Blog Post

A year into the pandemic, here’s how behavioral health care is changing—for the worse and for the better

By Clare WirthDarby Sullivan

March 29, 2021

    When the Covid-19 pandemic and economic downturn hit, the need for behavioral health care intensified. Last year brought a dangerous combination of economic insecurity, fewer opportunities for meaningful social interactions, reduced functioning of community services, national trauma from racist violence, and general dread about the existential threat of a global pandemic. As of February 2021, 39% of Americans reported symptoms of anxiety or depression. That’s almost four times higher than in 2019—and it almost certainly fails to capture the actual size of the need.

    There’s no way to sugarcoat the fact that the challenges are great and, in many ways, getting worse. But there is some good news. Behavioral health care has breached the national consciousness, and some industry stakeholders are making new steps toward lasting solutions.

    Here’s the latest on how Covid-19 is impacting behavioral health care—for the worse and for the better—and what we’re paying close attention to in the coming months.

    How Covid-19 is impacting demand for behavioral health care

    For the worse…

    The behavioral health crisis is not going to subside when Covid-19 does.

    A McKinsey analysis shows a potential 50% increase in the prevalence of behavioral health conditions in 2021 due to Covid-19, which they note is likely an underestimate. Data also shows higher rates of anxiety, depression, binge drinking, difficulty sleeping, irregular eating, and worsening chronic conditions.

    Over 81,000 people died from drug overdose in the 12-month period ending in June 2020, a 20% increase over the year prior and the highest ever recorded in the U.S. Elevated deaths of despair (those related to suicide, alcohol, and drugs) are likely to continue due to the lingering economic impact of Covid-19.

    This “second pandemic” is inherently a health equity crisis—particularly for those who sit at the intersection of racial and economic marginalization.

    According to new survey data from the Kaiser Family Foundation, essential workers, communities of color (especially Black and Latino adults), adults in households with job loss, and young adults all reported symptoms of behavioral health conditions at higher rates compared to their counterparts. In addition, children’s mental health-related ED visits accounted to a significantly higher proportion of pediatric ED visits in April through October 2020 than in 2019.

    For the better…

    There are early signs that (some) stigma is dissipating.

    Unlike most other specialties, need and demand are not interchangeable in behavioral health. Even when services are available and affordable, patients can be reluctant due to deeply engrained cultural norms. Thus, reducing stigma can unlock demand for lower-acuity behavioral health services before patients become acute and require costly, intensive services.

    During the Covid-19 crisis, more people are assessing if they need support and seeking help when they do. Mental Health America reported a 93% increase in people using their online anxiety screenings and a 62% increase in people using their depression screens in 2020 over 2019. Also, according to a recent Optum survey of about 1,200 commercial, Medicare, and Medicaid patients, about half of respondents received more behavioral health support in 2020 than before.1 There’s also anecdotal evidence we’re having more conversations about our mental health.

    But we promised cautious optimism for a reason. There is not yet enough data to definitively conclude that behavioral health stigma has declined during the Covid-19 pandemic, or by how much. In reality, certain conditions (such as substance use disorders) are more likely to remain stigmatized than others (such as depression and anxiety). In addition, not all demographic groups are starting from the same place. Receiving mental health treatment is more stigmatized in certain populations, such as Asian American and Pacific Islanders (AAPI) and Black communities.

    How Covid-19 is impacting supply of behavioral health care

    For the worse…

    The underlying incentives (and lack of incentives) to provide behavioral health care haven’t changed.

    There’s a strong business case that behavioral health care reduces the total cost of care and improves patient outcomes. But it’s not a revenue growth engine for health systems because payers generally don’t provide adequate reimbursement. And the capacity of traditional behavioral health providers is diminishing amid the current economic crisis. More than half of traditional behavioral health providers have had to close programs, and nearly two-thirds have had to cancel or reschedule appointments, or turn away patients entirely.

    Ultimately, patients pay the price. Many don’t receive the care they need. And if they do, many end up paying out of pocket.

    Structural barriers to supply persist.

    Telehealth can extend the reach of the current workforce only so far. The psychiatrist shortage is worsening as the bulk of current providers prepares to retire. The industry has gotten creative by creating specialized psychiatric nursing and APP roles, and upskilling social workers to try to fill the gap. But recent improvements disproportionately benefit patients with low-acuity needs.

    PCPs are maxed out, or close to it. Plans and provider organizations have often turned to busy PCPs to handle some of the lowest acuity behavioral health needs. Before Covid-19, half of all behavioral health conditions were treated in primary care. And PCPs said even more patients started coming to them with behavioral health concerns during the pandemic, according to a recent Advisory Board survey (full report coming soon).

    But PCPs are already overloaded—half report being burnt out. Our survey found only 20% receive incentives for behavioral health screening, 21% receive ongoing training in this area, 25% have embedded behavioral health staff, and 30% receive on-demand expertise to address patients’ behavioral health needs.

    For the better... 

    High utilization of tele-behavioral health services and sizeable investments in behavioral health startups show promise for addressing certain needs.

    Covid-19 has validated the potential for scaled access to low-acuity interventions, as evidenced by consistently high demand for telehealth and the continued emergence of well-funded start-ups. Tele-behavioral health use has held at peak Covid-19 levels. About 66% of psychiatry visits are still virtual. In contrast, other specialties have plateaued with around 15% to 20% of visits occurring virtually. Also, in 2020, $2.4 billion was invested in U.S.-based digital health start-ups that address behavioral health needs.

    But with all advancements in telehealth there’s a potential to deepen disparities. While telehealth can dramatically increase access to care, many patients face barriers that prevent them from using virtual options. Also, new companies don’t cover the full range of behavioral health needs. For example, startups focused on substance use disorder and developmental disorders have not garnered anywhere near the same level of investment as companies focused on other behavioral health needs.

    Employers are sizing up their own responsibilities.

    About half of U.S. workers report struggling with mental health issues. The bulk of employers are responding—surveys show they intend to expand access to behavioral health and well-being services in 2021. And employer-focused start-ups such as Lyra Health and Modern Health are priming to support. They scored $75 million and $35 million deals, respectively, in H1 2020.

    What we’re watching

    Behavioral health is at a pivot point in the U.S. Here are some questions we’ll be watching this year:

    • Patient demand: How will patient needs evolve during recovery from the pandemic? How will that manifest over time (absenteeism, PTSD symptoms, etc.)? How long will recovery take?
    • Stigma: Will the prevalence of behavioral health needs significantly—and quantifiably—reduce stigma?
    • Provider role: How will the role of providers evolve as employers and direct-to-consumer vendors fill unresolved gaps in behavioral health access?
    • Vendor consolidation: Will vendors partner with one another to provide a continuum of care?
    • Medical-behavioral care integration: Will vendors integrate their efforts with provider organizations or remain siloed? Would integration be sustainable for providers?
    • Long-term changes: Ultimately, will Covid-19 catalyze long-term transformation of the U.S. health system’s incentives and capacity to address pervasive behavioral health needs?

    1. Advisory Board is a subsidiary of Optum. All Advisory Board research, expert perspectives, and recommendations remain independent.

    Nick Cericola contributed to this post.

    Our take: How Covid-19 will impact behavioral health services

    The psychological impact of the Covid-19 pandemic is unprecedented—fear, isolation, distrust. This is rapidly increasing the need for behavioral health services. But there are significant gaps and barriers that stand in the way of people getting the help they need.

    Keep reading to get our take.

    Get our take

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