The Implications of COVID-19 for Mental Health and Substance Use


The COVID-19 pandemic and resulting economic downturn have negatively affected many people’s mental health and created new barriers for people already suffering from mental illness and substance use disorders. In a recent KFF poll, nearly half (45%) of adults in the United States reported that their mental health has been negatively impacted due to worry and stress over the virus. As the pandemic wears on, it is likely the mental health burden will increase as measures taken to slow the spread of the virus, such as social distancing, business and school closures, and shelter-in-place orders, lead to greater isolation and potential financial distress. Though necessary to prevent loss of life due to COVID-19, these public health measures expose many people to experiencing situations that are linked to poor mental health outcomes, such as isolation and job loss. Additionally, feelings of anxiety are increasingly common, as people are fearful of themselves or loved ones falling ill and are uncertain of the repercussions of the pandemic.

This brief explores mental health and substance use in light of the spread of coronavirus. Specifically, we discuss the implications of social distancing practices and the current financial crisis on mental health, as well as challenges to accessing mental health or substance use services. We draw on data on mental health prior to the COVID-19 pandemic and, where possible, include recent KFF polling data on the mental health effects of the pandemic. Key takeaways include:


  • A broad body of research links social isolation and loneliness to poor mental health; and recent data shows that significantly higher shares of people who were sheltering in place (47%) reported negative mental health effects resulting from worry or stress related to coronavirus than among those not sheltering in place (37%). Negative mental health effects due to social isolation may be particularly pronounced among older adults and households with adolescents, as these groups are already at risk for depression or suicidal ideation.

  • Research shows that job loss is associated with increased depression, anxiety, distress, and low self-esteem and may lead to higher rates of substance use disorder and suicide. Recent polling data shows that more than half of the people who lost income or employment reported negative mental health impacts from worry or stress over coronavirus; and lower income people report higher rates of major negative mental health impacts compared to higher income people.


Poor mental health due to burnout among front-line workers and increased anxiety or mental illness among those with poor physical health are also concerns. Those with mental illness and substance use disorders pre-pandemic, and those newly affected, will likely require mental health and substance use services. The pandemic spotlights both existing and new barriers to accessing mental health and substance use disorder services.


Background


Prior to the COVID-19 pandemic, nearly one in five of U.S. adults (47 million) reported having a mental illness in the past year, and over 11 million had a serious mental illness, which frequently results in functional impairment and limits life activities. Prevalence of depression and anxiety was also high: In 2017-2018, nearly 17 million adults and an additional 3 million adolescents had a major depressive episode in the past year. In 2018, nearly a third (32.5%) of adults reported feeling worried, nervous, or anxious on a daily, weekly, or monthly basis.

Deaths due to drug overdose have increased more than threefold over the past 19 years (from 6.1 deaths per 100,000 people in 1999 to 20.7 deaths per 100,000 people in 2018). In 2018, over 48,000 Americans died by suicide, and in 2017-2018, over ten million adults (4.3%) reported having serious thoughts of suicide in the past year.


Mental Health Risks Due to Social Isolation


In response to the current coronavirus crisis, most state and local governments are requiring closures of non-essential businesses and schools, prohibiting large gatherings, and requiring quarantines for travelers, in addition to encouraging social distancing. A majority of states have declared mandatory stay-at-home orders for all but non-essential workers. A broad body of research links social isolation and loneliness to both poor mental and physical health. Former U.S. Surgeon General Vivek Murthy has brought attention to the widespread experience of loneliness as a public health concern in itself, pointing to its association with reduced lifespan and greater risk of both mental and physical illnesses (Dr. Murthy serves on the KFF Board of Trustees). Additionally, studies of the psychological impact of quarantine during other disease outbreaks indicate such quarantines can lead to negative mental health outcomes. There is particular concern about suicidal ideation during this time, as isolation is a risk factor for suicide.


In the Early April KFF Tracking Poll, conducted March 25-30, 2020, we found that 47% of those sheltering in place reported negative mental health effects resulting from worry or stress related to coronavirus (Figure 1). This rate is significantly higher than the 37% among people who were not sheltering in place reporting negative mental health impacts from coronavirus. Of those sheltering in place, 21% reported a major negative impact on their mental health from stress and worry about coronavirus, compared to 13% of those not sheltering in place.


Mental Health Risks Associated with Poor Physical Health


According to the CDC, people who have chronic illnesses such as chronic lung disease, asthma, serious heart conditions, and diabetes are among those with a high risk of severe illness from COVID-19. Research shows that mental health disorders are common comorbidities among patients with these and other chronic illnesses. The Early April KFF Tracking Poll found that 53% of those with fair or poor health status reported that worry or stress related to coronavirus has negatively impacted their mental health, compared to 44% of those with excellent, very good, or good health status (Figure 5). Of those with fair or poor health status, 29% reported a major negative impact on their mental health, compared to 17% of those with excellent or good health status.


Discussion


In recognition of the mental health implications of the COVID-19 pandemic, the World Health Organization released a list of considerations to address the mental well-being of the general population and specific, high-risk groups, including health care workers, children, and older adults. The CDC has also shared information and recommendations regarding stress and coping in their online COVID-19 resources. Additionally, the National Institute on Drug Abuse has noted that while little is known about COVID-19 in relation to substance use, there are potential associations between severe COVID-19 and substance use disorder.

The pandemic is likely to have both long- and short-term implications for mental health and substance use. Those with mental illness and substance use disorders pre-pandemic, and those newly affected, will likely require mental health and substance use services. Consequently, the pandemic spotlights both existing and new barriers to accessing mental health and substance use disorder services. In 2018, among the 6.5 million nonelderly adults experiencing serious psychological distress, 44% reported seeing a mental health professional in the past year. Compared to adults without serious psychological distress, adults with serious psychological distress were more likely to be uninsured (20% vs 13%) and be unable to afford mental health care or counseling (21% vs 3%). For people with insurance coverage, an increasingly common barrier to accessing mental health care is a lack of in-network options for mental health and substance use care. Those who are uninsured already face paying the full price for these and other health services. As unemployment continues to increase and people lose job-based coverage, some may regain coverage through options such as Medicaid, COBRA, or the ACA Marketplace, but others may remain uninsured.

Limited access to mental health care and substance use treatment is in part due to a current shortage of mental health professionals, which will likely be exacerbated by the COVID-19 pandemic. While some mental health providers are increasing their use of telemedicine in light of social distancing, not all are able to do so. The recently-passed Coronavirus Aid, Relief, and Economic Security Act (CARES Act) may help to address the likely increased need for mental health and substance use services. It includes a $425 million appropriation for use by the Substance Abuse and Mental Health Services Administration (SAMHSA), in addition to several provisions aimed at expanding coverage for, and availability of, telehealth and other remote care for those covered by Medicare, private insurance, and other federally-funded programs. It also allows for the Secretary of the Department of Veterans Affairs to arrange expansion of mental health services to isolated veterans via telehealth or other remote care services. These provisions may alleviate some of the acute need for remote mental health and substance use services. In addition, the CARES Act extends the duration of, and expands, Medicaid Community Mental Health demonstrations, which are currently underway as part of efforts to increase care access and quality at community behavioral health clinics.

As policymakers continue to discuss further actions to alleviate the burdens of the COVID-19 pandemic, data will be required to measure its growing effect on mental health and substance use. The increased need for mental health and substance use services will likely become a long-term problem even as new cases and deaths due to the novel coronavirus subside.


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