Axios AM Deep Dive: Our mental health crisis

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America’s mental health crisis began long before the coronavirus pandemic did, but a year and a half of loss, stress, isolation and treatment disruption has only increased the number of Americans struggling with their mental health.

Why it matters: As demand rises well beyond pre-pandemic levels, the system is facing burned-out providers and staffing shortages, and even more people who need care aren’t getting it. 

The big picture: Mental health care was already inequitable and in short supply before the pandemic.

But the number of people reporting symptoms of anxiety or depression skyrocketed during the pandemic and has remained high.

Substance use has increased as well, and an alarming number of children and adolescents are showing up in emergency rooms seeking mental or behavioral health treatment.

"The pandemic has created an extraordinary sense of loss in many people's lives, and it's created abrupt change with great uncertainty about when that change is going to end. And that has really turned many people’s lives upside down," Surgeon General Vivek Murthy said in an interview.

Driving the news: A group of children's health care organizations this month declared a national emergency in children's mental health.

The Biden administration this month released a set of recommendations for schools and providers on how to support students with behavioral health needs. It also put out a new overdose prevention strategy.

Meanwhile, many state psychiatric facilities are short-staffed and running out of beds,  Kaiser Health News recently reported.

State of play: Not everyone will bounce back once the stress of the pandemic fades.

"The pandemic has been a source of trauma for many people, and when you think about it in that context, the effects of trauma take time to resolve," Murthy said. "And they don’t always resolve on their own — they don’t always resolve by removing the source of the trauma."

"As things start to get normal, the full brunt of the trauma they’ve been through starts to surface in their lives, and they have to deal with that," he added. "So that’s why I think this is the right time for our country to have a conversation about mental health."

What we're watching: Plenty of people who are struggling with anxiety or depression will be OK if they learn effective coping skills or gain access to treatment. 

But public experts fear that if left unaddressed, some people's mental health struggles will only get worse. 

"All mental illness tends to make people more vulnerable to addiction, partly because people find that a lot of these medications and substances that can be addictive are helpful in dealing with the mental health issues they’re having," said Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials.

And not everyone has equal access to care. In fact, some of the same people hit hardest by the stresses of the pandemic — like low-income families or people of color — may be most at risk of not getting the mental health treatment they need.

The bottom line: We may be exiting the worst part of the coronavirus pandemic, but we're just beginning to grapple with the subsequent mental health epidemic.  

We have the opportunity now to do better than just go back to how things were in 2019, Murthy said. 

"If we just flip back to how we were pre-pandemic, we will have lost a powerful and important lesson from this pandemic, which is [that] we have to invest in our mental well-being.”

1. America's shadow epidemic

The toll of a year and a half of pandemic losses, stress and isolation.

A vintage anatomical drawing of the brain in fragmented pieces. 

Deep Dive - Mental Health

America’s mental health crisis began long before the coronavirus pandemic did, but a year and a half of loss, stress, isolation and treatment disruption has only increased the number of Americans struggling with their mental health.Why it matters: As demand rises well beyond pre-pandemic levels, the system is facing burned-out providers and staffing shortages, and even more people who need care aren’t getting it.

The U.S. faces a range of health care flashpoints — unaffordable drugs, opioids, vaping — as we debate whether to adopt universal care. For now, the Affordable Care Act is the law of the land, but Republicans want to issue it a final death blow.

Health

Data: CDC; Note: Asian, Black and white respondents identified as non-Hispanic and are of a single race; Chart: Jacque Schrag/Axios

Young adults and people of color are disproportionately reporting symptoms of anxiety or depression, according to CDC data. 

By the numbers: The portion of U.S. adults reporting these symptoms has hovered around 30% since this spring — a drop from the more than 40% of adults reporting symptoms last winter. 

In 2019, only 11% of adults reported symptoms of anxiety or depression, per the CDC.

