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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Menthol use has increased over the past decade among U.S. adults who smoke cigarettes, according to a study by researchers at Columbia University Mailman School of Public Health and The City University of New York. Menthol use is much more common among adult smokers who are younger, from racial/ethnic minoritized groups, and those with mental health problems. The results are published in the journal Nicotine and Tobacco Research.

Menthol use was common among approximately two out of five cigarette smokers overall. Over 80 percent of Black smokers preferred menthol in 2020, which is stable relative to prior reports. “That approximately 50 percent of smokers who were Hispanic, female, ages 18-25 and 26-34, lesbian/gay and adults with mental health problems, used menthol in 2020 is higher than previously reported and suggests use has expanded across all segments of the population of adults who smoke cigarettes,” noted said Renee D. Goodwin, PhD, in the Department of Epidemiology at Columbia Mailman School.

Canada and the United Kingdom have banned menthol as a characterizing flavor while action in the U.S. Food and Drug Administration has been lacking, although the Center for Tobacco Products announced its intention to issue a product standard that would ban menthol as a characterizing flavor in cigarettes. However, given the regulatory process required to issue a product standard and the potential for tobacco industry litigation, menthol cigarettes will likely remain on the market for a considerable amount of time, note experts.

“Our results suggest that banning menthol as a characterizing flavor in cigarettes by the U.S. Food and Drug Administration could have a widespread impact on public health, especially among younger people and marginalized groups,” said Goodwin.

To estimate trends in menthol use among adults who smoke cigarettes by sociodemographic, mental health, and substance use variables, the researchers analyzed nationally representative annual, data from 128,327 individuals ages 18 and older residing in the U.S. from the 2008-2019 and 2020 from the National Survey on Drug Use and Health (NSDUH). Depression was assessed using the DSM-IV criteria for a major depressive episode.

There was a significant overall increase in menthol cigarette use among adults smoking cigarettes from 34 percent in 2008 to 41 percent in 2019. In 2020, 43 percent of adults who smoked cigarettes in the past month used menthol. Menthol use was most common among Black adults (80 percent). Over 50 percent used methol in the following groups: Hispanic, female, young (ages 18-34), lesbian/gay, those with serious psychological distress, and with cigar use. Menthol use grew more rapidly among adults ages 26-34, among Hispanics, light cigarette users (1-5 per day) and those who smoked cigars.

A notable finding was the increase and majority menthol use among Hispanic adults over the study period (34 percent in 2008 to 48 percent in 2019) and 51 percent in 2020, with a more rapid increase among Hispanic compared with Non-Hispanic white smokers. “Until now there was a lack of research in this area,” observes Goodwin, who offers a number of possible explanations for the increased popularity of menthol cigarettes among Hispanic smokers. “For one, there is evidence of greater marketing of menthol cigarettes to Hispanic adults.”

“Our study shows persistent and unmitigated inequities in menthol use among tobacco use disparity group members in particular,” said Goodwin. “Data from 2020 demonstrate that the increase in menthol use among smokers over the past decade was broadly evident across subgroups.”

Co-authors are Ollie Ganz and Cristine Delnevo, Rutgers University School of Public Health; Andrea H Weinberger, Yeshiva University and Albert Einstein College of Medicine; Philip H Smith, Miami University; and Katarzyna Wyka, The City University of New York.

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Expanding Medicaid coverage for adults also helps to cover children, according to a new study by researchers at Columbia University Mailman School of Public Health, the University of Chicago, and MIT. The study examined Oregon’s 2008 Medicaid lottery and found that for every nine adults who gained healthcare coverage, one additional child also enrolled. The research describes the impact of expanded adult Medicaid eligibility on the enrollment of already-eligible children.

The findings of the paper, “Out of the Woodwork: Enrollment Spillovers in the Oregon Health Insurance Experiment,” are published in the August 2022 issue of American Economic Journal: Economic Policy.

In the lottery, some low income uninsured adult enrollees were randomly selected to be allowed to apply for Medicaid. Winning or losing the lottery did not change whether their children were eligible for coverage. The researchers asked whether expanding eligibility for one group, adults, helped to bring another group, their children, into coverage. Prior studies have referred to this phenomenon as the “woodwork effect” or the “welcome mat effect”.

“Our study shows that expanding Medicaid eligibility can improve insurance coverage rates for people who weren’t even the target of the expansion,” said Adam Sacarny, PhD, the study’s first author and an assistant professor of health policy and management at Columbia Public Health. “In this case, when adults signed up for Medicaid, their children gained coverage, too.”

