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No Going Back:

How the pandemic will reshape the mental health landscape in America.

It is no secret that America’s approach to mental healthcare has never been inadequate. Rather than being proactive, it is fundamentally reactive, and the current COVID-19 pandemic throws this into stark relief. There is an epidemic of mental illness brewing in America, and it will not go away when lockdowns are lifted. Does the country have what it takes to turn this potential disaster into a renaissance for our mental health system?

In an April 14 article, Garen Staglin notes that in the present crisis, “ everyone is being encouraged to manage symptoms of stress and anxiety stemming from new work environments, fear of contracting the virus and unexpected financial insecurity,” and he opines that, “in terms of eroding stigma and normalizing conversations about mental health, this change in behavior and expectations bodes extremely well for the new, post COVID-19 reality.”

Could the global pandemic achieve a paradigmatic change in society’s attitudes and approaches toward mental illness — and, crucially, public and private funding for mental healthcare? Some mental health activists and advocates are hopeful, but the issues are multifaceted and complex and will require a concerted, sustained effort from virtually all sectors in America.

One of the many lessons being learned from COVID-19 is that preparedness, prevention, and early intervention are crucial for dampening the impact of this pandemic, and these will be vital for the containment of future health threats. The same approach needs to be taken to mental health. As Mental Health America emphasizes, “Mental health conditions should be treated long before crisis. . . . Left untreated, people slowly lose their ability to [be] . . . healthy, successful, and contributing members of their community. They become isolated from the community and often end up homeless, in jails, or in hospitals. The community misses out through lost productivity and relationships.”

Lockdowns and other measures necessarily taken in an effort to “flatten the curve” have led to increased levels of loneliness, depression, intimate partner violence, child abuse, substance misuse, and suicide. Across the country, crisis services have seen spikes in volume, and many are stretched beyond their already meagre resources. Soaring unemployment rates and massive economic contractions at national and global levels are having devastating impacts on the most vulnerable. Those already living with food insecurity, unstable or nonexistent housing, zero-hour employment, and chronic illness are at much greater risk of infection and death. When surviving from day to day was the reality before the pandemic, the current additional stresses and fears can push people into mental illness or intensify their existing mental health challenges.

The pandemic is “a forced reckoning” for an America whose track record for the underprivileged is poor, and where the homeless number more than half a million. Abandoned by society, more than one in five homeless persons suffer from mental illness, and at least 16% have a substance use disorder. Without fundamentally different, compassionate, well-funded approaches to help these individuals regain their lives, this country faces the prospect of skyrocketing mental illness, addiction, violence, and crime in the wake of COVID-19, and the increasing disintegration of an already frayed and threadbare social fabric.

Large-scale policy change at the federal level is required to address not only the existing inadequacies of our mental healthcare system, but the storm surge of maladies that are coming with the battle against the coronavirus crisis. In a piece for JAMA Internal Medicine, Sandro Galea, Raina M. Merchant, and Nicole Lurie warn that “[t]he worldwide COVID-19 pandemic, and efforts to contain it, represent a unique threat, and we must recognize the pandemic that will quickly follow it — that of mental and behavioral illness — and implement the steps needed to mitigate it.”

Those on the frontlines of the battlefield are our first responders and healthcare workers, and close behind them the swathes of support personnel who are vital for hospitals and other care facilities to keep functioning: custodial workers, porters, and food-service staff. In location after location, caregivers are being overwhelmed by the volume and severity of cases, are facing shortages of crucial supplies and drugs, and are experiencing anxiety, depression, insomnia, and despair. At best, we are only at the end of the beginning of this pandemic, so if we aren’t caring for our caregivers, the healthcare system will swiftly be in peril. In a March 18 memo, the World Health Organization urges managers and leaders of health facilities to remember that “[k]eeping all staff protected from chronic stress and poor mental health during this response means that they will have a better capacity to fulfil their roles. . . . [T]he current situation will not go away overnight and you should focus on longer-term occupational capacity rather than repeated short-term crisis responses.”

The wider population, too, will inevitably experience a sharp rise in anxiety, depression, and in some cases PTSD, with those conditions’ attendant manifestations and sequelae. As there will not be enough mental health specialists to handle the burgeoning need, plans must be made now for alternative provision mechanisms. Education and training regarding psychosocial issues should be provided to health system leaders, first responders, and health care professionals. The mental health and emergency management communities should work together to identify, develop, and disseminate evidence-based resources related to disaster mental health, mental health triage and referral, needs of special populations, and death notification and bereavement care. . . . Mental health professionals can help craft messages to be delivered by trusted leaders.

The tasks are many, but turning away from mental illness and the inadequacies of our mental healthcare system is no longer a viable option. By grasping the nettle, we can redress centuries’ old errors in America’s social contract, particularly our ways of (not) treating mental illness. The current threat is a chance to advance our understanding of how to provide prevention-focused, population-level, and indeed national-level psychological first aid and mental health care, and to emerge from this pandemic with new ways of doing so.

An emphasis on the holistic health of mind, body, and spirit is essential to enable us to work together towards our new normal. In the face of this unprecedented challenge, we have an opportunity to bridge the divide between physical and mental health realms, for the betterment not only of those struggling with mental health issues but of society in its entirety. An under-recognized piece of this bridge across the body–mind divide is the role of nutrition in our mental wellbeing. The nascent field of integrative psychiatry encourages health practitioners to understand how what we eat can have significant negative or positive effects on our cognition and emotions. What happens in your gut, genetic medical conditions, and chronic pain can all affect your mental health. Likewise, depression, anxiety, and stress all impact your physical body. Openness to new models for mental/emotional functioning and health will help America revamp its approach to mental healthcare in policy and practice.

COVID-19 is taking us on a voyage never before navigated by humanity. Traveling through uncharted waters is perilous and requires calm, careful, deliberate decisions and actions, taken for the safety and survival of all passengers. But it also offers us the opportunity to draw a new map of mental health and how we engage with it, not only now, but into the uncertain future. We owe it to this country’s present and future generations to grasp this chance and forge lasting change that will bring greater wellbeing to our citizens, communities, and nation.

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