This blog series is written by New Paradigm Recovery Operations Director Joshua Cagney, who is currently writing his dissertation on the relationship between mental health treatment the effects of COVID-19 on disorder acuity and how mental health treatment center system structure can best address these needs in the long run.
In early April of 2020 I sat in front of a computer monitor with another clinician preparing for our evening substance use treatment intensive outpatient group. Our clients were home – working from home, ordering food from home, managing life from home, and receiving treatment at home. In the virtual world we were all attempting to make the most of what we had – and we were all struggling. We had a small group of five clients that evening, and as we began check-ins for the evening, I noticed one client staring directly into the screen: his eyes wide, mouth slightly agape, face ashen, and a slow trickle of blood emerged from his left nostril as he stared blankly into cyberspace.
He had relapsed on multiple substances. In a world of no accountability and oversight, of fear and uncertainty from the media and forced isolation, men and women around the world struggled with mental health in ways that no one was prepared for. Those men and women who entered the pandemic with existing substance use diagnoses – in addition to the accompanying diagnoses of anxiety and depression which almost always exists – suddenly were cut off from the engagement which offered them some semblance of hope and identification. So, I asked myself, “What are we doing? Do we even know what we are doing?” The consequent answer: we had no idea what we were doing. In fact, no one did.
It could be easily said that there is no global crisis greater than the one we currently face with the COVID-19 pandemic. It has effectively changed the way every individual operates and interacts with the world around them. To be sure, mental health (MH) treatment has seen two profound yet fundamental shifts: first, the way in which treatment is performed; and second, the demand for MH treatment has increased dramatically since the initial stages of the pandemic in the spring of 2020 (ASAM, 2020).
As the operations director of a dual diagnosis MH treatment center, I have watched the changes in MH and behavioral health care with no small amount of concern, and I have contemplated myriad questions about “what ought we do” to best meet the needs of patients/clients, in the world of evolving MH treatment. My experience has not been unique, but it has been an insider view on the issues from both a client-centered care perspective, and the perspective of treatment facilities whose mission is to meet the needs of a changing society, when we recognize the need for systemic change and transformation (Columb, Hussain, & O’Gara, 2020).
The issues that we face societally, and as an industry, are neither explicitly about MH nor isolation; rather it is the relationship between the two which needs to be understood and examined. It is understanding the relationship that offers the greatest insight for MH treatment facilities positioned to address the needs of presenting patients. Mental health concerns and complex issues are progressive over the duration of the pandemic (Tam, Mezuk, Zivin, & Meza, 2020). Over 30% of adults in the U.S. now reporting symptoms consistent with an anxiety and/or depressive disorder (Kaiser Family Foundation, 2020).
Average Share of Adjults Reporting Symptoms of Anxiety or Depressive Disorder During the COVID-19 Pandemic, May-July, 2020
Among these adults, over 20% report needing, but not receiving, mental health counseling or therapy (Kaiser Family Foundation, 2020). Mental health symptoms have increased during the COVID-19 pandemic. In fact, average biweekly data for October 2020 found that 37.7% of adults in the U.S. reported symptoms of anxiety and/or depressive disorder, up from 11.0% in 2019 (Kaiser Family Foundation, 2020). In mid-July of 2020, 53% of adults in the United States reported that their mental health has been negatively impacted due to the coronavirus. This is significantly higher than the 32% reported in March of last year (Panchal, et al., 2020).
Compounding the significance of the pandemic on MH treatment, patients suffering from SUD are particularly susceptible to COVID infection – reciprocal relationship between at-risk behavior and increasing the likelihood of SUD. People with SUDs were significantly overrepresented among those with COVID-19, making up 15.6% of the COVID-19 group versus just 10.3% of the total sample (Wang, Kaelber, Xu, & Volkow, 2020). In those patients with lifetime SUD diagnoses, they experienced more severe outcomes from COVID-19 than others, including hospitalization (41% versus 30%) and death (9.6% versus 6.6%) (Volkow, 2020).
Based on geography and on the nature of infection, local isolation policies, and on the prevalence of SUD and MH needs, there is great disparity in how MH treatment facilities are addressing presenting issues (National Council for Behavioral Health, 2020). With no determinant date for when the pandemic will end, and no realistic predictor of how the relationship between isolation, MH, and addiction will impact patients, MH treatment centers are critical front lines for addressing both the severity of presenting MH conditions and ensuring the stability of patients over the long run (SAMHSA, 2020). Given that MH treatment centers represent the front line and stabilization hub for patients with MH and addiction needs where forced isolation exists (ASAM, 2020), safety (SAMHSA, 2020), effective care (NIDA, 2020), family support (Bowen, 1993), aftercare (Hari, 2018), triage and transition to other levels of care (Kaufman & Yoshioka, 2005), and community dialogue (National Council for Behavioral Health, 2020) all represent significant issues that ought to be examined when endeavoring to understand how MH treatment centers are structured and positioned.
