Health Letter, January 2021
By Michael T. Abrams, M.P.H., Ph.D.
A tremendous amount of treatable human suffering and death is associated with the constellation of illnesses collectively referred to as mental health and substance use disorders (MHSUDs). Such disorders are disabling brain-based diseases commonly subcategorized as either mental health (psychiatric) or substance use (abuse or dependence) problems, and they often co-occur (for example, 49% of those with serious mental illness have used illicit drugs, whereas only 17% of those without mental illness report such substance use). Depression, anxiety, compulsions and schizophrenia are especially common and debilitating mental disorders; alcohol or opioid dependence are common substance use disorders.
The most recent annual survey data compiled by the U.S. Substance Use and Mental Health Services Administration found that in 2019 25% of non-institutionalized adult Americans suffered from a mental illness or substance use disorder. In 2018, 48,000 Americans died by suicide, making it the tenth-leading cause of death overall and the second-leading cause among those under the age of 34. In 2019, more than 76,000 Americans died from overdoses of opioids or psychostimulants such as cocaine and methamphetamine.
International calculations from the year 2016 indicate that MHSUDs are directly tied to 7% of all disease burden (losses due to premature death or dysfunction) and 19% of all years lived with some disability. In the U.S., those numbers are higher because relative MHSUD burden is especially concentrated in developed countries. In fact, data from 2019 suggests that MHSUDs were the most destructive disease category in the U.S. (more so than musculoskeletal disorders [for example, back pain, arthritis], cancers, cardiovascular diseases, or injuries). In 2019, MHSUDs accounted for approximately 17% of all disease burden in the U.S.
Persons with MHSUDs often experience physical (“somatic,” not brain-based) health challenges. Using a representative U.S. sample of non-institutionalized adults, one study of data from 2010-13 published in Health Affairs quantified physical disorders in persons with behavioral disorders (MHSUDs, including dementia and developmental disorders). More than half of the nearly 37 million MHSUD cases studied had at least four distinct physical disorders — such as hypertension (38%), arthritis (31%) and diabetes (15%) — and 85% of the total medical costs were to treat those comorbidities (meaning only 15% of the costs were specifically for MHSUD care). This study further showed that in 2013 dollars the average adult with MHSUD consumed over $18,000 per year in medical services, double the per capita health expenditures seen in that same year.
This substantial burden of MHSUD existed before the COVID-19 pandemic. The highly infectious and deadly coronavirus has exacerbated that burden.
National Institute of Mental Health (NIMH) and National Institute on Drug Abuse (NIDA) perspectives
The National Academies of Sciences, Engineering, and Medicine (National Academies) recently hosted the first in a three-part webinar series about MHSUDs and COVID-19. Keynote speakers were national biomedical scientific leaders in both relevant subdisciplines: Joshua Gordon and Nora Volkow, Directors of the NIMH and NIDA, respectively.
Dr. Gordon cited work published in Lancet Psychiatry demonstrating apparent bidirectional causal or intensifying pathways between MHSUD and COVID-19, meaning that each disease increases the risks of the other. Based on analysis of data from just over 62,000 U.S. COVID-19 cases, this research found that within 90 days of a COVID-19 diagnosis, a psychiatric diagnosis was over two times as likely to emerge than within 90 days of an influenza diagnosis. In the other direction, this research found that a psychiatric diagnosis prior to the onset of the pandemic in January 2020 increased the relative risk of contracting COVID-19 by 65% compared with no such psychiatric history. In line with a post-traumatic-stress-like response to any unforeseen calamity, the risk of anxiety disorders in the wake of COVID-19 infection were greater than the risk of depression. The reasons for the association between COVID-19 and an increased risk of psychiatric disease were said to be “unknown and [to] require urgent investigation,” but those in the opposite direction were plausibly related to challenges that persons with MHSUD may experience regarding social distancing, smoking or other health behaviors and psychotropic medications that increase the risk of inflammatory illness.
