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Mental Health and Reopening debate

The debate over reopening the country has been framed as a binary one: Physical Health vs Economic Health. What about Mental Health?

The mental health crisis we feared is underway. As a practicing psychiatrist and mental health researcher in New York City, the evidence is clear. The combination of ongoing social distancing and stay-at-home orders are confining us physically and emotionally. The results of our closed society are mounting feelings of isolation and fears of financial ruin. Much like the economic effects of the lockdown, the damage to each of our mental health is cumulative and long lasting.

Those of us treating people are noticing trends. First, people who were already in mental health treatment are getting worse. Second, those who once flew under our radar, perhaps with mild depression and anxiety, can no longer cope. Finally, individuals that pre-lockdown were healthy are developing mental health issues due to the crisis.

As some states are opening up and others are still deciding, all states are weighing how to proceed. Given how severe the mental health consequences of lockdown are, why is the re-opening debate mostly overlooking this crucial component?

The medical doctor in me, who spent much of his internship in Emergency Departments and Intensive Care Units knows the risk of re-opening is great and that it must be done with care and caution. Still, we cannot frame this

debate solely as a choice between physical health and economics.

Data has begun to emerge regarding the mental health toll of the pandemic. Utilization of mental health services is increasing. Online platforms for treating mental health, such as Talkspace, have seen as much as a 65% increase in use. Calls to crisis support services and sexual assault hotlines have also reported increases in traffic. Finally, local governments across the country report increases in domestic abuse calls.

Americans are also seeking medications to combat the unprecedented uncertainty about the future. Express Scripts, a national mail-order pharmacy, reported prescriptions for mental health medicines jumped 21% and anti-anxiety medications increased by 36%. I have seen this trend in my New York City practice. Several of my long standing patients have requested increases in their medications, citing how hard it was to tolerate the long term confinement to their apartments and houses.

The increase in mental health problems from COVID-19 and stay-at-home orders are superimposed on an already growing mental health problem in the United States. Predating the COVID-19 pandemic, CDC data shows that suicide rates across all ages and ethnic groups have increased 30% between 2007 and 2017. Among youth, the increase has been over 50%, between 2009 and 2017. Since 2015, antidepressant prescriptions have increased by 15% overall and 38% for adolescents.

Looking to the future, many of the anticipated mental health effects of stay-at-home orders are linked socio-economic factors. For example, unemployment is associated with elevated rates of suicide. Recessions and poverty are associated with increases in substance abuse and domestic violence.

At present, mental health is seen as an ancillary consequence of COVID 19. This is about to change. The combination of the pre-COVID mental health crisis, the growing mental health consequences of lockdown, and mental health effects of emerging economic issues will snowball. Mental health needs to be a central part of the re-opening debate, and it needs to influence action.

Okay. Now what?

We could continue to open up. I am a mental health physician and trained researcher in both public health and epidemiologic methods. I have followed the science of the pandemic since January. I have weighed our options and I believe that there are small ways of reopening that would have drastically improved everyone’s mental health but will only add a minimal risk to the development of new cases.

If we don’t continue to open up. Then, we need to start working to mitigate the risks of a growing mental health crisis ASAP. And we need more than just hotlines and texting services. We need more decisive actions such as: (A) Implementing mechanics for surveillance, reporting and intervention around domestic violence and child abuse. (B) Bolstering our poorly funded mental health systems to prepare for the increase in mental illness expected from the quarantine/lockdown. (C) Enforce and strengthen the Mental Health Parity Act, as many private and publicly-insured Americans either lack mental health coverage or are unable to find in-network providers

Overlooking mental health from the reopening debate is emblematic of its second tier status in American Society. Including mental health in this debate demonstrates true parity with physical illness. More urgently, it protects us from a new pandemic.

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