COVID-19

The COVID-19 Pandemic

COVID-19, the disease caused by the SARS-CoV-2 virus, reached pandemic status early in 2020 and has contributed to a behavioral health crisis. Due to worry and stress over COVID-19, people are having difficulty sleeping and eating, and their chronic conditions are worsening.1 The fear, isolation, and disruption of normal activities that people are experiencing due to COVID-19 have contributed to increased depression, anxiety, and substance use.2 The pandemic has also created barriers to treatment and care for people with mental health and substance use disorders (SUDs).3

The need for behavioral health treatment services is growing. Most behavioral health organizations have seen an increase in demand for services.4 An estimated 75,000 additional people could die of suicide and alcohol or drug misuse if we cannot address the behavioral health impact of the COVID-19 pandemic effectively.5

Implementing integrated behavioral health care in primary care and other ambulatory care practices is a promising strategy for addressing this need. Telehealth and other technologies can provide valuable tools for increasing access to integrated behavioral health services during the pandemic.

This page provides information on the:

  • Impact of the COVID-19 pandemic on the behavioral health of the general public and healthcare workers.
  • Impact of SUDs on COVID-19 outcomes.
  • Barriers to behavioral health treatment the COVID-19 pandemic has created.
  • Use of telehealth and other technologies to advance integrated behavioral health during the COVID-19 pandemic.

Impact of COVID-19 on Behavioral Health

The financial, economic, and educational disruptions caused by the pandemic, as well as concerns about contracting COVID-19 and difficulty accessing healthcare, are adversely affecting people’s mental health and substance use.

  • Over 13 percent of U.S. adults reported serious psychological distress in April 2020, compared with 3.9 percent in 2018.6
  • U.S. adults have reported elevated symptoms of anxiety, depression, stress, and trauma since the onset of the pandemic.2
  • Compared with 2019, the percentage of mental health-related emergency department visits for children ages 5–11 and 12–17 increased by 24 percent and 31 percent, respectively.7 
  • Primary care clinicians are reporting an increase in patients with mental health concerns and substance misuse during the COVID-19 pandemic.8
  • In June 2020, 13.1 percent of U.S. adults reported starting or increasing use of substances.2
  • Positive tests for heroin and nonprescribed fentanyl have increased. Use of nonprescribed fentanyl increased significantly for those with positive tests for amphetamines, benzodiazepines, cocaine, and opiates.9 
  • Reports of nonfatal and fatal overdoses have increased during the pandemic.10,11,12

The pandemic is also affecting the mental health of nurses, doctors, therapists, paramedics, physician assistants (PAs), lab technicians, and other healthcare workers in the United States.

  • Over 75 percent of healthcare workers reported experiencing stress, anxiety, or burnout.13
  • Nearly 60 percent (57 percent) of primary care clinicians reported health declines from stress and fatigue during the pandemic.8
  • More than three-quarters (78 percent) of psychiatrists reported high levels of burnout before the pandemic,14 and psychologists and psychiatrists are reporting more burnout due to the pandemic.15

Impact of Substance Use Disorder on COVID-19 Outcomes

For people with SUDs, the mental health effects of the pandemic may trigger relapse and intensify substance use, and substance use can increase risks associated with coronavirus infection.16,17,18 People with SUDs are more likely both to develop COVID-19 and experience worse outcomes (e.g., hospitalization and death) than those without SUDs. Of people with SUDs, those with opioid use disorder (OUD) are the most likely to develop COVID-19.19

Barriers to Behavioral Health Treatment

The financial and economic stressors of the COVID-19 pandemic and the social distancing and shelter-in-place precautions to mitigate the pandemic have created several barriers to behavioral health care and treatment, including:

  • Loss of income, employment, and health insurance coverage;3
  • Reduced capacity and closure of mental health and substance use treatment facilities;3,4
  • Reduced capacity for harm reduction services;19,20 and
  • Disruption of public transportation services.3

The pandemic has worsened the existing lack of capacity to meet behavioral health needs, with 64 percent of counties in the United States reporting a shortage of mental health providers.21

Prepandemic, the recruitment and retention of behavioral health providers was difficult due to low wages, limited benefits, small reimbursement amounts, heavy caseloads, and stigma of mental health and substance use. Behavioral health training was lacking for primary care physicians, registered nurses, and PAs, and collaboration was insufficient among hospitals, community mental health centers, and other community organizations.22

The pandemic has further strained the behavioral health and primary care workforces:

  • More than one-quarter (26 percent) of behavioral health organizations have laid employees off.4
  • About 43 percent of behavioral health organizations have reported decreased hours for staff.4
  • More than half (54 percent) of behavioral health organizations have closed programs.4
  • One-quarter of primary care clinicians have permanently lost practice members.8
  • About 41 percent of primary care clinicians have unfilled staff positions.8
  • About 44 percent of primary care clinicians have had salary cuts.8

Use of Telehealth and Other Technologies to Advance Integrated Behavioral Health During the COVID-19 Pandemic

Telehealth, Telemedicine, Telepsychology, and Telepsychiatry

To mitigate barriers to mental health and substance use treatment during the pandemic, the Centers for Disease Control and Prevention released guidance for increased use and coverage of telehealth. In addition, the Centers for Medicare & Medicaid Services (CMS) has expanded the flexibility of Medicare and Medicaid coverage for telephone and video health visits.23,24,25

Several resources can assist in expanding use of telehealth:

Medication-Assisted Treatment for Opioid Use Disorder via Telehealth

Federal agencies and States also relaxed prescription regulations and reimbursement procedures to enable the adoption, use, and coverage of telehealth for medication-assisted treatment (MAT) for OUD.24,26 Clinicians can use telemedicine for aspects of treatment that previously required an in-person visit (e.g., initiating buprenorphine and dispensing take-home methadone doses). In addition, patients can obtain larger supplies of the medications for OUD treatment.27 AHRQ has conducted a rapid review and found no difference in retention for OUD treatment when provided via telehealth versus in person.28

The Drug Enforcement Administration (DEA), SAMHSA, and CMS have released several guidance documents to assist in providing MAT for OUD via telehealth.

