DMEJ

   Duke Medical Ethics Journal   

988: Protecting Mental Health Post COVID-19

By: Julia Caci

COVID-19 has opened the floodgates to an already precarious mental health situation in the United States. The pandemic has created new, inconceivable levels of grief that have exacerbated an already staggering mental health crisis. Stresses -- about personal health, the safety of loved ones, job security, and an insecure economy, just to name a few -- have plagued the nation for over a year and a half. The result? A tripling of reported mental health and anxiety symptoms -- particularly among low-income Americans and people of color (Kearney). And if history is any guide, these adverse mental health effects will far outlast the pandemic; according to Joshua C. Morganstein, assistant director at the Centre for the Study of Traumatic Stress in Maryland, the “‘tail’ of mental health needs often continues long after the infectious disease subsides” (Savage). As vaccines become readily available and we begin to inch towards normalcy, the immediate effects of COVID will begin to subside, but the mental health impact will not. Thus, even as we remove our masks and reenter the world of concerts and large gatherings, we should expect to see a growing number of Americans in crisis. This may have devastating consequences. 

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Even before the pandemic, the US had an unusually large mental health disease burden. In 2019, an American died a “death of despair” (a preventable death caused by drugs, alcohol, or suicide) every three minutes (“Pain in the Nation”). To make matters worse, despite having the highest incidence of mental illness and suicide rate among developed nations, the US is among the least prepared to manage mental health crises, according to an analysis done by the Commonwealth Foundation. Despite the fact that many US adults want mental health care, less than half can access it—with many citing cost and inability to find a doctor as primary barriers to care (Tikkanen, et al.).

"At the end of the day, resolving the nation’s mental health crisis isn’t going to be as easy as changing a hotline number... That said, the 988 bill is a great start for dealing with the mental health issues in post-COVID America, and we should continue to seek improvement as we celebrate the new law."

So, if Americans so badly want and need mental health care, why is it so hard to come by? In part, mental health care is just too hard to find. The United States suffers from a lack of coordinated care, meaning that mental and physical health are treated as separate entities. For example, despite being a common “first-stop” for general health concerns, only 30% of primary care physicians have a psychiatrist on their team (Tikkanen, et al.). As a result, if someone goes to their trusted primary care doctor with symptoms of depression, that doctor may have no idea where to refer them to. This lack of coordination causes confusion. Most people know where to go for a broken leg or a sinus infection, but not when they start experiencing debilitating anxiety. And even if they know where to go, they might not be able to afford help once they get there. Despite recent efforts to institute mental health parity, mental health coverage is often complicated and expensive—forcing many Americans to pay steep out-of-network fees in order to get help. 

The result of all of this? Many Americans forego preventative mental health care altogether. In the absence of adequate preventative care, psychological stressors can turn into mental health emergencies. And, again, without coordinated care, people with these emergencies don’t know how to get help. Thus, they turn to 911 as a last resort.  It’s estimated that almost 20% of 911 calls are mental health related -- a number that’s expected to rise in the coming months (Abramson). However, much like the primary care office, 911 response teams don’t come equipped with psychiatrists, leaving mental health at the wayside. At best, this may delay care as police officers attempt to connect the person in crisis with the appropriate resources. At worst, a 911 call can have deadly consequences. 

When police officers arrive at the scene of a behavioral crisis they often don’t have the tools to help the person in crisis. It’s estimated that a quarter of fatal police encounters occur in response to mental health-related calls (Westervelt). Even when cases don’t escalate to death, people in behavioral crises often face unnecessary incarceration or trauma, rather than gain access to the support they need. Even worse, this phenomenon disproportionately affects already vulnerable populations; Black and Latino Americans are more likely to be killed by police officers after making such calls. 

Clearly, something needs to change. As we exit this pandemic, we need to pour just as many resources into amending our mental health response as we did into developing vaccines and reforming our economy. Mental health crises may be harder to spot than rising COVID cases and lost jobs, but they can have devastating effects that long outlast mask mandates and Delta surges. Furthermore, just as we adamantly help those with physical injuries, we need to meet people in crisis with the same compassion and care, not violence. 

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Photo credit to Storyblocks

Fortunately, many people agree that our mental health system needs reform, and members of Congress are currently working on crafting solutions. One promising effort is the new 988 law. In October of 2020, the National Suicide Hotline Designation Act designated the number 988 as the new universal hotline number for mental health crises with the goal of diverting calls from the 911 hotline (S.2661.). 988 will also replace the current national suicide hotline number, which is long and hard to remember. The law is set to go into effect in 2022. 

