Has the Pandemic Finally Convinced Doctors to Take the Link Between Physical and Mental Health Seriously?
In September 2020, six months into the coronavirus pandemic, the number of Americans experiencing depression and anxiety hit an all-time high, according to the non-profit advocacy group Mental Health America. More recently, in December, 51% of adults surveyed by the Kaiser Family Foundation reported that stress related to COVID-19 had negatively affected their mental health. These stats should surprise absolutely no one. The question, of course, is what are we doing about it?
Mental health has long taken a back seat to physical health, despite the fact that the two are clearly intertwined. Research has shown, for instance, that adults who have depression as well as coronary artery disease (CAD) are 59% more likely to have a serious cardiovascular event (like a heart attack or stroke) compared to others with CAD who are not depressed. Depression and anxiety are also associated with worse outcomes for people with cancer, autoimmune diseases, and other serious or chronic conditions.
But treating mental and physical health in tandem just makes sense, Reynold Panettieri, MD, professor of medicine at the Rutgers Robert Wood Johnson Medical School and director of the Rutgers Institute for Translational Medicine & Science, tells Health. "It's impossible to separate the two," he says.
That might certainly turn out to be the case for many COVID "long haulers" who remain ill for weeks or months after they were infected. Although there's still much we don't know about the virus, emerging evidence suggests that it has the potential to affect the brain and cause physiological changes that—when coupled with the trauma of becoming ill with a novel virus during a pandemic—might make holistic care more important than ever.
An estimated 20% of people who contract COVID meet the diagnostic criteria for a mental health issue such as anxiety or depression within 3 months of diagnosis, according to research published in November 2020 in the Lancet. Other research—a survey of 5,163 COVID survivors who had symptoms for longer than 21 days, led by Natalie Lambert, PhD, an associate professor at Indiana University School Medicine—found that 79% of survivors complain of fatigue, 55% report headaches, and 54% say they have difficulty concentrating. Memory issues, dizziness, insomnia, and a loss of taste and/or smell are also common.
Are these brain problems, emotional problems, or some combination of the two? "Sometimes it doesn't matter if it's the chicken or egg that came first," Laura Boxley, PhD, a neuropsychologist in the Department of Psychiatry and Behavioral Health at The Ohio State University Wexner Medical Center (OSUMC), tells Health. "Neurological phenomenon can be associated with psychiatric symptoms, and psychiatric symptoms can lead to neurological issues."
Determining how COVID impacts the nervous system is an area of active research; an international group of scientists has formed the Global Consortium to Study neurological dysfunction in COVID-19 (GGS-NeuroCOVID) for the specific purpose of studying it. Based on what we know so far, it seems that the virus might attack the front lobe of the brain in some people, neuroscientist Caroline Leaf, PhD, author of Cleaning Up Your Mental Mess (due out in March) and founder of the podcast of the same name, tells Health. That's the area responsible for decision-making, problem-solving, and impulse control. Decreased activity in this area could cause depressive symptoms as well as the mental "fogginess" that some survivors have described.
In other patients, the virus might damage blood vessels in the brain or cause encephalitis (brain inflammation). Long Island-based photographer Diana Berrent had a fairly mild case of COVID in March 2020, but in the months that followed she developed crushing headaches, insomnia, and even hallucinations.
When Berrent, who is the founder of the COVID-19 patient advocacy group Survivor Corps, finally went for imaging tests to get to the root of her terrible headaches, she was told that her head presented as if she had suffered a severe physical trauma. "They asked me if I was sure I hadn't been in a car accident," she tells Health. (She hadn't.)
It might seem logical that COVID survivors who seek out medical care for symptoms that could be mental and/or physical in nature would be thoroughly evaluated for both, but that isn't happening in many cases. Instead, patients are often simply written off.
In the Survivor Corps Facebook group, COVID long haulers frequently complain about being ignored or even gaslit by doctors who insist the problem is "all is their head." In April 2020, Brenda Batka went to an ER near her home in Brooklyn with chest pain and palpitations that she believes stemmed from contracting COVID about a month earlier. "I was given Xanax and told to 'calm down,'" the 43-year-old sports massage therapist tells Health. Her EKG ended up coming back abnormal, yet the doctor who treated her remained convinced that her only problem was anxiety and sent her home.
"There is an anxiety component, and I know I'm depressed," Batka explains, adding that she cries almost daily. She had previously battled anxiety and depression, but having COVID-19 and the stress of living through a pandemic caused these mental health issues to flare. She also has numerous physical symptoms that come and go, including shortness of breath, chest pain, brain fog, and numbness and tingling throughout her body.
Yet thus far, she hasn't been able to find a doctor to help her. Batka says she's more than willing to see a neurologist, cardiologist, and therapist, but that getting appointments with all these providers is going to take months. When she recently asked her internist to get her started on antidepressants (which, unlike Xanax, are not addictive), she was turned down.
Why is such a disjointed approach the norm? For starters, mental health has long been viewed as less important than physical health. Compounding the problem is the fact that the health care system is overwhelmed, and mental health care is particularly lacking.
"There's a huge public health crisis in this country, and now there's a mental health crisis to go along with it," Julia Samton, MD, a New York-based psychiatrist, tells Health. "There aren't enough resources to go around, and there's no consistent care that can be accessed across different socioeconomic groups."
