Proceedings of a Workshop
Mental Health and Substance Use Disorders in the Era of COVID-19
The Impact of the Pandemic on Communities of Color
Proceedings of a Workshop—in Brief
On November 23, December 3, and December 14, 2020, the Forum on Mental Health and Substance Use Disorders of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine (the National Academies) hosted a virtual workshop titled Mental Health and Substance Use Disorders in the Era of COVID-19: With a Special Focus on the Impact of the Pandemic on Communities of Color.1 The workshop featured invited speakers and discussions that addressed how the coronavirus disease 2019 (COVID-19) pandemic has influenced (1) mental health and substance use disorders (SUDs); (2) changes in access to health care and delivery of services for people with mental health disorders and SUDs; and (3) the mental health well-being of the health care workforce—each with a particular focus on the impact of the pandemic on communities of color and how the pandemic has created, revealed, and exacerbated longstanding racial and ethnic disparities in behavioral health care.
This Proceedings of a Workshop—in Brief summarizes the presentations and discussions that occurred at the workshop. A broad range of views2 was presented during the presentations and discussions.
MENTAL HEALTH AND SUBSTANCE USE DISORDERS IN THE ERA OF COVID-19
The Mental Health Impact of COVID-19
Joshua Gordon, director of the National Institute of Mental Health (NIMH) of the National Institutes of Health (NIH),3 began his presentation by highlighting that COVID-19 and psychiatric disorders have a bidirectional association. This means that if a person has a psychiatric disorder, they are at an increased risk of developing COVID-19, and of those diagnosed with COVID-19, approximately 6 percent will develop a new psychiatric disorder (including mood disorders and anxiety disorders) over the next few months (Taquet et al., 2021). “Overall, that means that about 18 percent of people recovering from COVID-19 in the ensuing 3 months will have a psychiatric diagnosis, including, of course, the large group of people who had a preexisting [diagnosis],” said Gordon. He added that self-report surveys of individuals in the general population show increasing rates of symptoms of mental distress, but these are not diagnoses. In June 2020, 31 percent of adults in the United States reported anxiety or depression symptoms, 26 percent reported trauma or stressor-related disorder symptoms, 13 percent reported starting or increasing substance use, and 11 percent seriously considered suicide (Czeisler et al., 2020). Another area of concern, added Gordon, is the increased risk of young
1 The workshop agenda, presentations, and other materials are available at https://www.nationalacademies.org/our-work/mental-health-and-substance-use-disorders-in-the-era-of-covid-19-exploring-the-impact-of-the-pandemic-on-communities-of-color-a-workshop (accessed December 24, 2020).
2 The views contained in this Proceedings of a Workshop—in Brief are those of individual workshop participants and do not necessarily represent the views of all workshop participants, the planning committee, or the National Academies.
3 No endorsement of the National Academies’ programs or services by NIH is intended.
people reporting suicidal ideation. The cause of the increase in symptoms is unclear and could include the pandemic itself, the mitigation measures, the economic impacts, or a combination of these factors (Czeisler et al., 2020).
Gordon turned to the issue of accessing mental health care services, noting a steep decline in mental health–related emergency department (ED) visits but a slow return to pre-pandemic levels of ED visits for mental health reasons in the pediatric population (Leeb et al., 2020). Gordon stressed the importance of understanding data from COVID-19 in the context of prior emergencies to inform responses to the pandemic. Previous disasters, mass traumas, and epidemics have shown that people often experience psychiatric symptomatology—even reaching the level of a diagnosable mental illness—in the ensuing few months (Ahern et al., 2006; Koenen et al., 2017). Individuals with few social supports, a history of trauma or mental illness, exposure to morbidity or mortality, ongoing stressors, and occupational and financial strain are at increased risk (Ahern et al., 2006; Koenen et al., 2017). Additionally, “we have a pandemic that is dramatically influencing minority and underserved communities … to a much greater degree than the general population, and that means that those individuals in those communities are essentially doubly at risk,” said Gordon. “They are more likely to have been impacted, and they have existing risk factors that raise their risk of mental health consequences.”
Gordon explained that treating new or worsening illness in the context of the pandemic can be achieved through the expansion of tele-mental health, although it is important to ensure that tele-mental health does not exclude vulnerable populations or increase disparities. Gordon concluded by noting that NIMH wants to go beyond disseminating knowledge to expanding knowledge, so it has created many funding opportunities and grants to study interventions and their impacts on mental health, particularly among vulnerable populations, including older adults, frontline workers, children, rural and urban populations, and racial and ethnic minorities.
To move forward and promote mental health recovery, Gordon encouraged:
- Providing practical assistance, such as shelter, food, safety, and economic stability;
- Practicing healthy coping strategies, such as noting accomplishments, setting reasonable expectations, exercising, maintaining schedules, eating well, getting rest, talking with a support network, and avoiding substance use; and
- Treating new or worsening illness with evidence-based screening, assessment, treatment, and care coordination.
The Intersection of COVID-19 and Substance Use Disorders
Nora Volkow, director of the National Institute on Drug Abuse of NIH,4 began by noting the importance of understanding the intersection of the U.S. opioid crisis and the pandemic. She explained that the opioid crisis began with overdose deaths due to prescription medication, then heroin use, and now a third phase, which is fentanyl, a synthetic opioid of extremely high potency. Volkow added that recent years have also seen an increase in mortality associated with psychostimulant drugs, such as cocaine or methamphetamine (NIDA, 2020).
It has been extremely difficult to get real-time data that capture overdose deaths during the pandemic, said Volkow. Between March and May 2020, individuals testing positive for fentanyl, methamphetamine, cocaine, and heroin increased by 32 percent, 20 percent, 10 percent, and 12 percent, respectively (AMA, 2020). Some data also show that overdoses increased up to 43 percent per month (between January and May 2020) as compared to the same months in 2019 (ODMAP, 2020). She pointed out that while overdose does not necessarily lead to mortality, the pandemic is exacerbating the risk of dying from overdose.
