Jonathan Adler, MD, FACEP
Co-editor in Chief and CMO, CredibleMind
Clinical Assistant Professor, Tufts University
Emergency Physician, Beth Israel Lahey Health, Burlington, MA

Deryk Van Brunt, DrPH
Founder and CEO, CredibleMind
Clinical Professor, UC Berkeley School of Public Health

CredibleMind is a population mental-health platform supporting emotional well-being and spiritual growth that connects people to evidence-based self-help interventions.

Natural History of Mental Health Impacts

Humans constantly experience death and despair on a wide scale due to natural disasters and violent conflict. Across humanity, about 56 million people die each year.[1] Natural disasters, including contagion, killed 11,000 people in 2019 and 120,000-150,000 die in violence associated with armed conflict. For perspective regarding scope and scale of the most severe mental health outcomes, in the pre-COVID-19 era, suicide accounts for about 780,000 deaths worldwide annually,[2] and about 48,000 in the US.[3]

Delayed or secondary morbidity and mortality associated with disasters often exceed that of the original event. Cholera is expected after flooding or earthquakes disrupt infrastructure. Other infectious diseases and maternal/fetal mortality skyrocket in refugee settings without infrastructure or healthcare. But what of our mental and emotional well-being? This is often the greatest casualty in the wake of a crisis.

Mental health in the United States has not benefited from population-health approaches as have other clinical success stories, such as the decreasing mortality associated with heart disease (60% reduction since 1968,[4] though it is still the #1 cause of mortality in the US). Mortality from suicide has increased about 17% since 1981. About half of US adults will experience a mental health issue in their lifetime, and about 20% experience this each year. Workplace stress – at baseline – accounts for about $190 billion in health costs and $1 trillion in lost productivity[5] and 84% of workers report they are not comfortable discussing mental health with their employer.

At-risk populations are under-served – about 111 million people live in a Mental Healthcare Health Professional Shortage Area[6] and it was previously estimated that an additional 250,000 behavioral health professionals would be needed to meet treatment demand over next 5 years.[7]

Now add a worldwide pandemic of extraordinary scope to this discouraging situation of mental health in the United States. Virtually no nation is untouched. This pandemic has unique characteristics that amplify fear, terror, anxiety, stress, and grief, including:

Because of all these factors, COVID-19 is causing mental and emotional harm on a worldwide scale. Based on experience from many prior natural disasters, this wave of impact will be prolonged and severe. This is referred to as the “second curve” that needs addressing just as surely as the need to prevent infection. Lancet recently highlighted emerging evidence of mental health impacts of COVID-19:[8]

• 891% increase in call volume from this time last year at SAMSHA’s Disaster Distress Helpline, a federal mental health crisis hotline; 338% increase since February.[9]
• Well Being Trust and Robert Graham Center analysis: 75,000 additional deaths in the US from drugs, alcohol, and suicide due to coronavirus pandemic second curve.[10]
  – Baseline 181,686 such deaths in 2018[11]
• Meadows Mental Health Policy Institute analysis: for every 1% increase in the unemployment rate, over a year we could lose 775 more Americans to suicide and 1,100 to overdose, as well as 10,000 more suffering addiction.[12]
• More than 60% of Americans have reported increased stress or anxiety due to Covid-19.[13]
• Mental Health America monitors anxiety: 19% increase in screening for clinical anxiety in the first weeks of February, and a 12% increase in the first two weeks of March.
• American Psychiatric Association poll of more than 1,000 U.S. adults: 48% anxious about the possibility of getting coronavirus, 36% say pandemic is having a serious impact on their mental health.[14]
• Review the effects of SARS and MERS Quarantines[15]:
  – Having a history of psychiatric illness was associated with experiencing anxiety and anger 4–6 months after
  – Longer durations of quarantine were associated with post­-traumatic stress symptoms, avoidance behaviors, and anger
  – For healthcare workers, 3 years after the SARS outbreak: being quarantined was associated with alcohol abuse and avoidance behaviors such as missing direct contact with patients and not reporting to work

Solutions to Flatten the Second Curve

Capability and capacity are needed on several levels to mitigate the second curve. A full-spectrum population mental-health approach to this problem is required, rather than the haphazard, post-hoc treatment interventions that have traditionally been the focus of modern medicine in the mental health arena. Intervention with counseling, cognitive behavioral therapy and medications all have a role in addressing the second curve. It is vital that this role be small and limited – any other outcome represents failure – because the treatment of large swaths of our population by these means is not possible due to limitations of resources and the need for distancing. Further, the clinical situation requiring such intensive interventions represents an advanced stage of mental anguish to be avoided – often when a person is unable to function normally, has exhausted existing coping mechanisms, has significant negative symptoms consistent with a clinical diagnosis and may well be unable to work or be contemplating self-harm. Intervention is needed upstream, prior to these harms.