Even before COVID hit, there weren't enough psychiatrists in many areas of the country to meet the demand. "Due to the pandemic, the rates of psychiatric illnesses have exponentially increased, and many individuals who have endured COVID-19 are waiting for months at a time to see a psychiatrist," Leela R. Magavi, MD, regional medical director for Community Psychiatry, a California-based telehealth network of psychiatrists, therapists, and psychiatric nurse practitioners, tells Health. "Many have full schedules and no openings for new patients."
Money, of course, is another big factor. While there's been a lot of talk about mental health parity and even some legislation that technically ensures equal coverage for mental and physical health, there are major gaps in the system. Many Americans have their health insurance coverage tied to their jobs, yet the pandemic has led to high levels of unemployment. Even if you've managed to keep your job and the insurance that comes with it, don't expect to have an easy time finding a therapist or psychiatrist who accepts your plan. Many of these experts don't even take insurance at all because of how little the insurance companies reimburses them.
Will the pandemic help bring mental health out of the shadows and nudge us toward a more balanced and integrated approach to wellness? While sweeping changes are likely to be slow-going, there have been some positive trends. Post-COVID care centers are popping up across the country, and many of them do include a mental health component.
At Robert Wood Johnson (RWJ) University Hospital "we've initiated an interdisciplinary program [for COVID survivors] that includes pulmonary doctors, internists, neurologists, and infectious disease specialists," says Dr. Panettieri, a pulmonologist. Social workers, occupational therapists, and psychiatrists are part of the team, too. Anyone who has had COVID can access the program, though most participants are referred by a physician who's familiar with it. Patients are initially assessed by a primary-care provider who then decides which specialists—sometimes but not always including a mental health expert—should weigh in.
OSUMC has adopted a similarly integrative approach. Patients who were admitted to the hospital with COVID receive outpatient follow-up from both physicians and mental health specialists, and the goal is to help survivors cope with their most pressing concerns—regardless of the cause.
For instance, "we might not have a quick treatment for cognitive fog, but we do have compensatory strategies," says Boxley. A rehabilitation psychologist or an occupational therapist might advise such a patient to set alarms or ask family to check in on them so they remember to take their medications. If the same patient meets the criteria for an anxiety disorder or clinical depression, they'll be simultaneously referred to a therapist or psychiatrist.
"There is a tremendous amount of stigma surrounding mental health, and folding it into a broader health evaluation gives us the opportunity to talk to patients who may not otherwise have scheduled an appointment with a psychologist," says Boxley. "It gives us the opportunity to educate patients about the dynamic relationship between physical, cognitive, and emotional health. For example, the body's immune response to COVID may be related to cognitive symptoms such as delirium and cognitive fog. Untreated depression can also prolong a difficult recovery."
Of course, plenty of people who haven't contracted COVID are also struggling with depression and anxiety. While a large percentage are surely not getting the help they need, there are some glimmers of progress. Telehealth has exploded this past year—more than 80% of behavioral health providers started using it for the first time during the pandemic, according to a survey conducted by Tridiuum, a digital behavioral health company—and remote access has the potential to make mental health more accessible to everyone. "Telepsychiatry and teletherapy have helped save lives," says Dr. Magavi.
Other positive signs: In October, the American Medical Association joined forces with several groups, including the American Academy of Child & Adolescent Psychiatry and the American Psychiatric Association, to create the Behavioral Health Integration (BHI) Collaborative. The BHI Collaborative is currently organizing an online compendium of resources designed to help primary care physicians implement mental health into their practices. In the future, they group plans to offer webinars and other training resources for doctors.
Meanwhile, several federal and private sector organizations, including the Centers for Disease Control and Prevention (CDC) and the National Action Alliance for Suicide Prevention, have created a coordinated National Response team and launched an Action Plan designed to strategize ways to improve mental health care across the nation. One key goal is enforcing the Mental Health Parity and Addiction Equity Act, which is supposed to ensure that health insurance plans cover behavioral health as thoroughly as they cover medical and surgical care.
Will these initiatives translate to lasting real-world change? It's too early to say. But it's clear that, at the very least, the pandemic has prompted some people to talk more freely about mental health or at least acknowledge the existence of ailments like depression and anxiety.
In a letter published in the BMJ, two British health experts noted that "the awareness of COVID-19's universal threat to our well-being has connected people in a new way worldwide," and predicted that "talking about our mental health will become a new norm."
Boxley is hopefully that the shared experience of living through a pandemic might serve to increase awareness of mental health issues, though she admits that she hasn't yet seen proof of that change. "What I know is that health care providers have an opportunity to bring a more sophisticated, integrated message about physical and mental health to the table at a time when patients may need it the most," she says.
Sadly, the best way to destigmatize mental health might simply be for people to experience it firsthand. Says Dr. Magavi: "Many individuals who once perceived depression as a fabricated concept have suffered from the disease due to the pandemic. I have had patients confide in me and assert, 'I never believed in this until I felt it myself.' Individuals of all backgrounds and ages are suffering, and now more than ever, we need to come together to advocate for mental health parity in all domains."
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