Turning to the bidirectional association between COVID-19 and psychiatric disorders that Gordon referenced, Volkow added that people with SUDs have a higher risk of getting infected with COVID-19, and if infected, often have worse outcomes than those without an SUD. That increased risk of infection is likely due to social circumstances, but drug use can also have physiological effects on pulmonary, cardiac, metabolic, and immune systems that are directly targeted by COVID-19. Additionally, among those with SUDs, the risk of infection is highest for individuals with opioid use disorder (OUD) (Wang et al., 2020). While having an SUD significantly increases a person’s risk of dying from COVID-19, that risk is even higher for Black people, said Volkow, which further highlights how the pandemic has exacerbated existing inequities.
Volkow detailed the many structural challenges of addressing SUDs during COVID-19, including stress, stigma, reduced access to medications for OUD, limited access to peer support groups or other sources of social connection, decreased likelihood of an observer who can administer naloxone to reverse an overdose (due to social distancing), social isolation and the loss of support networks, increased demand for health care that imposes limitations on the systems used to treat SUDs, decimation of the economy, increased homelessness, and job loss.
4 No endorsement of the National Academies’ programs or services by NIH is intended.
The stigma associated with SUDs, she emphasized, has had devastating consequences for the opioid crisis and its intersection with the pandemic because it can prevent people from seeking treatment and exposes them to much higher-risk behaviors, which results in much worse outcomes. “We need to systematically abolish [stigma]…. If we want people to actually be able to achieve recovery and to prevent drug use, then we need to ensure that we are able as a society to provide social interactions that are rewarding and meaningful. And it is through them that we will be able to not just prevent people from taking drugs, but we will also be able to prevent the devastating consequences of addiction,” Volkow concluded.
Racism Is a Public Health Crisis
The United States is experiencing three “conversing convulsions,” said Michelle Williams, dean of the faculty at the Harvard T.H. Chan School of Public Health. “A biological convulsion brought on by the pandemic, an economic convulsion that the pandemic has uncovered, and a societal convulsion which really came to the fore as a traumatic event when we saw George Floyd’s life taken away in 8 minutes and 46 seconds,” she said. These three forces, elaborated Williams, have fostered a series of conversations and realizations about how racism is a fundamental public health crisis. She noted that the unequal health outcomes that Dr. Martin Luther King, Jr., spoke about in 1966 are still present more than 50 years later, as evidenced by the data presented by Gordon and Volkow.
During the 1918 influenza pandemic, Williams explained, Black people were often stigmatized, blamed for getting sick, and relegated to substandard hospitals where the systems available to them would quickly become overwhelmed. “If that sounds heartbreakingly familiar, it should,” she said. Williams noted that some people have referred to the pandemic as “a great equalizer” because everyone at the country is at risk. “The virus does not discriminate, but our society always has, and because of this persistent discrimination, week after week, month after month, communities of color have borne the brunt of this crisis,” said Williams.
She explained that regardless of where someone lives in the United States, their experience with COVID-19 is strongly related to who they are, which is a reflection of the systemic inequality that plagued the country long before the pandemic began. Williams mentioned not only inequalities in exposure to the disease but also inequalities in access to health care for those who get sick, exacerbated by inequalities in underlying health conditions that make COVID-19 even more deadly. The pandemic has shone a harsh light on what public health experts have long known, which is that racism itself is a public health crisis, observed Williams. This crisis has manifested in the scourge of police violence that disproportionately kills Black Americans; in the vestiges of colonization, slavery, and discrimination; in a pandemic that is devastating the population of color; and in the disproportionate mental health impacts in Black communities.
Williams reiterated that systemic racism has affected Black and brown Americans long before the pandemic began due to the toll of individual racism (such as having health concerns downplayed by white health care providers), daily discrimination (which has been documented to create chronic diseases), racist policies (such as segregation, redlining, mass incarceration, and voter suppression), and the defunding of public schools and social programs.
Access to health care also continues to be a significant challenge for Black Americans, said Williams. A survey from 2018 found that of the 4.8 million Black Americans with mental illness, nearly 70 percent do not receive treatment (SAMHSA, 2020). Even if they do, she added, it is unlikely that they will find a mental health provider with the same cultural background, as only 4 percent of psychologists in the United States are Black (SAMHSA, 2020).
The connection between physical and mental health disparities and racism is undeniable, said Williams, but can be addressed by using existing data to illuminate the ways in which structural racism drives inequality both within the health care system and through disparities in wealth, opportunity, access to quality education, housing, healthy foods, and green space. The challenge in public health, in Williams’s view, is one of awareness and funding. She added that bending the arc toward population health equity in the United States could be achieved by:
- Demanding radical large-scale investments in public health at the municipal, state, and national levels;
- Making a national mental and physical health disease surveillance and reporting system that makes data available in a timely manner and includes information about the social determinants of health;
- Investing in building a more diverse pipeline and robust mentorship system in public health departments so they are better able to provide culturally competent, trusted services; and
- Investing in place-based interventions that address not only physical and mental health care but also the social determinants of health, such as school quality, employment opportunities, access to green space and healthy food, and access to high-quality preventive care.
Williams concluded her remarks by insisting that “we must be an America that finally reckons with the sins of discrimination that pervade American society in health care and across all facets of our daily life. If we are able to
do that, in the end, that will be the great equalizer and will save countless lives and ensure the opportunity for all to thrive.”
The Disproportionate Impact of the Pandemic on Communities of Color
To understand racial inequity and health inequity in this country, it is necessary to understand their history and how racism operates at multiple levels, said Brian Smedley, chief of psychology in the public interest and acting chief diversity officer at the American Psychological Association (APA). Agreeing with Williams, he added that for too long, some have pretended that racism is simply an interpersonal phenomenon with a few “bad apples.” Rather, Smedley explained, racism operates at structural, institutional, interpersonal, and internalized levels—all of which are complicit in the deep inequities occurring as a result of the COVID-19 pandemic.
Referring to the deliberate policy practices mentioned by Williams, such as the history of U.S. government support for residential segregation, Smedley went further to say “the fact that we have not corrected that historical inequity is in itself a form of racism that maintains the deep racial inequities that we are seeing today.” Smedley remarked that the United States is actually witnessing a syndemic, in which the COVID-19 pandemic is fueled by and is exacerbating preexisting social and economic inequality. Smedley noted that the preexisting conditions that place people of color at a heightened risk for poor outcomes did not miraculously appear and are not the result of biologic, genetic, or behavioral factors or simply a lack of access to health care. “They were, in fact, created by policy and practice in this country that deliberately and significantly disenfranchised and marginalized many populations, particularly people of color,” explained Smedley.
