Three steps to flatten the mental health need curve amid the COVID-19 pandemic.

INTRODUCTION

The call to flatten the curve of COVID‐19 has been adopted worldwide. The practice of physical distancing aims to reduce the exponential growth of the virus, preventing the complete inundation of health care systems and saving countless lives. However, as the wave of new COVID‐19 cases begins to crest, a second wave of health concerns will require our attention and our timely response. In this commentary, we extend the model of exponential transmission of COVID‐19 to mental health need. We identify actions across mental sectors from individuals to systems that may help to address the growth of mental health needs secondary to COVID‐19.

THE GROWTH OF MENTAL HEALTH NEEDS

The expected surge of mental health needs following the current crisis will surpass the capacity of current mental health systems. Before the pandemic, 50% of people needing mental health services in high resource countries lacked access to care, with rates of unmet care up to 90% in low resource countries (Demyttenaere et al., 2004). In the United States, before COVID‐19, 11.8 million people reported having unmet mental health needs (Christidis, Lin, & Stamm, 2018).

Emerging data in countries struck earlier by COVID‐19 signals a significant increase in mental health need. A recent cross‐sectional survey of 1,257 health care workers in China found that responders were experiencing concerning levels of depression (50.4%), anxiety (44.6%), insomnia (34%), and distress (71.5%; Lai et al., 2020). These data are consistent with previous large‐scale disasters. One year after the 2003 outbreak of severe acute respiratory syndrome, survivors showed concerning levels of depression, anxiety, and stress with 64% reporting likely psychiatric disorders (Lee et al., 2007). Similarly, research following 9/11 found that 10% of responders reported clinically significant levels of posttraumatic stress 11 to 13 years after the event (Bromet et al. 2016).

Despite the amount of prior research, the exact magnitude of mental health needs resulting from COVID‐19 is largely unknown. The COVID‐19 pandemic is not constrained to a particular city or region and almost everyone will know someone affected by COVID‐19. Thus, it is crucial that proactive steps are taken to flatten the mental health need curve before the demand for services further overwhelms system capacity. We outline three specific steps that likely will be essential: individual response, innovative research, and workforce development.

A PROACTIVE MENTAL HEALTH RESPONSE

Prevention: A call for individual level response

A proactive response to flatten the mental health need curve begins at an individual level. During the course of the pandemic, most can be expected to experience the emotional strain of threat and uncertainty. Psychoeducation on the fight‐or‐flight response to stress can help individuals understand their own physical and emotional reactions and identify when to seek additional support. In addition to psychoeducation, empirically‐informed strategies for reducing the stress response including limiting news consumption, establishing regular eating, sleeping, and exercise habits, and increasing social connection should be widely disseminated. Practicing individual psychological care may be especially important to mitigating the long‐term effects of chronic stress among frontline workers. Individual prevention through psychoeducation and evidence‐base strategies can promote resilience, thus reducing the overall number of people needing intensive treatment.

Intervention: A call for psychological research

As researchers race to develop a vaccine and therapeutic treatments, there is also a necessity to develop and study innovative psychotherapy protocols that address comorbid and acute presentations of mental health disorders. Novel treatments focusing on the intersection of acute grief, trauma, depression, and anxiety will be essential to care for those most impacted by COVID‐19. Individuals who lose a loved one to COVID‐19 will be confronted with a host of risk factors for poor mental health outcomes. Individuals likely will have been cut off from their loved one at the time of death, robbed of traditional mourning practices, grieving in a context of social isolation, and faced with the ongoing threat that they or other friends or family members may contract the same virus that took the life of their loved one. With more than 40,000 COVID‐19 related deaths in the US already and an estimated four bereaved adults per death, the mental health toll of COVID‐19‐related bereavement will be substantial. Unfortunately, there are no well‐established treatment protocols for acute grief, let alone treatment protocols equipped to support the multi‐faceted needs of this unique population. If we are to effectively reduce the mental health demand, these protocols must not only be developed, but rapidly studied to ensure that early intervention efforts are as effective as possible. Further, given the disproportionate impact of this virus on ethnic minorities, novel treatment protocols will need to take particular care to include content for diverse population and resource‐restricted settings.

Prevention and intervention: A reimagined mental health workforce

As officials consider how to ensure universal access to a vaccine upon its development, there will also be a need to consider methods for increasing access to mental health care given the anticipated shortage of providers. Before this pandemic, an estimated 20% of the US population needed mental health care, yet only 0.1% of the population was trained to deliver it. Even if we are able to flatten the mental health need curve, there is no question that our system of mental health care as presently constituted is not positioned to handle the current level of need, let alone the increased need brought on by COVID‐19. As such, we need to rethink who is able to provide mental health services. Task shifting (i.e., moving mental health care to less specialized workers) has been shown to be an effective approach to expand services globally. However, the United States is far behind in the adoption of task shifting. One avenue to help flatten the mental health need curve, while also addressing the previous access to care crisis, is to train non‐licensed professionals (e.g., educators, community mental health workers, youth development professionals) to deliver evidence‐based strategies. An expanded workforce would both increase prevention efforts and also build health system capacity to intervene and mitigate the emotional impact of COVID‐19.

As a global community, we have come together in an effort to flatten the curve of COVID‐19 transmission. Now, as the rates of viral transmission begin to attenuate, an additional effort, focusing on mental health, must be undertaken. COVID‐19 has and will continue to negatively affect the functioning and well‐being of countless individuals in the form of anxiety, grief, and trauma. Crucially, this effect will likely grow as more individuals and their friends and loved ones become infected. Thus, a proactive and comprehensive mental health response characterized by individual practice of empirically‐driven strategies, creation of innovative treatments, and workforce development is needed to address mental health amid the COVID‐19 pandemic.