The pandemic's continued impact on mental health

The paper covered issues such as the disparate uptake in Covid-19 vaccines, poor health outcomes based on social determinates of health (SDoH), members not obtaining preventive care due to fear of getting the virus, and how chronic health conditions have exacerbated since the start of the pandemic.

Once someone is diagnosed with Covid-19, there is an increased likelihood for that person, or another household family member, to experience a mental health event.

Introduction

With the United States surpassing more than 1 million deaths from Covid-19 since the start of the pandemic, healthcare providers and payers have been rightly focused on the clinical health of their members. EXL Health previously offered research about Covid-19 and clinical care in a March 2021 white paper “Delivering the Vaccine is Just the Beginning: How to Confront the Long-term Impact of COVID.” The paper covered issues such as the disparate uptake in Covid-19 vaccines, poor health outcomes based on social determinates of health (SDoH), members not obtaining preventive care due to fear of getting the virus, and how chronic health conditions have exacerbated since the start of the pandemic.

This white paper continues that research by expanding the scope of healthcare beyond clinical care to examine the pandemic’s effect on mental health. The findings offered within are based on EXL Health benchmark data from January 2020 through December 2021. The white paper shows the rise in mental health events in both Covid-positive patients and their families since the start of the pandemic, provides analysis of mental health-related events and the connection to the pandemic, and offers recommendations for healthcare organizations to consider mitigating the growing incident rate of mental health events among its members.

For many people, what first started as an acute fear of contracting the Covid-19 virus quickly turned into bouts of mental and emotional anguish.

Key findings from EXL Health benchmark data:

EXL Health conducted research using its benchmark data to analyze mental health issues during 2020-2021 to find conclusions about the rate of mental health events among its adult members specifically in relation to a Covid-19 diagnosis.

  • More females than males were diagnosed with Covid-19 across all age groups in 2020-2021. Similarly, more females than males experienced a mental health event, and this proportion has been increasing year over year since 2017.
  • The occurrence of a first mental health event for all members spiked in 2020 at 28%, but declined to 23% in 2021, which is a similar percentage to 2019 rates.
  • The overall occurrence of a documented mental health event for all members increased dramatically from 6% prepandemic to 29% in 2021.
  • Approximately 11% of all patients diagnosed with Covid-19 reported a mental health event within 90 days of their diagnosis.
  • One out of every 25 Covid-19 positive patients had a Covid-19 negative family member experience a mental health event within the first 90 days of the patient’s Covid-19 diagnosis.

The current state of the U.S. population

As the United States continues to struggle through the Covid-19 pandemic, the mental health of the population has come more into focus among researchers, health care providers, and the media. For many people, what first started as an acute fear of contracting the Covid-19 virus quickly turned into bouts of mental and emotional anguish. Since March 2020, the entire U.S. population has been dramatically impacted by the death of family members and friends, job loss and inconsistent income, and long periods of isolation and loneliness—often all happening at the same time.

Two years later with the pandemic dragging on, the mental health of the U.S. population has morphed from acute grief into an ongoing malaise. While the immediate fear of severe illness has subsided with the steep decline in the U.S. death rate, overall uncertainty remains. No one can say what will happen next with the pandemic as a whole.

However, someone’s daily life is often swiftly upended by a Covid-19 diagnosis, making even the most mundane routine fraught with uncertainty.

According to the October 2021 Stress in America survey by the American Psychological Association, “about half of U.S. adults say that the uncertainty of the pandemic has made planning for their future feel impossible, while nearly a third say their stress levels are so high that they sometimes struggle with even basic decisions, such as what to wear or what to eat.1

The rise in mental health events among U.S. adults

Research conducted by EXL Health found similar conclusions about the rise of mental health care issues due to the pandemic, as shown by the increased rate of mental health events among adult members specifically as it relates to a Covid-19 diagnosis. Using EXL benchmark data, the EXL Health team reviewed Covid-19 diagnosis rates by gender and age, along with reported incident rates of mental health events documented through a doctor’s office visit or by a telehealth session.

For the purpose of this white paper, a mental health event is defined using terminology associated with the ICC codes for 1) anxiety order, unspecified; 2) generalized anxiety disorder; 3) major depressive disorder, single episode, unspecified; 4) major depressive disorder, recurrent, moderate; and 5) other specified anxiety orders.