Smedley highlighted results from the APA Stress in America™ survey, which found that 67 percent of Black adults cited discrimination as a significant source of stress in their lives in the fall of 2020—up from the 55 percent that reported this in May and June 2020. Similarly, 60 percent of all U.S. adults and 80 percent of Black adults cited police violence toward people of color as a significant source of stress (APA, 2020). Smedley explained that COVID-19 has exposed inequities that have been persistent for generations, and these inequities are seen within marginalized groups, such as people and older adults of color; direct care workers (who are often women, people of color, and/or immigrants); people with disabilities; incarcerated populations; and migrant families in detention centers. In the same survey, when questioned about a significant source of stress, 80 percent of the Hispanic population cited contracting COVID-19; 70 percent reported on meeting basic needs, such as food and housing; and 70 percent reported on accessing health care (APA, 2020).
Smedley highlighted numerous potential strategies to combat the COVID-19 pandemic’s disproportionate impacts on communities of color (SAMHSA, 2020), including
- Policy strategies, such as the following:
- Disaggregating data by race and ethnicity at the local and national levels.
- Increasing flexibility in treatment policies and payments for OUDs.
- Providing guidance for federal stimulus opportunities.
- Expanding and increasing the flexibility of telehealth coverage.
- Community-based strategies, such as the following:
- Utilizing faith-based leaders, community-accepted first responders, community-based organizations, community health workers, and technology to convey COVID-19 information.
- Health care workforce strategies, such as the following:
- Leveraging virtual and telehealth opportunities.
- Building a more diverse workforce by fast-tracking immigrant, refugee, and bilingual health care professionals who have until now been closed out of the health professions.
Smedley explained that APA launched an initiative called #EquityFlattensTheCurve.5 In order to flatten the curve, “we must tackle bias, stigma, and discrimination at the root of these inequities and the structural forms of racism that are currently hampering our ability to mitigate risk and provide equitable opportunities for good health for all,” said Smedley. He added that this initiative has four goals: (1) connecting the voices of health equity, public health, and psychology to educate policy makers and leaders; (2) reducing bias, stigma, and discrimination related to the pandemic; (3) promoting social cohesion, inclusion, and equity as necessary to help mitigate the virus’ spread; and (4) promoting policies and practices that reduce inequity and address the public health needs of diverse populations.
“[A lack of social cohesion is] one of the reasons why the United States is experiencing such deep inequities in high infection rates and mortality rates relative to other developed nations. I believe it is in part because we are a
deeply divided country, one that has been even more divided as a result of the resurgent racism and expressions of hatred leveled against many minoritized communities,” concluded Smedley.
EXPLORING THE IMPACT OF COVID-19 ON ACCESS TO HEALTH CARE AND DELIVERY OF SERVICES FOR PEOPLE WITH MENTAL HEALTH AND SUBSTANCE USE DISORDERS
COVID-19 poses an existential threat to the treatment of mental health disorders and SUDs, said Brendan Saloner, associate professor in the departments of health policy and management and mental health at the Johns Hopkins Bloomberg School of Public Health. He identified three reasons for this threat: (1) congregate care settings pose a risk of spreading disease, (2) the populations that are at elevated risks of mental health disorders and SUDs also have elevated risks of both contracting and dying from COVID-19, and (3) closing clinics to prevent the spread of COVID-19 resulted in fewer access points for patients and a loss of revenue for care providers. Saloner added that federal and state policy solutions have been enacted in response to these threats, such as new regulatory flexibilities with telehealth, take-home provisions for methadone and buprenorphine, and financial relief for providers. However, he cautioned, these regulations are limited to the duration of the declaration of a public health emergency and will be phased out after the emergency ends.
Despite emerging models for providing medications for OUD, such as the take-home provisions, Saloner explained that providers are not under any obligation to adopt these provisions. Therefore, he believes that implementation is going to vary widely by provider.
Saloner noted that early evidence from the pandemic shows an increase in the need for treatment of mental health disorders and SUDs. There has been a rise in symptoms of depression, anxiety, and loneliness that has persisted throughout 2020 (McGinty et al., 2020). Provisional data6 from the U.S. Census Bureau also show an increase in the rate of drug overdoses. Importantly, there are disparities in unmet needs across racial and ethnic groups as well as across income levels (U.S. Census Bureau, 2020).
An initial sharp decrease in service use in spring 2020 is now being followed by a rapid rebounding of mental health visits (Ziedan et al., 2020). The 12-fold increase (Pierce et al., 2021) in psychologists offering telehealth during the pandemic is encouraging, said Saloner, because it has improved the continuity of care and may become a permanent option after the pandemic. Saloner concluded by noting the continuing gaps in the research and questions that will be important to understand, such as the following:
- How many patients using services prior to the pandemic will continue to stay in virtual care models? How many have been disconnected from care?
- How much new need for treatment has been caused by the pandemic? What resources are available to meet the demand?
- Has quality of care changed under telehealth? How does quality vary based on patient characteristics?
- What will be the long-term need for a continuum of services to support changing needs (e.g., acute psychiatric crisis, anxiety disorders, bereavement, and addiction recovery)?
Impact of COVID-19 on Demand for and Access to Behavioral Health Care
The pandemic has seen a significant increase in the need for behavioral health care, said Joe Parks, medical director of the National Council for Behavioral Health (NCBH).7 Comparing June 2019 and June 2020, anxiety, depression, and suicidal ideation have increased approximately 3-fold, 4-fold, and 2-fold, respectively (Czeisler et al., 2020). Serious suicidal ideation was even higher among unpaid caregivers, persons aged 18–24, essential workers, Hispanic persons, and Black Americans.
Parks explained that NCBH conducted a member survey between August and September 2020 to understand the economic impact of COVID-19 on their behavioral health organizations. On average, organizations lost 22 percent of their revenue during COVID-19, and 32 percent received funding from the first round of provider relief (NCBH, 2020). These financial struggles, said Parks, are resulting in a reduced capacity to deliver services: 26 percent of organizations laid off employees, 24 percent furloughed employees, and 43 percent decreased staff hours. Additionally, 54 percent have closed programs, and 65 percent have had to cancel, reschedule, or turn away patients (NCBH, 2020).