Early identification of problematic and of symptomatic mental health concerns

While professional caregivers can play a vital role in this step, most of the identification will come from individuals themselves. In the pre-COVID era there was already a huge delay before symptomatic mental health concerns were being addressed with therapy. The delay from onset of symptoms to treatment contact is 6-8 years for mood disorders (such as depression) and 9-23 years for anxiety disorders.[16] Most people eventually seek treatment, 88-94% for mood disorders and 27-95% for anxiety.

About 75% of people with a mind wellness issue work on their health by themselves, without the help of a professional.[17] Given the ubiquitous mental health impacts of COVID-19 in the setting of social distancing, self-identification of a problem, concern or goal is the only approach that can be adequately scaled for population mental health interventions to be brought to bear. While the majority of people already seek to help themselves with emotional well-being, there is significant room for improvement to destigmatize mental health concerns and there remains a need for access to evidence-based approaches and resources.

There is yet to be good coordination of efforts, however many federal and state agencies, hospitals and health departments, corporate entities including health insurance payors, other healthcare facilities and non-profit foundations are focused on providing support for our emotional well-being – including the important steps of educating the public and de-stigmatization regarding mental health concerns. There are of course calls for better coordination, such as that of the Well Being Trust for its Framework for Excellence.

“We can all help flatten the 2nd Curve of rising mental health, addiction and harm-triggered by economic and social dislocation. This starts by turning to one another with kindness and compassion. But it also asks us to engage in supporting our behavioral health workforce and assuring much needed investment in the infrastructure.”[18] – Tyler Norris, CEO of the Well Being Trust

That framework correctly emphasizes the necessary social determinants of mental health and the roles of health systems, workplaces, governmental and community agencies as well as the judicial and educational systems to both support and effect care. Identification of a concern, problem, or goal, either by an individual, by a loved one, or by a caregiver is the first step.

Role for Technology and Telemedicine

Patient use of technology regarding medical concerns is widespread. Pew Research Center reports that 90% of US adults use the internet and that 76% report that they have used email or messaging services to communicate with others in response to the SARS-CoV-2 pandemic; 70% report internet searching for information about the coronavirus and 25% used the internet for work meetings.[19] Other Pew Research Center polling results[20] show 32% have had a virtual party or social gathering with family or friends and the same percentage have ordered food through an App from a restaurant; 18% have participated in an online fitness class; many are practicing yoga and meditation via digital forums. Not surprisingly prevalence is higher among younger, more educated, and more urban Americans. The use of video communication allows family and friends to remain “connected” during isolation or hospitalization, helping to offset loneliness, anxiety, and stress. Technology also provides access to resources that may be helpful for people experiencing pandemic-related mental health concerns.

“Use of our website to access resources for improving mental health and well-being has grown steadily during the pandemic. For example, visits to the Mindfulness topic center are up 300% and we’ve seen large increases also in use of evidence-based resources and of our emotional health assessments.” [21] – Marcos Athanasoulis, CTO, CredibleMind

The use of telemedicine for patient encounters has exploded in the past months and we can expect this trend to continue. Patients have extremely limited physical access to healthcare; however, most have communication at least by telephone and often using video technology. While still too early for there to be much data, the hospital system employing one author (Jonathan Adler, Beth Israel Lahey Health) has massively ramped up telemedicine capacity, scaling previously existing capacity by a factor of 10 over a period of months. Trinity Sciences conducted a brief poll of 561 healthcare providers and reported that 46% of caregivers across a range of practices have increased use of telemedicine since the onset of the pandemic.[22] The role of telemedicine during the pandemic is obvious.

Firstly, healthcare provider contact with patients provides an opportunity to identify acute mental health concerns. This opportunity may be squandered unless the caregiver has already internalized the importance of mental health and emotional well-being and therefore is attentive to cues and concerns that may be voiced, or better yet, the caregiver actively seeks information from the patient on how they are doing. Caregivers play an important role in de-stigmatizing mental health concerns directly during an interaction. This can be accomplished by many means (generally beyond the range of this current discussion) such as legitimizing concerns; “This pandemic has a lot of us on the ropes emotionally. How are you doing mentally through all this?”

