealth Care Alliance®
The need for behavioral health services has always outpaced availability. Over the past several decades, we’ve had a persistent shortage of psychiatrists, therapists, and other behavioral health providers1. While this is especially true in remote areas, there is an overall lack of resources to meet growing demand. Access and affordability are also major hurdles to overcome when managing behavioral health needs, and pre-COVID guidelines that required services to be delivered face-to-face further reduced access for individuals who could not see providers in traditional office settings.
The barriers to finding, accessing, and affording mental health services have been especially devastating to the most vulnerable individuals among us—those living with significant medical, behavioral, and social support needs. These gaps have led to inefficient, siloed care that often prioritizes high-cost physical needs while deemphasizing the biological and emotional impact of mental health on quality of life. The COVID-19 pandemic exacerbated these gaps while shining a brighter light on the need for fully integrated, holistic care.
Addressing the mental health crisis in the U.S. will require transformational change across the healthcare continuum. By delivering integrated, consumer-centric care, reducing mental health stigmas, and forging stronger partnerships between payers and providers, we can begin to build a strong foundation for this change.
Mental health can be an important factor influencing a patient’s morbidity and mortality. Individuals with significant clinical needs are at higher risk when also managing behavioral health diagnoses. For example, a patient who has heart disease and depression is at statistically higher risk than someone who has heart disease but not depression2. The correlation between physical and mental health is even more profound when a patient is living with a severe behavioral health condition, which can reduce life expectancy by 10-25 years3.
Social determinants of health also impact an individual’s mental and physical well-being. This is especially true for individuals who are dually eligible for Medicare and Medicaid, since these populations may often deal with myriad illnesses, disabilities, substance use disorders (SUD), and/or limited financial means. For example, extreme and persistent stress associated with significant financial constraints can lead to increases in epinephrine levels, which can in turn damage blood vessels, increase blood pressure, and lead to adverse events, such as a heart attack or stroke. This level of stress can impact anyone at any stage of life, but can be especially devastating for our senior population living with chronic conditions.
While the underlying connection between mental and physical health is clear, siloed care persists. Although most clinical guidelines today require a behavioral health assessment as part of an annual wellness checkup, for individuals who have complex medical needs, behavioral health is not always prioritized. Additionally, individuals with both mental health and substance use needs may not receive the integrated care that is necessary to improve overall health and quality of life. Many outpatient clinics focused on mental health do not sufficiently manage SUD, while those focused on SUD may not know how to care for people with co-occurring mental health diagnoses. This disconnect emphasizes the need for integrated care.
As demand for mental health services spiked due to the pandemic, COVID-19 further limited access and availability for those in need of treatment. During the early days of state-mandated quarantines, mental health services were considered non-essential. Even life-saving programs, such as those geared toward suicide prevention, were disrupted. Additionally, many suffering from SUD who needed community-based rehabilitation services could not access these facilities due to social distancing requirements and capacity limitations.
According to the World Health Organization, the global prevalence of anxiety and depression increased by 25% during the first year of the pandemic4. There were over 100,000 deaths caused by drug overdose during the first year of the pandemic alone—nearly 29% higher than the previous year5, as reported by the Center for Disease Control.
Although restrictions have started to lift across the country, a pre-COVID-19 gap in access still exists.
As the pandemic slowly becomes endemic, the mental health crisis will continue. As the Chief of Psychiatry at Commonwealth Care Alliance® (CCA), an integrated healthcare organization specifically focused on individuals with significant needs, I’ve seen the impact that the shortage of mental health services has on our most vulnerable populations. Solving the mental health crisis long-term will require a deeper appreciation for the biological, societal, and cultural factors that drive behavioral health disorders. It will also require changes in how we coordinate and deliver care.
To build this foundation for change, we must:
Addressing the mental health crisis, especially for individuals with significant needs, will not be easy. Although there are no quick fixes, the pandemic forced us to implement new rules, guidelines, processes, and technologies and increased motivation for change. By building on this existing foundation and focusing on delivering fully integrated, holistic care, we may be on our way to a sustainable solution.
1 Mental Health Care Health Professional Shortage Areas (HPSAs) | KFF