Particularly interesting, noted Parks, is that the hardest hit organizations were primarily paid under the fee-for-service payment methodologies. He remarked that fee-for-service was the least resilient form of funding, and prospec-
6 For more information, see https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm (accessed January 4, 2021).
tive payment methodologies and grant-funded mental health services (such as federally qualified health centers, certified community behavioral health centers, and capitated delivery systems) were financially resilient because they had more latitude to shift services and change care delivery. “This really revealed the weakness and the relative failure of our major payment methodology,” said Parks, explaining that it was difficult for the fee-for-service models to respond to these kinds of serious and unforeseen changes.
Another significant outcome of the pandemic will likely be a permanent change in the way in which patients prefer to receive care, added Parks. When patients were asked if they would prefer telehealth to in-person visits even after the pandemic ends, 70 percent replied that they would use telehealth for half or more of their visits. Patients cited numerous reasons for this preference, including flexibility in appointment times, child care coverage, inability to take time off work to get to and from an appointment, and increased comfortability in their own homes (NCBH, 2020). Additionally, 75 percent of patients reported the same or better connection with their therapist or case manager. The expanded availability of telehealth has opened up access to individuals who would not otherwise have gotten into services at all, such as people from rural communities, said Parks. Parks noted, however, that it is more difficult to engage people in early recovery from SUDs through telehealth, particularly in group treatment. In closing, Parks encouraged:
- Bearing in mind how the chronic underfunding of the behavioral health care system and fee-for-service payment models have resulted in the inability to adapt to economic stress;
- Providing direct relief to behavioral health providers and organizations;
- Increasing access to medications for OUD;
- Enacting long-term changes to telehealth, such as allowing tele-prescribing for OUD;
- Implementing prospective payment methodologies nationwide; and
- Expanding access to certified community behavioral health centers.
Key Concepts That Sustain Mental Health Inequities
Systems-level factors are driving the mental health disparities seen today, said Ruth Shim, the Luke & Grace Kim Professor in Cultural Psychiatry and professor in the Department of Psychiatry and Behavioral Sciences at the University of California, Davis. Despite patient-level factors (e.g., fear, mistrust, self-stigma,8 cultural differences in treatment-seeking behaviors) and provider-level factors (e.g., lack of cultural competence, implicit biases, language barriers, lack of a diverse workforce) that are important, it is the systems-level factors, such as the social determinants of health, racism, discrimination, and societal stigma, that impact the cost of care and fragmentation of services and create and maintain inequities, she added.
“When we think about health inequities … we are really talking about systemic avoidable and unjust social and economic policies and practices that drive those differences in health outcomes. It is not just an intrinsic or an internal difference that you find in certain populations or certain groups, [it is a] creation of these inequities from the policies and practices that we promote in our society,” remarked Shim.
Shim further explained that the risk factors that contribute to adverse mental health outcomes—such as homelessness, housing instability, adverse early life experiences, discrimination, interaction with the criminal justice system, adverse features of the built environment, poverty, unemployment, and low education—are shaped by the unfair and unjust distribution of opportunity created by policies and social norms. These policies and norms are in turn shaped by how society values certain people and populations. Therefore, in Shim’s view, intervention at the level of the risk factor is too late. For example, she added, this value system resulted in laws and policies where the use of crack cocaine resulted in mass incarceration, but the use of opioids led to public health interventions.
Mental health inequities exist and persist for many reasons, explained Shim, such as
- Essentialism (the belief that there are distinct, unchanging, and natural characteristics that define social groups and facilitate their categorization);
- Erasure of context (the failure to consider sociohistorical context when seeking to understand the etiology of inequities);
- Biological determinism (the false belief that racial groups are biologically and genetically different); and
- Cultural determinism (the false belief that differences in racial groups are the result of cultural factors) (Shadravan and Barcelo, 2021).
8 Self-stigma occurs when individuals internalize negative attitudes held by members of the public. For more information, see https://journals.sagepub.com/doi/10.1177/070674371205700804 (accessed February 18, 2021).
Shim added that communities of color have not only seen a divestment of resources but experienced oppression resulting in powerlessness that prevents people from having a voice. The work, said Shim, is therefore figuring out how to prevent forms of oppression, such as voter suppression, in order to increase political representation so that the needs of a community can be prioritized in policy making and the decision-making process.
In terms of the inequities related to COVID-19—the case and death rates are disproportionately higher among Black, Hispanic, and Indigenous populations—Shim pointed out that the focus is again often on individual differences rather than, for example, the impacts of socioeconomic status, access to care, or how frontline workers are more likely to be people of color than white people. The higher death rates, concluded Shim, mean that people of color are more likely to know someone among their immediate friends and family who has died, and it will be important to consider the impact of this bereavement when designing interventions to address the social determinants of mental health.
The Disproportionate Impact of COVID-19 on Accessing Care for Youth and Families of Color
Margarita Alegría, professor in the Department of Psychiatry at Harvard Medical School and chief of disparities research at Massachusetts General Hospital, began by noting that the ecology of inequality leads to negative mental health outcomes for many youth and emerging adults of color. Furthermore, she added, when these individuals seek treatment, they face many barriers to accessing care, which only exacerbates the problem.
It is important to ensure access to behavioral health services for youth and emerging adults of color, stressed Alegría, because economic instability due to the COVID-19 pandemic can contribute to posttraumatic stress disorder (PTSD) and hinder child development (Fortuna et al., 2020). Additionally, pandemic-related fear and associated anxiety and depression symptoms are higher for Hispanic persons, Asians, and immigrants living with small children (Fitzpatrick et al., 2020). Anti-immigration legislation has also created a threatening environment with heightened uncertainty and fear, added Alegría, which can affect mental health well-being.