Medicaid provides health insurance coverage to 81 million people in the U.S., including 34 million children. About 7 percent of children who are eligible for Medicaid haven’t signed up for coverage and are still uninsured. The paper adds to the existing literature about the barriers to enrolling in health insurance and other social programs. It also sheds new light on the policies of the 2010 Affordable Care Act, which included an expansion Medicaid to cover low-income people. The researchers studied an earlier, randomized expansion of Medicaid for adults that took place in 2008 in Oregon.

“This research highlights the value of conducting further secondary studies of randomized trials,” said Sacarny. “When you link trials with additional administrative data, you can use them to study additional, potentially really important questions for economic and social policy.”
 
The study also provides a new perspective on the broader impacts of Medicaid coverage expansions. “We found evidence of these woodwork effects,” said co-author Amy Finkelstein, PhD, a professor in MIT’s Department of Economics. “We reject the hypothesis that these types of spillovers don’t occur. On the other hand, relative to claims in the media and in some previous work about potentially large woodwork effects, in excess of half of the direct effect, our effects are quantitatively much smaller than what was conjectured.”
 
While the researchers found meaningful woodwork effects, they also found that the effects were short-lived. They showed that children of lottery winners saw an immediate jump in coverage as their parents signed up, but children of lottery losers eventually gained coverage, too.

“Therefore, our results suggest that woodwork effects mainly to encourage earlier enrollment for children who would have otherwise gained coverage later,” observed Sacarny.
 
The results point to two reasons there is incomplete coverage among people who are eligible for Medicaid, according to Sacarny. First, Medicaid’s eligibility rules can be complicated and some families may not be aware of them. In this experiment, when adults “won” the opportunity for to enroll in Medicaid, they may have learned about their children’s eligibility. Second, applying for Medicaid can be burdensome: at the time in Oregon, the application packet was 46 pages long with up to 19 pages of fill-in prompts. However, since the application was for an entire household, an adult signing up could easily include their children. 

“Incomplete enrollment in social insurance programs is pervasive including in the Medicaid program,” said Sacarny. “The present study demonstrates the many ways that randomized trials, like Oregon’s, can be used to generate further findings. Given a valid experiment, scholars can think creatively about how to identify its effects, and keep leveraging that experiment to produce rigorous results.”

Katherine Baicker, professor and dean at the University of Chicago Harris School of Public Policy, is a co-author.

The study was supported by the National Institute on Aging.

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More than a dozen states will open vaccine eligibility to all adults this week in a major expansion of COVID-19 shots for tens of millions of Americans amid a worrisome increase in virus cases and concerns about balancing supply and demand for the vaccines.

Meanwhile, the director of the Centers for Disease Control and Prevention said Monday that she had a recurring feeling of “impending doom” about a potential fourth wave of infections after cases in the U.S. rose 10% over the last week. She pleaded with Americans not to relax preventative practices such as social distancing and mask-wearing.

“Just please hold on a little while longer,” Dr. Rochelle Walensky said during a White House briefing. Several Northeastern states and Michigan have seen the biggest increases, with some reporting hundreds or thousands more new cases per day than they were two weeks ago.

A new study by the CDC concluded that the Pfizer and Moderna vaccines were 90% effective after two doses, a finding that Walensky said should offer hope.

States opening eligibility to anyone ages 16 and older on Monday included Texas, Oklahoma, Louisiana, Ohio, North Dakota and Kansas.

The rapid expansion has fueled concerns that the number of eager vaccine seekers will far outstrip the available supply of shots, frustrating millions of newly eligible people who have waited since late last year for a chance to get an injection. Other officials have put their faith in a promised glut of vaccines and instead turned their attention to the next challenge: Pressing as many people as possible to get the shots so the nation can achieve herd immunity at the earliest opportunity.

Vaccination rates in Texas have lagged behind much of the U.S., and although state officials Monday put at least part of the blame on delays in data reporting, they also acknowledged that appointment slots are going unfilled.

Demand “has definitely decreased over the past couple of weeks,” said Imelda Garcia, the head of the state’s expert vaccine allocation panel.

Texas is supposed to receive more than 1 million new doses this week. On Monday, the state launched a new online vaccine scheduler and phone number, taking a bigger role in efforts that had largely been done at the local level.

