On Our Minds Archives

Jonathan Muther, PhD

A quadrupling of the reported prevalence of mental illness and substance abuse since the onset of the pandemic might suggest a need to improve access to behavioral health services. The truth is our behavioral health system was overburdened and in need of an overhaul well before the pandemic. Both nationally and in Colorado, fewer than half of the individuals with identified symptoms of mental illness actually receive care. Those experiencing substance use disorders fare even worse, with indications that as many as 80% or more reporting they did not receive care. These data are pre-pandemic. Over the past year, the gap between need for treatment and acquisition of services has only widened and it is not surprising.

The necessary measures taken to reduce the spread of the disease and resulting impact mimic the risk factors for onset of mental illness and substance use disorders. Isolation, loneliness, job loss and financial uncertainty, fear of getting sick, and loss of loved ones are just some of the stressors so commonly experienced by many the past year. School closures, the shift to online learning, the forced absence of cherished rites of passage like prom and graduation ceremonies, even the missed conversations with friends during passing periods, have had a major impact on our youth. Throughout the pandemic youth aged 11 to 17 years have been the most likely to screen positive for moderate to severe symptoms of anxiety and depression. Suicidal ideation is on the rise and increases in deaths of despair seem to be a daily headlines. Further, political tension, systemic racism, and gun violence are among the many social, political, environmental, and cultural factors that need to be addressed as underlying causes of distress in this country.

Opportunities exist to improve our behavioral health infrastructure so that at a minimum, every individual with an identified behavioral health need can receive care and a comprehensive population health-based approach for regular and routine screenings. Any measure of prevalence rates for mental illness and substance abuse is likely a gross underestimation because we do not query enough people. Screening surveys often cannot reach adequate numbers due to logistical (i.e., digital literacy), perceptual (i.e., stigma) and cultural (i.e., no services in one’s preferred language) constraints, among other reasons. 

There are two commonly cited strategies we can engage in to achieve better access to behavioral health services for more people: telehealth and workforce expansion. Both are likely to lead to meaningful change, yet both are loaded with misconceptions that must be better understood and overcome to make a difference.

Telehealth dramatically improves access and reduces no-show rates. This was the case prior to the pandemic and telehealth capacity (in all forms) has allowed us to maintain rates of service on par with rates pre-pandemic. At the same time, we must also ensure that the utility of such services is not compromised for rural communities and individuals of color who have limited access to high-speed internet and/or cell phone service. We also cannot over-rely on telehealth as the be-all-end-all solution. For example, a clinician scheduled for eight therapy visits has two no-shows in-person, yet the telehealth clinician has zero no-shows for their phone or video conference therapy sessions. While improving no-show rates is critical, the real problem is relying on these clinicians to only have eight planned sessions per day. With this approach, we will be making little progress toward the overall goal of getting more people seen,  so other types of brief encounters must be pursued. Let’s not mistake improved no-show rates due to telehealth as meaningful progress toward the real goal of better access for all. We need to utilize smart technologies and simultaneously end our over-reliance on the conventional therapy hour as the sole method of behavioral health intervention. Screenings, consultations with medical providers, brief interventions, shorter episodes of care and measuring progress toward treatment must become the norm. If an individual does not make clinically significant change within three or four encounters with their behavioral health specialist it does not mean they just need more time, it means the approach to treatment needs to be different. Technology-based treatments involving periodic mood and stress inventories that allow for instant messaging and check-ins outside of a therapy hour, that engage an individual totally independent of involvement with a clinician, or that allow for group & peer learning at the convenience of the individuals schedule are just a few ways smart technologies can be optimized. We must pursue such platforms to assist us in making meaningful progress toward care for more individuals.

The most important consideration related to workforce is the allocation, or distribution of clinicians across settings. Until we become strategic about ensuring clinicians are working in the settings where individuals are most likely to present for a behavioral health-related concern, we will continue to see individuals fall through the cracks and not be seen at all. Knowing where to find a clinician is a far more important factor in accessing care compared with the often-cited stigma, or being afraid or embarrassed to seek care. We need more clinicians in school-based health centers and primary care clinics that collaborate closely with specialty care providers offering higher levels of care for the most severe clinical presentations. The result would be increased access across the entire spectrum of service delivery for all presentations in all settings. We must also continue to pursue advancements specific to frontline interventions, such as co-responder models to prevent criminalization of mental illness and overreliance on what has become the de facto mental health system…corrections. Importantly, workforce expansion, including investment in recruitment and retention strategies such as loan reimbursement, is also a necessary step toward improving access to behavioral health care. While intentional efforts to expand training programs and recruit students to enter the behavioral health field are necessary and likely helpful in years to come, we simply cannot wait to see the long-term impact of such efforts. We need to broaden the workforce to include roles like peer specialists, community health workers, “promotoras,” and mental health first responders. A triage model with utilizing such trained professionals can help us achieve a much better impact but still fall short of the ultimate goal.

The COVID-19 pandemic forced many heath inequities into broad daylight. As we heal from the pandemic, we have the opportunity and responsibility to reform and build systems and services to achieve better behavioral health outcomes. Telehealth, smart technologies, and expanded workforce can help us care for acute and chronic behavioral health needs.