Compared to 2019, the proportion of mental health–related ED visits has increased by 24 percent for children aged 5–11 and 31 percent for children aged 12–17 in 2020 (Leeb et al., 2020). Emerging adults aged 18–29 are reporting the highest rates of depression and anxiety symptoms during the pandemic, and the barriers faced by this age group in seeking and obtaining treatment are only magnified for racial and ethnic minorities (NeMoyer et al., 2020; U.S. Census Bureau, 2020). Additionally, many minority children rely on services provided through Medicaid: Black children comprise 14 percent of the U.S. population but represent 20.8 percent of the children receiving Medicaid (Brooks and Gardner, 2020). However, low Medicaid reimbursement rates during the pandemic have made it difficult for safety net providers to operate due to significant losses in monthly revenues, explained Alegría.
Prevention and community engagement will be the key to alleviating these issues, asserted Alegría, due to high rates of food insecurity, child poverty, greater financial need, school avoidances or suspensions, rising rates of suicide, exposure to violent environments, and limited access to telehealth and school-based services among households of color. Multi-level interventions targeting community and work life for those with mental illness have been linked to increased housing stability and well-being, community-level interventions targeting the built environment have been shown to reduce depressive symptoms, and integrating social services with mental health care using community health workers has improved patients’ ability to cope with stress (Alegría et al., 2018).
Investing in youth and emerging adults of color will have a long-term impact on the recovery of our nation, said Alegría, as the growing proportion of minority youth will contribute to the growth of the nation’s working-age population and be responsible for much of the economic growth. At the same time, the aging white majority will become dependent on this demographic’s contributions to programs such as Medicare and Social Security, which, in her view, highlights the necessity of continued investment in and support of youth and emerging adults of color. In conclusion, Alegría encouraged:
- Increasing investments in social services to emphasize the importance of social determinants of health as a component of mental health care and substance use treatment;
- Expanding federal regulations to fund novel behavioral health treatment programs for communities of color with high COVID-19 exposure and unemployment rates;
- Addressing inequities in access by bridging community services to youth who formerly received care through school settings or community colleges;
- Integrating mental health, addiction, and infectious disease care within public health infrastructure, free of charge and without eligibility requirements for children and emerging adults; and
- Accelerating the expansion of the mental health and addiction workforce through training and educating professionals and paraprofessionals and implementing performance measurement to determine if there are improvements in access and quality.
Disrupting the Dehumanization of COVID-19 on Communities of Color
Howard Stevenson, the Constance Clayton Professor of Urban Education and professor of Africana studies at the University of Pennsylvania and director of the Racial Empowerment Collaborative9 and Forward Promise,10 shared his work on developing evidence-based, culturally responsive interventions in communities. In particular, he is trying to create measures and interventions that capture the racialized experiences of Black and brown people and how those experiences undermine health. Stevenson noted that as part of communication with community leaders, Forward Promise frames its communication around the idea of a healthy village. He asked, “What does it take to create a healthy village and community to help young boys and young men of color heal, grow, and thrive?”
Referring to Shim’s presentation, Stevenson noted that there are narratives and elements of dehumanization within education, health, criminal justice, and work systems in society. This dehumanization, which includes the persistent invalidation of a characteristic, animalistic distortion, or the idea that people of color are unworthy of and do not need basic human dignities, manifests in narratives, policies, and practices that threaten the health of people of color (Haslam and Stratemeyer, 2016). A growing body of research is examining how racialized stress and trauma differ from other types of stress. Historical colonization and racial trauma cannot be overlooked, asserted Stevenson, in not only interventions but also measurement. The historical trauma that occurs as a result of racism, colonialism, and dehumanization preceded and accompanied COVID-19, Stevenson explained.
Expecting an individual to survive through resilience does not take into account long-term collective environmental impacts, noted Stevenson. He asked, “How do you navigate both discrimination and racism on a daily basis but also hold on to your traditions, your world views, and your healing strategies to actually help you get through it? And the question is, how is it possible to do that when the larger services and systems not only do not appreciate that worldview but are still dehumanizing in their ignorance—sometimes unintentional and sometimes quite blatant?”
Stevenson expressed concern that the current and intergenerational trauma of Black and brown lives continues to be underestimated. However, knowing the stories of communities of color and understanding the role of white supremacy can help address the historical dehumanization that undermines present health policies and practices, explained Stevenson.
Stevenson noted that grantees of Forward Promise shared that the pandemic quickly exposed inequities that have persisted in communities of color for generations: “The history and consequences of being denied health care, good schools, access to food, paid leave, fair wages, and other social supports is being magnified as the pandemic continues to unfold in communities” (Forward Promise, 2020).
In conclusion, he shared an African proverb: the lion’s story will never be known as long as the hunter is the one to tell it. “If we are going to be more relevant in not only our interventions but our research, we are going to have to think better about the measurement of the conditions of people of color in communities as well as their worldviews and practices,” said Stevenson.
THE MENTAL HEALTH WELL-BEING OF THE HEALTH CARE WORKFORCE DURING COVID-19
The Impact of COVID-19 on State Mental Health Systems in 2020
Ted Lutterman, senior director of government and commercial research at the National Association of State Mental Health Program Directors Research Institute, shared the results of a survey that was intended to assess how public mental health systems were being impacted by the pandemic. State Mental Health Authorities (SMHAs) served 8.1 million individuals in 2019 (NRI, 2020). Their typical responsibilities include operating psychiatric inpatient services, funding or operating community mental health services, planning for mental health service development, addressing unmet needs, setting standards for services, licensing mental health providers, monitoring quality and outcomes, and coordinating financing and delivery of services with other state government agencies. Importantly, noted Lutterman, SMHAs disproportionately serve persons of color and people that are economically disadvantaged.
States experienced a decrease in use of state psychiatric hospitals, reporting that this was due to limited admissions (51 percent), social distancing guidelines (44 percent), closing units or wards (20 percent), decreased demand (22 percent), or other reasons (27 percent). However, 17 percent of states reported an increased demand in state psychiatric hospital services (NRI, 2020). Lutterman noted that this was often due to general hospitals temporarily closing their psychiatric units in order to focus on COVID-19-positive patients.
Many states reported workforce issues, such as staffing shortages due to team members being infected. Some states brought back retirees or moved administrative personnel back into direct patient care, remarked Lutterman. In the beginning of the pandemic, staff were unable to obtain adequate supplies of personal protective equipment (PPE).