Overview of EXL Health findings regarding mental health

The findings revealed that during the review period of Jan 2020 to December 2021, more adult females than males received a Covid-19 diagnosis, and this rate was across all age groups. Similarly, more females than males experienced a mental health event during this same time period. However, the highest percentage of people who experienced a mental health event during this time period was all members age 45+, both male and female, as compared to younger members.

People who had never seen a health care provider for a mental health condition had their first occurrence during the height of the pandemic. New occurrences of mental health events for all members spiked in 2020 at 28%. However, first-time occurrences declined in 2021 to 23%, a percentage similar to pre-pandemic levels in 2019.

An interesting finding from the EXL Health research is that the rising need for mental health care did not just affect the Covidpositive. One out of every 25 Covid-positive patients had a Covid-negative family member experience a mental health event within the first 90 days of the patient’s diagnosis.

Females of all ages had 55% of the diagnoses, while men of all ages had 45%.

Details and analysis about EXL Health key findings

1. During the review period, more adult female members across all age groups were diagnosed with Covid-19 than male adults. Females of all ages had 55% of the diagnoses, while men of all ages had 45%. All members between 46 and 64 years old had the highest level of Covid-19 diagnosis at 30%, with females in this age group at 53% and males at 47%. The number remains high for those 65+ years old, especially older females, diagnosed at 57% as compared to males at 43%. (See Figure 1.)

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Figure 1. Covid-19 diagnosis: U.S. population distribution by age and gender, 2020-20212.
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Figure 2. U.S. base population by age and gender, 2020-213.

2. Between 2017 and 2021, the overall occurrence of a documented mental health event for all members increased dramatically from 6% in 2017 to 29% in 2021. The rate of female members engaging with a healthcare professional for a mental health event steadily increased from 58% to 62% during this time period. (See Figure 3.)

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Figure 3. Overall occurrence of a mental health event, by gender and occurrence rate, 2017-2021.4.

At the same time, the rate of a first occurrence of a mental health event for all members spiked in 2020 at 28%. First occurrences declined in 2021 to 23%, a percentage similar to pre-pandemic levels in 2019. Females again made up the larger share of reported events with 60% of the first-time events in 2017, which grew yearover- year to 64% by 2021. (See Figure 4.)

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Figure 4. First occurrence of a mental health event, by gender and occurrence rate, 2017-2021.5.

In general, people 45+ years old reported a mental health event at a larger percentage than their younger peers.

3. When focusing on the pandemic year 2020-2021, females regardless of age continue to show the highest levels of overall occurrences of a mental health issue, with 64% of all reported mental health events as compared to males at 36%. In general, people 45+ years old reported a mental health event at a larger percentage than their younger peers. (See Figure 5.)

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Figure 5. Overall occurrence of a mental health event, by age and gender, 2020-2021.6.

Additionally, the data from 2020-21 shows mental and behavioral health issues disproportionately affecting the female population in the U.S. Once again, 63% of all first-time occurrences of a mental health event were reported by females. The largest total for all members by age was 65+, with ages 46 to 64 close behind. (See Figure 6.)

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Figure 6. First occurrence of a mental health event, by age and gender 2020-217.

All of these findings of mid-life patients having the most significant mental health issues matches anecdotal evidence in media reports of emotionally burned-out parents, especially working mothers, responsible for their children’s education at home as well as trying to work remotely. A May 2022 report8 by The Ohio State University Office of the Chief Wellness Officer and College of Nursing revealed that 66% of parents reported being burned out.

“Being female, the number of children living in the home, anxiety in the parent, having child(ren) with the diagnosis of either anxiety or Attention Deficit Hyperactivity Disorder (ADHD) and parental concern that their child(ren) may have an undiagnosed mental health disorder were strongly associated with parental burnout.”

Similar to the timeframe of the EXL Health data, the Ohio State study was conducted from January to April 2021, in the thick of the pandemic, providing insights into how much Covid-19 affected the mental health of parents.

The pandemic increased rates of depression and anxiety in the U.S. population in general, whether or not someone was diagnosed with Covid-19. Boston College researchers found reports of anxiety and depression rose significantly from April to November 2020, to rates more than four times higher than in 2019, according to the journal Translational Behavioral Medicine. Based on data from over 1.3 million U.S. adults surveyed, the report also showed increased use of prescription medications and counseling services9.

