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Lesley Pink: Hello and welcome to Critical Point, brought to you by Milliman. I'm Lesley Pink, and I'll be your host today. In this episode of Critical Point, we're going to be talking about mental health and the COVID-19 pandemic. Specifically, we'll discuss the range of mental health and substance use issues sparked-- or made worse--by the pandemic, how different populations are being affected, and the rising demand for mental health services. Joining us today is Stoddard Davenport, a healthcare management consultant with Milliman who has written extensively on a range of behavioral health issues, including mental health parity, the opioid epidemic, and population health strategies. Thanks for chatting with me today, Stoddard.

Stoddard Davenport: Thanks for having me, Lesley. Glad to be here.

Lesley Pink: Let's talk a bit about a paper that Milliman released in January to lay the groundwork. In that paper, there was a note that the National Institute of Mental Illness estimated that one in five adults in the U.S. experiences mental illness in a given year. What are the most common mental illnesses in this country?

Stoddard Davenport: Sure, yeah. So to kind of set the background a little bit for mental health in the United States before the pandemic, I just want to clarify that mental health takes many forms, right? So the most common form would be the symptoms that many of experience from time to time that don't necessarily constitute a disorder yet still impact our well-being and happiness-- things like stress, anxiety, sadness, fear, etc. Those are things that everybody experiences that don't always rise to the level of a disorder, but when we're talking about mental illness, depression and anxiety disorders are generally the two most commonly diagnosed illnesses in the United States, and while one in five adults in the United States experience mental illness in a given year, the impact is actually a lot bigger when you consider the overall impact on households.

Research we've completed shows that for a typical family of four, for example, over 43% of households had at least one family member that was in treatment for a behavioral health condition within a given year, and the risk for either the kids or the parents in a household is about doubled when the other has a mental health condition. So that just sets the stage for how prevalent behavioral health conditions are in the United States before the pandemic, and kind of what quote unquote "normal" might look like prior to the pandemic.

Lesley Pink: Now let's talk about the pandemic. As the COVID-19 pandemic started back in March, we started to see extreme measures being put in place-- people having to isolate at home, social events canceled, people working from home, schools closed. So besides the actual pandemic that people were dealing with, they were also dealing with a sense of isolation, a lack of normalcy in their daily life. What effect did this have on the nation's collective mental health?

Stoddard Davenport: Yeah, the mental health impacts of COVID-19 have really been substantial. Going back to kind of that distinction between mental health symptoms versus mental health disorders, the emergence of this new disease has led many to fear for their own health, for the health of their loved ones, to worry about the future and what that may hold. Social distancing requirements and other public health actions have created feelings of isolation and, for many, frustration as well. The economic consequences have been substantial and have contributed to feelings of stress or anxiety or fear, and individuals have a wide range of reactions to these circumstances. For some, these challenges might just be temporary and things may sort of return to normal once we kind of get through the other side of this and life kind of normalizes a bit again. Others may experience chronic challenges that are going to drive their mental health over the longer term. So it's kind of this two-fold impact of in the moment temporary stress as well as contribution to increasing chronic challenges that I think we're going to be grappling with for some time to come.

Lesley Pink: As we talk about these numbers, I saw that the U.S. Centers for Disease Control and Prevention published some survey results in August, and that noted that almost 41% of U.S. adults reported struggling with their mental health or substance use, both related to the pandemic and to some of the measures put in place to contain it. Can you talk about these results?

Stoddard Davenport: Yeah, that CDC survey is one of the best insights we have so far into both kind of the extent of the mental health impacts that have happened after the pandemic began as well as kind of how the impacts vary between different populations, and this was a survey, again, completed in June. So we were a few months into a lot of the public health measures in the United States, but not at our current peak obviously, so just to kind of frame where this falls. As you noted, according to that survey, over 40% of adults reported struggling with mental health or substance use; 31% were reporting symptoms of anxiety or depression; 26% reported symptoms of trauma- or stressor-related disorders related to COVID-19; 13% reported having started or increasing substance use to cope with the pandemic; and 11% reported having seriously considered suicide in the past 30 days.