2. Anxiety and depression symptoms vary by age and race

Coronavirus

Young adults and people of color are disproportionately reporting symptoms of anxiety or depression, <a class="gtmContentClick" data-vars-link-text="according to CDC data" data-vars-click-url="https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm" data-vars-item="in_content_link" href="https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm" target="_blank">according to CDC data</a>. By the numbers: The portion of U.S. adults reporting these symptoms has hovered around 30% since this spring — a drop from the more than 40% of adults reporting symptoms last winter. <ul><li>In 2019, only 11% of adults reported symptoms of anxiety or depression, <a class="gtmContentClick" data-vars-link-text="per the CDC" data-vars-click-url="https://www.cdc.gov/nchs/data/nhis/mental-health-monthly-508.pdf" data-vars-item="in_content_link" href="https://www.cdc.gov/nchs/data/nhis/mental-health-monthly-508.pdf" target="_blank">per the CDC</a>.</li></ul>

The number of children struggling with mental health issues has skyrocketed amid the pandemic, and the crisis isn't abating as life returns to normal. 

Why it matters: Many children won't just bounce back to normal on their own, experts say, and will need additional care and support in their homes, schools and broader communities. 

State of play: Even before the pandemic, children's mental health was worsening. 

 One in five children experienced a mental health condition in any given year, according to the Children's Hospital Association, and the suicide rate among 10- to 24-year-olds was rising. 

The pandemic exacerbated this alarming trend. 

In the first half of this year, children's hospitals reported a 45% spike in reported cases of self-injury and suicide among kids 5-17 compared to 2019, per the CHA.

The CDC also reported higher rates of mental health-related emergency room visits among children in 2020 compared to the prior year. 

What they're saying: "It really has reached crisis levels," said Lee Beers, president of the American Academy of Pediatrics. "There was probably some hope that as kids returned to in-person schools, there would be access to some services in schools, but we’re really not seeing it let up at all."

“We know stresses during this really important developmental period can have impacts for many years to come if you don’t address them in the moment," she added.

What's happening: Kids' lives were completely disrupted by the pandemic, when they stayed home from school and often lived in near-isolation. On top of that, many picked up on the stresses of their families. 

An estimated 140,000 children lost a caregiver to the virus as of this summer, a National Institutes of Health study reports. That means roughly 1 in 500 children were either orphaned or lost their grandparent caregiver.  

"Losing a parent is probably one of the most profound traumatic losses that can happen for a young person," said Tamar Mendelson, director of the Center for Adolescent Health at the Johns Hopkins Bloomberg School of Public Health. "Those kind of experiences are going to have a lasting impact."

What we're watching: Experts say school-based interventions could make a particularly large difference in addressing the crisis. 

“This may be a much easier gateway to mental health care for many young people, and if there is screening and consultation or services available onsite at schools, many more children are going to be able to connect with those," Mendelson said. 

What you can do: Whether you're a parent, teacher, library volunteer or Little League coach, you can help kids in crisis. 

"Good, thoughtful interventions really do work, and safe, stable, supportive relationships with adults really make a big difference," Beers said. 

3. The kids really aren't OK

Many children won't just bounce back to normal on their own.

Illustration of a vintage, ripped photo of a sick child.

The number of children struggling with mental health issues has skyrocketed amid the pandemic, and the crisis isn&#x27;t abating as life returns to normal. Why it matters: Many children won&#x27;t just bounce back to normal on their own, experts say, and will need additional care and support in their homes, schools and broader communities.

There's been a drastic increase in the number of Americans who need mental health care, putting even more stress on a system that was already strained by the significantly lower pre-pandemic demand. 

Between the lines: In a competition for scarce resources, the most vulnerable people — particularly those who don't have access to care or can't afford it — are most likely to lose out. 

The big picture: Access to mental health care has been an issue for decades, and the system has long struggled with provider shortages and spotty insurance coverage.

But demand for care has spiked during the pandemic, and like other health providers, many of those who specialize in mental health are burned out. 

"Prior to the pandemic, we had a workforce system that could not meet the need when it comes to mental and behavioral health care, and the pandemic has only exacerbated that," said Vaile Wright, senior director for health care innovation at the American Psychological Association.

By the numbers: Psychologists are reporting increases in demand for care since last year — when demand had already spiked compared to before the pandemic, according to a recent survey by the APA.

