Behavioral Health in America During the COVID-19 Pandemic: Meeting Increased Needs Through Access to High Quality Virtual Care

Mental Health in America During the COVID-19 Pandemic

Stress and worry are expected responses from real or perceived health threats and uncertainty. We know from 2 prior notable coronavirus events, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), that anxiety, depressed mood, and other mental health conditions may rise during and following an outbreak. ^4,5 Rapid synthesis of research from across the globe during the first several months of the COVID-19 pandemic has already documented significant increases in psychological distress worldwide, especially among females, younger age groups (< 40 years), those with chronic illnesses, and the unemployed. ⁵

In the U.S., mental illness prevalence was high even before the pandemic, affecting more than 1 in 5 (20.6%) U.S. adults in 2019. ⁶ However, as of November 2020, studies have demonstrated that almost 2 in 5 U.S. adults were living with anxiety or depression symptoms and the prevalence of substance use and suicidality have also increased, with no sign of abating. ^1,7 The public health measures instituted to control spread of COVID-19, such as physical distancing requirements and closure of workplaces and schools, as well as fear of exposure risk are contributing to social isolation, reduced physical activity, workplace strain, and may as a result be contributing to the higher rates of mental health issues seen in 2020. ⁸ This may be expected to continue as long as COVID-19 remains a threat and even for a time period after that.

In our experience at AbleTo, an organization that provides virtually-delivered behavioral health care and coached digital behavioral therapy across the U.S., we have witnessed higher severity of psychological symptoms among individuals participating in our clinical programs during COVID-19 compared to those participating prior to the pandemic. We have also observed high levels of work-related burnout in certain populations (e.g., health system employees) engaged in AbleTo digital behavioral therapy programs during the pandemic.

As with the physical health outcomes of COVID-19, the mental health impact of COVID-19 has disproportionately affected certain populations. ^{7 -9} Centers for Disease Control data show that members of diverse racial/ethnic communities, younger adults, essential workers, and unpaid adult caregivers reported worse mental health, increased substance use, and higher suicidal ideation versus their counterparts. ^1,7 And while barriers to mental health care have been seen across all age, sex, and race/ethnic groups, younger adults have been more likely than older adults to report high rates of symptoms as well an inability to access mental health services despite an identified need during the pandemic. ⁷

Virtually-Delivered Mental Health Care Overcomes Barriers

Barriers to, and disparities in, access to mental health care in the U.S. are not new problems. For decades, provider shortages, geographic challenges, cost, and other issues have meant that fewer than half (42.6%) of U.S. adults with a behavioral health condition received any treatment in the past year. ^6,10,11 For those who do receive treatment, finding treatment that is of high quality is an additional challenge. ¹² This means that, even pre-pandemic, far too many individuals with behavioral health conditions were not receiving needed treatment. COVID-19 brought additional challenges with in-person care posing risk of contracting COVID, new time constraints with many adults working from home and balancing parenting and home-schooling responsibilities, and additional strains on capacity given the increase in mental health prevalence during the pandemic.

Prior to the pandemic, we were already witnessing a shift toward acceptance of innovative approaches to delivery of behavioral health services. Telebehavioral health care (i.e., synchronous interaction with a licensed mental health professional by telephone or secure video) was increasingly being recognized as a solution to overcome access barriers by eliminating geographic and health system challenges such as clinician shortages. Delivering care in a private remote environment and making care available during non-working hours also has the advantage of overcoming barriers posed by stigma. ¹³ Telehealth can connect individuals to care quickly, reducing long wait times associated with care in the community. ¹¹ As such, virtual solutions of this nature were optimally poised to serve the increased mental health needs of patients that have arisen during the pandemic (Figure 1).