States also reported that their staff were highly stressed from working additional shifts and juggling child care (NRI, 2020). Thirteen states have changed licensure rules or regulations during the pandemic to expand the use of advanced practice nurses and/or physician assistants. The state mental health workforce in both hospitals and community providers are being stressed by COVID-19, resulting in reduced face-to-face services, frequent absences, and increased overtime and temporary replacement staffing needed in hospitals, summarized Lutterman.
Lutterman noted that community mental health systems reported a reduction in group services. Seventy-six percent of SMHAs implemented a new hotline or warmline system in response to COVID-19. Mental health crisis services saw an increase in calls to suicide and crisis hotlines but a decrease in behavioral health clients in crisis stabilization programs (NRI, 2020).
All states that participated in the survey reported that the increased flexibility in telehealth was beneficial to providing behavioral health services, and many are requesting that this continue after the end of the public health emergency declaration. One positive outcome of increasing the use of telehealth was a reduction in no-shows at community mental health providers (NRI, 2020). However, noted Lutterman, telehealth can create issues related to privacy and confidentiality, particularly for children in group homes or foster care. Many children missed out on school-based mental health therapy during the pandemic as well (NRI, 2020). In closing, Lutterman cautioned that the costs of providing services have reportedly increased, and future budget shortfalls are looming challenges facing SMHAs and their service providers.
Mental Health of the Health Care Workforce During COVID-19
It is well established that there are significant disparities in who is infected by COVID-19 in the United States, said Albert Wu, professor in the departments of health policy and management, epidemiology, and international health at the Johns Hopkins Bloomberg School of Public Health. At the time of the virtual workshop, Kaiser Health News reported that 1,445 health care workers died after contracting COVID-19 on the job; it was more than 2,900 before the end of 2020 (Jewett et al., 2020). “Workers of color are more frequently exposed to COVID patients, are more likely to lack sufficient PPE, work in high-risk settings like nursing homes, or live outside of the hospital in densely populated communities or residences—all of which increase their risk of infection,” explained Wu.
Unsurprisingly, working in health care settings during the pandemic has had a significant negative impact on emotional well-being. Wu noted that in the short term, health care workers felt anger, frustration, anguish, grief, fear, and anxiety for themselves and their families. In the long term, worsening mental health conditions (e.g., insomnia, burnout, and PTSD) are emerging, and risk factors include direct exposure, frontline work, low social support, and being a nurse (Sanghera et al., 2020).
Wu explained that disasters elicit more or less predictable psychological patterns (SAMHSA, 2000). “After the initial impact of the pandemic and a subsequent heroic phase, we have, since March, collectively slid into a long and deep period of disillusionment…. Where we are now is after the adrenaline has worn off, after original altruism and optimism and frenzied behavior has calmed down, and reality has set in. Resources are now more limited and people are beginning to feel abandoned,” said Wu.
Attempts have been made to provide support both to workers and the general population, explained Wu, and most of those policies have been “color blind.” He added that the term originally referred to race-neutral government policies that aim to reject discrimination of any kind so as to promote the goal of racial equality. However, according to Wu, in more recent years, the term has been used to refer to policies where legislators fail to consider preexisting disparities, thereby increasing the risk that those disparities may be worsened. “In general, many policies do not wind up working for everyone, and it is primarily white Americans who are able to benefit from them,” he said.
Wu shared Johns Hopkins’ 10 Principles of Crisis Leadership11 from a program it developed on frontline crisis leadership with the goal of enhancing the well-being of health care workers by strengthening crisis leadership and communication; it has trained more than 1,000 managers. Wu highlighted one principle, which stated that transparent, timely, and truthful communication is essential, even and especially when things are not going well.
Impact of the Pandemic on Health Care Workers from Communities of Color
The pandemic, economic downturn, racial injustice, and the 2020 presidential election all contributed to the stress of the nation, said Arthur Evans, chief executive officer and executive vice president of APA. However, explained Evans, different groups of people are experiencing the pandemic in different ways: parents are more stressed than non-parents, women are more stressed than men, young adults are more stressed than older adults, and communities of color are more stressed than white communities. Health care workers face additional and additive stressors, such as fear of
11 For more information, see https://www.hopkinsmedicine.org/joy-at-jhm/office-of-well-being/covid/frontline-crisis-leadership.html (accessed January 8, 2021).
contracting COVID-19, burnout, lack of or inadequate PPE or medical equipment, compassion fatigue, isolation from families and loved ones, direct and vicarious trauma, feelings of responsibility and guilt, stigma from others, and moral injury, which contribute to the worsening mental health conditions detailed by Wu.
Communities of color are also experiencing unique stresses, said Evans. They are more likely to contract COVID-19, have challenges in getting testing and treatment, and become seriously ill or die. People of color are also more likely to be employed in service industries where they are going to experience greater exposure to the virus, which increases the likelihood that they might contract it (APA, 2020). In the beginning of the pandemic, Black men also expressed fear that wearing a face covering would expose them to racial profiling and police harassment—a unique stressor experienced by people of color (Taylor, 2020).
All of these additional stressors can result in heightened vigilance, race-based traumatic stress, decreased resilience, increased depression and anxiety, and increased psychiatric disorders, explained Evans. He noted that faith and spirituality, social supports, and positive racial and ethnic identities can serve as protective factors.
Evans noted other evidence-based strategies that can help protect the mental health of health care workers (Greenberg et al., 2020), including
- Normalizing conversations about psychological health;
- Building resilience by acknowledging challenges and providing resources;
- Identifying traumatic stress early, following up with health care workers that miss work, and offering support;
- Infusing mental health considerations into policies and procedures that involve health care workers;
- Providing psychologically safe forums in which health care workers can make sense of their experiences;
- Creating multiple pathways to help the greatest number of people;
- Acknowledging the unique challenges faced by health care workers who are part of communities of color; and
- Recognizing the diversity that exists within communities of color.
People of color in the health care workforce face a double burden of stress, so addressing their unique needs warrants conceptual shifts in research, policy, and practice, asserted Evans. There are individual-, organization-, system-, and societal-level factors that drive mental health disparities. Research efforts frequently examine individual-level factors, noted Evans, despite the fact that the broader systemic and societal factors (such as housing policy, education, and residential segregation) have a greater impact on people’s mental health.
