Ann Mongoven is the associate director of Health Care Ethics at the Markkula Center for Applied Ethics. Views are her own.
The attention of world and nation is focused on the infectious threat of Covid-19, resulting in historically unprecedented measures such as lockdowns and social distancing. However, there is another—potentially equally as dangerous—mental health crisis emerging from the social disruption caused by the coronavirus outbreak. Fear of illness, economic displacement, social isolation from infection-control policies, and uncertainty associated with Covid-19 all can trigger or heighten mental health distress.
Unless as concerted a societal response is aimed at Covid-19’s mental health crisis, its consequences could be as adverse as the infectious outbreak.
To be successful, the American response must confront key ethical questions:
- How should we negotiate ethical tradeoffs between the risks to mental health of prolonged economic shutdown and the risks of the virus?
- Do we need ethical policies for mental health emergency triage and allocation just as much as we do for ventilators and other scarce medical resources?
- How can individuals, families, and communities simultaneously:
- inculcate habits that support mental health resilience, and
- combat harmful unwarranted stigma that still may accompany acknowledgment of mental health distress, mental illness, depression, or addiction?
- How can we incorporate wider community training in psychological first aid, and increased attention to mental health needs, in current pandemic response and in future public health emergency preparedness-planning?
- What kind of reformed insurance-system and healthcare delivery-system could provide continuous, integrated (physical and mental) healthcare to all, even during public health emergencies—including to disadvantaged communities?
In May 2020, experts from the Wellbeing Trust warned that the Covid pandemic could cause 75,000 “deaths of despair” from drug and alcohol abuse, and suicide, in the United States. (Currently there have been more than 90,000 deaths from Covid-19.) Evidence mounts that pandemic stresses are triggering higher rates of addiction and domestic violence. Half of Americans surveyed reported the pandemic has hurt their mental health. Yet mental health was not earmarked for support in the first two coronavirus-relief bills passed by the U.S. Congress.
Just as the coronavirus has highlighted inequalities and organizational fault lines within American primary and critical care, so too with mental health. American mental healthcare is delivered by a diffuse delivery system, within a complex health-insurance landscape that failed to provide universal coverage even before the pandemic. In March and April of 2020, approximately 34 million Americans are known to have lost employment during “lockdowns,” with the American Medical Association estimating 27 million at immediate risk of losing health insurance.
Hispanic, African-American, Native-American, and undocumented communities have experienced disproportionately high rates of job loss compared to others, just as they have suffered disproportionate losses to Covid-19. Correlatively, they also bear disproportionate mental health burden. These disturbing parallels have prompted new efforts to incorporate social determinants of health into healthcare planning.
Frontline medical responders in areas where Covid-19 surges strain emergency and intensive care resources report high levels of post-traumatic stress with future delayed reactions likely. Two suicides among frontline responders in hard-hit New York City called national attention to the toll. Researchers at New York’s Mount Sinai Hospital estimate that 25-40% of frontline responders will suffer some form of PTSD.
At the same time, innovative responses to the increased mental health needs generated by the pandemic have the potential to improve support for mental health care beyond the pandemic. These responses include:
- creative uses of e-therapy and teletherapy, and relaxation of former policies that restricted their use;
- insurance policy changes including streamlined Medicaid application processes and new emergency enrollment periods for Affordable Care Act plans in several states—both aimed to assist those losing employer coverage;
- collaboration among some state-licensing boards to facilitate treatment across geographic boundaries for displaced patients;
- streamlined processes for the distribution of addiction medicines;
- new coalitions of lay support for those in distress, often including trained referral to volunteer experts;
- celebrity advocacy validating speaking openly about the mental health stresses of the pandemic and flagging resources;
- increased public attention to personal and social habits that support mental health resiliency;
- new initiatives to provide trauma support for frontline medical responders;
- increased community training in psychological first-aid and renewed attention to mental health in emergency preparedness planning.
All of these responses are important, constructive, and life-saving. At the same time, they point to the need for more comprehensive response to the mental health burden Covid-19 imposes on individuals and populations. To respond humanely to the current crisis, we must finally completely expunge lingering dualistic conceptions of the relationship between body and mind. Just as a successful response to Covid-19’s infectious disease threat must confront longstanding weaknesses in American healthcare allocation and delivery, so too must a successful response to the mental health threat. Many have called for a consistent national plan to address the infectious danger of novel coronavirus. We also need a consistent national plan to address the mental health danger.
Because there is no health without mental health.