Preventing infections and saving people’s lives continue to be the most imminent COVID-19 priorities. But COVID-19 doesn’t pose a threat to just physical health. It takes a toll on behavioral health as well— including mental health, resilience and well-being, and substance use.
Experience from previous pandemics and natural disasters suggests that COVID-19 will likely exacerbate anxiety, depression, addiction issues, suicide, and other pre-existing mental health challenges on a national scale. Many COVID-19 patients will recover from the illness relatively quickly, but research suggests the threat to behavioral health will last much longer--and affect many who don’t contract the virus.
Research shows that behavioral health issues such as Post-Traumatic Stress Disorder (PTSD) have long-term effects. For example, Abt conducted a congressionally mandated longitudinal study of more than 2,000 Vietnam veterans and found that 11 percent of combat veterans still suffered from PTSD (e.g., intrusive nightmares, memories, and anxiety) over three decades after exposure to war zone trauma, and about a third suffered from major depression. Vietnam veterans with PTSD had a higher risk for chronic health problems, and Black and Hispanic Vietnam vets were two to three times more likely than white vets to develop PTSD.
As the pandemic continues with no clear end in sight, we need to transition from the immediate response and proactively prepare for the long-term needs in communities facing increasing behavioral health demand. Several recent studies show increasing levels of behavioral health conditions. The Substance Abuse and Mental Health Administration’s (SAMHSA) crisis hotline, for example, registered a 1,000 percent increase in April 2020 over April 2019. And a survey of adults in June 2020 reported substantially higher levels of a range of behavioral health conditions compared with June 2019. Moreover, the study revealed that the impacts are disproportionally affecting younger adults, racial and ethnic minorities, essential workers, and unpaid adult caregivers. Another recent study reported that the prevalence of depression symptoms has roughly tripled from pre-pandemic levels.
Fortunately, the mental health community’s long experience with traumas, from hurricanes to terrorist attacks to wars, provides us with tools and best practices to help those affected. Unfortunately, COVID-19’s geographic scale, ruinous financial destruction, and widespread risk of illness and death pose significant challenges.
A comprehensive, integrated response should include increasing access to care for those currently impacted, as well as prevention efforts promoting coping strategies to stem further increases in behavioral health conditions.
Access to timely and effective behavioral health care, particularly for marginalized populations, was a challenge before COVID and will likely be exacerbated as the pandemic persists. In 2016, for example, 11.8 million American adults believed that they had a need for mental health services during the previous year that went unmet, according to the American Psychological Association. Cost and lack of knowledge about where to get services were major factors in failing to get treatment. In addition, the supply of providers is woefully inadequate, and the shortfall is expected to get worse.
A 2016 report from the Health Resources and Services Administration (HRSA) found shortages in 2013 for the nine most common behavioral health practitioners, from psychiatrists to mental health and substance abuse social workers. Most specialties were projected to have shortages exceeding 10,000 each by 2025.
Prevention efforts can include a range of community- based strategies, including health communication to raise awareness of behavioral health conditions, mitigation strategies, and addressing stigma related to accessing behavioral health care.
How Abt Can Help
Abt has experience with many of the approaches and interventions that can help address the challenges that lie ahead, including sound, data-informed, and integrated strategies.
Increase Access to Quality Health Services
A comprehensive approach to expanding capacity would include increased support for community behavioral health centers, integration of behavioral health into primary care and other healthcare settings, expanded use of telehealth, and ensuring access to crisis lines.
It’s critical to assess the behavioral health landscape in a particular community to determine the right mix of services needed. To understand behavioral health capacity in Massachusetts in 2016, Abt compiled and analyzed data on the prevalence of behavioral health issues, the capacity of the workforce, cost and coverage issues, and access to care.
Increasing efficiency also can improve access for clients. Wait times, for example, can be a stumbling block to access. We used mixed methods to evaluate the wait time in Massachusetts for outpatient mental health appointments and investigated which underlying facilitating factors and barriers contribute to disparities in access to care. The process of connecting with an outpatient mental health provider is complicated and onerous. Clients experienced long wait times from the point at which a need for outpatient services was identified. Waits are longer for children and adolescents than adults. In addition, behavioral health providers’ selective insurance acceptance practices led to delays in accessing services. A major barrier is often low reimbursement rates, especially for Medicaid and Medicare. With COVID-related unemployment, many individuals and families have lost insurance altogether, further limiting access to care.
Access to more services is not enough, though. Services must be high quality. Abt has experience with quality improvement (QI) processes that can help ensure effective services. An Abt-led team supports a QI collaborative of more than 100 health practices implementing the Centers for Disease Control and Prevention (CDC) Opioid Prescribing Guideline and associated QI measures in primary care practices. The team is evaluating the systems’ QI efforts to implement the guideline, including assessment of QI measures collected, and has done work to support systems in using behavioral health providers to enhance implementation of the guideline.
