In this national household sample of 2,810 U.S. adults who had received mental health treatment at some point in their lives, the impact of COVID on mental health treatment access was compared across three groups: participants with SMI, a mental disorder without serious impairment, and those with any lifetime treatment without current serious impairment. The SMI group had substantially increased odds of reporting inability to access mental health care and of having psychotropic prescription delays relative to those with any lifetime mental health treatment. Participants with a mental disorder without current serious impairment also had increased odds of these treatment barriers compared to those with any lifetime treatment, though the odds were attenuated compared to the SMI group. Among individuals with SMI, having Medicare insurance increased the odds of reporting inability to access care during COVID.
Compared to the any lifetime treatment group, individuals with SMI had 6 times greater odds of reporting an inability to access mental health care. Those with a mental disorder without serious impairment also had an increased likelihood of disruption of treatment compared to those with any lifetime treatment, though this risk was attenuated compared to the SMI group. These results suggest that individuals experiencing greater functional impairment from a mental disorder had elevated risks of not receiving adequate treatment during COVID.
The lack of a consensus definition of SMI makes comparing our findings and those of previous studies challenging, but our findings are in line with previous research that reported reduced access to mental health care for individuals with SMI during early COVID (2022) compared to pre-COVID who were not able to access telemedicine services [20, 12, 21, 10]. Our results are in contrast to a Veteran’s Administration (VA) study that found fewer telemedicine video visits, but no difference in overall visits, in the initial COVID period compared to the pre-pandemic period, which may reflect the unique VA health system [9]. A New Hampshire Medicaid study of community mental health centers that defined any mental illness as SMI found a 4.9% increase in telemedicine interruptions compared to the year prior, and that patients with schizophrenia had the least interruptions, but it is unclear if these findings would generalize to populations and states that includes large urban centers [11].
Our study extends previous work showing that early in the pandemic, among Medicare beneficiaries, there were decreases in psychiatric prescription fills for individuals with SMI even with telehealth [8], and the expansion of telemedicine did not increase medication adherence in this population [22]. Individuals with SMI had a four-fold greater odds of reporting having prescriptions delayed than those with any lifetime treatment. Medicare beneficiaries, in general, tend to be older and more likely to have a disability compared to the general population. Our results extend the psychotropic prescription disruption findings to a broader SMI population of housed non-elderly adults and suggest that the disruptions persisted past the early pandemic (2020). Regardless of mental illness group, having any substance use disorder increased the odds of disruptions in accessing mental health care and delays in psychotropic prescription access compared to no substance use disorder. We did not directly examine access to substance use treatment, but previous research shows individuals with substance use disorders tend to have low rates of substance use treatment and engagement [23].
Among the SMI subpopulation, those with Medicare compared to private insurance were more likely to report inability to access mental health care. One explanation is that non-elderly adults on Medicare (20% of SMI sample) need to have a disability to enroll in Medicare, and thus, require a high level of treatment access that in turn may contribute to their risk of experiencing an inability to access mental health care. Alternatively, the barriers to mental health services for Medicare beneficiaries, such as inaccurate provider directories and insurance denials [24], or providers less likely to take public than private insurance [25], could explain the findings. Further research is needed to clarify if individuals with SMI covered by Medicare during COVID had a provider who did not have enough availability to meet their needs, or whether they had difficulty finding a provider.
This study has several implications. First, individuals with SMI had the highest odds of reporting inability to access mental health care or having prescriptions delayed. Despite being a group in high need of ongoing treatment access, this suggests that the access received still might not match the needs of this group. Regardless of diagnosis, individuals with a MDPS mental disorder causing serious functional impairment (the SMI group) had the highest odds of unmet treatment needs. Second, among those with SMI, those with Medicare compared to private insurance were significantly more likely to report inability to access mental health care. More research will be needed to understand whether those with Medicare insurance face barriers such as shortage of providers who accept Medicare [25, 26], inaccurate provider directories [24], or insurance denials [27], or whether the provided services are not enough to meet their needs.
A key strength of the study that increases the importance of the findings is the study design. Mental disorders were diagnosed based on semi-structured psychiatric interviews conducted by trained clinicians, which increases diagnostic accuracy. The survey was based on a national household probability sample and included a large number of participants and is not limited to a single database or population. We included data beyond the initial months of the pandemic. Trained clinicians provided assessments of severity of functional impairment in addition to diagnoses.
Among study weaknesses, inability to access mental health treatment was a binary response that did not capture key service nuances such as quality of care, number of times of occurrence, duration of inability to access treatment and was not confirmed by pharmacy or health utilization data. Nevertheless, self-report healthcare utilization has been shown to correlate with administrative data [28]. The survey question did not distinguish between in-person versus telemedicine access and prior research showed heterogeneity between access and type of service delivery [12]. The study could not determine whether inability to access care was due to establishing care, barriers to existing care or subjective dissatisfaction with the number or quality of care received. The lifetime mental treatment group could have not needed to access mental health care, which may contribute to them reporting having no access difficulties. Though a national sample, the overall MDPS survey response rate was low, which could reduce the representativeness of the sample [15]. Weighting, however, may attenuate selection bias. Third, the MDPS study included only seven mental disorders, and many individuals who did not meet criteria for an MDPS disorder may have needed treatment for a different mental disorder (e.g., panic disorder, personality disorders) [29]. The GAF is a scoring system of mental illness severity based on global function but does not specify diagnoses and scoring can be subjective [17]. In this study, clinicians were trained in GAF administration and had team case reviews to reach consensus. Future studies of impairment should also include functional outcomes, such as employment status or social functioning. How to characterize function in those with mental illness is not yet defined or standardized, and our findings should be taken within this context.
In conclusion, in this large national survey, conducted 2020–2022, individuals with SMI were more likely to report mental health treatment disruptions (inability to access mental health care, delayed psychotropic prescription) during COVID, compared to non-SMI groups. Individuals with SMI on Medicare were more likely to report inability to access care. To narrow the mental health treatment gap, future research should also focus on discerning which individuals with a mental illness causing serious functional impact are most likely to experience access difficulties and mechanisms for access difficulties. More research should discern whether mental health services meet the needs of those whose illness has an associated serious impact on daily life.