Dr. Gordon also cited a survey study published by the Centers for Disease Control and Prevention as exemplary of many other surveys which recently assessed the behavioral health impacts of the pandemic. That survey of more than 5,400 U.S. adults was conducted in June 2020. It found that symptoms indicative of MHSUD-related pathology were markedly more common months into the COVID-19 pandemic than one year earlier. The self-reported prevalence of anxiety symptoms (26%) and depression (24%) in June 2020 were notably elevated from 8% and 7%, respectively, from one year earlier.
The CDC study also found that initial or increased substance use to cope with the stress of the pandemic was reported in 13% of respondents in the June survey, and serious thoughts of suicide were reported by 11% (approximately twice the proportion observed in 2018). Dr. Gordon was careful to note such data mark only acute symptoms rather than fully diagnosable MHSUDs. He made a special point of noting that increased suicidal ideation (thoughts) among young people was a very concerning indicator of the COVID-19 pandemic’s adverse effects on mental health. Despite this concern, Dr. Gordon said that available data on suicide attempts or deaths have not revealed increases yet in those devastating outcomes. To support that preliminary conclusion, he showed data from a colleague — Dr. Greg Simon, who leads NIMH’s Mental Health Research Network — pertaining to approximately 20 million persons that demonstrated that between July 2019 and June 2020 visit counts with self-harm diagnoses (numbering in the hundreds each month) had remained stable.
The final data slide shown by Dr. Gordon described the “virtual” visit trend, medical visits by video or phone. The data presented again were from his colleague, Dr. Simon, and described trends in such virtual visits from January 2020 through April 15, 2020, stratified by race (white, black, Hispanic). The data showed that around mid-March as in-person visits plummeted, there were rapid increases in phone and video visits that were similar across these three racial groups despite concerns about the technological disparities. This optimistic assessment of access to virtual treatment for MHSUDs requires follow-up. The potential for telehealth is certainly the present and future for a substantial proportion of behavioral health services, but the consequences of “physical distancing” on MHSUD treatment should not be underestimated, especially as it pertains to such services for young children, homeless people and other uniquely vulnerable populations.
Nora Volkow’s presentation at the National Academies forum discussed the impact of the COVID-19 pandemic on the opioid overdose epidemic that immediately preceded it. Unfortunately, emerging data shows that the latter epidemic seems to have resurged with COVID-19. Review of 293,253 urine drug screens collected before the initial COVID-19 surge in the U.S. (January 2019 to mid-March 2020) and 17,456 samples after COVID-19 (mid-March to May 2020) shows that illicit fentanyl use increased from 4.3% to 5.8%, which is concerning because such fentanyl (50 to 100 times more potent than heroin or morphine) is known to have fueled much of the most recent wave of the opioid overdose epidemic.
More importantly, overdose data compiled by the Washington Post and New York Times and presented by Dr. Volkow show worrying upward trends between 2019 and 2020. Based on analysis of electronic health records corresponding to over 73 million persons in the U.S., Dr. Volkow also cited her own research demonstrating that recent substance use disorders involving alcohol, cocaine and especially opioids significantly increased the risk of contracting COVID-19 by seven to ten times, depending on the disorder, and that a history of substance use disorder and COVID-19 was correlated with significantly higher death rates for African Americans than for Caucasians (12% versus 8%).
Dr. Volkow, distinguished as a neurobiologist in her approach to understanding substance use disorders, was remarkably sociological in the closing of her keynote remarks to the National Academies forum. Her last two slides focused especially on the devastating effects of stigma (shame, disgrace) and social isolation — constructs related to one another, the latter of which is an obvious negative effect of social distancing. Stigma, Volkow said, serves to discourage the social integration people need to avoid substance misuse and to recover if they become dependent. “[The] pandemic is making us more aware about why we need to address social stigma, because stigma penalizes social interactions,” she said.
The challenge, especially now in the age of COVID-19, is to develop MHSUD treatment strategies that minimize such penalties now and after the COVID-19 crisis recedes. Proper funding and flexibility to deliver MHSUD services in the short term will likely be key even as most governments across the world are being forced by economic pressures to reduce their already-paltry MHSUD services budgets. Time will tell if the U.S. and other nations can respond wisely to this challenge. Those actions will likely influence the joint and separate disease courses of MHSUD and COVID-19.