Americans are not getting the mental health assistance they need during the worst pandemic of the last century, according to the inaugural State of the Nation’s Mental Health report released Monday by Anthem, the largest for-profit managed health care company in the Blue Cross Blue Shield Association.
That is especially true for the youngest, oldest and most impoverished – the very groups often hardest hit by the sickness, death and economic uncertainty brought on by Covid-19, the report said.
“Rates of anxiety and depression reported by patients went up and yet the ability to access mental health services actually went down,” said Dr. Shantanu Agrawal, Anthem’s chief health officer.
The Anthem publication follows a report released Friday by the US Government Accountability Office exploring the country’s ability to access mental and behavioral health services during the pandemic.
The GAO reported that 68% of nearly 3,400 community clinics that serve low-income people with mental health and substance abuse conditions had to cancel, reschedule or turn away patients over the past three months due to lack of staff or funds.
“Our community health clinics were already underfunded before the pandemic, so if you then have any reduction in revenue that has an immediate effect,” said Chuck Ingoglia, the president and CEO of the National Council for Behavioral Health, which represents many of the nation’s community clinics.
“Covid has disproportionately impacted low-income individuals, and these are the same individuals that are served by our member agencies,” Ingoglia said. “Yet at the same time it has been harder for them to continue to access their necessary mental health or substance abuse treatment.”
‘A perfect storm for mental health needs’
For over a year now, the pandemic has shaken the United States to its core, delivering one devastating blow after another and cracking the very foundations of our lives – mentally, physically, emotionally.
Add to that the stress of “a burgeoning alcohol and drug crisis … deep structural problems related to social injustice in our country” and we have “a kind of perfect storm for mental health needs,” said Dr. Charles Marmar, the chairman of the department of psychiatry at NYU Langone Medical Center.
“There is a profound increase in the need for high quality, accessible, equitable mental health care for all Americans. There is no question about that,” said Marmar, who also directs the Center for Alcohol Use disorder and PTSD at NYU.
Warning signs of what Marmar calls a “wave of devastation” due to the mental health consequences of Covid-19 have been mounting for some time.
Within two months of lockdown in 2020, a Kaiser Family Foundation poll found worry or stress had led 56% of US adults to experience at least “one negative effect on their mental health and well-being, such as problems with sleeping or eating, increased alcohol use or worsening chronic conditions.”
Almost 41% of Americans were struggling with mental health issues stemming from the pandemic, including depression, anxiety and suicidal thoughts, according to a US Centers for Disease Control and Prevention survey conducted in June 2020.
In August of last year, the Commonweath Fund looked at mental health concerns around the world and found the US ranked first among nine nations, including Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden and the UK.
Some 33% of American adults reported experiencing stress, anxiety or great sadness that was difficult to cope with alone. Yet mental health care was least accessible in the US of any of the nine nations, the report said.
During the pandemic, about 4 in 10 adults in the United States have reported symptoms of anxiety or depressive disorder, the Kaiser Family Foundation reported. Young adults between the ages of 18 and 24 were especially hard hit – more likely to report substance use than all adults (25% vs. 13%) and suicidal thoughts (26% vs. 11%).
“Prior to the pandemic, young adults were already at high risk of poor mental health and substance use disorder, though many did not receive treatment,” the KFF report said.
The State of the Nation’s Mental Health report is an analysis of health insurance claims from 27 million members enrolled in Anthem’s individual, employer-sponsored, Medicare and Medicaid health plans in all 50 states.
The report found diagnosis and treatment for mental health services was worse for young children under age 12 and adults over the age of 75 than other age groups.
The drop was particularly acute if the child or senior was on Medicare or Medicaid, which would be true for many of the economically distressed areas hardest hit by Covid-19.
Seniors often experienced difficulty using telehealth services that require video, even if they even had a computer or smartphone at hand, which many do not, said clinical psychologist Vaile Wright, the senior director for health care innovation at the American Psychological Association.
“Older adults do generally tend to prefer audio-only telehealth options, as opposed to video conferencing,” Wright said. “We really need to keep audio-only visits covered by insurance – going forward that’s going to be really important for that population.”
Children were in virtual schools, which removed the one-on-one observations by teachers that might spot signs of ADHD, behavioral or adjustment issues, Agrawal said.
“Teachers often make those initial, informal diagnoses, and they notify the parent,” Agrawal said. “During the pandemic, those kinds of interactions were happening a lot less, which meant children were probably being underdiagnosed.”
Even if a child is successfully diagnosed, the lack of behavioral and mental health providers that specialize in youth could hinder a child’s ability to receive treatment, Wright said.
“We have a shortage of all mental and behavioral health providers in the country, and that worsens when we’re talking about those who work with kids,” she added.
Treatment for lower income, people of color
A September 2020 survey of members of the National Council for Behavioral Health found demand for mental health services was way up. Yet despite the need, the survey found 26% of the community clinics had laid off employees, 24% had furloughed employees and 43% had decreased staff hours.
“On average, organizations have lost 22.6% of their revenue over the past three months during COVID-19,” the survey stated, adding that “39% believe they can only survive six months or less.”
Another struggle was obtaining personal protective equipment. One-fourth of the clinics didn’t have enough PPE to last two months, the September survey found.
