The United States (US) has long faced disparities and inequities in mental health care. There are more than 5500 mental health professional shortage areas across the country, affecting nearly 120 million Americans (HRSA, 2020). More than 75% of all U.S. counties have a shortage of mental health professionals and almost all US counties have an unmet need for psychiatrists (Thomas et al., 2009). In addition, rural areas and areas with a high proportion of racial and ethnic minorities across more than one-third of U.S. counties have no access to outpatient mental health services (Cummings et al., 2013). The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates the prevalence of mental illness in adults at close to 50 million (SAMHSA, 2019) and an estimated 7.7 million children have also experienced mental illness (Whitney & Peterson, 2019).
Despite these numbers, fewer than half of adults and children receive necessary mental health services (SAMHSA, 2019; Whitney & Peterson, 2019). The high prevalence of mental illness among adults and children, including the number of individuals not receiving care, highlights existing access barriers. Additionally, the pervasive stigma associated with mental health, especially among racial and ethnic minority groups, makes this segment of the population less likely to seek and accept services. Their resistance exacerbates mental health disabilities, putting these groups at risk to endure a higher burden of illness (APA, 2017).
The emergence of COVID-19 and the accompanying stay-at-home orders; restrictive hospital visitation policies; social and physical distancing; the abrupt transition to telecommunications; and the loss of personal interactions worsens an already prevalent mental health crisis in the United States. Communities are grappling with the suspension of “normal” life as seen by the widespread closure of non-essential businesses and schools, and discontinuation of those social functions that keep people connected. Compounded by the effects of social isolation, quarantine, critically ill family and friends, death, and economic stress, the challenges of mental illness may be quietly increasing (Pfefferbaum & North, 2020).
Major media outlets across the nation have been reporting the widespread effects of the COVID-19 pandemic and its impact on the economy, health, and society. The swift transition to online learning, remote work, videoconferencing, and telehealth has forever changed the way we interact. This transition has been challenging in healthcare due to the industry foundation of in-person interaction with providers (Keesara et al., 2020). This “new normal” has increased the public’s equity concerns on rising reliance on an electronic platform and telehealth for medical services, including mental health services.
Vulnerable populations have limited access to internet and technology, rendering them unable to engage in therapeutic telehealth services. Individuals with pre-existing mental illness(es) are at increased risk for episodes of acute exacerbation of symptoms due to the loss of routine services as a result of COVID-19 and the social implications. Naturally, the emphasis has been placed on ensuring the capacity to care for the influx of patients with COVID-19, limiting the system’s ability to adequately care for patients’ mental health needs due to reduced bed availability in inpatient settings (Choi et al., 2020). In addition, staffing issues caused by healthcare workers becoming infected with the virus have challenged our ability to safely provide care for patients across all settings. Choi et al. (2020) suggests that psychiatric hospitals should expect an increase in admissions. However, staffing shortages have caused facilities to reduce admissions to ensure that currently hospitalized patients receive safe, appropriate care.
As we struggle to address current issues of patient care and outcomes, we also need to acknowledge the mental health and well-being of clinicians, especially nurses, who are on the frontlines battling the medical sequela of the COVID-19 pandemic. Prior to COVID-19, clinicians were already experiencing increased rates of burnout. Factors contributing to burnout include increasing job demands such as heavy workloads; moral distress and ethical dilemmas; new and increased use of technology; lack of resources; and work-life balance. Burnout can lead to injury, increased substance use, and mental health challenges that adversely impact a nurse’s personal life, but also poses risk to the safety and quality of patient care (NASEM, 2019).
The reported widespread shortages of equipment to care for patients and lack of adequate personal protective equipment (PPE) for healthcare workers has increased fear and induced anxiety, which could lead to burnout. A dire need for equipment and PPE still remains across the country and contributes to the fear and anxiety faced by frontline providers. In addition, the inequities of resource allocation to cities, states, and healthcare systems adds to the workforce burden (Ranney et al., 2020). Despite lack of proper protection, healthcare workers continue to provide high-quality, compassionate care in the fight against COVID-19, often risking themselves while balancing the psychological impact on their own physical and emotional health and that of their families. COVID-19 presents itself with increasing job demands, workload, and safety hazards that will undoubtedly exacerbate the issue of burnout and negatively impact clinician mental health and well-being.
Historically, infectious disease outbreaks lead to widespread fear, panic, and stress causing increased anxiety and depression. As seen in the 1918 flu pandemic, social distancing, quarantines, and limitations on public gatherings were the public health measures that helped to reduce the spread. Nurses were crucial to mitigating the impact of the infection by providing vital supportive care, much like they are providing today (D’Antonio, 2020). Infectious disease outbreaks leave the public and, disproportionally, healthcare workers to cope with death, threat to their lives, and changing work demands, which is further compounded by their individual fear, anxiety, and stress (Mohammed et al., 2015).