4. EXL Health found that the rising need for mental health care among both the Covid-19 positive patients and their families regardless of Covid status. According to EXL Health benchmark data, 11% of all patients diagnosed with Covid-19 reported a mental health event within 90 days of being diagnosed with Covid-19. Additionally, one out of every 25 Covid-positive patients had a Covidnegative family member experience a mental health-related event within the first 90 days of the patient’s diagnosis. Over 90% of these incidents occurred in families with two members.

Social determinants of health and mental health issues

The U.S. health care industry has become increasingly aware of social determinants of health for clinical care, especially in regard to health outcomes from a Covid-19 diagnosis. There is ample evidence of how race, ethnicity, financial stability and employment status, availability of food, affordability of housing and access to healthcare has adversely impacted health outcomes in general and specific to a Covid-19 diagnosis.

The same can be said for mental health outcomes related to a Covid-19 diagnosis. According to a survey by Translational Behavior Medicine, prevalence rates of probable mental health disorders were highest among their respondents who were young, less educated, single parent, female, Black and multi-racial.

Additionally, a recent research brief by the U.S. Department of Health and Human Services showed that income inequality is associated to a prevalence of depression and that adverse childhood experiences along with food and housing insecurity are correlated with anxiety disorder. “The findings from this study add to this growing body of literature and show that economic insecurity related to employment, education, and housing, along with problems related to social environment and childhood upbringing, can be risk factors in developing mental health conditions among patients with Covid-19, even among those with no recent history of mental illness.”10

Other issues affecting members in achieving successful mental health outcomes include limited access to healthcare, deferred care, lack of affordable insurance, limited availability of providers for behavioral and mental health issues, and limited levels of health literacy. Moreover, members dealing with a mental health issue who are affected by SDoH often are also managing a comorbidity condition, making their overall health care more complicated.

Recommendations

Using the findings presented in this white paper, healthcare payers and providers should focus on members who are at the greatest risk for ongoing mental health issues. Women of all ages, but especially those in mid-life who are managing children and careers, are among the greatest need for intervention. Payers and providers should consider designing a proactive outreach program for those newly diagnosed with Covid-19, determine the best method of outreach based on SDoH, understand that family members who are not Covid-positive also might be in need of mental health care, and then provide continued follow up based on when a mental health event is likely to occur.

Healthcare analytics can help in finding the most critical cases and then creating and implementing an outreach program. Payers and providers can quickly identify the most at-risk members and prioritize them for mental health care by using artificial intelligence and other behavioral health analytics to screen for individuals by demographics, along with social and clinical risk factors. Organizations can also use predictive models for behavioral health event predictions such as ER admits, early detection, clinical risk, intervenability for effective care planning, and channel preferences.

Dealing with Covid-19 has been the primary healthcare activity for everyone since the start of the pandemic. Members have fallen behind in their routine and preventative care, including mental health. While members may now be focused on rescheduling their annual cancer screenings, many are still delaying their mental health care. Payers and providers should focus on reaching those already diagnosed as well as being proactive in managing emerging mental health cases from the pandemic.

 

1. https://www.apa.org/monitor/2022/06/news-pandemic-stress-decision-making
2. EXL Health benchmark data: Covid diagnosed; Age > 18; year 2020-21.
3. EXL Health benchmark data: Covid diagnosed; Age > 18; year 2020-21.
4. EXL Health benchmark data: Mental health related events; Age > 18; year 2017-21.
5. EXL Health benchmark data: Mental health related events; Age > 18; year 2017-21.
6. EXL Health benchmark data: Mental health related events; Age > 18; year 2020-21.
7. EXL Health benchmark data: Mental health related events; Age > 18; year 2020-21.
8. https://wellness.osu.edu/sites/default/files/documents/2022/05/OCWO_ParentalBurnout_3674200_Report_FINAL.pdf
9. https://academic.oup.com/tbm/article/12/2/273/6400280
10. U.S Department of Health and Human Services: Mental Health Consequences of Covid-19: The Role of Social Determinants of Health Research Brief. https://aspe.hhs.gov/reports/mental-health-consequences-Covid-19-role-social-determinants-health-research-brief#:~:text=A%20significantly%20greater%20percentage%20(2.7,%2D19%20symptom%20(1.4%25).