And just to sort of frame how some of those vary to what we saw before the pandemic-- we don't have kind of that exact same survey instrument completed prior to the pandemic for sort of a perfect baseline, but earlier survey instruments show that in 2019, 24.5% of adults had any mental illness or substance use disorder; 11% had symptoms of anxiety or depression, so that's about a third of what we're seeing now; and 4.8% had serious thoughts about suicide in a prior year. So compare that 4.8% over an entire year to 11% just in the prior 30 days as measured in June.

Lesley Pink: That's significant. That's seems to me like a huge jump, especially for something as serious as suicide ideation.

Stoddard Davenport: Right. Yeah, I think you're right, and I think when we think about how this is going to play out over the longer term-- as I mentioned before, for some it's just sort of temporary stressors they're going to get through. It might look different for those that have acute crises during the pandemic-- things like drug overdoses or suicide attempts or things like that. Those I think are things that really ought to be sort of triaged more substantially than some of these other things that we may have more time to help folks get through.

Lesley Pink: When you were talking about these statistics, how are different populations being affected? For example, we've seen racial disparities in the prevalence of COVID-19. Are we seeing similar disparities in mental health related to COVID? Are there certain groups that are getting hit harder or that are faring worse than others?

Stoddard Davenport: Yeah, there's quite a bit of variance in the mental health impacts at least from what we see coming out of the CDC survey that we've been talking about. The prevalence of COVID-19-related behavioral health symptoms has been about twice as high for individuals that had preexisting behavioral health diagnoses. So if you came into the pandemic already in treatment for a behavioral health condition, this has really, for a lot of folks, doubled the symptoms they're experiencing.

There have been studies that have found that COVID-19 patients are at greater risk for a psychiatric diagnosis post-hospitalization, and that they're also at greater risk-- and folks with psychiatric diagnoses are also at greater risk of contracting and having serious outcomes from COVID-19. There's also reason to believe that COVID-19 can directly exacerbate some psychiatric or neurological symptoms, too, so that's concerning. There's a lot of concern for younger people in terms of mental health impact. So 75% of those aged 18 to 24 reported at least one adverse mental or behavioral health symptom. That's about five times the rate for those aged 65 or older. Twenty-five percent of those aged 18 to 24 reported starting or increasing substance use to cope, and again, that compares to 3% for those aged 65 or older.

There's pretty big differences by employment status, too. Essential workers are 40% more likely to report symptoms of anxiety or depression compared to nonessential workers, and they're more than twice as likely as nonessential workers to have started or increased substance use to cope. And as you alluded to, there are also substantial differences by race and ethnicity. To kind of set the backdrop for that, according to data from the CDC, both infection rates and mortality rates are high for Black individuals as well as indigenous and Latinx people as well compared to white individuals. There's a lot that drives this, including different occupational exposures. Some of the folks in these communities work in higher risk jobs where they might be more likely to have exposures there. Differences in socioeconomic status, access to healthcare, etc. -- all of this plays out not just in terms of COVID-19 and contracting it and having severe outcomes from it, but also in terms of mental health impacts as well.

Coming back to that CDC survey, they found more adverse mental or behavioral health symptoms for those same populations that are also at higher risk of COVID-19, and for Black individuals the mental health impacts have also overlapped with significant events like racial justice protests in the wake of the deaths of George Floyd and Breonna Taylor and more, and those have all added to the stress that they are experiencing this year in a really significant way.

Lesley Pink: And you mentioned that young adults have had a significant amount of mental health problems as well as essential workers, and Black and Latinx. Are there other groups that have been affected to the same degree, or are these groups the ones that have been hit the hardest?

Stoddard Davenport: Yeah, I think that's where things have looked the worst so far. So if you drill down into what the CDC found for suicidal ideation, which I think could arguably kind of be the most extreme adverse symptom of mental health that they measured there, the variation that really demonstrates the depth of distress experienced and the variation between different populations. So when you look at that measure, among those aged 18 to 24, more than 25% reported having seriously considered suicide in the past 30 days. That's a rate 13 times higher than experienced by those aged 65 or older, just to sort of put some context to how big of a divide there is there. Essential workers were nearly three times as likely as nonessential workers to have seriously considered suicide. Unpaid adult caregivers were more than eight times as likely as others, and Black respondents were more than twice as likely to have considered suicide compared to white respondents. Hispanic respondents were more likely than either. Interestingly, the unemployed actually fared better on some mental health measures than either essential or nonessential workers, keeping in mind that this survey was completed at a time when the enhanced unemployment benefits were still in effect back in late June, so that might play a role in somewhat mitigating the mental health impacts for some of the folks that were the most vulnerable to economic disruptions early on.

