The Implications of COVID-19 for Mental Health and Substance Use
The COVID-19 pandemic and resulting economic downturn have negatively affected many people’s mental health and created new barriers for people already suffering from mental illness and substance use disorders. In a recent KFF poll, nearly half (45%) of adults in the United States reported that their mental health has been negatively impacted due to worry and stress over the virus. As the pandemic wears on, it is likely the mental health burden will increase as measures taken to slow the spread of the virus, such as social distancing, business and school closures, and shelter-in-place orders, lead to greater isolation and potential financial distress. Though necessary to prevent loss of life due to COVID-19, these public health measures expose many people to experiencing situations that are linked to poor mental health outcomes, such as isolation and job loss. Additionally, feelings of anxiety are increasingly common, as people are fearful of themselves or loved ones falling ill and are uncertain of the repercussions of the pandemic.
This brief explores mental health and substance use in light of the spread of coronavirus. Specifically, we discuss the implications of social distancing practices and the current financial crisis on mental health, as well as challenges to accessing mental health or substance use services. We draw on data on mental health prior to the COVID-19 pandemic and, where possible, include recent KFF polling data on the mental health effects of the pandemic. Key takeaways include:
- A broad body of research links social isolation and loneliness to poor mental health; and recent data shows that significantly higher shares of people who were sheltering in place (47%) reported negative mental health effects resulting from worry or stress related to coronavirus than among those not sheltering in place (37%). Negative mental health effects due to social isolation may be particularly pronounced among older adults and households with adolescents, as these groups are already at risk for depression or suicidal ideation.
- Research shows that job loss is associated with increased depression, anxiety, distress, and low self-esteem and may lead to higher rates of substance use disorder and suicide. Recent polling data shows that more than half of the people who lost income or employment reported negative mental health impacts from worry or stress over coronavirus; and lower income people report higher rates of major negative mental health impacts compared to higher income people.
Poor mental health due to burnout among front-line workers and increased anxiety or mental illness among those with poor physical health are also concerns. Those with mental illness and substance use disorders pre-pandemic, and those newly affected, will likely require mental health and substance use services. The pandemic spotlights both existing and new barriers to accessing mental health and substance use disorder services.
Prior to the COVID-19 pandemic, nearly one in five of U.S. adults (47 million) reported having a mental illness in the past year, and over 11 million had a serious mental illness, which frequently results in functional impairment and limits life activities. Prevalence of depression and anxiety was also high: In 2017-2018, nearly 17 million adults and an additional 3 million adolescents had a major depressive episode in the past year. In 2018, nearly a third (32.5%) of adults reported feeling worried, nervous, or anxious on a daily, weekly, or monthly basis.1
Deaths due to drug overdose have increased more than threefold over the past 19 years (from 6.1 deaths per 100,000 people in 1999 to 20.7 deaths per 100,000 people in 2018). In 2018, over 48,000 Americans died by suicide,2 and in 2017-2018, over ten million adults (4.3%) reported having serious thoughts of suicide in the past year.
During this unprecedented time of uncertainty and fear, it is likely that mental health issues and substance use disorders among people with these conditions will be exacerbated. In addition, epidemics have been shown to induce general stress across a population and may lead to new mental health and substance use issues.
Mental Health Risks Due to Social Isolation
In response to the current coronavirus crisis, most state and local governments are requiring closures of non-essential businesses and schools, prohibiting large gatherings, and requiring quarantines for travelers, in addition to encouraging social distancing. A majority of states have declared mandatory stay-at-home orders for all but non-essential workers. A broad body of research links social isolation and loneliness to both poor mental and physical health. Former U.S. Surgeon General Vivek Murthy has brought attention to the widespread experience of loneliness as a public health concern in itself, pointing to its association with reduced lifespan and greater risk of both mental and physical illnesses (Dr. Murthy serves on the KFF Board of Trustees). Additionally, studies of the psychological impact of quarantine during other disease outbreaks indicate such quarantines can lead to negative mental health outcomes. There is particular concern about suicidal ideation during this time, as isolation is a risk factor for suicide.
In the Early April KFF Tracking Poll, conducted March 25-30, 2020, we found that 47% of those sheltering in place reported negative mental health effects resulting from worry or stress related to coronavirus (Figure 1). This rate is significantly higher than the 37% among people who were not sheltering in place reporting negative mental health impacts from coronavirus. Of those sheltering in place, 21% reported a major negative impact on their mental health from stress and worry about coronavirus, compared to 13% of those not sheltering in place.
