The use of psychiatric meds in the U.S., already sky-high, is on the rise as a result of Covid-19. That’s not surprising – it happened after the 9-11 attacks, the 2008 crash and other crises.
This graph comes from “America’s State of Mind,” an April 2020 report from Express Scripts. In the month from February 15 to March 15, prescriptions for depression, anxiety and insomnia rose 21%. Antidepressant use was up by 18.6%, while anxiety meds, chiefly benzodiazepines, rose a whopping 34.1%. Use of these drugs jumped 18% in the last week alone, when President Trump declared a state of emergency.
Let’s face it. There’s nothing natural about being in quarantine. And when a whole society goes into quarantine mode, the stress only multiplies. You may face enforced idleness. Or you may find yourself struggling to work from your kitchen table, home-schooling your children, or working long hours in a low-wage job which is now both “essential” and dangerous. You’re lonely or cooped up with your family to the point of madness, maybe both. You worry about the virus and you worry about how to pay the rent.
So you’re not taking this too well? Congratulations. You’re human. Maybe you have wrestled with anxiety or depression before, maybe not. Either way, it’s unlikely you have a brand-new “mental illness” that you did not have back in January. The world has turned strange, not you.
I hoped the US medical establishment would get this. Maybe I was naïve. Most of the official mental-health experts seemed to back off from urging us to “ask our doctor” if we had a “real medical disorder.” Instead they offered advice for weathering a tough situation: Keep a regular schedule. Try to get a bit of exercise. Reach out to loved ones for mutual support. Put on clothes every morning, even if you don’t have to. Some of this was trite, but, still, it was a refreshing change.
The Express Scripts report delivered a dose of cold, hard reality. As our leading Pharmacy Benefit Manager they control drug spending and access for millions of Americans in private insurance plans. While media experts tell us how they think mental health care should be, Express Scripts tells us how it is.
The worst news they brought by far: 75% of the drugs dispensed in that one mad week from March 9-15 were new prescriptions. Why is this so worrisome?
The risks doctors don’t mention
First, let’s talk about adverse reactions – the really bad “side effects” that plague a minority of people, especially on antidepressants. The very drugs our doctors rely on to “calm us down” can make some of us unbearably agitated, even suicidal. And no test or warning sign can predict who will react this way. Many of the victims will be like Stephen O’Neill: a well-balanced guy never known to be suicidal.
Intense mental and physical restlessness, known as akathisia, can set in, making suicide seem like the only relief. Some will develop “psychotic” delusions. For others, the anxiety-reducing effects of the drug can become extreme, erasing normal worries and inhibitions. People may cease to care about their work, neglect their children or show out-of-character recklessness.
You won’t be told about drug-dependence either. After 30 days or so of taking a drug for a short-term crisis, you may find yourself hooked long-term. This is common and serious with antidepressants. With benzodiazepines, like Xanax and Ativan, it’s the rule. According to Express Scripts, benzo consumption had dropped about 12% in recent years, due perhaps to two concerns: the dangers of combining them with opioid painkillers, and the risk of falls and confusion in seniors. In one month, the Covid-19 crisis has erased that decline completely.
Medical journals are just as bad the doctors they sell to. Its difficult to find an article about the hazards of meds other than this recent one.
Home Alone with a New Medication
The risks are greatest when starting a drug, or changing the dose putting all those new users in the second week of March in danger.
Consumer activist Janet Schiel put it very well: If you are going to use these drugs, you need a buddy system. Someone needs to know: someone who knows your usual “baseline” state and can watch for any sudden behavior changes. Janet learned this the hard way: her husband Joe jumped off a balcony to his death in 2016, thirty days after starting an SSRI antidepressant for short-term job stress. Joe and his loved ones could both see the changes, but no doctor warned them about how dangerous these changes could be.
Most doctors don’t warn or monitor. They may have been told that only teenagers face this risk, or only those with a past history of suicidal feelings. The doctor who gives you a pill ain’t going to be your buddy. Fewer of us anyway have a family doctor who knows our history, and doctor visits grow shorter every year.