Evans stressed that “disparities for communities of color play out differently in different communities. You cannot assume that, in New York, the disparities will look the same in Wichita or Los Angeles. So it is really important to collect the data … so that you have a better understanding of why [disparities are] different in your particular community.” He then encouraged that people work with the individuals from those communities to understand and develop solutions to the problems and then implement them in partnership.
In closing, Evans noted that “one of the things that I think is important for people to recognize for all communities of color but—particularly for the professional staff—is every day that they walk into their building they are putting on different forms of PPE. Some of it is to protect them from the physical issues related to the virus, but some of it is psychological. It’s like the physician who wears his scrubs everywhere to prevent forms of discrimination from happening to them.” The issues that communities of color are facing now are significant, he added, but many of these issues preexisted the pandemic. Strategies that are being employed now can help address these issues in the long term.
Planning committee co-chairs Larke Huang and Deidra Roach thanked the speakers and participants for their vital contributions to the virtual workshop and noted the importance of attending to the intersection of the pandemic and mental health and substance use issues. Huang remarked that “deep-seated racism is exacerbating mental health and substance use issues and really drawing the line between life and death in the era of COVID-19 for communities of color. The pandemic has lifted and highlighted the pain of the deep racism in our country, which is so critical to all of our health, mental health, and well-being.” Roach acknowledged that this is a critical point in the United States and applauded the speakers for illuminating the challenges and imagining viable solutions to some of the most daunting public health challenges in human history.◆◆◆
Ahern, N. R., E. M. Kiehl, M. L. Sole, and J. Byers. 2006. A review of instruments measuring resilience. Issues in Comprehensive Pediatric Nursing 29(2):103–125.
Alegría, M., A. NeMoyer, I. Falgàs Bagué, Y. Wang, and K. Alvarez. 2018. Social determinants of mental health: Where we are and where we need to go. Current Psychiatry Reports 20(11):95.
AMA (American Medical Association). 2020. Issue brief: Reports of increases in opioid related overdose and other concerns during COVID pandemic. http://www.asapnys.org/wp-content/uploads/2020/07/Issue-brief_-Reports-of-increases-in-opioid-related-overdose-and-other-concerns-during-COVID-pandemic.pdf (accessed December 24, 2020).
APA (American Psychological Association). 2020. Stress in America. https://www.apa.org/news/press/releases/stress/2020/report-october (accessed January 4, 2021).
Brooks, T., and A. Gardner. 2020. Snapshot of children with Medicaid by race and ethnicity, 2018. Georgetown University Health Policy Institute Center for Children and Families. https://ccf.georgetown.edu/wp-content/uploads/2020/07/Snapshot-Medicaid-kids-race-ethnicity-v4.pdf (accessed January 5, 2021).
Czeisler, M. É., R. I. Lane, E. Petrosky, J. F. Wiley, A. Christensen, R. Njai, M. D. Weaver, R. Robbins, E. R. Facer-Childs, L. K. Barger, C. Czeisler, M. E. Howard, and S. M. W. Rajaratnam. 2020. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic—United States, June 24–30, 2020. Morbidity and Mortality Weekly Report 69:1049–1057.
Fitzpatrick, K. M., C. Harris, and G. Drawve. 2020. Fear of COVID-19 and the mental health consequences in America. Psychological Trauma: Theory, Research, Practice, and Policy 12(S1):S17–S21. http://dx.doi.org/10.1037/tra0000924.
Fortuna, L. R., M. Tolou-Shams, B. Robles-Ramamurthy, and M. V. Porche. 2020. Inequity and the disproportionate impact of COVID-19 on communities of color in the United States: The need for a trauma-informed social justice response. Psychological Trauma: Theory, Research, Practice and Policy 12(5):443–445. doi: 10.1037/tra0000889.
Forward Promise. 2020. COVID-19 community impact and response. http://forwardpromise.org/wp-content/uploads/2020/05/COVID19-Community-Impact-and-Response_Final.pdf (accessed January 8, 2021).
Greenberg, N., M. Docherty, S. Gnanapragasam, and S. Wessely. 2020. Managing mental health challenges faced by healthcare workers during COVID-19 pandemic. BMJ 368:m1211.
Haslam, N., and M. Stratemeyer. 2016. Recent research on dehumanization. Current Opinion in Psychology 11:25–29.
Jewett, C., R. Lewis, and M. Bailey. 2020. More than 2,900 health care workers died this year—and the government barely kept track. Kaiser Health News. https://khn.org/news/article/more-than-2900-health-care-workers-died-this-year-and-the-government-barely-kept-track (accessed January 8, 2021).
Koenen, K. C., A. Ratanatharathorn, L. Ng, K. A. McLaughlin, E. J. Bromet, D. J. Stein, E. G. Karam, A. Meron Ruscio, C. Benjet, K. Scott, L. Atwoli, M. Petukhova, C. C. W. Lim, S. Aguilar-Gaxiola, A. Al-Hamzawi, J. Alonso, B. Bunting, M. Ciutan, G. de Girolamo, L. Degenhardt, O. Gureje, J. M. Haro, Y. Huang, N. Kawakami, S. Lee, F. Navarro-Mateau, B. E. Pennell, M. Piazza, N. Sampson, M. Ten Have, Y. Torres, M. C. Viana, D. Williams, M. Xavier, and R. C. Kessler. 2017. Posttraumatic stress disorder in the World Mental Health Surveys. Psychological Medicine 47(13):2260–2274.
Leeb, R. T., S. Price, S. Sliwa, A. Kimball, L. Szucs, E. Caruso, S. Godfred-Cato, and M. Lozier. 2020. COVID-19 trends among school-aged children—United States, March 1–September 19, 2020. Morbidity and Mortality Weekly Report 69:1410–1415.
McGinty, E. E., R. Presskreischer, H. Han, and C. L. Barry. 2020. Psychological distress and loneliness reported by U.S. adults in 2018 and April 2020. JAMA 324(1):93–94.
