As mental health needs rise, providers  see solutions

Since the coronavirus and its accompanying economic shutdown took hold in the United States, there’s been a staggering rise in Americans dealing with mental health conditions.

A survey of roughly 2,000 American adults surveyed in late April found that more than 70% of them met the criteria for “moderate to serious mental distress.” That’s more than triple the amount who met the criteria from a similar survey in 2018. A May study from the Pew Research Center found that one-third of Americans reported “high levels of psychological distress,” with even higher rates among poor Americans and those with disabilities.

Here in New Hampshire, mental health professionals are concerned about the impact that the pandemic will have on a health care system that is already stretched thin.

“The pandemic has clearly been a very traumatic event,” said Dr. William Torrey, professor and vice chair for clinical services for the Department of Psychiatry at Dartmouth-Hitchcock Medical Center in Lebanon.

Trauma is closely linked with mental health conditions like depression and anxiety, particularly for those who have existing psychiatric conditions. “All of those stressors that come with the pandemic can bring out those illnesses and make them worse,” Torrey said.

Because of that, many providers in New Hampshire are preparing for an influx of new patients, and trying to improve the way that the state’s medical system delivers mental health care.

“It’s a very challenging situation,” Torrey said. “Before the pandemic, there were very significant gaps in the mental health and addiction care system to begin with. Because of long-standing discrimination against people who have challenges with mental health and substance use disorder, society hasn’t invested adequately in care.”

While the state is a long way off from a robust and accessible mental health care system, there are specific policy steps that could improve mental health outcomes in New Hampshire, providers say. At least one of them is already making significant progress in the state.

On March 18, Gov. Chris Sununu issued an emergency order that allowed for expanded access to telehealth services throughout the state. The order ensured that Medicaid would pay for telehealth services during the pandemic, something that most private insurers also agreed to do. That allowed the state’s providers to continue to serve their clients at a critical time, said Jay Couture, president of the New Hampshire Community Behavioral Health Association and CEO of Seacoast Mental Health Center, which provides services in Portsmouth and Exeter.

Now, the state legislature is considering making that change permanent via Senate Bill 555, being considered this week. Couture says that making lasting changes to mental health reimbursements would improve access to mental health and substance abuse treatment for Granite Staters.

“This really is an incredible opportunity to do something that would have probably taken years,” she said.

Despite research showing that delivering healthcare via video or phone is effective, providers and insurance companies have been slow to embrace telehealth “because it’s so new and different,” Couture said. Prior to the pandemic, telehealth services would only be reimbursed if the services were delivered in a very specific way, Couture said. Usually, that involved a patient being in one clinic, talking remotely with a doctor in another clinic.

Since the pandemic, providers can reach patients at home, by video or phone, and be paid by insurance companies for their services. With this form of telehealth services, patients don’t need to worry about transportation or childcare, to an extent. People with mental health conditions who are uncomfortable leaving their home may be more apt to connect with care if it can be delivered remotely.

“I believe telehealth can help reduce barriers to access,” Couture said. “We can connect with the individual or family, and get them the service they need in the way that works for them.”

In addition to SB555 passing in New Hampshire, federal changes are needed to continue to increase access to telehealth services, Couture said. Some healthcare privacy considerations under HIPPA have been relaxed during the pandemic, making it easier to deliver care remotely. Making those changes permanent could encourage more telehealth services, without compromising patient confidentiality, Couture said. For example, policy changes could allow patients to sign forms digitally that usually require an ink signature.

Kenneth Norton, the director of the National Alliance on Mental Illness’s New Hampshire chapter (NAMI NH), says that his organization has seen more people accessing therapy, support groups, classes and trainings digitally.

“In the realm of mental health, that is the biggest impact COVID has had,” he said.

Telehealth has challenges, like patients finding private space to talk to a therapist.

“I’ve heard of people doing a telehealth session in the bathroom with the door closed, because that’s the only room in the house where they can have privacy,” Norton said.

Some populations — particularly the elderly and people with substance use disorder — may not have access to a smartphone or computer and reliable internet access for video chatting. To combat that, community mental health clinics are offering services by phone as well as video, Couture said.

Telehealth isn’t necessarily cheaper than traditional therapy, Couture said, since clinics need to maintain the same salary and benefits for staff. However, if can help more people connect with care, a change that Couture would like to see stay in place.

“We have a real opportunity to improve the ability of our healthcare system to provide care across the spectrum of behavioral and physical health,” she said. “I hope the legislature supports that as well.”

One of the primary policy goals for NAMI NH has been to reduce emergency room boarding — the practice by which people needing psychiatric treatment are involuntarily held in emergency rooms for days on end until a bed in a psychiatric unit is found.

“It’s wrong medically, it’s wrong legally, it’s wrong ethically, it’s wrong morally, and it’s wrong economically,” Norton said, referring to the organization’s multi-pronged approach to fighting ER boarding.

For one day in late March, the state had no waiting list for psychiatric beds for the first time in eight years. There were a few reasons for that, Norton said: a new unit for adult patients had been opened at New Hampshire State Hospital in Concord after a children’s unit was relocated; in addition, concern over coronavirus may have been keeping people away from emergency rooms.

However, the issue of emergency room boarding isn’t over: on Tuesday June 9 there were 20 adults and 4 children waiting for psychiatric beds in New Hampshire, according to NAMI NH’s Facebook page, where a daily tally is posted. Norton said since March, numbers have hovered between 10 and 20 adults waiting each day. A lawsuit by the ACLU regarding emergency room boarding in New Hampshire is ongoing.

NAMI NH has also expressed concern with the state’s Crisis Standards of Care, activated via Emergency Order 33 on April 17. The section on mental health calls for continuation of timely delivery of mental health services, doesn’t mention suicide or drug overdose prevention, Norton pointed out. In addition, the plan says “In times of crisis, the capacity of inpatient behavioral health treatment units may be reduced.” Norton believes that’s the opposite of what people in the state need.

“There may be circumstances where psych admissions need to be increased,” he said.

Torrey, of Dartmouth-Hitchcock, hopes that the pandemic will speed up the integration of mental health into all healthcare settings, including primary care. Dartmouth-Hitchcock, one of the state’s largest healthcare systems, has begun screening patients for depression and anxiety when they come for primary care appointments.

In addition, Dartmouth-Hitchcock has been contracted by the state Bureau of Mental Health Services to establish a system for responding to episodes of first-episode psychosis. Three percent of Americans will experience psychosis during their lives, and intervening early during a person’s first episode of psychosis has been linked to fewer hospitalizations, higher quality of life, better health and improved functioning. NAMI is also involved with the effort to improve response to first-episode psychosis.

Because of its relatively small population and culture of pragmatism, Torrey believes New Hampshire is in a good position to build a mental health system that could be a model for other states.

“We’re a small enough state that we could have an organized approach to meeting people’s needs,” he said. “We’re a conservative state, and it’s conservative to try to address serious mental illness early, so you head off bigger issues later.”

The mental health community has proven means to respond to mental health crises, like the one we’re currently facing. It just needs political backing and funding to make an effective response possible.

“We need ongoing organization of the system and investment in the health of citizens,” Torrey said. “There’s no health without mental health.”

These articles are being shared by partners in The Granite State News Collaborative. For more information visit collaborativenh.org.