Virtual Recovery Support and Harm Reduction Services

Early in the pandemic, harm reduction services experienced decreased availability. Forty-three percent of syringe service programs (SSPs) reported a decrease in availability of services.19 Ten percent of emergency medical services (EMS) physicians reported that EMS in their area had discontinued intranasal naloxone.20

Some recovery support and harm reduction programs have adapted technologies to assist in providing virtual and socially distant services.

  • Twenty percent of SSPs are providing delivery-based services.19
  • Six percent of SSPs are providing mail-based services.19
  • Some harm reduction programs are providing curbside services or services via phone or internet (e.g., overdose prevention hotlines and virtual injection supervision).16,29
  • Peer support and recovery programs are providing virtual meetings.30

Limited resources and funding for behavioral health services have left some community mental health clinics, safety net hospitals, and private practices without the infrastructure needed to quickly adopt telehealth and support their staff in implementing new technologies and policies.31

Those clinicians that have shifted to telehealth anticipate continued use of telehealth after the pandemic.32,33,34 Patient demand for virtual mental health and substance use treatment is also anticipated to continue after the pandemic.35,36

Integrating behavioral health and primary care and providing those services via telehealth and other technologies is a promising solution for addressing the growing need for and barriers to mental health and substance use treatment during and after the COVID-19 pandemic.37 Given the impact of the pandemic on behavioral health, clinicians in primary care and other ambulatory care settings must be able to assess patients for issues with mental health and substance use and refer those patients to the appropriate behavioral health, recovery support, and harm reduction services.

Ongoing Information on COVID-19 and Behavioral Health

Several organizations have online resource collections addressing COVID-19 and behavioral health.

References

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  2. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 PANDEMIC — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1049–57. http://dx.doi.org/10.15585/mmwr.mm6932a1. Accessed February 1, 2021.
  3. Haley DF, Saitz R. The opioid epidemic during the COVID-19 pandemic. JAMA. 2020;324(16):1615–17. https://pubmed.ncbi.nlm.nih.gov/32945831/. Accessed February 1, 2021.
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  6. McGinty EE, Presskreischer R, Anderson KE, Han H, Barry CL. Psychological distress and COVID-19–related stressors reported in a longitudinal cohort of U.S. adults in April and July 2020. JAMA. 2020;324(24):2555-7. https://pubmed.ncbi.nlm.nih.gov/33226420/. Accessed February 1, 2021.
  7. Leeb RT, Bitsko RH, Radhakrishnan L, Martinez P, Njai R, Holland KM. Mental health–related emergency department visits among children aged >18 years during the COVID-19 pandemic — United States, January 1–October 17, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1675–80. http://dx.doi.org/10.15585/mmwr.mm6945a3. Accessed February 1, 2021.
  8. Quick COVID-19 Primary Care Survey: Series 23 Fielded Nov 13 – Nov 17, 2020. Washington, DC: Primary Care Collaborative; 2020. https://www.pcpcc.org/sites/default/files/news_files/COVID-19%20Round%2023%20National%20Executive%20Summary.pdf (PDF – 263 KB). Accessed February 1, 2021.
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  12. Ahmad FB, Rossen LM, Sutton P. Provisional Drug Overdose Death Counts. Hyattsville, MD: National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Accessed February 1, 2021.
  13. Mental Health America. The Mental Health of Healthcare Workers in COVID-19. 2021. https://mhanational.org/mental-health-healthcare-workers-covid-19. Accessed February 1, 2021.
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  15. Brier E. Psychological effects caused by the COVID-19 pandemic in health professionals: a systematic review with meta-analysis. Forbes 2020 Aug 6. https://www.forbes.com/sites/elisabethbrier/2020/08/06/the-covid-19-pandemic-is-causing-more-severe-mental-health-issues-and-more-burnout-among-psychologists-and-psychiatrists. Accessed February 1, 2021.
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  18. Wang QQ, Kaelber DC, Xu R, Volkow ND. COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States. Mol Psychiatry. 2021 Jan;26(1):30-39. Epub 2020 Sep 14. Erratum in: Mol Psychiatry. 2020 Sep 30. https://doi.org/10.1038/s41380-020-00880-7. Accessed February 1, 2021.
  19. Glick SN, Prohaska SM, LaKosky PA, Juarez AM, Corcorran MA, Des Jarlais DC. The impact of COVID-19 on syringe services programs in the United States. AIDS Behav. 2020;24:2466-68. https://doi.org/10.1007/s10461-020-02886-2. Accessed February 1, 2021.
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  21. Coe E, Crystal L, Enomoto K, Lewis R. A holistic approach for the U.S. behavioral health crisis during the COVID-19 pandemic. McKinsey Insights; 2020 Aug 6. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/a-holistic-approach-to-addressing-the-us-behavioral-health-crisis-in-the-face-of-the-global-covid-19-pandemic.
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