COVID-Related Mental Illness Rises, Capacity to Treat Falls

Ken Terry

May 06, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

During the COVID-19 pandemic, the percentage of Americans reporting symptoms of mental illness has increased, and the capacity to treat these disorders has decreased, a new report from the Government Accountability Office (GAO) shows.

The GAO cites a February 2021 survey by the National Council for Behavioral Health (NCBH), which showed that many of its member organizations had reduced staff and decreased services during the pandemic. Among the survey's findings:

  • 27% of member organizations reported laying off employees

  • 45% reported closing some programs

  • 23% furloughed employees

  • 35% decreased the hours for staff

  • 68% reported having to cancel, reschedule, or turn away patients in the previous 3 months

The NCBH, a nonprofit advocacy and consulting organization, reports that it has 3381 member organizations that serve over 10 million people with mental illness and/or addiction problems.

Another factor affecting access to behavioral health services is the limited capacity for inpatient services, especially for patients requiring in-person treatment, the GAO report notes.

Social distancing regulations during COVID-19 reduced the number of psychiatric beds in some hospitals, and other facilities stopped admitting patients with psychiatric diagnoses.

The only bright spot in all of this, said the GAO, was the increased use of, and payment for, telehealth therapy. Stakeholders interviewed by the GAO reported that telehealth had "improved access to behavioral health services for some patients not requiring in-person services and resulted in fewer missed appointments."

The GAO report did not explain why so many organizations that serve patients with mental illness had cut staff, reduced staff hours, and/or turned away or rescheduled patients. Some of it was undoubtedly attributable to the pandemic, which made patients less likely to schedule appointments with any healthcare provider.

Emergency Admissions Denied

In addition, the GAO presented anecdotal evidence that some payers had made it more difficult for healthcare professionals to be paid. For example, officials at the Virginia Hospital and Healthcare Association told the GAO that they had heard about an increase in delays and denials of inpatient claims for patients with physical and behavioral diagnoses.

In addition, the Texas Hospital Association reported that payments for behavioral health emergencies leading to admission, including suicide attempts, were denied or delayed.

NCBH officials said members reported that it often took longer for behavioral health claims to be processed than for medical/surgical claims to be paid.

Most respondents told the GAO that state Medicaid programs were the worst payers in this regard. In one hospital system in Oregon, for example, behavioral health claims were routinely denied for Medicaid patients who had received both medical/surgical and behavioral health services.

NCBH officials noted that it is common to experience longer delays in the payment of claims under Medicaid managed care plans than under state-administered Medicaid plans, owing to differences in standards as to what constitutes an acceptable claim.

Under a federal law passed in 2008, insurance coverage of mental health and substance use disorders is not supposed to be more restrictive than coverage for medical/surgical services.

"However, even before the pandemic, long-standing questions were raised about whether coverage or claims for behavioral health services are denied or delayed at higher rates than those for other health services," the report notes

Despite anecdotal reports, there is no evidence the pandemic has worsened this situation. GAO survey respondents said, "Payments were generally not affected by COVID-19 or it was too early to tell, apart from certain state-specific situations."

More Suicide Attempts

What has changed during the pandemic, the GAO said, is the prevalence of mental health disorders. Surveys by the Centers for Disease Control and Prevention (CDC) conducted from April 2020 to February 2021 showed that the percentage of adults reporting symptoms of anxiety or depression averaged 38.1%. Percentages ranged from a low of 33.9% in May to a high of 42.6% in November.

In comparison, another CDC survey showed that about 11% of adults reported these symptoms from January to June 2019.

Overdose deaths and suicide attempts have also increased since the start of the pandemic, the GAO reports. An analysis of CDC data published in February 2021 showed that emergency department visits for suicide attempts and drug overdoses were 26% and 36% higher, respectively, from mid-March through mid-October 2020 in comparison with the same period in 2019.

The GAO cited several reports that show that shortages of healthcare professionals were severe before the pandemic, particularly in rural areas, and that these shortfalls have continued.

Through September 30, 2020, the Health Resources and Services Administration designated more than 5700 areas in which there were shortages of mental health providers, the GAO reported. In these areas, where about one third of the US population lives, the number of mental health providers was enough to meet only 27% of the estimated need.

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