The COVID-19 Pandemic and Mental Health—Implementing Evidence-Based Interventions to Advance Equity and Reverse a Worsening Crisis

Access to quality and affordable mental and behavioral health care in the US has been difficult for decades. In 2020, an estimated 52.9 million adults experienced mental illness nationwide, with less than half receiving mental health services. The COVID-19 pandemic exacerbated the issue, with a 2021 survey of psychologists noting significant increases in requests for treatment of anxiety disorders, depressive disorders, and trauma- and stress-related disorders. Experts suggest that the intersection of the COVID-19 pandemic, structural racism, and mental health inequities meets criteria for synergistic epidemics because of the overwhelmingly negative health, economic, and social consequences for groups that were already marginalized.¹ Workforce shortages contribute to unmet behavioral health needs nationwide, particularly among rural, non-English speaking, Black and Hispanic populations, and among children and youth.

These conditions present both challenges and opportunities for health care and policy innovations. Recognizing the seriousness of the mental health crisis, local, state, and federal policy makers are considering how to support and implement solutions, including early identification and treatment for those at risk (eg, investments in suicide prevention and youth mental health), mental health workforce development programs, expanded access to telehealth, health insurance reform, and integrated treatment for persons with mental health conditions. However, current attention to implementing and scaling prevention and treatment strategies is insufficient to meet the nation’s needs and does not fully leverage existing evidence.

Imagine the loss of life had the world not focused on developing and providing a vaccine to prevent serious illness or death from COVID-19, but instead continued to wait until people developed COVID-19 before providing treatment. That is exactly what we are doing in terms of mental health. To address this major deficit, a recent National Academies of Science, Engineering, and Medicine report on mental health and development in children and youth has recommended using what is currently known regarding prevention strategies in mental health at the population level to implement and disseminate effective interventions to all communities.

Ample evidence has shown that prevention strategies can sometimes help prevent mental disorders. For example, recent meta-analyses of high-quality randomized clinical trials show that, on the average, the interventions studied can prevent 1 of 5 new episodes of major depression.^2,3 Moreover, 40% of these interventions have yielded reductions in incidence greater than 50%.⁴ A systematic review for the US Preventive Services Task Force (USPSTF) found that 39% of new episodes of perinatal depression could be prevented, and that some approaches yielded reductions of 50% or more.⁵ Some of these studies included tailored approaches for racially, ethnically, and socioeconomically minoritized groups. Based on these findings, the USPSTF recommended that pregnant and postpartum persons at risk of perinatal depression receive preventive interventions.⁶ Preventing half of all cases of perinatal depression would have a massive effect on maternal health and could also have a positive effect on the mental health of children and youth.⁷

However, barriers to implementing and scaling mental health interventions persist. One of the largest barriers, especially in marginalized communities, is a shortage of mental health professionals. Until this workforce shortage is resolved, alternative ways of providing effective mental health care are needed, such as through digital interventions, which focus on mood management methods to maintain a healthy mood.

The UK’s National Health Service Improving Access to Psychological Therapies project, a set of digitally delivered programs, found that among individuals who received computerized cognitive behavioral therapy as part of a stepped care approach, 58% recovered. This suggests that digital interventions for depression could be offered as a population health strategy. These interventions also could be used as a preventive strategy for people at risk for depression, such as those experiencing subclinical levels of symptoms. In fact, meta-analyses of fully automated digital interventions for depression have shown that they are effective in the treatment of depressive symptoms.⁸ Digital interventions also have been found to be effective in preventing new episodes of major depression in adults with subclinical depression.⁹

Digital interventions also have the potential to deliver mental health services at a reduced cost because they are not consumable interventions that are used up or consumed when administered. Like a nicotine patch that can only be used once, a session of psychotherapy consumes an hour of a professional therapist’s time. On the other hand, a digital intervention, such as a website or app, can be used repeatedly by different people without losing its therapeutic power. It can be accessible to thousands of people anytime, anywhere. Users do not have to adhere to therapists’ schedules or geographic locations. Furthermore, digital interventions may reduce the stigma that many individuals associate with seeking mental health care.

The cost of consumable interventions, especially those that require administration by a person, cannot be reduced below a certain limit. Furthermore, the ability to provide services is limited to the number of hours that clinicians can offer. On the other hand, the marginal cost of nonconsumable interventions—the cost of providing the service to one more person—goes down as more people use it. Consider an evidence-based website to prevent and treat depression that costs $1 million to construct and test. If 1000 people use it, the cost per person is $1000. If 100 000 people use it, the cost per person is $10. If 1 million people use it, the cost per person is $1, and so on. Adopting nonconsumable interventions as part of a stepped-care model for the nation would make mental health care for all closer to reality and more sustainable over the long-term.

The COVID-19 pandemic has revealed that it is extremely important to focus on prevention rather than putting resources exclusively into treatment. Applying this lesson to mental health means implementing evidence-based preventive interventions and scaling up nonconsumable interventions to prevent and treat mental health conditions.

Digital apothecaries, which are online portals hosting evidence-based digital mental health interventions, could make health care interventions accessible worldwide.¹⁰ Collection of data on the demographic characteristics and symptom profiles of users would allow scientists to determine whether outcomes vary by characteristics (such as gender, sexual orientation, race, ethnicity, language, income, and education) as the number of users grows. In addition, such a concerted effort could galvanize scientific collaborations and spur innovations that inform mental health resource allocation, practice, and policy.

The mental health crisis that has been intensified by the COVID-19 pandemic, as well as its disparate effects on marginalized communities, make shifting to prevention and to expansion of evidence-based mental health interventions even more urgent. Evidence that common mental disorders can be treated and prevented is strong. However, to avoid widening disparities, a strong focus on addressing social determinants and access barriers is needed. Implementing and disseminating evidence-based, equity-focused interventions that leverage technology holds promise for mitigating current morbidity and preventing a worsening of the mental health crisis.

Published: April 14, 2022. doi:10.1001/jamahealthforum.2022.1282

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Muñoz RF et al. JAMA Health Forum.

Corresponding Author: Lisa A. Cooper, MD, MPH, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205 (lisa.cooper@jhmi.edu).

Conflict of Interest Disclosures: Dr Muñoz reported receiving grants from the National Institute of Mental Health for mothers and babies course development and being a member of the National Academies of Sciences, Engineering, and Medicine consensus committee that authored one of the consensus reports cited in this article. No other disclosures were reported.