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Commentary

Delivering Mental Healthcare During the COVID-19 Pandemic

When the COVID-19 pandemic began in the spring of 2020, VA’s Office of Mental Health and Suicide Prevention (OMHSP) faced a number of challenges – to ensure the delivery of mental healthcare for Veterans with mental health needs, address the specific effects of COVID-19 on mental health and well-being, and support VA healthcare providers who were helping to address these challenges. 

Ensuring the Delivery of Care

At the onset of the pandemic, VA medical centers faced a significant challenge in shifting to virtual care. Providers had to figure out how to best care for Veterans remotely, either via telephone or video-teleconferencing. Keeping patients who needed residential  or inpatient care safe from COVID-19 while addressing their mental healthcare needs also presented a significant challenge. PTSD treatments posed an added difficulty, as some treatments encourage Veterans to approach trauma-related situations (e.g., crowded public places) that may not be available or safe when stay-at-home orders are in place. How to best implement virtual care and reorganize residential and inpatient care emerged as key priorities for VA medical centers.

OMHSP staff detailed several actions VA took to transition to virtual mental healthcare (Rosen et al., 2021). Whereas most of the research on telehealth had focused on video care, many Veterans experienced difficulty accessing video technology, often due to limited Internet connectivity, and had to rely on telephones to speak with their providers. In response, VA scaled up platforms for remote care and provided mobile devices and Internet access for Veterans in need. VA also undertook administrative and training enhancements to help clinicians deliver virtual care.

These efforts to deliver telemental healthcare proved successful, as VA sustained 91 percent of its pre-pandemic outpatient mental healthcare workload by quickly pivoting to virtual care. By June 2020, direct-to-home video encounters increased 11-fold and telephone contacts increased 5-fold relative to pre-pandemic levels (Rosen et al., 2021). In-person care decreased from 85 percent of visits before COVID-19 to only 20 percent of visits by June 2020. Distribution of tablets to enhance rural Veterans’ access to telehealth increased mental health visits, decreased visits to emergency departments overall and for suicide-related behavior, and decreased suicidal behavior (Gujral et al., 2022). OMHSP’s National Center for PTSD’s (NCPTSD) Consultation Program provided expert guidance on delivering PTSD treatment via telehealth. The PTSD Mentoring Program supported the clinical infrastructure to achieve the shift to virtual delivery of evidence-based psychotherapy for PTSD and provided ongoing technical assistance to help sites operationalize directives. VA also updated the PTSD Clinical Dashboard to include telephone and VA Video Connect-based telehealth.

Addressing the Impact of COVID-19 on Veterans’ Mental Health

The mental health impact of COVID-19-related stressors, such as illness, disruptions in social functioning, and economic hardships has been a significant concern since the onset of the pandemic over two years ago. Military Veterans may be particularly at risk for experiencing adverse mental health impacts related to the pandemic for several reasons. Relative to the general population, Veterans have a higher rate of pre-existing trauma, which may sensitize them to the negative impact of COVID-19 stressors. COVID-19 stressors may also exacerbate existing mental health disorders, which are experienced by Veterans at a higher rate than the general public. In addition, employment instability and financial difficulties pre-date the pandemic as commonly reported stressors among Veterans and these problems have worsened since the pandemic began. Further, restricted in-person services and reduced social interactions may be a particular concern for those Veterans who already have limited social engagement.

OMHSP responded to Veterans’ unique mental health needs during the pandemic by creating content on coping with COVID-19 for Veterans, VA providers, community and business leaders, and the public at large. A key article focused on how to help Veterans feel more comfortable wearing masks. NCPTSD developed the COVID Coach app designed for everyone, including Veterans and service members, to support self-care, stress management, and overall mental health during the pandemic. COVID Coach was released at the end of April 2020 and has since been downloaded almost 230,000 times.

Despite the negative impacts of COVID-19 on Veterans’ mental health and well-being, research that has followed Veterans over time found that many have been resilient in the face of the pandemic (e.g., Nichter et al., 2021). However, the experience of the pandemic has not been the same for all Veterans. Women Veterans or Veterans who are members of marginalized racial or ethnic groups may be at greater risk for adverse mental health outcomes. Knowing how to best meet their needs is critically important.

Supporting Mental Healthcare Providers

The COVID-19 pandemic has also increased stress on VA staff. Mental health providers working on site may face increased workload, risk of exposure, concern about safety and transmitting illness to others, and caring for very sick patients. Staff providing mental healthcare through telework had to adapt  to changing roles and faced reductions in social factors (adequate supervision, mutual support from co-workers) known to prevent burnout. Some mental healthcare providers are also helping other VA staff contend with loss, fear, exhaustion, or distress related to the pandemic. Staff are contending with these stressors in addition to pandemic-related workloads and increased caregiving demands outside of work. More research is needed on interventions that can support staff recovery and resilience. These approaches span self-care techniques (e.g., mindfulness, Whole Health), brief clinical interventions, work group-based approaches like Stress First Aid that destigmatize stress and encourage co-worker support, and organizational strategies to reduce stress and burnout.

Going Forward

We have learned many valuable lessons during this pandemic. First and foremost, consistent with our history, Veterans and our VA healthcare workers rose to the occasion. Despite many personal stressors, VA healthcare workers continued to deliver high quality mental healthcare to our Veterans. VA staff across the enterprise demonstrated creativity in meeting Veterans’ needs, and fully leveraged technology to ensure patient safety while delivering exceptional care. Our task moving forward is to apply the lessons learned during the pandemic to enhance future mental healthcare. Virtual modalities should continue wherever needed and desired. Intensive outpatient programs can work alongside our residential programs to broaden and bridge the continuum of services. Standardizing processes will improve access and continuity of care from admission to discharge.

Most importantly, we must remember our most valued resource is ourselves. Remember the passion we all had during those early career days? Let’s recommit to the oath we took. Lastly, let’s be sure we apply Whole Health principles to our personal lives so we may bring the best to our patients and families.

References

1. Gujral, K, et al. “Mental Health Service Use, Suicide Behavior, and Emergency Department Visits among Rural US Veterans who Received Video-enabled Tab-lets during the COVID-19 pandemic,” JAMA Network Open 2022; 5(4):e226250.
2. Nichter, B, et al. “Prevalence and Trends in Suicidal Behavior among US Military Veterans during the COVID-19 Pandemic,” JAMA Psychiatry 2021; 78:1218–27.
3. Rosen, CS, et al. “Virtual Mental Health Care in the Veterans Health Administration’s Immediate Response to Coronavirus Disease-19,” The American Psychologist 2021; 76:26-38.