Based on the current and projected supply of mental health professionals, the workforce is not prepared to meet the demand for services (HRSA, 2019). The incidence of suicide and suicide attempts continues to rise in the United States across all age groups, especially among adolescents, women, and older adults (Wang et al., 2020). With increasing suicide rates and the current prevalence of mental health issues combined with a lack of qualified professionals, COVID-19 presents an even greater threat to mental health. For example, social distancing is being used as a public health measure to mitigate spread of the virus. Under these circumstances, the potential for increased suicide risk is perpetuated by economic stress, social isolation, barriers to care, and co-morbidities (Reger et al., 2020).
These concerns can result in an unmet demand for services, which the declining supply of psychiatrists is unable to meet, thereby further decreasing access to care (Bishop et al., 2016; Faulkner et al., 2011). Despite a decline in the supply of psychiatrists, there continues to be growth in the number of psychiatric nurse practitioners who help offset the shortage of mental health providers (HRSA, 2019; Delaney & Vanderhoef, 2019). While there is a decline in the number of psychiatrists and growth in the number of psychiatric nurse practitioners, this workforce issue will be challenged by COVID-19 and the uncertainty of new mental health needs and the demand for providers.
While many alternative models of care (e.g., accountable care organizations [ACOs], patient centered medical homes [PCMHs]) incentivized through the Affordable Care Act of 2010 encouraged the integration of primary care and mental health services, the declining workforce and maldistribution of providers (e.g., urban vs. rural) pose barriers to this effort (Olfson, 2016). Primary care providers (PCPs) are increasingly called upon to provide mental health services in addition to routine primary care. Two-thirds of PCPs have reported difficulty with referring individuals for mental health services (Cunningham, 2009). This issue further highlights the challenges surrounding mental health workforce shortages and the barriers faced by PCPs to support the mental health needs of their patients.
PCPs are not adequately prepared to address the mental health concerns of the general population. Even with additional training, there is a lack of motivation among primary care providers to manage mental health issues due to limited incentives to provide such services (Olfson, 2016). Furthermore, mental health services, along with primary care, have historically been undervalued in insurance payment and reimbursement. There has been a decline in the number of psychiatrists accepting private and public insurance leading to increased out-of-pocket costs (Bishop et al., 2014). This combination of a decreased mental health workforce and decline in insurance coverage contributes to barriers related to access to care, with potential to exponentially exacerbate this public health problem.
COVID-19 has turned the United States healthcare system upside down. The challenges around this pandemic have further exposed disparities and inequities inherent in mental health care. As a psychiatric-mental health nurse, and from my own experience with COVID-19, I am keenly aware of the short- and long-term psychosocial impact on mental health and well-being that will permeate communities across the country. The literature remains in the early stages of documenting the impact of COVID-19 on mental health across global populations.
Early evidence in China shows that healthcare workers are experiencing increased rates of depression, anxiety, insomnia, and symptoms of distress (Kang et al., 2020; Lai et al., 2020). These mental health issues affect an individual’s ability to understand and make decisions, and can directly and indirectly impact the provision of safe patient care and the overall COVID-19 response efforts. They can have adverse effects on the mental health and well-being of healthcare workers (Kang et al., 2020). As seen in the SARS outbreak of the early 2000s, healthcare workers experienced distress related to their perceived vulnerability; concerns about personal and family health; alterations in workflow; isolation; and general lack of control. Reportedly, nurses experienced the highest levels of distress over any other healthcare worker during the SARS outbreak (Wong et al., 2005). These same themes appear to hold true today as we continue to face the global COVID-19 pandemic.
The psychological burden experienced by individuals, families, and clinicians impacted by COVID-19 cannot be ignored (Choi et al., 2020; Galea et al., 2020). For example, patients with COVID-19, who require inpatient hospitalization, often require critical care services. Righy et al. (2019) reported that 1 in 5 critical care survivors experienced posttraumatic stress disorder (PTSD) symptoms within the first year post-discharge. COVID-19 has drastically increased the demand for critical care services; if these statistics hold true, a significantly increased number of ICU COVID-19 survivors are at an increased risk to experience PTSD or other mental health issues that negatively impact quality of life. This is just one salient example of what is yet to come as a result of COVID-19. The fallout will inevitably result in a subsequent pandemic of mental health crises if not proactively addressed as we continue to endure and navigate the COVID-19 pandemic and public health response efforts (Choi et al., 2020).
The social and economic drivers of health, structural racism, and inequities are no longer hidden from plain sight and can no longer be ignored. These issues are palpable and at the forefront of the COVID-19 pandemic. People are dying every day and the disparity gaps continue to widen, becoming an abyss for underserved and marginalized populations. Mental health is a vital component of public health and must be addressed in tandem with all other healthcare related to COVID-19.
Historically, the public health infrastructure in the United States has been chronically underfunded. There was a time when the attention to public health was far more prominent than it is now, where public health systems and programs were considered a crucial component of delivering healthcare in the United States. An investment in mental health and public health is vital as we prepare for the predicted second wave and aftermath of COVID-19. Without a strong mental health workforce, our efforts may be futile to address negative impacts related to equity, social determinants of health, and mental health outcomes. If we remain ill-prepared, an unspoken “third wave” of COVID-19 may present in an unprecedented increase in mental health issues across the United States.
Marcus Henderson, MSN, RN
Email: marcushe@nursing.upenn.edu