In Kansas, where some local health officials have said they are also struggling to find people to vaccinate, another 400,000 people are now eligible for shots. Democratic Gov. Laura Kelly has been criticized by Republicans for a slow, disorganized vaccine rollout, and she faced more criticism Friday when she announced the plan to expand eligibility. One Republican lawmaker said people with chronic medical conditions could be left behind.

Louisiana Gov. John Bel Edwards has said the state will soon have enough shots for everyone who wants one, and that the challenge now is to make sure people want to get vaccinated.

Some counties in Illinois are being allowed to expand eligibility to all this week if they find doses are going unused. Meanwhile, in Chicago, the vaccine will not be available to everyone until at least May 1 because the city does not have enough shots on hand.

On Tuesday, Minnesota opens eligibility, followed by Indiana and South Carolina on Wednesday, Connecticut and Montana on Thursday and New Hampshire and Colorado on Friday. In New York, Gov. Andrew Cuomo announced that residents over 30 will be eligible for vaccinations starting Tuesday, and everyone over 16 will be eligible starting April 6.

Connecticut officials said “priority access” will be given to people with high medical risks or developmental disabilities once everyone 16 and up is eligible. That could include some hospitals organizing dedicated clinics or reserving appointment slots for people with those conditions, officials said.

Arizona opened up eligibility to everyone 16 and up last week, but it has since been dealing with an unintended consequence: Interest in volunteering at four state-run vaccination sites plummeted almost immediately. Since February, thousands of volunteer shifts filled up within an hour. Now many remain vacant, said Rhonda Oliver, CEO of HandsOn Greater Phoenix, a nonprofit handling online volunteer recruitment.

“People saw it as a way to get the vaccine sooner,” Oliver said. “We anticipated a drop-off, but we just didn’t expect it to go off a cliff in a matter of 24 to 48 hours like this.”

On Wednesday, the first day of the new eligibility, only 70 of the scheduled 145 volunteers appeared at State Farm Stadium in Glendale, and dozens of people either withdrew earlier or simply did not show up. Oliver said that put an unfair burden on volunteers who did show up and could not take breaks.

The shortage of volunteers should not affect wait times for those with appointments, Oliver said. HandsOn Greater Phoenix is hoping to lessen the hemorrhaging by reaching out to large companies and community groups looking for service activities. The group is also encouraging friends or family members who have been vaccinated to volunteer together.

Many other states are still limited by a continued lack of supply.

California officials said the state can administer 3 million shots a week now, and Democratic Gov. Gavin Newsom has predicted that maximum capacity will climb to 4 million by the end of April. But supplies have limited the effort so far to 1.8 million shots per week, a figure that is expected to increase to 2.5 million per week in the first half of April and then 3 million by the end of April, when everybody 16 and older will be offered the vaccine.

Santa Clara County Health Officer Dr. Marty Fenstersheib said his county has been told it will get 58,000 doses this week, but the state will begin allowing about 400,000 more people between the ages of 50 and 64 in the county to sign up as of Thursday, in addition to the current backlog.

“We don’t have the vaccine, and we are concerned,” Fenstersheib said.

Among the methods officials are employing to reach underserved communities are vans that can be used as mobile clinics that travel to hard-hit neighborhoods and provide on-the-spot vaccinations.

In California, mobile clinics are helping to vaccinate farmworkers who may not have transportation to larger vaccination sites or who cannot navigate the state’s online signup portal. The city of Los Angeles also plans to have 10 mobile vaccination teams. Colorado Gov. Jared Polis said Monday that four mobile bus clinics will distribute vaccines to underserved communities.

While demand has dropped off in some communities, it’s as brisk as ever in others, and sign-up hassles continue.

Dwight and Kate Blint both got their first shots Saturday in Hartford, Connecticut, but it took some time and work to do it. For starters, the process to sign up online was simply too confusing, so they decided to call on the phone for appointments. But the two, both 56, with jobs in communications in the insurance business, could not spend hours on the phone. Dwight Blint’s mother, who is retired, agreed to call.

“It took four or five tries, waiting on the phone for a half hour to speak to someone to be told we don’t have an appointment,” he said. “We’re talking hours.”

The effort was smoother for University of Utah professor Bill Johnson. He said he was bracing for a time consuming and confusing experience but instead found it remarkably easy.

“We had to make the appointment online and got in two days later,” said Johnson, 59, who got his first shot at the convention center in Salt Lake City. “It took us 10 minutes to drive there, and they jabbed us two minutes after we arrived.”

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