Secondly, once a caregiver has identified concerns, several evidence-based interventions are possible. Clinician-guided self-help has been shown effective in several settings.[23], [24] Self-help recommended by physicians is shown to be effective to treat several mental health concerns, including depression. In one clinic’s experience, the reduction in symptoms of depression and anxiety was about 50% (measured by PHQ-9 for depression and GAD-7 for anxiety).[25] Multiple modalities have been investigated and demonstrated good effect, including suggested reading (bibliotherapy), face-to-face sessions punctuated by reading assignments and completing mood diaries, computer-based cognitive behavioral therapy, and recommendations to increase the amount of positive “meaningful” activity for depression as well as recommending an App.[26]

Thirdly, there is an important role for telemedicine-based counseling and other interventions such as cognitive behavioral therapy. Digital counseling options broaden the range of treatment modalities available during social distancing or quarantine.

Telemedicine, therefore, plays a critical role in flattening the second curve. Its primary benefit is for those in more advanced stages of mental illness needing significant intervention. The primary limitation of telemedicine is the inability to scale to a national population level.

Evidence-based, Upstream Self-help

Multiple forms of self-help have been shown to be useful interventions for mental health concerns in the same way that clinician-guided self-help has a firm evidence base. In some situations, self-help outcomes can be as effective as therapist-administered treatments.[27], [28], [29] As approximately 75% of US adults that have mental health and emotional well-being issues, work on those issues on their own[30] (prior to the pandemic), use of self-help interventions will be a critical component of addressing mental health concerns associated with the pandemic. In particular, the advantages of these interventions include:

• Can be scaled with nation-wide access
• Can be rapidly deployed (in contradistinction to “turning a big ship” such as modifying social determinants of health)
• Interventions can take place in an “upstream” setting – prior to severe disease or symptoms, prior to work lost and absenteeism, prior to the need for intensive interventions such as counseling or medications
• Resources can be accessed without physically visiting a healthcare provider or telemedicine

The body of evidence regarding the utility of self-help approaches is both steadily growing in scope and improving in quality. One problem of upstream self-help is decreased efficacy among people who work on a mental health concern using non-validated approaches. Use of evidence-based resources and interventions, to the extent that there is reliable data, can ameliorate this difficulty and improve outcomes on a large scale. This is more important than ever in the current time of healthcare access shortage and isolation. Examples of evidence-based self-help outcomes are shown in the Figure below.[31], [32]

Examples of self-help interventions with evidence:
Yoga – Meta study of 35 trials, 74% note significant decrease in stress and/or anxiety symptoms with Yoga.
Exercise – 34% reduction in depression, as effective as antidepressant medication and psychotherapy

The list of approaches for which there is significant positive evidence is long and growing, such as certain Apps benefiting mood and anxiety disorders, and forest bathing decreasing cortisol and blood pressure levels. Other interventions with evidence include:

• For anxiety – Apps, breathwork, cognitive behavior therapy (CBT, including digital programs), creative expression, herbs and supplements, meditation and mindfulness, nutritional interventions, tai chi and yoga.
• For depression – Apps, CBT, exercise and body movement, herbs and supplements, meditation and mindfulness, Tai chi and yoga
• For addiction and recovery – 12-Step programs, cannabidiol, CBT, meditation and mindfulness and emerging evidence for psychedelics & entheogens.

Connecting people facing a challenge to an evidence-based self-help intervention is a vital component of a population mental-health solution to decrease the second curve.

The World Economic Forum11 notes that 2.6 billion people are currently living under some kind of “lock-down” or quarantine restrictions and they predict that this “will result in a secondary epidemic of burnouts and stress-related absenteeism in the latter half of 2020.” Clearly the epidemic that we must start battling immediately is the second curve of mental and emotional harms being wrought by the COVID-19 pandemic. It is not an exaggeration to predict that the morbidity and mortality impacts of the second curve may be greater than the direct health impacts of the pandemic itself. Now is the time for action.

Actions your organization can take to contribute to a population mental-health solution:

1. Identification of well-being concerns: Do all you can to destigmatize mental health concerns and increase engagement and support for your employees or the populations you serve.