Today, federal support for businesses, including the most recent US Covid economic stimulus packages, are “certainly helping organizations get back to baseline,” said NBCH’s Ingoglia.
“But these were organizations that were already underfunded – when Covid hit they had to go out and buy tablets and smartphones for both the staff and some of their clients so they could continue to provide services.
“So, returning to baseline is not going to be good enough to accommodate the increased demand we expect,” Ingoglia said.
How to tell if you need help
There are key signs you can look for, in yourself and in loved ones, that can signal growing anxiety, depression, panic attacks or potential suicidal behaviors.
Anxiety: Having difficulty concentrating, poor sleep, restlessness and irritability are signs that anxiety may be taking over your life in an unhealthy way, according to the American Psychological Association. Persistent or excessive worry about your health or finances, often feeling overwhelmed by emotions, and a general sense that something bad is going to happen are more signals.
Panic attacks: At times, anxiety can spiral out of control, leaving you in a full-fledged panic attack. You may feel as if you’re having a heart attack: Your heart rate may speed up or pound in your chest. You may tremble, sweat, feel like you’re choking or have shortness of breath and feelings of dread.
Such attacks can happen suddenly, without warning, and leave some people “fearful about when the next episode will occur, which can cause them to change or restrict their normal activities,” the APA said.
Depression: Depression often begins with a lack of energy and interest or pleasure in daily activities. You may develop an inability to concentrate and feel worthless or guilty about an action or the lack thereof. Paradoxically, you can experience significant weight loss or gain a lot of weight; You can also either sleep all the time or develop insomnia and sleep little. You may even begin to think of death or suicide.
Signs of suicidal thoughts: Often triggered by a recent loss through death, divorce or separation, many of the signs that a person is at risk for suicide duplicate those of depression and anxiety: a loss of interest in friends or hobbies; changes in sleep patterns, eating habits and personality; low self-esteem, sadness, withdrawal, irritability and feelings of guilt or worthlessness.
People who are at risk for suicide may begin behaving erratically and talk about dying or harming themselves. They may show “no hope for the future, believing things will never get better or nothing will change,” according to the APA.
What you can do for yourself
Choose healthy behaviors. Instead of sitting on the couch, go outside and get some fresh air, sunshine and exercise, experts suggested. Exercise naturally creates endorphins, the body’s feel-good hormones. Eating healthy, staying away from excess alcohol (a depressant) and getting plenty of sleep will also help your body – and mind.
Reach out and talk. “Create a space for dialogue,” said Anthem’s Agrawal. “Ask your parents, ask your children, ask your spouse, your siblings: ‘What it was like to go through this pandemic?’”
By having those discussions, you can work to uncover mental health issues that may otherwise not have been noticed, he said.
“And when you find those issues, offer support to your family member, but also help them get that professional support if they need it,” Agrawal said. “That can go a long way towards addressing stigma, and not uncover the issue and then try to cover it back up.”
Seek out support. Look to federal, state and local resources. If the situation is potentially life-threatening, get immediate emergency assistance by calling 911. If it’s not, then start with the distress hotlines.
The Substance Abuse and Mental Health Services Administration, or SAMHSA, has a national helpline – 800-662-HELP (4357) – which provides free, confidential treatment referral and information in English and Spanish 24/7, every day of the year.
The American Psychological Association also has a webpage of resources for suicide, substance abuse and domestic violence.
You don’t have to wait until it’s a crisis to find help, said Reginald Williams, vice president of International Health Policy and Practice Innovations at the Commonwealth Fund, which works to advance equity in US health care.
“There are things called ‘warm lines,’ where people can go and and express their concerns, express their frustrations and they can get connected to services and resources to help them,” Williams said.
Mental Health America has a webpage of “warm lines” in states across the country.
“Warm lines are generally a peer-run hotline that provides support for a person who may have some sadness, some grief, feeling a little bit overwhelmed, but may not be having thoughts about harming yourself or others,” Williams said.
Seek ongoing therapy. If you have health insurance or other resouces, try to find a therapist. Most clinics and therapists are offering phone or video telehealth visits. Many employers are offering free access to therapists as part of their employee benefit plans, and many communities have mental health centers with sliding scale fees.
Call the intake line of the psychiatry outpatient clinic of the closest medical school near you, suggested NYU’s Marmar.
“The social workers and intake workers there know all the regional resources. It works every time, and what’s great is you’re getting a quality referral,” said Marmar.
Get CNN Health's weekly newsletter
Sign up here to get The Results Are In with Dr. Sanjay Gupta every Tuesday from the CNN Health team.
Many people don’t choose to go to therapy, said experts, because they believe that makes them “weak” or they feel it would be too invasive.
But that’s not what therapy is, Eve Byrd, director of the Carter Center’s Mental Health Program, told CNN in a prior interview. “Therapy is really an educational activity.” A therapist’s role is to “help you think about different ways to react to situations” and “more positive ways of interacting with individuals,” she said.
It’s OK not to be OK sometimes. In some ways, our national stress over a deadly virus has brought us together, and makes all of us aware of how fragile we can be, in both body and mind.
“I certainly would have preferred to not have a pandemic in order to really understand what a priority our mental health is and our well being is,” Wright said.
CNN’s Kristen Rogers and Naomi Thomas contributed to this report.