Dr. Robert Trestman presents to White House COVID task force

What Psychiatry learned during the COVID19 Pandemic and what we should do to Prepare for the Future

“My sincere thanks for this opportunity to address the Health Equity Taskforce. My name is Robert Trestman. I am Professor and Chair of Psychiatry at the Virginia Tech Carilion School of Medicine and the Carilion Clinic and I am here as a representative of the American Psychiatric Association. 

We are in unprecedented times and our system of providing treatment for mental illness and substance use disorders was already fragmented and underfunded.  The pandemic led to dramatic increases in depression and anxiety disorders among those previously well and serious exacerbation of functional impairment among those who previously dealt with mental illness and or substance use disorders. This is reflected in part by an unprecedented 29% increase in overdose-related deaths over a 1 year period. Our most vulnerable or disenfranchised experienced a disproportionate morbidity and mortality during this pandemic. Just one example: this week, Virginia’s public system shut 5 of 7 psychiatric hospitals to new admissions. Of 5,500 clinical positions, 1620 are vacant; over 100 resignations occurred over the past two weeks. This is a completely predictable failure resulting from chronic underfunding and the lack of coherence and resilience in the system. Our emergency rooms are overflowing and the wait for ambulatory appointments are typically two months or longer. We are now in the “second pandemic” of exacerbated mental illness and substance use disorders compounded by despair and continuing inequities.

Let me address in turn multiple systems components that we target in advance of the next pandemic to address system resilience and health equity:

Prevention

Stigma and discrimination against those with mental illnesses and addiction still persists today and is one of the biggest challenges to patients accessing care. We propose to actively address the culture-specific stigma of mental illness and substance use disorders and reduce cultural impediments to care via educational and media outreach.

Addressing issues that give rise to mental illness and substance use disorders is a great investment. Based on our knowledge of Adverse Childhood Experiences and trauma, we know how to prevent or reduce the severity of many such disorders. We propose to enhance school counseling programs and partnerships to address concerns of neglect and abuse. Expand early childhood access to pre-k programs, food programs, and stable family settings. Actively divert children from juvenile justice involvement to clinical, evidence-based treatments.

Housing

The US Housing and Urban Development 2020 Annual Homeless Assessment Report described to Congress an increase in homelessness for the 4th straight year. People with untreated serious mental illness comprise an estimated one-third of the total homeless population in the United States and an even higher percentage of women and individuals who are chronically homeless.  People identifying as African American accounted for 39 percent of all people experiencing homelessness. We propose to expand access to permanent housing with appropriate supports. “Housing First” supportive housing models are particularly effective because they combine affordable housing with case management and mental health services. These models also reduce the costly use of emergency departments and psychiatric hospitalizations. For those with SMI in one such program, there was a decrease of 46% in behavioral health facility costs and a 20% reduction in psychiatric hospitalizations. 

Let’s turn now to Clinical Care

Access

It is the position of the APA that health care, including treatment of mental illness and SUD,  is a human right: everyone should have access to health care. We propose Universal insurance coverage with meaningful access to appropriate providers of care for mental illness and substance use disorders at parity with other medical conditions.

Acute care

The lack of appropriately staffed inpatient psychiatric beds and a crisis continuum exacerbates the challenges of getting patients who are in crisis the care they need when they need it. While there is some variability based on multiple factors, there is general agreement that the nation should have about 35 psychiatric beds/ 100,000. APA is expected to release a model detailing geographic-specifics later this year.

Workforce

The pandemic accelerated the trend for physicians and nurses to retire, worsening the existing multi-disciplinary shortage. This has to do with both pipeline and burnout concerns. We propose an increase GME training for Psychiatry and appropriate support for other disciplines. We also propose to actively work to change culture of clinical workforce to accept help as normal, not a weakness. This needs to be tied to medical board regulatory changes that reduce fear of compromising licensure.

Technology

After the shift to mostly remote appointments during the COVID-19 pandemic, no show appointments rates decreased significantly. When it comes to access, telepsychiatry is indispensable. Our experiences during COVID-19 and research from nearly 50 years of use show us it can work effectively. Federal and state governments have responded to the crisis by easing restrictions around telehealth related to live video sessions and audio-only (telephone). We propose that the lifted restrictions should continue after the pandemic is over to stimulate innovation. Audio-only should be reimbursed until our disadvantaged citizens have access to affordable universally-available broadband.

Psychiatry and Primary Care

Patients with serious mental illness have a life expectancy usually estimated to be 10 years less than otherwise expected. Those from disadvantaged populations are at compounded risk. We propose to expand uptake and implementation of evidence-based programs such as the collaborative care model. The Collaborative Care model treats patients in the primary care office, it improves access to care and provides early intervention and prevents patients from getting worse with no care or with an inability to refer out to specialty care.  The model treats a population of patients, tracking progress and adjusting treatment over time, versus referring out to one-to-one care where we know with this increased need for mental health and substance use care that it is simply not available. 

Substance Use

Deaths from drug overdoses are at an all time high. Studies found substance use was used to cope with pandemic-related stress. Groups that were more likely to do so disproportionately included marginalized groups and ethnicities. Much has been done to improve Medicaid coverage and financing of substance use disorder services but we need to strengthen our workforce. The current training of physicians in the recognition and treatment of SUD is inadequate to meet the needs of the diverse and growing population of people needing substance use disorder treatment. We propose a standardized, interdisciplinary core curriculum on SUDs that provides a base for future learning, helps reduce stigma towards individuals with SUD, introduces basic screening and treatment approaches, and addresses the complexities and comorbidities of SUD. 

Serious Mental Illness (SMI) and Incarceration

In 44 states, a jail or prison holds more individuals with mental illness than the largest remaining state psychiatric hospital; in every county in the United States with both a county jail and a county psychiatric facility, more seriously mentally ill individuals incarcerated than hospitalized with people of color being disproportionately incarcerated. This doesn’t even address those with SUD. We have an opportunity to improve our response through the new three-digit code 9-8-8 crisis intervention number.  If properly funded and supported, communities can create a clinically-based crisis continuum to ease the burden on the criminal justice system and use crisis teams to meet the needs of people with mental illness in crisis by getting them into treatment and creating a more equitable system.

Thank you for this opportunity to address the Task Force.”