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AHRQ: Agency for Healthcare Research and Quality

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.

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

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

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

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.

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

News and Resources

  1. Panchal N, Kamal R, Orgera K, Cox C, Garfield R, Hamel L, Chidambaram P. The implications of COVID-19 for mental health and substance use. Kaiser Family Foundation; April 21, 2020. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/. Accessed February 1, 2021.
  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.
  4. Member Survey: National Council for Behavioral Health Polling Presentation. Washington, DC: National Council for Behavioral Health; September 2020. https://www.thenationalcouncil.org/wp-content/uploads/2022/11/NCBH_Member_Survey_Sept_2020_CTD2.pdf (PDF - 926 KB). Accessed February 1, 2021.
  5. Petterson S, Westfall JM, Miller BF. Projected Deaths of Despair During the Coronavirus Recession. Oakland, CA: Well Being Trust; May 2020. https://wellbeingtrust.org/wp-content/uploads/2020/05/WBT_Deaths-of-Despair_COVID-19-FINAL-FINAL.pdf (PDF - 4.34 MB). Accessed February 1, 2021.
  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.
  9. Niles JK, Gudin J, Radcliff J, Kaufman HW. The opioid epidemic within the COVID-19 pandemic: drug testing in 2020. Popul Health Manag. 2020 Oct 8. https://pubmed.ncbi.nlm.nih.gov/33031013/. Accessed February 1, 2021.
  10. Alter A, Yeager C. The Consequences of COVID-19 on the Overdose Epidemic: Overdoses Are Increasing. Elkridge, MD: Overdose Detection Mapping Application Program; May 2020. https://odmap.org:4443/Content/docs/news/2020/ODMAP-Report-May-2020.pdf (PDF - 768 KB). Accessed February 1, 2021.
  11. Issue Brief: Reports of Increases in Opioid- and Other Drug-Related Overdose and Other Concerns During COVID Pandemic. Chicago: American Medical Association Advocacy Resource Center; December 2020. https://www.ama-assn.org/system/files/2020-12/issue-brief-increases-in-opioid-related-overdose.pdf (PDF - 703 KB). Accessed February 1, 2021.
  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.
  14. Summers RF, Gorrindo T, Hwang S, Aggarwal R, Guille C. Well-being, burnout, and depression among North American psychiatrists: the state of our profession. Am J Psychiatry. 2020 Oct 1;177(10):955-64. https://doi.org/10.1176/appi.ajp.2020.19090901. Accessed February 1, 2021.
  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.
  16. Schlosser A, Harris S. Care during COVID-19: drug use, harm reduction, and intimacy during a global pandemic. Int J Drug Policy. 2020 Sep 1:102896. https://doi.org/10.1016/j.drugpo.2020.102896. Accessed February 1, 2021.
  17. Ornell F, Moura HF, Scherer JN, Pechansky F, Kessler F, von Diemen L. The COVID-19 pandemic and its impact on substance use: implications for prevention and treatment. Psychiatry Res. 2020 May 13:113096. https://dx.doi.org/10.1016%2Fj.psychres.2020.113096. Accessed February 1, 2021.
  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.
  20. Cone DC, Bogucki S, Burns K, D’Onofrio G, Hawk K, Joseph D, Fiellin DA. Naloxone use by emergency medical services during the COVID-19 pandemic: a national survey. J Addict Med. 2020 Dec;14(6):e369-71. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7647432/. Accessed February 1, 2021.
  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.
  22. The State of the Behavioral Health Workforce: A Literature Review. Chicago: American Hospital Association; 2016. https://www.aha.org/system/files/hpoe/Reports-HPOE/2016/aha_Behavioral_FINAL.pdf (PDF - 119 KB). Accessed February 1, 2021.
  23. Medicare Telemedicine Health Care Provider Fact Sheet. Baltimore: Centers for Medicare & Medicaid Services; 2020. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet. Accessed February 1, 2021.
  24. Livingston NA, Ameral V, Banducci AN, Weisberg RB. Unprecedented need and recommendations for harnessing data to guide future policy and practice for opioid use disorder treatment following COVID-19. J Subst Abuse Treat. 2021 Mar;122:108222. Epub 2020 Dec 3. https://doi.org/10.1016/j.jsat.2020.108222. Accessed February 1, 2021.
