The Mental Health Crisis: The Impact On Our Most Vulnerable Populations  

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.

How Mental Health Impacts Physical Health

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.

How COVID-19 Escalated the Mental Health Crisis

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. 

Building a Foundation for Transformational Change

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:

• Meet patients where they are: The COVID-19 pandemic forced monumental changes that gave patients greater flexibility. The adoption of telehealth enabled providers and patients to connect during lockdowns and helped providers reach patients who traditionally struggled with in-office visits due to disabilities, clinical conditions, lack of transportation, or other factors. By continuing to provide greater flexibility (with telehealth, in-home visits, and night and weekend appointments), we can begin to close the access gap.  
• Deliver integrated care: Integrated care entails evaluating medical, behavioral, and social support needs simultaneously to ensure holistic care that improves not only health but also quality of life. The exacerbated mental health crisis caused by the pandemic further demonstrated the imperative to fully evaluate a patient’s comprehensive needs. For instance, while some of our nation’s most vulnerable populations—older adults with chronic conditions—were forced to stay vigilant and guard their physical health over the past two years, for many, their mental health suffered. This ultimately may have led to further progression of their pre-existing medical conditions. By delivering fully integrated care, clinicians could have minimized this impact by offering the emotional support needed for better medical outcomes.
• Build strong relationships between payers and providers: To address the affordability and availability factors, payers and providers must align on a shared mission to make behavioral health services accessible to all. This means building strong relationships, reassessing payment structures, aligning on quality outcomes, and eliminating barriers to patient care. 
• Improve care coordination and delivery for substance use disorders: The ever-growing opioid crisis hit new highs during COVID-19⁵, exposing gaps in service that telehealth could not mitigate. Historically, substance use disorders have also been misunderstood and sometimes improperly treated. Since these conditions are considered mental disorders, many, even in the clinical community, lack true appreciation for the causal biological factors. To address this particular crisis, we need better education for all stakeholders and proactive evaluation of causes and symptoms.
• Reduce stigma by normalizing mental health needs: While physical illnesses can be tangible—with symptoms that are easy to see and feel—mental health illnesses are sometimes “invisible” to the untrained eye. Also, historically, people with severe behavioral health disorders have suffered discrimination and marginalization due to cultural and societal biases. By normalizing and humanizing the need for a healthier state of mind, we can reach even more individuals who desperately need these services. Reducing this stigma begins with proper education about mental health issues and a stronger relationship between patients, providers, and health plans. 

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.