• Create, and empower, a Chief Well-Being Officer to educate other organizational leaders about both the scope of mental health concerns and the value, including ROI, of interventions.
• Destigmatize mental health concerns by openly acknowledging them and creating, or purchasing, a steady stream of educational materials.
• Provide access to both counseling and self-help resources and take steps to actively promote engagement with these tools.

2. Role of technology: Seek opportunities to leverage internet and mobile-based technology to engage directly with your employees or the populations you serve, and to direct them to interventions.

• Roles such as a Chief Well-Being Officer, head of HR and Employee Wellness Officer play an important role in identifying resources and platforms to engage users in the process of maintaining or improving their well-being. Select platforms and partners that provide broad access to a wide range of education and well-being resources.
• Hospitals and community health organizations seek to provide resources for internal employees facing challenges associated with caregiving during a pandemic.
• Increase or outsource access to telemedicine resources including for behavioral health concerns.
• Leverage data on utilization of resources to inform future decisions on priorities for education and interventions.

3. Access to evidence-based self-help: Provide access to resources and platforms for your employees or population you serve.

• Enhance EAP offerings to include education about and access to self-help resources.
• Promote engagement with employee or community well-being education and resources. Partner with companies or platforms that provide engagement tools to increase utilization and access to the resources that your organization has invested in as well with resources they offer to your users.
• Assess partnerships or platforms based on their capacity to identify evidence-based self-help resources to your employees or populations you serve.