  25. U.S. Department of Health & Human Services. Telehealth: Delivering Care Safely During COVID-19. Last reviewed July 2020. https://www.hhs.gov/coronavirus/telehealth/index.html#. Accessed February 1, 2021.
  26. Manz J, Mette E. State Strategies To Maintain Opioid Use Disorder Treatment During the Coronavirus Pandemic. Washington, DC: National Academy for State Health Policy; 2020 Mar 20. https://www.nashp.org/state-strategies-to-maintain-opioid-use-disorder-treatment-during-the-coronavirus-pandemic/. Accessed February 1, 2021.
  27. Bao Y, Williams AR, Schackman BR. COVID-19 could change the way we respond to the opioid crisis—for the better. Psychiatr Serv. 2020 Dec 1;71(12):1214-5. https://doi.org/10.1176/appi.ps.202000226. Accessed February 1, 2021.
  28. Chan B, Gean E, Arkhipova-Jenkins I, Gilbert J, Hilgart J, Fiordalisi C, Hubbard K, Brandt I, Stoeger E, Paynter R, Korthuis PT, Guise JM. Retention Strategies for Medications for Addiction Treatment in Adults With Opioid Use Disorder: A Rapid Evidence Review. Rockville, MD: Agency for Healthcare Research and Quality; July 2020. Report No. 20-EHC012. https://www.ncbi.nlm.nih.gov/books/NBK560315/. Accessed February 1, 2021.
  29. Antezzo M, Mette E, Manz J. Harm Reduction in the COVID-19 Era: States Respond With Innovations. Washington, DC: National Academy for State Health Policy; October 2020. https://www.nashp.org/harm-reduction-in-the-covid-19-era-states-respond-with-innovations/. Accessed February 1, 2021.
  30. Substance Abuse and Mental Health Services Administration. Your Recovery Is Important: Virtual Recovery Resources. https://www.samhsa.gov/sites/default/files/virtual-recovery-resources.pdf (PDF - 245 KB). Accessed February 1, 2021.
  31. Youn SJ, Creed TA, Wiltsey Stirman S, Marques L. Hidden Inequalities: COVID-19’s Impact on Our Mental Health Workforce. Silver Spring, MD: Anxiety and Depression Association of America; May 2020. https://adaa.org/learn-from-us/from-the-experts/blog-posts/professional/hidden-inequalities-covid-19s-impact-our. Accessed February 1, 2021.
  32. Sammons MT, VandenBos GR, Martin JN, Elchert DM. Psychological practice at six months of COVID-19: a follow-up to the first national survey of psychologists during the pandemic. J Health Serv Psychol. 2020 Nov;46(4):145-54. https://doi.org/10.1007/s42843-020-00024-z. Accessed February 1, 2021.
  33. Pierce BS, Perrin PB, Tyler CM, McKee GB, Watson JD. The COVID-19 telepsychology revolution: a national study of pandemic-based changes in US mental health care delivery. Am Psychol. 2021 Jan;76(1):14-25. Epub 2020 Aug 20. https://psycnet.apa.org/fulltext/2020-61592-001.html. Accessed February 1, 2021.
  34. From Virtual Care to Hybrid Care: COVID-19 and the Future of Telehealth: Insights From the 2020 Amwell Physician and Consumer Survey. Boston: Amwell; September 2020. https://static.americanwell.com/app/uploads/2020/09/Amwell-2020-Physician-and-Consumer-Survey.pdf (PDF - 254 KB). Accessed February 1, 2021.
  35. New Harris Poll Survey Offers Insights Into Potential of Telepsychiatry During and After the COVID-19 Pandemic. Dublin, Ireland: Alkermes; July 2020. https://investor.alkermes.com/news-releases/news-release-details/new-harris-poll-survey-offers-insights-potential-telepsychiatry. Accessed February 1, 2021.
  36. Parks J. Impact of COVID-19 on Demand for and Access to Behavioral Healthcare. Mental Health and Substance Use Disorders in the Era of COVID-19: With a Special Focus on the Impact of the Pandemic on Communities of Color: A Workshop (Part 2). Exploring the Impact of COVID-19 on Access to Health Care and Delivery of Services for People With Mental Health and Substance Use Disorders. Washington, DC: National Academies of Sciences, Engineering, and Medicine, 2020 December 3. https://www.nationalacademies.org/event/12-03-2020/mental-health-and-substance-use-disorders-in-the-era-of-covid-19-with-a-special-focus-on-the-impact-of-the-pandemic-on-communities-of-color-a-workshop-part-2. Accessed February 1, 2021.
  37. Carlo AD, Barnett BS, Unützer J. Harnessing collaborative care to meet mental health demands in the era of COVID-19. JAMA Psychiatry. 2020 Oct 21. Online ahead of print. https://pubmed.ncbi.nlm.nih.gov/33084852/. Accessed February 1, 2021.