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Figure 1: Percent of Adults Who Say Worry or Stress Related to the Coronavirus Has Had a Negative Impact on Their Mental Health, Based on Sheltering-in-Place Status
Similarly, those saying their lives have been disrupted “a lot” (57%) or “some” (44%) by the coronavirus outbreak are more likely to report negative mental health impacts than those who say their lives have only been disrupted “a little” or “not at all” (28%). Twenty-eight percent of people experiencing a lot of disruption in their lives due to coronavirus reported major negative mental health impacts, compared to 15% of those experiencing just some disruption and 10% of those with little or no disruption.3
Differing Effects of Social Isolation by Group
Older adults are more likely than people of other ages to develop serious illness if they contract coronavirus. Due to their increased vulnerability to the virus, it is especially important for this population to practice social distancing, among other safety measures. These measures may limit their interactions with caregivers and loved ones, which could lead to increased feelings of loneliness and anxiety, in addition to general feelings of uncertainty and fear due to the pandemic.
The recent KFF Tracking Poll found that older adults were less likely than adults ages 18 to 64 to report that worry or stress related to the coronavirus has had a negative impact on their mental health (31% vs. 49%, respectively).4 However, research also shows that older adults are already at risk of poor mental health due to experiences such as loneliness and bereavement. In 2018, an estimated 27% of adults ages 65 and older reported living alone (roughly 14 out of 51 million).5 Additionally, in 2018, 13.7% of older adults reported feeling depressed on a daily, weekly, or monthly basis; and 22.6% reported feeling worried, nervous, or anxious on a daily, weekly, or monthly basis.6 Older adults are particularly at-risk for depression, which is often misdiagnosed and undertreated within this population. The prevalence of depression increases for those who require home health care or are hospital patients. Suicidal ideation is a related mental health risk among older adults. In 2018, older adults accounted for nearly one out of five suicide deaths (9,102 out of 48,344) in the U.S.; more than 80% of these suicides were among males.7 Research shows that older, white males have the highest suicide rate in the U.S.
HOUSEHOLDS WITH CHILDREN OR ADOLESCENTS
In order to help slow the spread of coronavirus, nearly every state in the U.S. has closed schools, affecting 30 million students, and, subsequently, their parents or guardians. These closures could affect families beyond a disruption in their child’s education. Guidance from the Centers for Disease Control and Prevention (CDC) regarding long-term school closures states that students depending on school services such as meal programs and physical, social, and mental health services will be impacted and that mental health issues may increase among students due to fewer opportunities to engage with peers.
Existing mental illness among adolescents may be exacerbated by the pandemic, and with school closures, they will not have the same access to key mental health services. As shown in Figure 2, from 2016-2018, over three million (12%) adolescents ages 12 to 17, or more than one in ten, had depression and/or anxiety. Suicidal ideation is another major mental health risk among adolescents. While suicide is the tenth leading cause of deaths overall in the U.S., it is the second leading cause of deaths among adolescents ages 12 to 17.8 Suicidal thoughts and suicide rates among adolescents have increased over time; the crude rate of suicide deaths among adolescents was 7.0 per 100,000 in 2018 vs. 3.7 per 100,000 in 2008.9 Additionally, substance use is a concern among adolescents. Research shows that substance use among teens often occurs with other risky behaviors and can lead to substance use problems in adulthood. In 2017, more than one in ten high school students reported using illicit drugs10 (14%) or misusing prescription opioids (14%).
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Figure 2: Percent of Adolescents Ages 12-17 with Anxiety, Depression, and Depression and/or Anxiety, 2016-2018
With long-term closures of childcare centers and schools, many parents are experiencing ongoing disruption to their daily routines. Findings from the Early April KFF Tracking Poll show that among parents with children under the age of 18, nearly three out of five (57%) women say that worry or stress related to the coronavirus has negatively impacted their mental health, up from 36% of women in the KFF tracking poll conducted two weeks prior. The Early April KFF Tracking Poll also finds that women with children under the age of 18 are more likely to report negative impacts to their mental health than their male counterparts (57% vs 32%, respectively).
Mental Health Risks due to Job Loss and Income Insecurity
According to the most recent data from the Department of Labor, 5.2 million people filed for unemployment benefits during the week of April 5, bringing the four-week total to a historic 22 million people filing for unemployment. Certain industries have been hit harder than others, such as the leisure and hospitality sector. Analysts at S&P Global predict the U.S. unemployment rate will continue to rise in the wake of the pandemic and that the country is nearing a recession. Research also shows that job loss is associated with increased depression, anxiety, distress, and low self-esteem; and may lead to higher rates of substance use disorder. Additionally, as unemployment rises and a recession nears, suicides may increase. During the Great Recession, the U.S. unemployment rate rose to 10% and was associated with increases in suicide rates.
In the Early April KFF Tracking Poll, 54% of those who lost income or employment reported negative mental health impacts from worry or stress over coronavirus, compared to 40% of those who had not lost income or employment (Figure 3). Twenty-six percent of people experiencing job or income loss reported major negative impacts on their mental health, compared to 15% of those who had not experienced job or income loss.
