The Mental-Health-Care System Isn’t Ready for Covid-19 Either

(Bloomberg Businessweek) -- Those uneasy feelings you’re likely having right now—the disorientation, the low-lying fear that gets more intense at night, the helplessness, the tightness in your chest—there’s a medical term for that. Mental health professionals call it adjustment disorder, or symptoms that occur in people who are having trouble coping with everyday life as a result of a major disruption or loss.

Life during a pandemic has even the most resilient drowning in new levels of stress. School and work closures around the world look like they might stretch on for months. The volatile markets and sudden job losses have added a layer of economic insecurity that wasn’t a factor in people’s lives just a few weeks ago. Meanwhile, the rates of novel coronavirus infections are rising exponentially, creating worries about what day-to-day activities are safe. For those at highest risk of complications or already ill, there’s the fear of getting sick, or sicker. In the worst cases, there’s the grief of losing loved ones.

Covid-19 hasn’t just disrupted how our lives work, it has disrupted how our minds work. “We’re constantly drawing on past experiences to make predictions about the future,” says Mimi Winsberg, a psychiatrist and co-founder of Brightside, a mental health telemedicine service. “That feature of our brains is working in overdrive, if you will, because many of the things that we have learned to expect are suddenly different. We’re trying to adjust to a new set of a rules, a new set of circumstances.”

The U.S. was already in the midst of a mental health crisis even before Covid-19 hit. Rates of suicides and drug overdoses have been climbing in recent years. In 2017, 17.3 million adults in the U.S. had at least one major depressive episode. Despite a law that requires insurers to cover mental health care, they routinely deny claims or limit coverage. Patients in some states are 10 times more likely to pay for expensive out-of-network visits for behavioral health than for primary care. Many people don’t seek treatment at all: One report found that stigma and shame keep 80% of people out of treatment.

Coronavirus has the potential to make things worse. People aren’t only isolated from care, but from each other. In the U.S., more than a quarter of people live alone, and studies have linked loneliness to substance abuse and mood disorders. Others are stuck inside with abusive partners or are living in already strained relationships. Those managing addiction could risk relapse without in-person meetings or access to rehab. Some will bounce back after a return to normalcy, but for others, unmanaged stresses could lead to bigger problems down the line. “Much like how we don’t know how many asymptomatic coronavirus carriers are going to manifest into needing care, we’re seeing the same thing in mental health,” Winsberg says. “All of us that are struggling with the adjustments to new circumstances, some percentage will actually manifest into clinical anxiety or depression.”

Demand for remote therapy has already spiked. Talkspace, the text and video chat therapy service endorsed by gold-medal Olympian Michael Phelps, has seen a 65% increase in customers since mid-February. Neil Leibowitz, Talkspace’s chief medical officer, says the company has also been flooded with inquiries from employers who want to set up the service for their workers, many of whom are juggling full-time parenting duties on top of their jobs, too. Insurers have also reached out, though he wouldn’t disclose names. Winsberg’s Brightside, an app that offers treatment and medication for anxiety and depression, has seen a 50% bump in new users since the start of the quarter. Big Health, a digital therapeutics company, is releasing free programming that uses cognitive and behavioral techniques to combat poor sleep and anxiety. More than 50 companies have signed up or expanded their use of programming including big employers such as Nike, Target, and supermarket chain HEB.

The American Psychiatric Association finds video-based sessions “equivalent” to in-person care for diagnosis, treatment, quality, and patient satisfaction. Yet, insurance hasn’t always covered it. Facing surging demand and a potential mental health epidemic, insurers are scrambling to make changes. Aetna Inc. is offering no-copay telemedicine, including mental health care, until June 4. The insurer has also relaxed its rules to allow for telephone and video therapy and is now reimbursing for additional services such as virtual intensive outpatient treatment for conditions like substance use disorders. UnitedHealth Group Inc., the nation’s largest insurer, is offering anxiety and stress management care at no cost through an app called Sanvello and is allowing providers to treat patients by video or phone through April 30. Anthem Inc. is waiving copays and co-insurance for mental and behavioral health visits through telehealth provider LiveHealth Online.

The federal government has also relaxed some of its privacy standards. In March, the Department of Health and Human Services issued guidance that it would not impose penalties for providers unable to comply with HIPAA rules during the Covid-19 nationwide public-health emergency. (The Health Insurance Portability and Accountability Act dictates how providers communicate with patients to guard the privacy of medical records.) That means, for the time being, therapists can conduct sessions using free and widely available services including FaceTime, Google Hangouts, or Skype. The government did warn that public-facing services such as Facebook Live and TikTok shouldn’t be used by mental health providers.

Much like we’ve seen elsewhere in the U.S. health-care system, the sudden and growing need for care has left mental health providers overwhelmed. One problem: There aren’t enough therapists to go around. “Demand has increased substantially for American mental health, and our supply hasn’t changed in a meaningful way,” says Ken Duckworth, chief medical officer for the National Alliance on Mental Illness. Historically, practitioners could only serve patients in states where they were licensed, but states are rapidly working to relax those requirements to accommodate the influx of need. Each locality has its own licensing permissions, though, leaving companies like Talkspace having to wade through a patchwork of regulations.

“There are potentially four different boards with four different regulation sets in each of the 50 states for us to monitor,” says Lindsay Henderson, director of psychological services at AmWell, a major telehealth medicine provider. AmWell works with more than 2,000 hospitals and more than 50 health plans and offers remote mental health care from licensed independent social workers, psychologists, licensed professional counselors, and licensed marriage and family counselors. “We are leading very carefully and very conservatively and making sure we are sure of every state-specific regulation change before we make any changes in how our network is practicing. It is labor-intensive and time-consuming.”

Not all behavioral health issues can be addressed from afar, and people who need more hands-on treatment could fall through the cracks. Duckworth volunteers in an early-psychosis program that had to close because of coronavirus, forcing patients to find other options—and quickly. He knows of one psych ward that had to temporarily stop accepting patients after a positive Covid-19 diagnosis, though he didn’t want to share the name. There are people in need of electroconvulsive therapy or hospital-based mental health services that might be temporarily suspended because of new hospital policies. He recommends people call their health plan or primary-care doctor if they can’t immediately find services.

“It’s not really a system,” he says of the U.S. mental health infrastructure. “It’s a patchwork quilt of individuals and well-meaning policy people trying to provide large numbers of services to large numbers of people in a payment structure that is varied and complex. It’s quite a challenge.”

If you or someone you know is struggling, contact the National Suicide Prevention Lifeline at 800 273-8255.

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