Mental Health in the Era of COVID-19: Observations From a Frontline Provider

Forced isolation, disrupted routines and tension at home have become hallmarks of life during the COVID-19 pandemic. Among the byproducts have been significant increases nationwide in mental health-related issues, according to the Centers for Disease Control and Prevention (CDC).

In late June 2020, 40.9% of adults who responded to a CDC survey of mental health, substance use and suicidal ideation during the pandemic (MMWR Morb Mortal Wkly Rep. 2020;69:1049-1057) reported at least one adverse mental or behavioral health disorder. Compared with the second quarter of 2019, the prevalence of symptoms of anxiety disorder more than tripled — from 8.21% to 25.5% — and the prevalence of depressive disorder nearly quadrupled — from 6.5% to 24.3%.

How one psychiatrist sees it

Cleveland Clinic child and adolescent psychiatrist Tatiana Falcone, MD, has watched those statistics play out in real time in her practice. As the situation with COVID-19 has evolved locally since March, she and her colleagues have analyzed institutional statistics and adapted their care to try to better meet the needs of individuals with new and existing mental health challenges.

“We reviewed data on admissions for suicidal ideation or suicide attempts in patients from all 13 of our emergency rooms for the first three months of the pandemic,” says Dr. Falcone. “We found that the number of consultations decreased, but we think that was because the stay-at-home orders made people afraid to come in for treatment, not because they didn’t have serious symptoms.”

To facilitate care for patients with mental health issues during the early days of the pandemic, Cleveland Clinic’s Neurological Institute expanded its use of the institution’s Express Care® Online platform for virtual visits. To do so, they had to overcome a significant barrier: lack of insurance coverage.

“Before the pandemic, less than 50% of insurers were covering telemedicine,” says Dr. Falcone. “Some patients were afraid of the bill if they had a virtual visit.” The solution, employed across Cleveland Clinic, was to waive fees for telemedicine services for three months for any patients who lacked coverage.

“We went from doing 60% of our psychiatry consultations with telemedicine before to 98% after the pandemic,” says Dr. Falcone. “We also implemented online screening for depression and anxiety before online visits. In addition to our usual screening for suicidality, we’ve implemented scales such as the Ask Suicide-Screening Questions (ASQ) toolkit,” an efficient four-question instrument validated for use in youth and adults. Dr. Falcone and her colleagues have found it particularly appropriate for patients who have mental health issues associated with chronic illness.

Both new and exacerbated cases

During the early days of COVID-19, many of the children and adolescents who received treatment from the Neurological Institute experienced significant social issues. Some of these issues were created by the pandemic, while others — such as a history of family trauma or underlying conditions — were preexisting and exacerbated by the extraordinary circumstances.

“A small space that normally would be OK for a family now may be inadequate when everyone has to be together all day,” says Dr. Falcone. “The children’s schoolwork is online, but maybe they don’t have a computer. Their parents have to teach them while also doing their regular jobs. It has been really hard and frustrating, particularly for lower-income families, and the caregiver burden is translating to more suicidal ideation and suicide attempts.”

The recent CDC survey found that certain population subgroups were at particular risk. In the 30 days before being surveyed by the CDC, 18.6% of adult Hispanics reported seriously considering suicide, versus 7.9% of white non-Hispanics. Unpaid caregivers for adults (30.7%), essential workers (21.7%) and individuals aged 18 to 24 years (25.5%) also were among the most likely to say they had given serious consideration to ending their own lives.

Among the preexisting conditions Dr. Falcone believes have been most exacerbated by the pandemic are post-traumatic stress disorder, trauma- and stressor-related disorder, and autism spectrum disorder (ASD). For some individuals, the isolation has been worsened by an absence of support services they typically rely on.

“We’ve seen kids with developmental disabilities or ASD struggling because they went from having in-person programs for six to eight hours a day to now having them one hour a week virtually,” says Dr. Falcone. “Structured summer programs were curtailed, which made it hard for some parents to keep their jobs.”

Heightened emphasis on early intervention

Across the board in recent months, psychiatrists at Cleveland Clinic have increased the frequency of mental health visits and their overall outreach to current patients as well as those they may not have seen since well before the arrival of COVID-19.

“If patients are under a lot of stress because of the pandemic, we monitor them more closely for suicide; some we see weekly,” says Dr. Falcone. “We check in on patients who aren’t coming for appointments to see how they are doing and whether anyone in their home has been sick. Our goal is to get to people when they are sad or anxious, not when things have gotten so bad that they’ve attempted suicide.”