Yet systemically treatment centers are woefully under-resourced when it comes to meeting public MH needs across the socioeconomic spectrum (Matias, Dominski, & Marks, 2020). Strangely, this rise in the demand for MH care can be seen in a positive light: it reflects not just an increase in need, but a decrease in the stigma associated with MH treatment and healthcare (Lipson, Lattie, & Eisenberg, 2019). This does not, however, mitigate the new issues associated with MH: comorbidity and exacerbation of existing MH conditions – and the impact that these have had on the mental health treatment community.
Mental health practitioners – psychologists, licensed clinical social workers, psychiatrists, counselors – remain limited in supply amidst the growing surge of mental health need. The number of psychologists has grown 3.5% since 2010, while the population is estimated to have grown 6.5% (Substance Abuse and Mental Health Services Administration, 2019), and the number of psychiatrists in medical practice has actually decreased by more than 36% (PsychCentral, 2018).
In short, mental health treatment centers are reliant on using less, to treat more, for a population that is suffering from a previously unknown series of MH issues and conditions. Systemically the MH treatment center community suffers from resource depletion, but also suffers from an antiquated level of treatment systems and structure.
Next week we will be gin discussing what systems are in place, and how we can evolve to begin better meeting patient acuity and addressing long term stability and care. In the meantime, however, I would love to hear from you about your personal and professional experiences – and bring that feedback into coming blog articles.
ASAM. (2020, September). Ongoing Management of the Continuum of Addiction Care During COVID-19. Retrieved from American Society on Addiction Medicine: https://www.asam.org/docs/default-source/covid-19/15-tf_ongoing-management-of-continuum-one-pager-8-31-version-2_final.pdf?sfvrsn=6dba58c2_2
Bowen, M. (1993). Family Therapy in Clincal Practice. Lanham: Jason Aronson.
Columb, D., Hussain, R., & O’Gara, C. (2020). Addiction psychiatry and COVID-19: impact on patients and service provision. Irish Journal of Psychological Medicine, 37(3), 164-168. doi:10.1017/ipm.2020.47
Hari, J. (2018). Lost Connections: Uncovering the Real Causes of Depression – and the Unexpected Solutions. New York: Bloomsbury.
Kaiser Family Foundation. (2020, November 19). Mental Health and Substance Use State Fact Sheets. Retrieved from Kaiser Family Foundation: https://www.kff.org/statedata/mental-health-and-substance-use-state-fact-sheets/
Kaufman, E., & Yoshioka, M. R. (2005). Substance Abuse Treatment and Family Therapy. Rockville: Substance Abuse and Mental Health Services Administration.
Lipson, S. K., Lattie, E. G., & Eisenberg, D. (2019). Increased Rates of Mental Health Service Utilization by U.S. College Students: 10-Year Population-Level Trends (2007–2017). Psychiatric Services 2019, 70, 60-63. doi:10.1176/appi.ps.201800332
Matias, T., Dominski, F., & Marks, D. (2020). Human needs in COVID-19 isolation. Journal of Health Psychology, 871-882. doi:10.1177/1359105320925149
National Council for Behavioral Health. (2020, April 28). COVID-19 Guidance for Behavioral Health Residential Facilities. Retrieved from National Council for Behavioral Health: https://www.thenationalcouncil.org/covid-19-guidance-for-behavioral-health-residential-facilities/
NIDA. (2020). Common Comorbidities with Substance Use Disorders Research Report. Washington, D.C.: National Institute on Drug Abuse. Retrieved November 25, 2020, from https://www.drugabuse.gov/publications/research-reports/common-comorbidities-substance-use-disorders/introduction
Panchal, N., Kamal, R., Orgera, K., Cox, C., Garfield, R., Hamel, L., . . . Chidambaram, P. (2020, August 21). Kaiser Family Foundation. Retrieved from The Implications of COVID-19 for Mental Health and Substance Use: https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
PsychCentral. (2018, August 30). Mental Health Professionals: US Statistics 2017. Retrieved from PsychCentral: https://psychcentral.com/blog/mental-health-professionals-us-statistics-2017#6
SAMHSA. (2020, May 7). Considerations for the Care and Treatment of Mental and Substance Use Disorders in the COVID-19. Retrieved from Substance Abuse and Mental Health Services Administration: https://www.samhsa.gov/sites/default/files/considerations-care-treatment-mental-substance-use-disorders-covid19.pdf
Substance Abuse and Mental Health Services Administration. (2019). National Mental Health Services Survey (N-MHSS): 2018. Data on Mental Health Treatment Facilities. Rockville, MD: Substance Abuse and Mental Health Services Administration.
Tam, J., Mezuk, B., Zivin, K., & Meza, R. (2020). U.S. Simulation of Lifetime Major Depressive Episode Prevalence and Recall Error. American Journal of Preventative Medicine, 59(2), 39-47.
Volkow, N. (2020, October 5). New Evidence on Substance Use Disorders and COVID-19 Susceptibility. Retrieved from National Institute on Drug Abuse: https://www.drugabuse.gov/about-nida/noras-blog/2020/10/new-evidence-substance-use-disorders-covid-19-susceptibility
Wang, Q. Q., Kaelber, D. C., Xu, R., & Volkow, N. D. (2020). COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States. Molecular Psychiatry. doi:10.1038/s41380-020-00880-7