How COVID-19 lessons can transform US mental health care

By one estimate, as many people experienced serious psychological distress in just the first month of the pandemic as during the entire year before it began. Elevated rates of anxiety and depression have persisted, drawing new attention to the U.S. mental health system — including fault lines that have persisted for decades. 

Almost 20 years ago, the President’s New Freedom Commission took a hard look at mental health care and proposed solutions bearing an uncanny resemblance to those in circulation today: Expand telehealth to improve access to care, screen for mental disorders in primary care and launch a national campaign to reduce stigma and prevent suicides. While the U.S. health system has made other strides since then, those three recommendations represent points where COVID-19 might finally galvanize overdue change. 

Telehealth: In governors’ hands

Telehealth has been bandied about by policymakers for decades. A trove of evidence has shown that, for conditions such as anxiety and depression, it can be as effective as in-person care. Nevertheless, adoption has been incremental. Many private insurers decline to pay psychiatrists, psychologists and counselors at rates comparable to in-person visits, if at all. There are also gaps in available insurance billing codes.  

Enter COVID-19. When the U.S. Centers for Disease Control and Prevention cautioned against seeking non-essential medical services, mental health care plummeted. A survey by the National Council found that roughly 50 percent of interviewed behavioral health clinics had to lay off or furlough staff. 

In response, federal and state lawmakers temporarily bolstered telehealth — for example, allowing uses of videoconferencing platforms like Zoom, issuing new reimbursement codes to cover payment for telehealth, and establishing mandates that private health insurers must pay for telehealth services. 

As a result, the landscape of mental health services today looks remarkably different, with treatment by phone or videoconference a staple feature. But this progress could be lost. Absent some federal change, governors could dissolve mandates compelling private insurers to pay for telehealth. Will providers then continue to offer these services? Probably not. 

Integrating mental and physical health 

A longstanding priority of mental health advocates has been to ensure mental health and physical health care go hand-in-hand, including screening and treating mental health conditions in primary care — commonly called “integrated care.” Over the past 15 years, there has been overwhelming evidence these models work. University of Washington’s AIMS Center has documented over 90 randomized controlled trials showing that a version of this called the collaborative care model (CCM) improves both mental and physical health outcomes for patients. Cost analyses indicate that, for every $1 invested, there is a $12.75 return at the societal level. 

And yet few practices have implemented this model. Why? Because mom-and-pop health clinics operate much differently than academic medical centers where clinical trials typically take place. Asking smaller clinics to screen and treat mental health conditions affects everything from personnel to clinical workflow to billing systems. These upfront efforts, coupled with insufficient reimbursement rates, undermine the incentive to adopt integrated care. 

But COVID-19 has changed the conversation. Psychological distress, anxiety and depression — the secondary traumas of the pandemic — are affecting millions of Americans. In surveys, four in 10 adults reported elevated anxiety or depression during the past week. This level of need suggests that screening for mental health conditions should be as commonplace as measuring patients’ blood pressure.  

Combatting stigma, starting in schools

Rates of suicide among adolescents and young adults have increased by more than 50 percent over the past decade, despite efforts to destigmatize mental illness and thereby increase treatment seeking. Over the same period, one-off anti-stigma campaigns produced a mixed bag of results. A 2018 review by the National Academy of Sciences concluded, “because [these] efforts are largely uncoordinated and poorly evaluated, they cannot provide an evidence base for future national efforts.” 

An alternative vision is one in which children and adolescents receive consistent exposure to anti-stigma messaging. Schools are an excellent place to start. The most robust studies indicate that school-based mental health awareness programs are associated with improvements in mental health knowledge, attitudes and willingness to seek treatment. However, a minority of states currently have a mental health curriculum required by law, and the scope, scale and content of these curricula vary widely. 

In 2018, New York became one of the first states to institute a K-12 mental health education curriculum. The federal government could consider providing guidance on minimum standards for mental health education like those established by New York, fund and support curriculum development, and provide materials for dissemination through the Department of Education. 

In the wake of COVID-19

Over the past few weeks, Congress held hearings on ways to improve mental health care in the wake of the pandemic. Where the New Freedom Commission came up short 20 years ago, Congress now has an opportunity to make transformative changes today. 

There are several tangible next steps it could take. They include shoring up the advances in telehealth — at the very least a permanent extension of payment parity. If these mandates are rescinded, we will lose a valuable tool for reaching underserved communities. Investments in broadband infrastructure go hand-in-hand with this strategy. 

Federal agencies like the Centers for Medicare and Medicaid Services also could examine hurdles for care integration models like CCM. If the root cause for poor adoption is the practice transformation required, the Biden administration could consider an initiative similar to the Transforming Clinical Practices Initiative, through which thousands of clinical practices overhauled their payment systems. 

Lastly, states like New York are providing a blueprint for weaving anti-stigma campaigns into the fabric of our education system. With the return of millions of students who have been socially isolated while out of school, there is no time like the present to consider bolstering mental health literacy. 

It would be a powerful conclusion to the COVID-19 pandemic if, in the wake of the destruction caused by the virus, Americans reimagined a health system that was resilient against future threats — including the resulting psychological trauma. Policymakers have the opportunity now to cut short the pandemic’s long tail of mental illness by taking decisive action.  

Ryan K. McBain is a policy researcher at the nonprofit, nonpartisan RAND Corporation. He focuses on the design and evaluation of health policies and programs meant to reach vulnerable populations — including those coping with mental health conditions, HIV/AIDS, homelessness and poverty.