Amid COVID-19, rapid regulatory changes have further reduced barriers to accessing telehealth services. The Centers for Medicare and Medicaid Services (CMS) has issued waivers to increase access by health care provider type and geographic location, and invoked payment parity for tele-delivered services (versus in person) for Medicare members. Specifically, under these new waivers, Medicare can pay for mental health visits provided by licensed psychologists and clinical social workers via telehealth including in a patient’s home. ¹⁴ Additionally, the Health and Human Services office of the Inspector General has provided flexibility for health care providers to reduce or waive cost-sharing for telehealth visits paid for by federal health care programs, ¹⁴ thus reducing cost-related barriers to mental health care. A Medicaid Telehealth Toolkit has been released by CMS to support policy makers to navigate the complex state-level regulatory framework, and enable more rapid expansion of high quality telehealth services utilization. ¹⁵ These types of policy changes were designed with the intention of decreasing disparities in access to care; for example telehealth visits on a whole eliminate transportation barriers, and care delivered by telephone eliminates the need for stable internet. ⁹ Professional associations such as the American Psychiatric Association and the American Psychological Association have released practice guidance for delivery and billing for telehealth services to distil and disseminate these policy changes for providers and to the public. ^16,17

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Figure 1.

Barriers to behavioral health during COVID-19 overcome with virtual health care delivery.

Ease of access coupled with increasing acceptability and utilization of telebehavioral health care before COVID-19 has contributed to a rapid adoption of virtually-delivered mental health care over the past year apparent as early as the first months of the pandemic. The Department of Veterans Affairs, the largest health care system in the United States, reported a 556% increase in telebehavioral health encounters between March and April 2020 alone. ¹⁸ At our organization, we observed a significant increase in engagement in our telebehavioral health care services as early as April 2020 and across all age groups, health plan types, and U.S. regions. Clinician survey results from the American Psychiatric Association corroborate these utilization data and document more than 10-fold increases in the proportion of clinicians practicing via telehealth all or most of the time. ¹⁹

Digital mental health technologies are another virtual mental health resource that could help many due to ease with which they can be accessed at scale. ²⁰ The support provided by the numerous currently available mental health apps ranges from psychoeducation to self-guided therapy programs to evidence-based digital cognitive behavioral therapy supported by a coach. Like virtually-delivered behavioral health care, mental health apps also help overcome many of the barriers to mental health care noted above. As these solutions continue to evolve, focus should remain on ensuring they are high quality and evidence-based and integrated into a larger behavioral health solution set to meet the needs of patients across the spectrum of clinical need.

Virtually-Delivered Mental Health Care Is Effective to Improve Outcomes

While the rapid embrace of telehealth during the pandemic was borne out of necessity, there is indeed a rich evidence base demonstrating that virtual behavioral health delivery is effective and equivalent to face-to-face care in diverse populations and in a variety of settings. Virtual behavioral therapy has been demonstrated to be effective in treating depression, anxiety, post-traumatic stress disorder, and other common conditions. ²¹ When high quality virtually-delivered interventions are utilized in populations with medical comorbidities, clinical improvement in quality of life and chronic disease self-management behaviors can also be achieved, promoting reduction in avoidable hospital admissions. ^{22 -24} Improved workplace productivity outcomes, such as reduced absenteeism and presenteeism, have also been demonstrated. ^25,26 Achieving these outcomes associated with treating mental health conditions are all the more important during a time when preventive care and optimal lifestyle behaviors may be more challenging. For individuals undergoing existing mental health treatment who were concerned about risk of COVID-19 exposure, telehealth has also allowed for continuity of mental health care. That continuity is critical to mitigating adverse mental health outcomes that could have otherwise occurred as a result of delayed mental health and substance use treatment.

Simply shifting care from in-person to virtual does not guarantee quality care delivery, but utilization of technology platforms has the potential to actually maximize delivery of high-quality care by incorporating evidence-based protocol and practice guidelines. Technology platforms can also embed validated assessment tools to measure patient outcomes, enabling true measurement-based care and collection of additional patient data elements to identify high-risk patients in need of additional care resources and support care coordination efforts known to promote better mental health care outcomes. ¹² Organizations supporting virtual care delivery can further optimize quality by ensuring therapist workforce training, performance management, and continuing education. Accrediting bodies have taken the opportunity to establish quality standards for telehealth. As an example, URAC (Utilization Review Accreditation Commission) became the first independent, third-party national program to offer comprehensive oversight of telehealth programs, establishing a Telehealth Accreditation designed to evaluate key pillars of quality including data privacy and patient safety and recognizing telehealth organizations that uphold these quality measures. ²⁷

