Even before COVID-19, we were facing a mental health crisis: upwards of 20% of the US adult population met criteria for poor mental health and the majority (55%-70%) did not receive care (SAMHSA, 2018; Mojtabai, 2011). This was due, in equal parts, to an overburdened system and stigmatized beliefs.
The coronavirus — and its accompanying stressors — has put more strain on that broken system. The immediate response has been to transition to remote care, but are telehealth and virtual EAPs enough to combat the growing need for psychological support?
I sat down with Dr. Jennifer Kanady, Ph.D., to get her take. Dr. Kanady is the Clinical Innovation Lead for Sleep at Big Health. She received her Ph.D. in Clinical Science from the University of California, Berkeley, and specializes in the research and treatment of sleep and sleep disorders.
Lauren: We have heard from clients that the first thing they did to combat the growing mental health concern was to increase the capacity of virtual EAPs and waive co-pays for telehealth. Is this the right first step for employers?
Dr. Kanady: It is really commendable that employers quickly adapted to the current mental health crisis by moving to virtual platforms and waiving copays for certain services. These adoptions provide continuity of care for those who were already receiving it and easier access for those who may be struggling for the first time. However, telehealth services have several limitations.
Lauren: Makes total sense. What are those limitations?
Dr. Kanady: First, the quick adoption of telehealth has likely been challenging due to a lack of infrastructure and knowledge. To quickly meet demands, some providers had to transition to providing care on less secure platforms, creating privacy concerns.
Second, telehealth unfortunately doesn’t address pre-existing barriers to mental health care. For example, there was already a shortage of qualified providers before the pandemic; that doesn’t change by going online.
Third, engaging with telehealth services may be especially challenging during this time. We have heard from clients that EAP usage has been unchanged and in some cases, usage has been lower. Possible explanations for this include privacy concerns or time constraints — It may be difficult to have a private mental health session while social distancing at home and some may struggle to find the time with added responsibilities, such as home schooling and childcare.
Finally, it’s important that individuals have access to evidence-based care, which typically isn’t the function of an EAP.
Lauren: Is it safe to assume that many people who are experiencing poor mental health right now, are struggling for the first time?
Dr. Kanady: It is important to point out that the mental health symptoms experienced during COVID-19 are not unique. The most common presentations include worry and anxiety, poor sleep, low mood, and complicated grief. However, what is unique about COVID-19 is that more people are currently experiencing symptoms, some individuals for the first time and some with pre-existing conditions. This isn’t surprising given the heightened stress and uncertainty during this time.
Lauren: How might experiences differ across first time sufferers and those who have experienced poor mental health in the past?
Dr. Kanady: It’s possible that individuals who have received mental health care in the past are better equipped to handle this crisis, because they already have skills in place. Individuals experiencing mental health symptoms for the first time may experience more obstacles to seeking care. They may not understand that what they are experiencing is poor mental health (what is often referred to as low perceived need), they may not be aware of available resources, or they may feel embarrassed about seeking help (stigma).
Lauren: Outside of whether or not someone has pre-existing symptoms, how do you determine the level of care someone needs?
Dr. Kanady: One factor is certainly symptom presentation—those with more severe mental health symptoms often require more intensive, one-on-one care. Individuals with mild symptoms, on the other hand, likely won’t require expensive and time consuming one-on-one care; lower intensity care may be more appropriate.
Other things to consider are the individuals' needs and preferences. For example, some people may be uncomfortable in group settings or may prefer self-help options. Individual preferences and needs coupled with limited access to care is why the mental health field has been emphasizing the importance of adopting an integrated stepped care model.
Lauren: What is an integrated stepped care model?
Dr. Kanady: It is the practice of delivering the most effective and efficient care to individuals in need, and then stepping up to more resource-heavy care as needed. It is usually depicted in the form of a pyramid, with basic education at the bottom of the pyramid and one-on-one in-person care at the top. One point that may be especially relevant for self-insured employers is that care options at the bottom of the pyramid are not only effective for the management of symptoms, but also tend to be more cost-effective.
Lauren: Got it — so offer an efficient low-cost first step, then offer a resource-heavy option for those who need additional support. With that in mind, where do digital therapeutics (DTx) and telehealth fit within this model? How are they different?
Dr. Kanady: Both telehealth and digital therapeutics (DTx) fit nicely within the stepped care model, with digital therapeutics typically being offered first as DTx addresses some of the limitations of telehealth.
Telehealth still relies on human providers with limited availability. Unfortunately there continues to be a dearth of qualified providers and not everybody is able to have a mental health session between the typical work hours of 9AM - 6PM. Digital therapeutics on the other hand, are fully automated and therefore have the capacity to reach millions of individuals and can be accessed whenever the need arises.
Telehealth also doesn’t address common cognitive barriers to care such as stigma and the desire for self-help. For example, some individuals may be worried about their bosses finding out that they are using mental health resources. Digital therapeutics are fully automated, so they help to alleviate some of these potential concerns.
While the ensuing mental health crisis is alarming, it provides an opportunity to rethink our mental health system and embrace new, integrated forms of evidence-based care.
Benefits teams can expand coverage to their population by investing in not only telehealth, but also digital therapeutics. The future may be uncertain, but what is certain is that now is the time to prioritize mental health to prevent unnecessary suffering.