The greatest increases in demand are for treatment for depression, anxiety and trauma- or stressor-related disorders. 

Around two-thirds of psychologists surveyed said their waitlists have gotten longer since the pandemic started and that they don't have the capacity for new patients. Nearly half said they feel burned out. 

Between the lines: Different geographic and demographic populations struggle more than others with access to care. 

People in rural areas, non-English speakers and children are facing particularly acute provider shortages, Wright said. 

In 2020, white adults were more likely to have received any mental health treatment than Black, Hispanic or Asian adults, according to the CDC.

4. The mental health system is buckling under pandemic demand

It's putting even more stress on a system that was already strained.

Illustration of a caduceus and a prescription pad on a collage of torn paper

There&#x27;s been a drastic increase in the number of Americans who need mental health care, putting even more stress on a system that was already strained by the significantly lower pre-pandemic demand. Between the lines: In a competition for scarce resources, the most vulnerable people — particularly those who don&#x27;t have access to care or can&#x27;t afford it — are most likely to lose out.

The forced isolation, disruption to treatment and resource demands created by the pandemic have set America back in its efforts to end the opioid epidemic. 

What we're watching: It's not just opioids. The use of other substances, particularly alcohol, increased over the last year and a half, and experts say this may lead to more people struggling with addiction.

What they're saying: "Addiction is a disease of isolation," said Caleb Alexander, a professor of epidemiology at Johns Hopkins.

The pandemic "drove isolation," at least early on, Alexander said. "That is really important to avoid for those who are in recovery." 

The big picture: The number of drug overdose deaths hit an all-time high in 2020, according to provisional government data. That number kept climbing into 2021, and the government estimates that 99,000 people died between March 2020 and March 2021 — a 31% increase.

About 75% of overdose deaths in 2020 were from opioids, according to an analysis by The Commonwealth Fund. 

Overdose deaths increased among all demographic groups, but were especially high among men, young people and people of color, per the analysis.

Study after study has found that Americans are also drinking more alcohol.

"If you’re remote working, happy hour can start a lot earlier," said Vaile Wright, senior director for health care innovation at the American Psychological Association. 

"The pandemic provides just the perfect storm for encouraging substance use," she added.

Between the lines: Public health departments have been stretched to the max trying to address the pandemic itself. But these are the same departments that were already trying to fight the opioid epidemic. 

"You can only fight a war on so many fronts, and the efforts that public health departments have understandably put forth to address the pandemic have invariably required them to pull back on addressing other important public health matters," Alexander said. 

"I think the overdose epidemic is Exhibit A here." 

5. America's substance use crisis has spiraled

The opioid epidemic has gotten worse, and Americans are drinking more, too.

Old-fashioned illustration of syringes layered on torn paper.

The forced isolation, disruption to treatment and resource demands created by the pandemic have set America back in its efforts to end the opioid epidemic. What we&#x27;re watching: It&#x27;s not just opioids. The use of other substances, particularly alcohol, increased over the last year and a half, and experts say this may lead to more people struggling with addiction.

Axios Vitals

More and more, our mental health care is being delivered using tech solutions like smartphone apps, AI-powered chatbots and wearables — especially since the start of the pandemic. 

Why it matters: Technology has its flaws, but experts say it has been critical in addressing some of the obstacles in access to mental health care: too few providers and too little insurance coverage.

The pandemic turned out to be the perfect proving ground for many tech solutions.

"We literally overnight went from mostly in-person visits to 100% telehealth unless, like, you needed heart surgery. It was kind of a crazy paradigm," said Chris Molaro, CEO and co-founder of NeuroFlow, a company that integrates behavioral health tools into the workflow of specialists and primary care doctors.

During the early pandemic shutdowns, mental health apps already on the market got a major boost from consumer users. At the same time, providers who traditionally only met in person quickly jumped to telehealth with their patient rosters.

As demand for mental health providers surged, technology has offered tools that make it easier to scale and stretch resources where supply is lower, such as in rural areas.

What they're saying: "We've learned that technology can fill several big gaps when it comes to mental health care delivery," said Neha Chaudhary, co-founder of Stanford University's Lab for Mental Health Innovation.