For the last decade, we have incorporated these key quality elements into our work at AbleTo to ensure the benefits of telehealth can be truly realized and that we can deliver meaningful clinical outcomes for patients. Having a standardized platform with high-touch interactions with our national provider community proved particularly advantageous during the pandemic when we were able to deploy COVID-19 specific resources and care planning guidelines, along with training and standardized pulse surveys to gauge therapist needs and trends in patient concerns and challenges. During COVID-19, these established capabilities enabled us to quickly address behavioral health needs of patients across the nation and to drive clinically meaningful outcomes across a diverse patient population. For example, in a cohort of 2,356 adults with depression symptoms consecutively enrolled in AbleTo programs between April 1 and June 30 2020, mean reduction in symptom severity was greater than 50% overall and within demographic subgroups after ∼8 weeks of telebehavioral therapy (Figure 2).

Like telebehavioral healthcare, digital mental health apps are also positioned to improve the behavioral health symptoms affecting many during the pandemic. The need for more research on effectiveness of app-based programs to improve behavioral health has been acknowledged, as have features that distinguish the more efficacious apps. Quality features include apps that are cognitive behavioral therapy-based, address both anxiety and low mood, and are designed for non-clinical populations. ²⁸ These quality features are incorporated into AbleTo’s digital cognitive behavioral therapy solution, which is designed to address depression, anxiety, and social anxiety. All users have the support of a coach, which has also been associated with increased adherence and efficacy versus digital programs without human support. ²⁹ With mental health apps, one size does not fit all. OneMind PsyberGuide and the American Psychiatric Association have each published resources to inform mental health app selection for individuals, clinicians, and organizational leaders. ^30,31

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Figure 2.

Observed reductions in depression symptoms after telebehavioral therapy during COVID-19.

Health and Well-Being Leaders Can Improve Access to High Quality Behavioral Health Care During COVID-19

Mental health has been and should remain top of mind for organizational health and well-being leaders given rapid changes to life and work arising during the COVID pandemic. Working-age adults are facing new challenges as the lines between work and home life have become more blurred. Income and job loss due to the pandemic have created new stressors and have been linked to depression and anxiety symptoms, as well as changes in sleep and dietary habits and increased substance use. ⁸

Health and well-being leaders have an opportunity to positively impact the long-term physical and mental health of the nation by optimizing mental health and well-being through culture and resources available in the workplace and in communities. ^32,33

Workplace best practices associated with employee mental health and well-being were recently highlighted in a report by the Health Enhancement Research Organization (HERO; 33) and include:

Raise awareness about the importance of mental health and available mental health benefits. This is a vital step toward reducing stigma and may be most effective coming from senior leadership.

Each of these best practices has the potential to be positively amplified through increased awareness and by making evidence-based virtually delivered mental health solutions available and accessible to employees. These efforts are especially important to address the higher level of need seen during the COVID-19.

Future Directions

The COVID-19 pandemic has brought uncertainty, stress, and anxiety, coupled with public health measures that necessarily lead to social isolation. We are witnessing significant rates of mental health conditions and expect this trend to continue for the foreseeable future. Virtually-delivered behavioral health care is well established as an effective treatment modality, but there is still work that can be done to make it easier for those with behavioral health needs to identify high quality care and access it in a timely manner. Regulatory changes during the pandemic have made it easier for providers and individuals to engage in virtually delivered care; it is the hope of many mental health care providers and professional organizations that these positive changes potentially associated with increased access to timely care, be made permanent. Health and well-being leaders play a vital role in reducing stigma and promoting care solutions through clear communication and an organization-wide well-being culture that prioritizes mental health. Connecting individuals with high quality mental health care, including virtually delivered solutions, during COVID-19 and beyond may help mitigate adverse workplace and health outcomes associated with untreated mental health conditions.