Footnotes

• [1] https://ourworldindata.org/what-does-the-world-die-from Accessed 4/13/20.
• [2] https://www.statista.com/statistics/510952/number-of-deaths-from-natural-disasters-globally/ Accessed 4/13/20.
• [3] American Foundation for Suicide Prevention; afsp.org/statistics Accessed 5/6/20
• [4] Ritchey MD, Wall HK, George MG, Wright JS. US trends in premature heart disease mortality over the past 50 years: Where do we go from here?. Trends Cardiovasc Med. 2019 Sep 27;. doi: 10.1016/j.tcm.2019.09.005. [Epub ahead of print] Review. PubMed PMID: 31607635; PubMed Central PMCID: PMC7098848.
• [5] https://hbr.org/2019/12/burnout-is-about-your-workplace-not-your-people?_lrsc=351aa2df-b155-48a7-ae0f-e707951b5c58
• [6] Dr. Luis Padilla, Bureau of Health Workforce Health Resources and Services Administration U.S. Department of Health and Human Services, Statement Before the Subcommittee on Labor, Health and Human Services, Education and Related Agencies Committee on Appropriations U.S. House of Representatives Washington, D.C. April 12, 2018: https://docs.house.gov/ meetings/AP/AP07/20180412/108104/HHRG-115-AP07-Wstate-PadillaL-20180412.pdf
• [7] American Journal of Preventive Medicine News Editorial: Behavioral health workforce faces critical challenges in meeting population needs. May 17, 2016. https://www.ajpmonline.org/pb/assets/raw/Health%20Advance/journals/amepre/ AJPM_Jun18_Suppl_Behavioral_Health_Workforce_FINAL.pdf
• [8] Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, Rubin GJ. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020 Mar 14;395(10227):912-920. doi: 10.1016/S0140-6736(20)30460-8. Epub 2020 Feb 26. Review. PubMed PMID: 32112714; PubMed Central PMCID: PMC7158942.
• [9] A crisis mental-health hotline has seen an 891%spike in calls. Amanda Jackson, CNN. April 10, 2020.https://www.cnn.com/2020/04/10/us/disaster-hotline-call-increase-wellness-trend/index.html
• [10] https://wellbeingtrust.org/areas-of-focus/policy-and-advocacy/reports/projected-deaths-of-despair-during-covid-19/ Accessed 5/15/20 (link to pdf download of the analysis is here)
• [11] https://wellbeingtrust.org/news/new-wbt-robert-graham-center-analysis-the-covid-pandemic-could-lead-to-75000-additional-deaths-from-alcohol-and-drug-misuse-and-suicide/ Accessed 5/15/20
• [12] America’s COVID-19 Recovery Needs To Start Now. CNN, April 13, 2020. https://www.cnn.com/2020/04/13/opinions/mental-health-covid-19-coronavirus-kasich-harbin/index.html
• [13] Omada Health April 6, 2020 https://www.omadahealth.com/press/omada-mental-health-program-now-available-at-no-cost?hsCtaTracking=45d63df2-324b-4a1f-a7e9-a1b971858188%7Cb12f18f3-2299-435e-8530-b85376cfe3ed
• [14] Kaiser Permanente, Livongo expand access to myStrength mental health app. https://www.healthcareitnews.com/news/kaiser-permanente-livongo-expand-access-mystrength-mental-health-app
• [15] World Economic Forum; https://www.weforum.org/agenda/2020/04/this-is-the-psychological-side-of-the-covid-19-pandemic-that-were-ignoring/ Accessed 5/7/20
• [16] Wang PS, Berglund P, Olfson M, Pincus HA, Wells KB, Kessler RC. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):603-13. doi: 10.1001/archpsyc.62.6.603. PubMed PMID: 15939838.
• [17] Norcross, J. C. Integrating self-help into psychotherapy: 16 practical suggestions. Professional Psychology: Research and Practice, 37(6), Dec 2006, 683-693. https://psycnet.apa.org/buy/2006-22033-015. Accessed 5/25/20
• [18] https://wellbeingtrust.org/news/flattening-the-2nd-curve/ Accessed 4/22/20
• [19] “Americans turn to technology during COVID-19 outbreak, say an outage would be a problem”; March 31, 2020; Pew Research Center; https://pewrsr.ch/2WZCAQq Accessed 5/6/20
• [20] “From virtual parties to ordering food, how Americans are using the internet during COVID-19”, April 30, 2020;
• https://pewrsr.ch/3d1MwO3 Accessed 5/6/20
• [21] Personal Communication 5/6/20
• [22] https://www.businesswire.com/news/home/20200422005689/en/Forty-six-Percent-Healthcare-Providers-Wide-Range-Specialties Accessed 4/22/20.
• [23] Bergsma, A. Do self-help books help? J Happiness Stud 9, 341–360 (2008). https://doi.org/10.1007/s10902-006-9041-2
• [24] Bower P, Gilbody S. Stepped care in psychological therapies: access, effectiveness and efficiency. British Journal of Psychiatry 2005;186:11–17
• [25] Falbe-Hansen L, Le Huray C, Phull B, Shakespeare C, Wheatley J. Using guided self-help to treat common mental health problems: The Westminster Primary Care Psychology Service. London J Prim Care (Abingdon). 2009;2(1):61–64. doi:10.1080/17571472.2009.11493246
• [26] Moberg C, Niles A, Beermann D. Guided Self-Help Works: Randomized Waitlist Controlled Trial of Pacifica, a Mobile App Integrating Cognitive Behavioral Therapy and Mindfulness for Stress, Anxiety, and Depression. J Med Internet Res. 2019 Jun 8;21(6):e12556. doi: 10.2196/12556. PubMed PMID: 31199319; PubMed Central PMCID: PMC6592477.
• [27] Wilson, D. M., & Cash, T. F. (2000). Who reads self-help books? Development and validation of the self-help reading attitudes survey. Personality and Individual Differences, 29, 119–129.
• [28] Den Boer, P. C., Wiersma, D., & Van den Bosch, R. J. (2004). Why is self-help neglected in the treatment of emotional disorders? A meta-analysis. Psychological Medicine, 34, 959–971.
• [29] Cuijpers, P. (1997). Bibliotherapy in unipolar depression: a meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 28, 139–147.
• [30] Norcross, J. C. Integrating self-help into psychotherapy: 16 practical suggestions. Professional Psychology: Research and Practice, 37(6), Dec 2006, 683-693. https://psycnet.apa.org/buy/2006-22033-015. Accessed 5/25/20
• [31] Carpentier D, Romo L, Bouthillon-Heitzmann P, Limosin F. [Mindfulness-based-relapse prevention (MBRP): Evaluation of the impact of a group of Mindfulness Therapy in alcohol relapse prevention for alcohol use disorders]. Encephale. 2015 Dec;41(6):521-6. doi: 10.1016/j.encep.2015.05.003. Epub 2015 Jul 6. PubMed PMID: 26159682.
• [32] Bowen S, Witkiewitz K, Clifasefi SL, Grow J, Chawla N, Hsu SH, Carroll HA, Harrop E, Collins SE, Lustyk MK, Larimer ME. Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: a randomized clinical trial. JAMA Psychiatry. 2014 May;71(5):547-56. doi: 10.1001/jamapsychiatry.2013.4546. PubMed PMID: 24647726; PubMed Central PMCID: PMC4489711.