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Response to Commentary

Studying Mental Healthcare and Other Care During the COVID-19 Pandemic

The COVID-19 pandemic created both challenges and opportunities for VA medical operations and research. As described by the Office of Mental Health and Suicide Prevention (OMHSP), VA medical centers responded quickly to critical issues and implemented solutions based on what they knew at the time, which was often limited. The COVID-19 pandemic also challenged research funders to adopt new methods to facilitate essential and timely research. Initially, researchers focused on developing vaccines and new treatments – national efforts to which VA contributed. As a health system caring for nine million Veterans, VA also needed to answer critical questions about how to meet the needs of our patients while various services were interrupted, and how to protect our most vulnerable patients from the combined effects of economic stresses, social isolation, and generalized pandemic anxiety. In response, the Office of Research and Development (ORD) funded supplements to ongoing projects to add attention to COVID-19-specific outcomes; launched a national study and special solicitation on disrupted care and its effects on acute and chronic health outcomes; accelerated funding for long COVID-19 research; and joined interagency collaborations with NIH, CDC, and FDA on real-world studies of the effectiveness of vaccines and COVID-19 therapies. 

The Impact of Deferred and Disrupted Care on Mental Health

The Health Services Research and Development Service (HSR&D) funded two research initiatives to examine the possible connections between pandemic-related disruptions in VA care and Veteran mortality and morbidity across chronic, acute, and mental healthcare settings. In 2021, HSR&D released a Targeted Solicitation for Service Directed Research (SDR) on Pandemic-Related Disrupted and Deferred Care and funded the Disrupted Care National Project (DCNP). One aim of the DCNP is to examine the factors contributing to the excess non-COVID-19 mortality observed among Veterans during the COVID-19 pandemic. This analysis requires mapping trends in pre-pandemic and pandemic mortality, and analyzing these trends in relation to changes in VA healthcare utilization during the pandemic. This project will analyze changes in all-cause mortality and, once CDC data on cause-specific mortality is available, the project will also examine the pandemic’s impact on deaths from suicide, overdoses, and other acute and chronic conditions.

The DCNP is also coordinating VA investigators conducting research funded through the broader initiative on disrupted care. A key component of this project is to understand how the pandemic has broadly affected mental healthcare and mental health outcomes for Veterans. Projects underway are assessing the impact of COVID-19-related care disruptions on antipsychotic medication use and on treatment for overdoses and opioid use disorder (OUD). Other studies are examining the quality of telemental healthcare for Veterans during the COVID-19 pandemic.

VA successfully pivoted to virtual care during the pandemic with generally good outcomes. At the same time, this shift may have affected the care of specific Veteran groups such as those without Internet access, Veterans in residential addiction services, and those in inpatient mental health facilities. Understanding in more detail the patterns of change that occurred across the broad scope of mental health services during the pandemic will help VA maintain essential services for Veterans during future crises.

Structural and Social Determinants of Mental Health

Concern about Veteran mental health was an early research priority due to the prevalence of pre-existing mental health conditions in the Veteran population and the recognition that the pandemic could exacerbate isolation, stress, and anxiety. Many of the early research supplements in ORD went to VA mental health projects that examined how the pandemic affected their enrolled populations or that analyzed the efficacy of interventions adapted for specific pandemic concerns. The Mental Illness Research Education and Clinical Centers (MIRECCs) and OMHSP National Centers also undertook extensive work that examined the impacts of the pandemic. A September 2021 conference brought these groups together to review the learnings of these two centers. Key among their findings, the centers reported that during the first year and a half of the pandemic, VA saw an increase in generalized anxiety disorder but not a noticeable increase in other psychiatric outcomes and no increases in suicide-related indicators associated with the COVID-19 pandemic. Furthermore, some VA patients who were at an increased risk of experiencing psychological distress during the pandemic demonstrated resiliency and showed positive psychological outcomes (Pietrzak, Tsai, and Southwick, 2021).

Disordered substance use is a particular concern for VA, given national reports of increased opioid and alcohol-related deaths during the pandemic (Yeo, He, and Ting, 2022). From 2019 to 2020, there was a 30 percent increase in drug overdose deaths in the United States, with the highest rates among Black and American Indian or Alaska Native persons (Kariisa et al., 2022). In response to these national trends, VA increased opioid overdose education and naloxone distribution (OEND) in 2021 for VA patients at risk for opioid overdose. VA is still assembling national data on alcohol and opioid use in Veterans as well as drug overdose and alcohol-related mortality. However, existing research on alcohol consumption has shown that not all Veterans have responded to pandemic conditions in the same way. Women Veterans, Veterans with PTSD, and racial/ethnic minority Veterans tended to increase their alcohol consumption and binge drinking over the first year of the pandemic more than other Veteran groups (Davis et al., 2021). Also, Veterans who had pre-existing anxiety and high financial stress consumed more alcohol in the first six months of the pandemic (Tran et al., 2022).

These ongoing studies indicate the need to understand the structural and social determinants that increase isolation, stress, and economic hardship for those Veterans who are disproportionately affected by the pandemic. VA needs to translate this knowledge into policies, clinical treatment, and access to mental healthcare that more equitably address the needs of all Veterans.

Mental Health as a Window into the Complex Effects of the Pandemic

The pandemic profoundly disrupted the lives of millions of Veterans, affecting their employment, social networks, and healthcare. While we are gradually learning the range of health effects due to these disruptions, mental health provides an early and important window into the complex effects of the pandemic. As we examine the effects of COVID-19 to better prepare for the next pandemic, several general conclusions are warranted.

1. VA needs to focus on the needs of our most vulnerable patients who may require more proactive outreach, including those with mental health conditions.
2. Isolation and loss of social networks are bad for health. Alcohol and drug use, and deaths due to both, increased during the pandemic based on national statistics.
3. Not all our worst fears or expectations were realized. Despite increases in anxiety and depression during the pandemic, increases in suicides have not yet been reported within VA or in the U.S. population. Some populations we think of as vulnerable – those who are homeless, and those who are seriously mentally ill – may show more resilience than the average patient.
4. VA’s pivot to telehealth was a success and allowed continuity in mental healthcare. But there are patients and conditions for which telehealth may not be an adequate substitute for face-to-face care. As we continue to increase virtual care, we need to develop better methods to maintain services such as mental health screening, team-based care, primary care mental health integration, and urine testing for patients on medication therapy for opioid use disorder.

References

1. Davis JP, Prindle J, Castro CC, et al. “Changes in Alcohol Use During the COVID-19 Pandemic among American Veterans,” Addictive Behaviors 2021; 122:107052.
2. Kariisa M, Davis NL, Kumar S, et al. “Vital Signs: Drug Overdose Deaths, by Selected Sociodemographic and Social Determinants of Health Characteristics — 25 States and the District of Columbia, 2019–2020,” Morbidity and Mortality Weekly Report 2022; 71:940–947.
3. Pietrzak RH, Tsai J, Southwick SM. “Association of Symp-toms of Posttraumatic Stress Disorder With Posttraumatic Psychological Growth Among US Veterans During the COVID-19 Pandemic,” JAMA Network Open 2021; 4(4):e214972.
4. Tran DD, Fitzke RE, Wang J, et al. “Substance Use, Financial Stress, Employment Disruptions, and Anxiety among Veterans during the COVID-19 Pandemic,” Psychological Report 2022 Mar 24; online ahead of print:332941221080413.
5. Yeo YH, He X, Ting P, et al. “Evaluation of Trends in Alco-hol Use Disorder–Related Mortality in the US Before and During the COVID-19 Pandemic,” JAMA Network Open 2022; 5(5):e2210259.