NCBH (National Council for Behavioral Health). 2020. COVID-19 economic impact on behavioral health organizations. https://www.thenationalcouncil.org/wp-content/uploads/2020/04/NCBH_COVID19_Survey_Findings_04152020.pdf?daf=375ateTbd56 (accessed January 5, 2021).
NeMoyer, A., M. Cruz-Gonzalez, K. Alvarez, R. C. Kessler, N. A. Sampson, J. G. Green, and M. Alegría. 2020. Reducing racial/ethnic disparities in mental health service use among emerging adults: Community-level supply factors. Ethnicity & Health 1–21. Epub ahead of print. https://doi.org/10.1080/13557858.2020.1814999.
NIDA (National Institute on Drug Abuse). 2020. Opioid overdose crisis. https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis (accessed December 24, 2020).
NRI (NASMHPD [National Association of State Mental Health Program Directors] Research Institute). 2020. Impact of COVID-19 on state mental health services. http://nri-inc.org/media/1677/nri-2020-profiles-report-the-impact-of-covid-on-state-mental-health-systems.pdf (accessed January 8, 2021).
ODMAP (Overdose Detection Mapping Application Program). 2020. COVID-19 impact on U.S. national overdose crisis. http://www.odmap.org/Content/docs/news/2020/ODMAP-Report-June-2020.pdf (accessed December 24, 2020).
Pierce, B. S., P. B. Perrin, C. M. Tyler, G. B. McKee, and J. D. Watson. 2021. The COVID-19 telepsychology revolution: A national study of pandemic-based changes in U.S. mental health care delivery. American Psychologist 76(1):14–25. http://dx.doi.org/10.1037/amp0000722.
SAMHSA (Substance Abuse and Mental Health Services Administration). 2000. Field manual for mental health and human service workers in major disasters. https://store.samhsa.gov/sites/default/files/d7/priv/adm90-0537.pdf (accessed January 8, 2021).
SAMHSA. 2020. Double jeopardy; COVID-19 and behavioral health disparities for Black and Latino communities in the U.S. https://www.samhsa.gov/sites/default/files/covid19-behavioral-health-disparities-black-latino-communities.pdf (accessed December 24, 2020).
Sanghera, J., N. Pattani, Y. Hashmi, K. F. Varley, M. S. Cheruvu, A. Bradley, and J. R. Burke. 2020. The impact of SARS-CoV-2 on the mental health of healthcare workers in a hospital setting—A systematic review. Journal of Occupational Health 62(1):e12175. https://doi.org/10.1002/1348-9585.12175.
Shadravan, S., and N. Barcelo. 2021. Social injustice and mental health inequities. In Social (in)justice and mental health, edited by R. S. Shim and S. Y. Vinson. Washington, DC: APA Publishing.
Taquet, M., S. Luciano, J. R. Geddes, and P. J. Harrison. 2021. Bidirectional associations between COVID-19 and psychiatric disorder: Retrospective cohort studies of 62 354 COVID-19 cases in the USA. The Lancet Psychiatry 8(2):P130–P140.
Taylor, D. B. 2020. For Black men, fear that masks will invite racial profiling. The New York Times. https://www.nytimes.com/2020/04/14/us/coronavirus-masks-racism-african-americans.html (accessed January 11, 2021).
U.S. Census Bureau. 2020. Week 18 Household Pulse Survey: October 28–November 9. https://www.census.gov/data/tables/2020/demo/hhp/hhp18.html (accessed January 4, 2021).
Wang, Q. Q., D. C. Kaelber, R. Xu, and N. D. Volkow. 2020. COVID-19 risk and outcomes in patients with substance use disorders: Analyses from electronic health records in the United States. Molecular Psychiatry 26:30–39. https://doi.org/10.1038/s41380-020-00880-7.
Ziedan, E., K. I. Simon, and C. Wing. 2020. Effects of state COVID-19 closure policy on non-COVID-19 health care utilization. NBER Working Paper No. w27621. https://ssrn.com/abstract=3665892 (accessed March 18, 2021).
DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Kaitlyn Friedman and Laurene Graig as a factual summary of what occurred at the workshop. The statements made are those of the rapporteurs or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.
*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for this published Proceedings of a Workshop—in Brief rests with the rapporteurs and the institution.
Planning committee members included Larke Huang (Co-Chair), Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services; Deidra Roach (Co-Chair), National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health; Margarita Alegría, Harvard Medical School and Massachusetts General Hospital; Colleen L. Barry, Johns Hopkins Bloomberg School of Public Health; Howard H. Goldman, University of Maryland School of Medicine; Husseini K. Manji, Janssen Research & Development, LLC; and Lt. Commander Rashid Njai, Centers for Disease Control and Prevention.
REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Brendan Saloner, Johns Hopkins Bloomberg School of Public Health, and Darla Spence Coffey, Council on Social Work Education. Leslie Sim, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.
STAFF: Laurene Graig, Kaitlyn Friedman, Alexandra Andrada, Anesia Wilks, and Sharyl Nass, Board on Health Care Services, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine.
SPONSORS: This workshop was supported by Contract No. HHSN263201800029I, Order No. HHSN26300025 with the National Institutes of Health and Contract No. HHSP233201400020B, Order No. 75P00120F37108 with the Office of the Assistant Secretary for Planning and Evaluation along with Alkermes, Inc., American Board of Family Medicine, American College of Clinical Pharmacy, American Psychiatric Association, American Psychiatric Nurses Association, American Psychological Association, Association for Behavioral Health and Wellness, Council on Social Work Education, Janssen Research & Development, LLC, Optum Behavioral Health, Think Bigger Do Good Policy Series (a partnership of the Scattergood Foundation, Peg’s Foundation, Patrick P. Lee Foundation, and Peter & Elizabeth Tower Foundation), Well Being Trust, and the National Academy of Medicine. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
For additional information regarding the workshop, visit https://www.nationalacademies.org/our-work/mental-health-and-substance-use-disorders-in-the-era-of-covid-19-exploring-the-impact-of-the-pandemic-on-communities-of-color-a-workshop.
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Mental health and substance use disorders in the era of COVID-19: The impact of the pandemic on communities of color: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/26102.
Health and Medicine Division
Copyright 2021 by the National Academy of Sciences. All rights reserved.