Figure 3: Percent of Adults Who Say Worry or Stress Related to the Coronavirus Has Had a Negative Impact on Their Mental Health, Based on Job or Income Loss
People with low incomes are also more likely to report major negative mental health impacts from worry or stress over coronavirus. Twenty-six percent of those making less than $40,000 reported experiencing a major negative mental health impact, compared to 17% of those with incomes between $40,000 to $89,000 and 14% of those making $90,000 or more (Figure 4).
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Figure 4: Percent of Adults Who Say Worry or Stress Related to the Coronavirus Has Had a Negative Impact on Their Mental Health, by Household Income
Burnout and Strain Among Frontline Health Care Workers
Many hospitals across the country are overwhelmed with the growing number of patients presenting with symptoms of COVID-19. This has rapidly increased the demands on frontline health care workers, some of whom are also overwhelmed by supply shortages.
Research indicates that burnout in hospitals is particularly high for young registered nurses and nurses in hospitals with lower nurse-to-patient densities. Physicians are also prone to experiencing burnout and can consequently suffer from mental health issues, including depression and substance use. The risk of suicide is also high among physicians.
In a recent KFF poll, about half (51%) of people in households with a health care worker said worry and stress about coronavirus has had a negative impact on their mental health, which is statistically similar to the 44% of people experiencing a negative impact who do not live in households with a health care worker.11 A recent study examined the mental health outcomes of health care providers working in China during the coronavirus outbreak, finding that providers reported feelings of depression, anxiety, and overall psychological burden. This experience was particularly acute among nurses, women, and providers directly involved in diagnosing and treating patients with COVID-19.
Mental Health Risks Associated with Poor Physical Health
According to the CDC, people who have chronic illnesses such as chronic lung disease, asthma, serious heart conditions, and diabetes are among those with a high risk of severe illness from COVID-19. Research shows that mental health disorders are common comorbidities among patients with these and other chronic illnesses. The Early April KFF Tracking Poll found that 53% of those with fair or poor health status reported that worry or stress related to coronavirus has negatively impacted their mental health, compared to 44% of those with excellent, very good, or good health status (Figure 5). Of those with fair or poor health status, 29% reported a major negative impact on their mental health, compared to 17% of those with excellent or good health status.
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Figure 5: Percent of Adults Who Say Worry or Stress Related to the Coronavirus Has Had a Negative Impact on Their Mental Health, by Health Status
In recognition of the mental health implications of the COVID-19 pandemic, the World Health Organization released a list of considerations to address the mental well-being of the general population and specific, high-risk groups, including health care workers, children, and older adults. The CDC has also shared information and recommendations regarding stress and coping in their online COVID-19 resources. Additionally, the National Institute on Drug Abuse has noted that while little is known about COVID-19 in relation to substance use, there are potential associations between severe COVID-19 and substance use disorder.
The pandemic is likely to have both long- and short-term implications for mental health and substance use. Those with mental illness and substance use disorders pre-pandemic, and those newly affected, will likely require mental health and substance use services. Consequently, the pandemic spotlights both existing and new barriers to accessing mental health and substance use disorder services. In 2018, among the 6.5 million nonelderly adults experiencing serious psychological distress, 44% reported seeing a mental health professional in the past year. Compared to adults without serious psychological distress, adults with serious psychological distress were more likely to be uninsured (20% vs 13%) and be unable to afford mental health care or counseling (21% vs 3%).12 For people with insurance coverage, an increasingly common barrier to accessing mental health care is a lack of in-network options for mental health and substance use care. Those who are uninsured already face paying the full price for these and other health services. As unemployment continues to increase and people lose job-based coverage, some may regain coverage through options such as Medicaid, COBRA, or the ACA Marketplace, but others may remain uninsured.
Limited access to mental health care and substance use treatment is in part due to a current shortage of mental health professionals, which will likely be exacerbated by the COVID-19 pandemic. While some mental health providers are increasing their use of telemedicine in light of social distancing, not all are able to do so. The recently-passed Coronavirus Aid, Relief, and Economic Security Act (CARES Act) may help to address the likely increased need for mental health and substance use services. It includes a $425 million appropriation for use by the Substance Abuse and Mental Health Services Administration (SAMHSA), in addition to several provisions aimed at expanding coverage for, and availability of, telehealth and other remote care for those covered by Medicare, private insurance, and other federally-funded programs. It also allows for the Secretary of the Department of Veterans Affairs to arrange expansion of mental health services to isolated veterans via telehealth or other remote care services. These provisions may alleviate some of the acute need for remote mental health and substance use services. In addition, the CARES Act extends the duration of, and expands, Medicaid Community Mental Health demonstrations, which are currently underway as part of efforts to increase care access and quality at community behavioral health clinics.
As policymakers continue to discuss further actions to alleviate the burdens of the COVID-19 pandemic, data will be required to measure its growing effect on mental health and substance use. The increased need for mental health and substance use services will likely become a long-term problem even as new cases and deaths due to the novel coronavirus subside.
This work was supported in part by Well Being Trust. We value our funders. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.
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