Mental Health Care During the COVID-19 Era Remains Inaccessible to Many Distressed U.S. Adults


By Columbia Mailman School of Public Health

National trends underscore a public health need to broaden outpatient mental health care access to more distressed, older, and unemployed adults

U.S. adults experienced considerable psychological distress and adverse mental health effects as a result of the COVID-19 pandemic according to a study at Columbia University Mailman School of Public Health and Columbia University Irving Medical Center. Based on insurance claims, mental health care provider surveys, and electronic health records the research further revealed a decline in in-person outpatient mental health visits during the acute phase of the pandemic. Findings are reported in the Annals of Internal Medicine(link is external and opens in a new window).
“The trends and patterns we observed in the United States align with reports globally concluding that several mental health problems, including depression, and generalized anxiety disorder, have become more prevalent during than before the pandemic,” said Mark Olfson, MD, MPH, professor of Epidemiology at Columbia Mailman School of Public Health, and Dollard Professor of Psychiatry, Medicine & Law at Columbia University Irving Medical Center.
To characterize the psychological distress experienced, determine the level of outpatient mental health care, and describe patterns of in-person versus telemental health care, the researchers studied the responses of adults from the Medical Expenditure Panel Surveys by the Agency for Healthcare Research and Quality Component, a nationally representative survey of over 85,000 people. Psychological distress was measured with a 6-point scale range and outpatient mental health care use was determined via computer-assisted personal interviews.
The rate of serious psychological distress among adults increased from 3.5 percent to 4.2 percent from 2018 to 2021. While outpatient mental health care increased overall as well — from 11.2 percent to 12.4 percent, the rate among adults with serious psychological distress decreased from 46.5 percent to 40.4 percent. Young adults (aged 18 to 44 years significantly increased outpatient mental health care but this pattern was not observed for the middle-aged (aged 45 to 64 years) and older adults (aged >65 years).  Similarly, more employed adults reported outpatient mental health treatment care compared to the unemployed.

In 2021, 33 percent of mental health outpatients received at least one video visit. The likelihood of receiving in-person, telephone, or video mental health care varied across sociodemographic groups; percentages of video care were higher for younger adults than for middle-aged or older adults, women compared with men, college graduates compared with adults with less education, the seriously distressed, lower-income, unemployed, and rural patients.
“Thanks to a rapid pivot to telemental health care, there was an overall increase during the pandemic of adults receiving outpatient mental health care in the United States.  However, the percentage of adults with serious psychological distress who received outpatient mental health treatment significantly declined.  Several groups also had difficulty accessing telemental health care including older individuals and those with lower incomes and less education,” observed Olfson. “These patterns underscore critical challenges to extend the reach and access of telemental health services via easy-to-use and affordable service options.” 

“Increasing our understanding of the patterns we observed in terms of access to outpatient mental health care including in-person, telephone-administered, and internet-administered outpatient mental health services could inform ongoing public policy discussions and clinical interventions,” noted Olfson. “Identifying low-cost means of connecting lower-income patients to telemental health should be a priority, as well as increasing public investment to make access to high-speed broadband universal.”
“The national profile of adults who receive outpatient mental health care via telemental health – the younger adult, the employed, higher-income, and privately insured adults, raises concerns about disparities in access to virtual mental health care,” said Olfson.  “Unless progress is made in reducing these barriers, primary care clinicians will continue to encounter challenges in connecting their older, unemployed, and lower income patients to video-delivered outpatient mental health care.”
Co-authors are Chandler McClellan and Samuel H. Zuvekas, Agency for Healthcare Research and Quality; Melanie Wall, Columbia Mailman School of Public Health; and Carlos Blanco, National Institute on Drug Abuse.

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