Therapists and counselors may be just as clueless. Many routinely suggest you “ask your doctor” about a script. Bur most people on pills don’t even see a counselor: Express Scripts tells us that “anti-depressants are typically the first line of therapy for patients experiencing depression” and family doctors can “fill the void” in mental-health services by managing these meds. Express Scripts should know: it helps set standards of care, which often don’t authorize therapy until a pills-only approach has failed.
All these problems are magnified din the current crisis when any worsening of their mental state may be blamed on the shutdown rather than that new pill they’re on.
The quarantine will also cut them off from their usual supports. Who will notice that you don’t seem like yourself, when you see almost no one? Who will you ask about any strange thoughts?
The Age of Telepsychiatry
Then there’s telemedicine, which the Covid Crisis has brought from the fringes to the center of healthcare. That first script back in March 2020 may well have been written after a phone or video visit – all follow-up visits will now almost certainly be virtual.
Telemedicine has its uses. In a pandemic, it keeps both you and the doctor out of a possibly virus-laden clinic, and frees hospital staff to concentrate on the infected. If a doctor-patient relationship already exists, video may work well. But if not, a quickie initial assessment may now be even skimpier.
So what about psychiatrists? Most outpatients on psych drugs don’t see one. Those who do are increasingly limited to a few ten-minute “med-checks” per year.
It’s been suggested that psychiatrists should worry about their increasing replacement by other prescribers like GPs and nurse practitioners. As a profession, however, they seem quite happy with it. Their numbers have been shrinking for decades – a majority of America’s 3,155 counties lack even one psychiatrist, and the average age of practitioners now hovers around sixty.
As a result their services are in high demand. For-profit behavioral-health chains find their expansion plans stymied by the shortage. Any shrink who can fog up a mirror is guaranteed a job, which may consist largely of “supervising” the staff who actually deal with the patients and dole out the pills.
Thanks to Covid-19, telepsychiatry is on the upswing. Restrictions on the practice are tumbling, notably the requirement to hold a license in the state where the patient lives. Laws passed due to the opioid overdose crisis, mandating an in-person assessment prior to prescribing “controlled substances,” are also being waived. Sweetest of all, Medicare will now let doctors bill for video visits at their normal in-person rates.
The APA has embraced the trend, offering a “Telepsychiatry Toolkit” to help members get started, with advice on billing codes and rating scales patients can complete online. The return on investment for healthcare providers can be significant, they say – especially in prisons, nursing homes and emergency rooms.
Never let a good crisis go to waste
It’s all too easy to imagine these temporary measures becoming permanent. Way back in January a Colorado patient sued one of those for-profit hospitals for holding her against her will without good cause, just to pad the bill. It’s an increasingly common complaint. The shrink who certified her as a “danger to self or others,” she alleges, lived 2,000 miles away in Florida and never saw her at all.
The suit charged both the doctor and the hospital with “racketeering” in violation of Colorado’s organized-crime statutes. But what was racketeering in January just might be the standard of care by June.
This map from Express Scripts shows the States where antidepressant consumption is the highest. Anyone familiar with U.S. healthcare will recognize that orange pattern right away: These are States where poverty is highest, health care access lowest, and the opioid epidemic hit hardest.
Does this mean prescribing is more cautious in states with more psychiatrists and specialty care? Far from it. What it may indicate is an economic law: the less care given, the more pills dispensed. That’s what jump-started the opioid crisis, and may be one factor driving these soaring rates of psych meds.
Its a Wild World
Captain Kirk (aka J.R.) took a break after dictating the above, Dr McCoy (D.H.) here adding a quick note.
One of the things that has us puzzled about this crisis, looking at it from a distance, is that crises are normally good for mental health. People engaged in internal struggles find that earthquakes, wars, tsunamis and other problems distract them from the internal struggle and to their surprise sometimes they find they are coping not just better than expected but feeling rather well. Suicide rates go down.
Of course, in very few crises before this has there been such a relentless bombardment from the media telling people they are about to become nervous wrecks.