“I’m not alright”: Impact of COVID-19 on Mental Health

Written by Kat Griesmer, MD, MPH
Edited by Lauren Walter, MD

While the COVID-19 pandemic created ripples throughout nearly all aspects of society, it also exposed the desperate need for expansion of mental health resources, including forms of non-traditional access. Even prior to the pandemic, an inequitable divide in mental health services meant that many individuals were having difficulty finding providers or accessing basic mental health services. The National Alliance on Mental Illness reported that roughly one in five Americans experienced mental illness in 2019 and mental illnesses and substance use disorders represented one out of every eight emergency department (ED) visits for American adults [1].  And then COVID happened….

Today, 4 in 10 adults report depressive or anxiety symptoms, up from 1 in 10 only two years prior. At the beginning of the pandemic, in March-April 2020, EDs noted a global volume reduction of roughly 42%; however, the proportion of visits for mental health concerns rose [2]. Similarly, the National Syndromic Surveillance Program (NSSP) documented increased suicide attempts in 2020 as compared to 2019 [6]. One survey found that self-reported adverse mental health or behavioral symptoms during this timeframe were more prevalent in young adults aged 18 to 24 years (74.9% versus 15% in adults older than 65). Rates were also particularly increased in specific cohort populations including LGBTQ+, those with disabilities, and adult caregivers [7]. 

The pediatric population has proven just as vulnerable to the mental health effects of the pandemic. Similar to adults visits as described above, all cause pediatric ED visits decreased following the onset of stay at home orders in March 2020 and continuing into October 2020; however, the proportion of mental health-related pediatric ED visits increased greatly during the same period, predominantly in those aged 12-17 years, up 31% compared to the year previous [3]. One hypothesis for this is the limited number of resources available to children and adolescents during this period, including, but not limited to school counselors, mental health clinics, and even previously established care with delayed follow-up. The impact of decreased socialization and possibly exacerbated home life conditions (i.e. food insecurity, unstable family dynamics) during the initial wave of COVID may have also contributed. One study found those pediatric patients presenting with a psychiatric complaint post-pandemic were more likely to be admitted (50% versus 32%), suggesting possible increased severity in presentation. The same study noted that this pediatric population was less likely to have already had a prior psychiatric history or any previous outpatient treatment, further highlighting the stressor role COVID-19 may have played [4]. A retrospective study of over 42 freestanding children’s hospitals found an 11.8% increase, from Spring to Summer 2020, in suicide/intentional injury admissions [5].

What do these mental health numbers mean for those of us in the ED amid and post-pandemic? What can emergency medicine do in response? First and foremost, we have to acknowledge and understand the burden and impact of the pandemic on ourselves and our colleagues - we are not the exceptions to the rule. Multiple studies have found that health care workers have and continue to experience higher rates of depression and anxiety compared to the general population, disproportionately affecting women and nursing staff [8]. A recent survey study demonstrated that 85% percent of emergency physicians reported negative impact on their mental health secondary to COVID-19, along with over a doubling in feelings of burnout (16% to 41%). Almost 1/5 reported depression and insomnia [9]. Secondly, the connection between current mental health and the recent unprecedented disruption in our healthcare system is being felt diffusely. Exacerbated delays and difficulties in acquiring mental healthcare can be expected to continue, with overflow predicted to run toward the ED – proactive anticipation, from a health systems planning perspective, may help mobilize and proximate any available mental health or social work resources to assist. Third, while an increase in telehealth and digital utilization has provided novel and timely ways to connect patients with providers, the increase in mental health applications, or digital mental health (DMH) tools, should be considered in context and may not be as beneficial as in-person connectivity. Further, while these are useful alternatives in a locked down world, they may leave out populations without ready access to technology. In addition, there is little current data regarding the efficacy of DMH applications and few to no regulations placed on them currently; the few studies completed have a predominantly limited scope of population and follow-up. The role of DMH applications in the treatment of mental health should remain a topic of ongoing research consideration [10, 11]. 

As the pandemic continues, the persistent stress placed on mental health resources and EDs remains to be mitigated. For the foreseeable future, the trend of increased psychiatric-related visits to our EDs is likely to continue. As we face a ‘new normal,’ the truth is evident that COVID-19 has been mentally traumatic for many, including many of our ‘own.’ Modifying expectations and mobilizing resources will likely be necessary adjustments for some time yet. And perhaps, most importantly, consideration and check of one’s own well-being must be continually and deliberately regarded as well. 

References:

[1] Panchal N, Kamal R, Cox C, Garfield R. The Implications of COVID-19 for Mental Health and Substance Use. KFF. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/. Published 2021.

[2] Adjemian J, Hartnett K, Kite-Powell A et al. Update: COVID-19 Pandemic–Associated Changes in Emergency Department Visits — United States, December 2020–January 2021. MMWR Morb Mortal Wkly Rep. 2021;70(15):552-556. doi:10.15585/mmwr.mm7015a3

[3] Leeb R, Bitsko R, Radhakrishnan L, Martinez P, Njai R, Holland K. Mental Health–Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic — United States, January 1–October 17, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(45):1675-1680. doi:10.15585/mmwr.mm6945a3

[4] Ferrando S, Lynch S, Klepacz L et al. Psychiatric Emergencies During the Height of the COVID-19 Pandemic in the Suburban New York City Area. SSRN Electronic Journal. 2020. doi:10.2139/ssrn.3673198

[5] Gill PJ, Mahant S, Hall M. Reasons for Admission to US Children’s Hospitals During the COVID-19 Pandemic. JAMA. 2021;325(16):1676-1679. doi:10.1001/jama.2021.4382

[6] Holland K, Jones C, Vivolo-Kantor A et al. Trends in US Emergency Department Visits for Mental Health, Overdose, and Violence Outcomes Before and During the COVID-19 Pandemic. JAMA Psychiatry. 2021;78(4):372. doi:10.1001/jamapsychiatry.2020.4402

[7] Czeisler M, Lane R, Wiley J, Czeisler C, Howard M, Rajaratnam S. Follow-up Survey of US Adult Reports of Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic, September 2020. JAMA Netw Open. 2021;4(2):e2037665. doi:10.1001/jamanetworkopen.2020.37665

[8] Shaukat N, Ali D, Razzak J. Physical and mental health impacts of COVID-19 on healthcare workers: a scoping review. Int J Emerg Med. 2020;13(1). doi:10.1186/s12245-020-00299-5

[9] Dehon E, Zachrison KS, Peltzer-Jones J, et al. Sources of Distress and Coping Strategies among Emergency Physicians during COVID-19. Western Journal of Emergency Medicine. 2021. Ddi: 10.5811/westjem.2021.9.53406

[10] Longyear R, Kushlev K. Can mental health apps be effective for depression, anxiety, and stress during a pandemic?. Practice Innovations. 2021;6(2):131-137. doi:10.1037/pri0000142

[11] Friis-Healy E, Nagy G, Kollins S. It Is Time to REACT: Opportunities for Digital Mental Health Apps to Reduce Mental Health Disparities in Racially and Ethnically Minoritized Groups. JMIR Ment Health. 2021;8(1):e25456. doi:10.2196/25456