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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Journalists talk about how our stories need “real people.”

We like how they avoid jargon, are typically straightforward with their motivations, and help humanize the issues we present to our audiences.

I’ve always given at least lip-service to this journalistic reflex, but I might not have fully embraced it before reporting our series on Minnesota’s mental health crisis.

Over nine months of work, I found the “real people” we interviewed brought an emotional depth that was essential for telling the fuller story. There came with a price, since the deeply personal nature of these interviews made it difficult for me, at times, to maintain composure.

But that’s only part of it.

While reporting the second story in our series — an article on the wonky topic of mental health parity laws — it was patient Rylie Perkins who forced me to see what I now regard as the true nature of the trouble with accessing mental health care in our country. To use a technical term: It’s mucky. By that I mean the problem has more dimensions than we typically want to tackle, in life as well as journalism.

Rylie’s story was more than just the tidy patient-versus-insurer anecdote that I initially thought we’d need. It showed the more difficult reality that access to care often is challenging for a whole bunch of reasons that I will explain shortly.

We launched our Star Tribune series in March 2023 with an article that analyzed a novel data set that illustrated how hospitals’ financial incentives shortchange mental health care. I drew on newly acquired fellowship skills plus tremendously generous assistance from my Star Tribune colleague MaryJo Webster and senior fellow Andrew Ba Tran of The Washington Post.

A later story in the series reflected the many anecdotes I’d been hearing from patients and caregivers about the apparent mismatch between supply and demand with mental health care.

Patient Leinani Watson provided the opening anecdote for this article, shining attention on how the gaps are hitting particularly hard for young people. I struggled speaking through tears during one interview, as Leinani described methods she’d learned via social media to harm herself.

Yet another story in the project focused on mental health parity laws. These statutes are critically important because they require health insurers to provide comparable coverage for both mental and physical health care needs.

To start this article, I found a patient in New York who was lead plaintiff in a lawsuit alleging noncompliance at a hugely influential Minnesota-based health insurer. I interviewed her shortly after I went through training at the Center for Health Journalism’s 2022 Data Fellowship, and figured her story would perfectly bookend our article on mental health parity.

But a few months later, one of my editors asked a question: Wasn’t there someone more local we could photograph? This could have set me off.

“We’ve got an anecdote already!” part of me wanted to exclaim. “This is coverage of mental health!  It’s tough to find any patient willing to talk and be photographed, let alone one whose story speaks directly to an amorphous topic like mental health parity!”

Luckily, I’m from Minnesota, where cultural courtesy prevented me from saying any of this. More importantly, I quickly realized my colleague’s question was the chance to make our story even better.

My editors had given me time to develop a deep list of sources for these stories, even though it meant I failed miserably with deadlines.

So, I said I’d look for a closer-to-home option.

In the end, we still featured the plaintiff in the story, but I also worked with a local clinic to connect with eating disorder patient, Rylie Perkins.

As she was making lasagna one evening and my colleague Richard Tsong-Taatarii took photos, I quizzed Rylie about her story. I’d already talked with her a few times at that point, but the conversation helped convince me that her experience was about much more than just a conflict with a health insurer.

Yes, she’d experienced a denial — as well as an appeal that’s a longer story than I could fit into in print. But there were other factors. Staffing problems contributed to Rylie’s long wait to get into a treatment program and complicated her search for a psychiatrist, as well.

Perhaps most importantly in terms of mental health parity, Rylie had earlier in her life experienced the relative abundance of services that our health care system makes available to young athletes under the heading of sports medicine. When Rylie was a softball pitcher in high school and college, she got speedy access to outpatient surgery to alleviate a recurring wrist injury.

The contrast certainly felt like a mental health parity issue, but did it amount to a parity law violation? One of the big issues with these statutes is that it’s tough to know.

For me, Rylie’s story hit home because I’d previously taken my younger daughter to the doctor for a running injury. I was grateful for prompt help, but what if she’d been depressed or anxious or was suffering from an eating disorder?

Would we have found groups of psychiatrists competing to provide urgent care, with evening and weekend hours? How could we know the type of service to seek? What evidence would we find on effectiveness? Would we have hesitated to make the visit — opting for “self-care” instead — as we wondered if the mental health provider would have a demeanor that made my daughter feel comfortable talking?

We’ve all internalized, to varying degrees, negative perceptions about mental illness. Would our ambivalence about acknowledging the need for help lead us to inaction? And if we did muster the courage to seek care and then later had to fight my employer-sponsored health plan to pay the bill, would we have done so with zeal? Would I have sought help from the HR office at work, particularly if I’d been the one seeking mental health care?

In my reporting, it was a psychiatrist who told me that, first and foremost, the lack of parity reflects how our society values and thinks about mental health care. But I really learned this from Rylie.

Thank goodness for real people.

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“The Commander John Scott Hannon Veterans Mental Health Care Improvement Act is an honest and bipartisan solution to an issue that demands Congress’ immediate attention. The bill would boost care at VA facilities by expanding in-person and telehealth mental health services and allowing Guardsmen and Reservists to receive counseling at VA Vet Centers across the country. It would also expand the amount of non-VA community resources available to Veterans, wherever they may live, a key component of President Trump’s President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide (PREVENTS) initiative. The bill passed the Senate unanimously and we call on the House to give it the timely attention and bipartisan support it deserves.”

Secretary Robert Wilkie

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