Lesley Pink: Right. There's a complex stew of things that go into this. As we're seeing greater problems with mental health in the U.S., I would also assume that there would be increasing demand for mental health services. How is this being addressed-- or is it-- and how is the U.S. healthcare system, which is dealing with the COVID-19 pandemic, bracing for the increase in mental health demand?

Stoddard Davenport: Yeah, so to kind of put some flavor to what's been going on with the demand for mental health services… a lot of the familiar tools that we use to monitor use and costs for healthcare services in the United States have a bit of a lag to them, right? So it's hard to see sort of immediately emerging data on how folks are using behavioral health services. That said, it's been long enough now that we are starting to see, here and there, additional reports coming out about what's happened to different types of services, and we're seeing some evidence that although there was sort of a huge drop in care, foregone care, deferred care, things like that that happened early on in the pandemic, in some reports, behavioral health services dropped less than other types of care. So that could be because-- a function of behavioral health services may be happening in a little bit more of a one-on-one setting that folks felt safer continuing, or it could be that the demand was significant enough that it didn't sort of have as far to fall, or other factors could contribute to that.

But we're also seeing, in some of the reports that are coming out, that behavioral healthcare utilization is actually also rebounding faster than other types of care. In some cases, we're seeing it exceed pre-pandemic levels of use. But I think, in my view, the supply, our behavioral health workforce supply, may ultimately start to bottleneck our ability to respond, at least using specialty behavioral healthcare. So people are turning to other resources-- community resources, support from their peers.

There have been a lot of innovative startups in the behavioral health space that have been around for maybe awhile, but are all of the sudden seeing substantially more interest in their platforms as folks try to figure out how to fill the gaps. And telehealth has been really big, too. Both before and during the pandemic, behavioral health conditions have been really one of the leading drivers of use of telemedicine services. We have as many as 120 million Americans right now that live in areas with mental health professional shortage areas, and so interest in using telehealth to eliminate the need for patients and clinicians to be in the same physical space is probably going to stick around a lot longer than the pandemic. So that could be something that's helpful over the longer term.

Lesley Pink: And there have been certain provisions put in place that allow for behavioral health to be accessed via telehealth. Those went into effect pretty soon after the pandemic started, right?

Stoddard Davenport: Right. I think we've seen a lot of the payers offer additional flexibility. Services that maybe couldn't have been paid for via telehealth before are now being paid for-- things like that. It kind of remains to be seen which of those changes end up being permanent, but for now, there's definitely some additional flexibilities there for telemedicine that were not there prior to the pandemic.

Lesley Pink: We've talked a lot about behavioral health, mental health. Could we also talk about substance use disorder and how those struggling with that issue have been affected?

Stoddard Davenport: Yeah. So the opioid epidemic has been around for a long time. It's one of the-- I would say it was the top public health concern prior to the COVID-19 pandemic, and it's still with us, even if it's not in the spotlight as much now. We had kind of a brief moment there where we were seeing data come in from late 2017 into 2018 that was suggesting maybe we were turning a corner. There was a bit of a plateau in drug overdose deaths there for a bit. However, as more data emerges, it's kind of going the wrong direction again, so we're seeing drug overdoses back on the upswing. These deaths are not tracked in real time, like we have for COVID-19, so there's a lag in seeing kind of the actual experience play out there, but anecdotal media reports, things like that, are suggesting that overdose deaths are on the rise.

We know that-- based on what we know about risk factors for opioid use disorder-- COVID-19 is kind of a perfect storm in terms of increasing fear and anxiety and isolation and things like that-- economic uncertainty. Those things all contribute to really kind of setting things up to go the wrong direction here. Different reports have shown doubling in the prevalence of fentanyl in random samples of urine tests that were ordered in the first four months after March 13 when a lot of the lockdowns went into effect compared to the four months prior, in one health system. We've seen kind of a 2x increase in opioid-involved emergency department visits in March to June of this year compared to the same time period a year before.