This law will be an important tool as we exit COVID-19 and face a burgeoning mental health crisis. However, it’s not a silver bullet. This number alone will not do much without adequate infrastructure to back it up; after all, a crisis response number is only effective if it leads to a comprehensive and successful response. Bringing individuals in psychological crisis to the hospital will be pointless unless the hospital is equipped with the resources to support those individuals. Importantly, we must ensure that this law’s benefits are distributed to our nation’s most vulnerable, as they are the ones most likely to need it. 

First, who will be answering these new 988 calls? This new system will need to be staffed with trained, culturally competent operators who can successfully help a person in mental distress. And what if the person in crisis doesn’t speak English? Already, most 911 interpreters are monolingual, which causes confusion and wastes precious time as operators struggle to connect with interpreters (Banse). This problem will be even more pronounced with mental health calls, as callers will be in dire need of talk support. In a mental health emergency, every word and inflection in the voice of a responder matters. With an interpreter, important messages may be lost in translation. We know crisis intervention is much more effective when responders share experiences and identities with the people that they are helping. We also know that Latino and other minority communities’ mental health has been disproportionately impacted by COVID-19. Therefore, crisis response centers’ staff should reflect the communities they are serving—in order to make sure that this new law will help communities of color at least as much as it helps white, English-speaking ones. 

After the initial call, 988 teams will need to be prepared to provide through-and-beyond support to those in crisis. For example, if an individual needs additional support, will there be enough psychiatric beds available for them? Or will they be stuck in the ER, waiting for a psychiatric bed to open up? If we expect 988 to provide an avenue for people to access emergency psychiatric care, we need to also anticipate an influx in demand for psychiatric beds. And how will we make sure that people receive continued support after their immediate crisis ends? Will we send people back home as soon as they are feeling better, or will we provide them with through-and-beyond support so that we avoid another crisis in the future? The 988 number may help get a patient into the hospital, but it won’t make a long-term difference unless we have a system ready to care for that patient once they get there. 

At the end of the day, resolving the nation’s mental health crisis isn’t going to be as easy as changing a hotline number. Like most health policies, we need to consider equity, infrastructure, and payment before the program is rolled out. Otherwise, we risk missing an opportunity to make a true difference. That said, the 988 bill is a great start for dealing with the mental health issues in post-COVID America, and we should continue to seek improvement as we celebrate the new law. 

In any stories, please include: “988 is not yet active and people in crisis now should call 1-800-273-8255 to be connected to the National Suicide Prevention Lifeline or reach out to the Crisis Text Line by texting HOME to 741741.”

Review Editor: Sam Shi
Design Editor: Sibani Ram
References

Abramson, Ashley. “Building Mental Health into Emergency Responses.” Monitor on 

Psychology. American Psychological Association, July 1, 2021. 

https://www.apa.org/monitor/2021/07/emergency-responses. 

Banse, Tom. “What Happens When 911 Callers Don't Speak English?” Northwest News 

Network, August 19, 2014. 

https://www.nwnewsnetwork.org/human-interest/2014-08-18/what-happens-when-911-ca

llers-dont-speak-english. 

Kearney, A., Hamel, L., Brodie, M. “Mental Health Impact of the COVID-19 Pandemic: An 

Update.” Kaiser Family Foundation. April 14 2021. 

https://www.kff.org/coronavirus-covid-19/poll-finding/mental-health-impact-of-the-covid

-19-pandemic/?

“Pain in the Nation.” Trust for America’s Health. 2019. https://pitn.org

Savage, Maddy. “Coronavirus: The Possible Long-Term Mental Health Impacts.” BBC Worklife. 

BBC, October 18, 2020. 

https://www.bbc.com/worklife/article/20201021-coronavirus-the-possible-long-term-mental-health-impacts.

 S.2661. “National Suicide Hotline Designation Act of 2020.” 166th Congress (2019-2020). 

https://www.congress.gov/bill/116th-congress/senate-bill/2661

Tikkanen, Roosa, Katharine Fields, Reginald D Williams, and Melinda K Abrams. “Mental 

Health Conditions and Substance Use: Comparing U.S. Needs and Treatment Capacity 

with Those in Other High-Income Countries.” The Commonwealth Fund. May 21, 2021. 

https://www.commonwealthfund.org/publications/issue-briefs/2020/may/mental-health-c

onditions-substance-use-comparing-us-other-countries. 

Westervelt, Eric. “Removing Cops from Behavioral Crisis Calls: 'We Need to Change the 

Model'.” NPR. NPR, October 19, 2020. 

https://www.npr.org/2020/10/19/924146486/removing-cops-from-behavioral-crisis-calls-

we-need-to-change-the-model.