It can offer patients solutions that don't require travel to an office or sitting on a six-month waitlist, Chaudhary said.

It can also get around some of the stigma that plagues mental health care. "[I]t can take a lot to show up to, say, a doctor's office. It doesn't take that much to log into an app on your phone," Chaudhary said.

Another advantage: Devices can help track people's moods by prompting them to take surveys or tracking their activity levels, signaling to providers when a patient may be in acute crisis, said Johannes Thrul, assistant professor in mental health at the Johns Hopkins Bloomberg School of Public Health.

Yes, but: There is still a lot of junk out there when it comes to mental health tech. 

"There's a very wide range from things that are not at all based on evidence — they're very poorly done," Thrul said. "And then there are other things that have really good evidence behind them."

Regulatory bodies like the FDA are starting to get on top of this, but are behind. 

"We see this across technology where regulatory bodies are catching up with the development that's already happened," Thrul said. "And it's the same thing in mental health care."

The bottom line: The delivery of mental health care via tech is important. But it's not everything.

"Maybe I shouldn't say this as a technology CEO, but I think in health care technology it is going to be technology plus human interventions when appropriate," Molaro said. 

6. Tech is going all-in on mental health

Mental health care is increasingly being delivered through tech solutions like smartphone apps.

Photo illustration of medical drawings of a brain.

Photo illustration: Aïda Amer/Axios; Photos: Universal History Archive via Getty Images

Axios Pro: Deals

More and more, our mental health care is being delivered using tech solutions like smartphone apps, AI-powered chatbots and wearables — especially since the start of the pandemic. Why it matters: Technology has its flaws, but experts say it has been critical in addressing some of the obstacles in access to mental health care: too few providers and too little insurance coverage.

Axios Science

Getting outside is good for us — especially in a pandemic.

The big picture: Nature's benefits for mental health and well-being are part of the human experience and have been studied for decades. But the COVID-19 pandemic is a real-time experiment in studying exactly how green spaces can help us in difficult times.

The pandemic pushed many people toward screens for work and socializing. But that increased screen time also then made people break away to nature, says MaryCarol Hunter, who studies the effect of nature on mental wellbeing at the University of Michigan. 

Details: The isolation and loneliness of quarantining and social distancing, fear of illness, grief of loss and uncertainty about the future are all risk factors for anxiety, major depression and other mental disorders. 

From Mexico City to Malaysia to Finland, researchers are assessing the impact of exposure to nature on mental health during the pandemic and finding more evidence that spending time in nature — exercising, listening to birds and meditating — can help to reduce stress, anxiety and depression symptoms.

Even looking at plants inside or on a balcony appears to help.

Yes, but: There's unequal access to nature.

Black and Latino communities have "less access to urban nature than white communities," and "74% of communities of color live in nature-deprived areas," Ambika Chawla wrote earlier this year in Ensia, an environmental magazine.

The impact: Nonprofits like Groundwork Denver aim to improve access to green spaces in urban areas. 

Nature Sacred and other groups help communities create public spaces and connect people to nature with yoga, mindfulness programming and other activities.

7. 1 hopeful thing: Nature is healing

The pandemic is a real-time experiment in how green spaces can help us.

Vintage etching of a plant layered over torn paper. 

Getting outside is good for us — especially in a pandemic.The big picture: Nature&#x27;s <a class="gtmContentClick" data-vars-link-text="benefits" data-vars-click-url="https://news.stanford.edu/news/2015/june/hiking-mental-health-063015.html" data-vars-content-id="406b07bc-223b-48e0-a888-fd4bcad680c3" data-vars-headline="1 hopeful thing: Nature is healing" data-vars-event-category="story" data-vars-sub-category="story" data-vars-item="in_content_link" href="https://news.stanford.edu/news/2015/june/hiking-mental-health-063015.html" target="_blank">benefits</a> for mental health and well-being are part of the human experience and have been studied for decades. But the COVID-19 pandemic is a real-time experiment in studying exactly how green spaces can help us in difficult times.

America's substance use crisis has spiraled

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5. America's substance use crisis has spiraled