And, of course, as we noted from the CDC survey that we've talked about a good bit, 13% of adults have reported starting or increasing substance use to cope with COVID-19 stresses as of late June. One of the glimmers of hope amidst all that, however, is that we're seeing some additional flexibilities that have come into play for medication-assisted treatment. This consists of the use of medications, counseling, and other therapies for the treatment of substance use disorders, and in the past, medications such as buprenorphine could only be administered in an office-based setting by certain healthcare professionals that have been through a waiver process to get authority to do the prescribing and delivery there.

But in March 2020, the Drug Enforcement Administration gave some additional flexibility for that kind of care to be initiated through telehealth visits instead. And again, coming back to the issue of how many live in areas without the right care, we've got something like half the United States population that lives in counties that do not have a local medication-assisted treatment provider, and so there's a lot of interest in keeping those flexibilities around beyond the pandemic. So it could be a good thing if we have some additional flexibility and access there over the longer term. But I do want to point out that in terms of substance use disorders, it's really not just about opioids. Drug overdose deaths involving other substances have also been on the rise for several years, and a lot of the risk factors for these disorders are shared across all sorts of different substances. So there's a lot to keep an eye on here, and opioids are in the spotlight, but are certainly not the only substance that we're worried about and keeping our eye on.

Lesley Pink: As this pandemic goes on and on, how could this possibly affect the mental health of Americans down the line? We've been through this for a few months. We've seen spikes in anxiety and depression and thoughts of suicide. As it goes on, what could some of the lingering effects be on the U.S. population?

Stoddard Davenport: Yeah, it's a good question. I wish I had a crystal ball, but what we do know is economic conditions have been found to have kind of a really strong, persistent relationship to some behavioral health outcomes, and those who have experienced extended financial distress or career disruptions due to the pandemic may be at higher risk for long-term behavioral health challenges. There are some studies that have tied the recession of 2007 to 2009 to persistent increases in a range of behavioral health conditions and alcohol and drug use disorders and things like that. So over the longer term, I think those economic circumstances may be a pretty big driver of behavioral health outcomes.

There's also some concern about the long-term impacts on the social or emotional development and mental health outcomes for youth who've had socializing and education opportunities disrupted by the pandemic. And this is kind of a whole new world-- right?-- where during the recession from 2007 to 2009, you could still go to school, right? So I don't know that we have a recent historical comparator to really understand what that could look like or play out like, but it's something that a lot of folks are keeping an eye on and are going to be concerned about going forward as well.

Lesley Pink: That leads me to my next question. What does the road ahead look like on the mental health front? What can individuals, communities, doctors do to help mitigate these problems?

Stoddard Davenport: Yeah, yeah. So I mean our behavioral health system has been struggling to perform perhaps as well as we might like for a long time leading into the pandemic, and we're going to carry some of the challenges we've faced before with us into how we respond now. And as I mentioned before, capacity for specialty behavioral healthcare is concerning in some parts of the country or for some types of professionals.

Telehealth is one of the ways that we're reducing some of the access barriers, both by sort of eliminating the need for face-to-face care that could be a little bit higher risk in terms of COVID-19 transmission, but also helpful for eliminating physical distance barriers. Right? So when providers do not live where patients do, telehealth is a great way to connect the dots. We're seeing health plans put more effort into building their behavioral health professional networks. One thing we're keeping an eye on there is how folks are making an effort to stay compliant with mental health parity regulations by making sure that they offer flexibility during the pandemic and after on the behavioral health side that matches a lot of the additional flexibilities that have been offered on the physical health side. Keeping an eye on that both now and after the pandemic I think is going to be helpful.

We're seeing employers engaging with a lot of different strategies and offerings that might supplement the benefits they provided before. You're seeing things like apps for employees and their families to use to help with different activities or meditations you can do on your own. Some of those things may be helpful for a lot of folks, especially for folks that are experiencing mental health symptoms but perhaps not necessarily full-blown diagnosable disorders. And I think just kind of for the community at large, there's simple things all of us can be doing to help, like checking in on your friends and loved ones, keeping good social contact with the people in our circles, even if in a physically-distanced fashion, particularly for those that may be alone or at higher risk. I think it's kind of going to be an all-hands-on-deck kind of situation to keep an eye on folks as we move forward from this.

Lesley Pink: Great. Thank you for joining us, Stoddard. You've been listening to Critical Point presented by Milliman. To listen to other episodes of our podcast, please visit us at milliman.com or find us on iTunes, Google Play, Spotify, and Stitcher. Until next time.