From nearly the beginning of the Covid-19 pandemic, experts in psychology and psychiatry worried that there would be major increases in the number of people with mental health issues and diagnoses. Evidence now supports that those worries were well-founded, and the situation has been called a pandemic mental health crisis. Studies find clear increases in anxiety and depression in both adults and children and last December the U.S. Surgeon General, Vivek Murthy, issued an advisory on the youth mental health crisis that he noted has been exposed by the pandemic. Unsurprisingly, given the disproportionate impact of the pandemic, communities of color have been especially affected by the mental health consequences of Covid-19. Although suicide rates appear not to have increased in the American population overall during the pandemic, they are rising among Black, Latinx, and Asian American people. Suicidal ideation and attempts have increased in some groups, including adolescent girls.
Equally disturbing as the rise in mental health problems during the pandemic is the failure to provide increased access to mental health services. Although telehealth applications may be improving access to mental healthcare for some people, there is still a shortage of mental healthcare providers in many parts of the world, including the U.S., and many people have restricted access to care due to lack of affordability and insurance coverage.
Is There a Broader Solution To the Increase in Mental Health Problems?
Researchers have tried to figure out ways to improve access to care for people with mental health conditions and our attention was recently drawn to one such study. Published in the Journal of the American Medical Association, investigators from several Kaiser Permanente health facilities randomized nearly 19,000 patients who had endorsed having suicidal thoughts to one of three conditions: a care management condition in which care managers sent messages to patients encouraging them to have outpatient care; an online version of an evidence-based intervention called dialectical behavior therapy (DBT); or usual care. All the participants were free to also receive care in the usual way from the Kaiser Permanente system, but only those in the first two groups were offered additional care as well. The hope was that making proactive outreach attempts to people with a mental health issue, rather than relying on them to take the initiative to get help, might improve outcomes and reduce suicides and suicide attempts. The study was funded by the National Institute of Mental Health.
The results of this large and rigorously conducted study were disappointing. Neither additional intervention decreased the number of serious suicide attempts or deaths by suicide compared to continued usual care. In fact, the patients randomized to the shortened version of DBT had more suicidal events than the usual care only group, a finding we believe was probably a fluke.
Why would offering additional care to people suffering with suicidal thoughts not be helpful? There are several possibilities, many acknowledged by the authors of the study. One is that attrition from both outreach interventions was very high, with only 30% to 40% of people invited to actively engage with the interventions actually participating. Furthermore, it could have been that usual care provided to all the study participants was maximally effective, creating a ceiling effect whereby any additional care would not be able to make a difference
Another important limitation of the study was described by the study authors as follows: “The care management intervention tested in this trial was a low-intensity program delivered by online messaging with rare telephone contacts and no in-person visits.” Similarly, the DBT intervention was done online and involved only a portion of the elements usually incorporated into a DBT intervention for people with suicidal ideation. The authors point out that there is evidence from previous studies that these interventions might work, but one wonders if it would have been possible to do a much smaller study first to see if they worked with this particular design. With almost 19,000 people randomized, the study must have required a substantial amount of federal funds to run. While there is never any guarantee that a research study will yield positive results and the journal is to be commended for publishing a study with negative results, it still might have been prudent to do some exploratory work before launching into such a major undertaking.
This is particularly true because one might have anticipated that offering watered-down versions of mental healthcare would not be effective. Dialectical behavior therapy (DBT), for instance, has been shown in multiple studies to be an effective treatment for several conditions, but it is unclear that the online version used in the study would work as well. Shouldn’t that have been tested first? While it is understandable to want to provide help for as many people as possible at a time when mental health access is so difficult, it may be inadvisable to rush into offering diluted versions of evidence-based interventions to achieve that goal.
No Shortcuts to a Solution
The solution to the mental healthcare access problem—and thereby to the increase in mental health issues so many experts say we are facing—is to figure out how we can deliver the evidence-based interventions we already have to more people. For people with anxiety disorders, depression, and posttraumatic stress disorder (PTSD), there are both evidence-based psychotherapies, like cognitive behavioral therapy (CBT), and antidepressant medications that have proven effective. We doubt that anyone would contemplate reduced dose studies on such a large scale of proven medications for the treatment of other medical conditions like diabetes, heart disease, or cancer without some at least preliminary evidence that this might be effective. Why then do we assume that this is a good strategy for mental health disorders?
Many reasons for the current rise in mental health conditions have been advanced. Worry, loss of sleep, and economic strains from job losses are all posited factors. The pandemic has highlighted the huge disconnect between the scope of mental health problems and the availability of mental health interventions in this and many other countries. We need to join with the Surgeon-General’s call to work much harder to bridge that gap. It will probably require providing sufficient funding to allow people to engage with psychiatrists, psychologists, and other behavioral health professionals, both via telehealth and in person, using the tools we already know are effective. Attempts to find broader solutions to the treatment gap should be careful not to assume that diluted versions of those tools are going to be effective because shortcuts to solve the mental health crisis may well not work. We need to educate primary healthcare providers about how to recognize and treat mental health illnesses; train and deploy an adequate number of psychiatrists, psychologists, and therapists; provide appropriate insurance coverage for mental health needs, including better enforcement of already on the books mental health parity laws; and initiate better public health campaigns to educate people about the signs of mental health problems and their proven solutions. Doing this will be money well spent.