Foster a Health Care Workforce Able to Address Current and Emerging Needs
Behavioral health organizations face a current shortage of behavioral specialists, which will grow over time as demand increases. Addressing current, emerging, and long-term needs requires the ability to provide and evaluate training, data-informed analysis, and modeling to determine healthcare worker distribution and track workforce trends. Abt has considerable experience in designing and evaluating behavioral health training and expanding the workforce, as well as disseminating best practices. For example, Abt collaborated with Medscape/ WebMD to design a continuing education course based on evidence-based practices to enable primary care providers (PCPs) to detect and help patients with PTSD.
Abt conducted a quasi-experimental evaluation of the course with PCPs. Compared with physicians who did not take the course (538 physicians), those who completed it (258 physicians) showed significantly greater improvements in their overall knowledge about PTSD, including PTSD symptoms, psychotherapy treatments, and medications. They also showed more confidence in their ability to discuss psychotherapies, explain benefits and side effects of medicines, and use an evidence-based screening instrument to identify patients who might have or develop PTSD. These effects were sustained over a one-month period after completing the course.
Evaluating training is important to determine what works and to make mid-course corrections if needed. Abt’s evaluation of the NYC Mental Health First Aid (MHFA), a public education program, showed that it prepares individuals without clinical training to recognize signs of mental health and substance use concerns and to respond empathically and effectively. The training addresses behavioral health concerns for target communities, including youth, veterans, older adults, and higher education institutions. MHFA provides adults with tools to identify socio-emotional problems early, support young people in crisis, and help them access the services and support they need to recover and build resiliency.
While increasing the behavioral health workforce is critical, we must also ensure workers are supported to manage their workload. Frontline workers, including health professionals and first responders, are vulnerable to burnout and mental health issues, leading to retention challenges. Regular assessments can identify challenges early.
Data to Support Responsive Behavioral Health Care Systems
Collecting data to understand the impacts of COVID-19 on vulnerable households is critical to effective responses, and data collection and analysis is one of Abt’s specialties. In collaboration with the Saul Zaentz Early Education Initiative, Abt’s robust data collection platform supported an important survey of early child care providers and parents on the effects of COVID-19. The survey was designed and conducted to describe the impacts of the pandemic on children, families, and Department of Early Education and Care providers in Massachusetts, which experienced one of the earliest and most widespread outbreaks of COVID-19 in the U.S. Results showed that lower-income families had high levels of job loss, but also high levels of teacher and school outreach, as well as technology supports for continued remote education.
Abt’s COVID-19 Assessment & Tracking Tool (or CATT) is a web-based assessment tool that helps agencies and organizations collect essential data such as behavioral health services available during and after the COVID19 pandemic. The tool can help quickly analyze this information on a daily basis and facilitate fast action to address problems and plan for future needs. CATT is built on a combination of three simple, scalable concepts: a customizable landing page, a set of 25-30 questions based on an organization’s interests, and a dynamic dashboard for daily reporting.
Enhance Population Health and Health Equity
Improving population health for all requires a variety of approaches: coordination of health services, community- based partnerships, payment reform, communications strategies, and development of adaptable, outcome- focused, and sustainable programs.
Abt has seen the importance of coordinated care in our evaluation work on the Ryan White program, where providers have been pioneers in this area. They make sure HIV patients have access to a variety of other services, from substance use disorder treatment to housing.
Similarly, Abt is leading evaluation efforts on the Building Capacity to Evaluate Child Welfare Community Collaborations to Strengthen and Preserve Families (CWCC) project. This project supports community-level mobilization around the development of multi-system collaboratives that provide a continuum of activities and services designed to strengthen families, prevent child abuse and neglect, and avoid unnecessary placement of children. Abt is conducting evaluation-related technical assistance to strengthen grantees’ capacity to conduct site-specific outcome evaluations.
We also have considerable communications experience. The CDC Community Interventions for Infection Control Unit (CI-ICU) awarded Abt a contract for the 2016 Community Strategy for Pandemic Influenza Mitigation in the United States: Pre-Pandemic Planning Guidelines for the Use of Non-pharmaceutical Interventions. We delivered communication, dissemination, and evaluation strategies for the guidelines. We also created tailored media, social media, and marketing materials for quick dissemination, targeting key audiences in communities. The audiences included administrators, teachers, school nurses, and health center staff, community- and faith- based organizations serving vulnerable populations, households, and health communicators. In addition, we developed a comprehensive evaluation plan to assess the communications and dissemination strategies, including a framework of evaluation metrics and tools.
During the Zika outbreak, our team of health communicators, graphic designers, and public health professionals worked with the CDC to create a crisis communications campaign comprising nearly 370 creative pieces in two months. We used digital and social media, including animated banner ads, Facebook and Instagram ads, and Google AdWords to target niche audiences. Other media channels included in- flight magazines, newspapers, radio, and billboards. The campaign reached 37 million people and earned a MarCom Platinum Award.
Our extensive capabilities evaluating program effectiveness can help identify what works and what doesn’t. This focus on both implementation and outcomes can inform ways to adapt programs to unique and changing environments. The result will be sustainable programs tailored to community needs. That’s critical because experience suggests the pandemic’s effects on behavioral health may last for decades. Abt stands ready to apply extensive relevant experience to provide responsive, tailored strategies to attenuate these long- term effects and support communities and systems in promoting behavioral health.