Addressing Mental Health and Substance Use Disorders Amid and Beyond the COVID-19 Pandemic

Pre-pandemic, the prevalence of mental illness was estimated at 1 in 5 adults, ¹ and the US was facing an opioid epidemic. ² Despite the high prevalence of mental health concerns and substance use disorders, numerous barriers to treatment and systematic limitations, including a shortage of professionals, limited access, lack of adequate funding, and stigma meant that as many as 70% of people with these conditions never sought treatment. ^3,4

The cumulative and profound physical, psychological, economic, and social toll of the COVID-19 pandemic has exacerbated the mental health and substance use crisis in America. ⁴ As Czeisler et al. comprehensively outline in the opening article of this issue of Knowing Well, Being Well, there has already been a very significant adverse impact on mental health. By mid-July, more than 50% of American adults reported that the worry or stress related to the coronavirus had negatively affected their mental health. ¹ One in 3 adults now report experiencing symptoms of anxiety or depression. ¹ More than 40 states have experienced increases in opioid-related mortality, ⁵ and drug overdoses in the U.S. may reach an all-time high in 2020. ² There are also new barriers to treatment. ¹ The pandemic exacerbated the shortage of mental health professionals ¹ and disrupted treatment and recovery programs for substance use. ²

Former U.S. Representative Patrick Kennedy, a long-time advocate for mental health care, said “This pandemic will fuel the fire of our country’s mental health crisis unless organizations unite in a call to action. There’s no more time for debate and discussion–we need all hands on deck to fast track the strategies we know will work.” ⁶

Indeed, for many employers, increased mental health concerns amid the pandemic underscored the need to ensure more comprehensive benefits and programs and adequate communications about them, as well as a culture that supports taking advantage of those services. ^7,8 Although nearly 80% of employers offer an Employee Assistance Program (EAP), only 10% of employees use it. ⁷ In response to a survey conducted in April of this year, 65% of employees reported that they did not believe that their employers offered programs or services to support or improve their mental well-being. ⁷ Another recent survey indicated that 69% of employees reported that it was safer to remain silent about workplace stress at their company. ⁹ In their article in this issue, Mochari-Greenberger and Pande summarize the recent report by the Health Enhancement Research Organization ¹⁰ on best practices in employee mental health and well-being, which include raising awareness about the importance of mental health and available services. Ideally, employers will not silo mental health but will instead build it as a critical component of the culture of their organizations ⁸ —ensuring it is visibly supported and that senior leadership stresses the importance of mental health and the programs available ¹⁰ to increase awareness and decrease stigma. ⁸ Sumner et al. provide a compelling argument in their article for integrating mental and physical health.

It is also imperative to train managers to recognize and handle mental health concerns. ⁸ On average, only 25% of U.S. managers have received such training, and more than 50% are unsure about how they would provide assistance to a colleague who approached them with a mental health concern. ⁷ Mental Health First Aid, a public education program that enables non-mental health professionals to identify and respond to individuals exhibiting signs of a mental illness or substance use disorder, ¹¹ may be a promising training tool for managers in some organizations. Research indicates that the curriculum can increase mental health literacy, reduce stigma, and increase intention to and confidence for carrying out helpful actions (e.g., listening, offering emotional support, identifying possible sources of support). ¹¹

The provision and support of services by employers is an important first step in addressing mental health concerns and substance use disorders. Equally important are the quality of and access to those services. One promising approach to reducing barriers to treatment is to provide access to mental health care remotely. The rapid transition to telemedicine amid the pandemic may help address access issues for mental health care ⁴ and treatment for opioid addiction. ¹² As Mochari-Greenberger and Pande describe in detail later in this issue, AbleTo, a provider of virtually-delivered behavioral health care and coached digital behavioral therapy, has developed a robust, evidence-based virtual mental health services platform to accomplish that goal. Other mental health benefit providers have also modified or expanded services to meet the needs of now a predominantly remote workforce. ³ Talkspace, an online therapy company, had a 65% increase in client demand from February to May of 2020. ⁴ Digital mental health solutions have been identified as another potential catalyst for the transformation of behavioral health care and a critical component of benefits packages. ⁹ As Mochari-Greenberger and Pande underscore, it is essential to evaluate the efficacy of mental health apps. One resource for doing so is the One Mind PsyberGuide, a website developed by Dr. Stephen Schueller that reviews mental health apps. ¹³

There is also an urgent need to remove barriers to and stigma surrounding evidence-based treatment for individuals with a substance use disorder. ⁵ Mendell’s article recounts how his personal tragedy inspired a national movement to end stigma, raise awareness, and transform addiction treatment in the U.S. via rigorous quality measurements and assessments.

Employer’s efforts to address mental health are increasingly supported by local and national initiatives. Leveraging their role as a gathering place and community hub, many libraries are educating staff and their patrons about mental health and substance use. ¹⁴ Some librarians have been trained in mental health first aid, and other libraries are teaming up with mental health professionals to offer workshops and education (e.g., training in naloxone) and/or hiring social workers. ¹⁴ Nationally, the Action Alliance’s Mental Health & Suicide Prevention National Response to COVID-19 is a public-private partnership dedicated to creating sustainable change in mental health and suicide prevention. ⁶ Among their 6 priorities is ensuring equitable delivery of comprehensive and effective suicide prevention and mental health services for members of diverse racial and ethnic groups; LGBTQ individuals; and others disproportionately impacted by the pandemic. The focus on historically disadvantaged communities is crucial given persistent disparities in treatment-seeking; the fact that stigma may be an even larger barrier to treatment seeking among these groups; and ongoing concerns about the representativeness and cultural competence of treatment providers. ¹⁵ All too often, law enforcement is called upon for mental health emergencies, which can have fatal consequences. Serious mental illness plays a role in more than 25% of fatal police shootings. ¹⁶ Absent from those statistics are other fatalities at the hands of police officers in response to mental health emergencies, illustrated this summer in the untimely death of Daniel Prude at the hands of police in Rochester, NY. ¹⁷ Mr. Prude was reportedly using illicit substances to cope with the death by suicide of his nephew in their shared home. ¹⁸ More effectively engaging the communities of color in mental health care will require culturally sensitive care (including more racial awareness) and significantly more diverse treatment providers. ¹⁷

As the articles in this issue reflect, the time to act is now, and investment in mental health systems will yield benefits that far outlast the Great Pandemic of 2020. Our COVID-19 response must include primary, secondary, and tertiary prevention and treatment for mental health conditions and substance use disorders with a particular emphasis on those most vulnerable. ¹⁹ And we can all model the appropriateness of seeking assistance. As Charlie Mackesy recently wrote in his best-selling The Boy, the Mole, the Fox and the Horse: ²⁰

“What is the bravest thing you’ve ever said?” asked the boy.

“Help,” said the horse.

“Asking for help isn’t giving up,” said the horse. “It’s refusing to give up.”