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Ayanna Pressley Discusses Disparate Impact Of COVID-19 On BIPOC, Immigrant, & Low-Income Communities

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This article examines how social distancing measures affected different socioeconomic groups differently, highlighting issues of inequality during the pandemic.

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Helen Jenkins, Bill Hanage, Miguel Hernán

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FXB Center for Health & Human Rights | Harvard University

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Coordinated and Evidence-Based Easing of Social Distancing Restrictions That Centers Equity and Justice is the Only Way to Save Lives and Protect the Poor During the COVID-19 Pandemic

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The following statement was issued by the Poor People’s Campaign Health Justice Advisory Committee on May 3, 2020. FXB Center Director Dr. Mary T. Bassett, Executive Director Natalia Linos and Dire…

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Economic Scarring: The Long-Term Impacts of COVID-19

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Economic Scarring: The Long-Term Impacts of COVID-19

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An analysis of the lasting economic effects of the pandemic on different sectors of society and the workforce.

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The US recovery from COVID-19 in international comparison

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The U.S. is significantly outperforming its G10 peers in the economic recovery from COVID-19, Robin Brooks and Ben Harris find.

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The New Normal: A Roadmap to Resilience in the Pandemic Era

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The New Normal: A Roadmap to Resilience in the Pandemic Era

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Explores how the pandemic has reshaped society and what these changes mean for our future civic and social interactions.

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The Digital Divide: Distance Learning's Greatest Challenge

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The Digital Divide: Distance Learning's Greatest Challenge

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Examines how remote learning during the pandemic exposed and exacerbated existing educational inequities.

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Access to online learning amid coronavirus is far from universal, and children who are poor suffer from a digital divide

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In the midst of the COVID-19 pandemic, teachers, parents, school districts, and communities are doing their best to replace in-person with online learning. But as a recent Washington Post article notes, the move to e-learning prompted by school closures has “exposed the technology divides”—with K--12 students who lack the resources they now need to learn…

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Learning Loss and Educational Inequities

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Learning Loss and Educational Inequities

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Analysis of how school closures and remote learning affected student achievement across different demographic groups.

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The Hidden Pandemic: Mental Health Impact of COVID-19

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The Hidden Pandemic: Mental Health Impact of COVID-19

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Explores the psychological effects of isolation, anxiety, and uncertainty during the pandemic across different age groups.

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Nirmita Panchal, Rabah Kamal, Rachel Garfield

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Note: This brief was updated on March 20, 2023 to incorporate the latest available data.

Concerns about mental health and substance use remain elevated three years after the onset of the COVID-19 pandemic, with 90% of U.S. adults believing that the country is facing a mental health crisis, according to a recent KFF/CNN survey. The pandemic has affected the public's mental health and well-being in a variety of ways, including through isolation and loneliness, job loss and financial instability, and illness and grief.

Over the course of the pandemic, many adults reported symptoms consistent with anxiety and depression, with approximately four in ten adults reporting these symptoms by early 2021, before declining to approximately three in ten adults as the pandemic continued (Figure 1). Additionally, drug overdose deaths have sharply increased - largely due to fentanyl - and after a brief period of decline, suicide deaths are once again on the rise. These negative mental health and substance use outcomes have disproportionately affected some populations, particularly communities of color and youth. As the end of the declaration of the public health emergency nears - on May 11, 2023 - many people continue to grapple with worsened mental health and well-being and face barriers to care.

This brief explores mental health and substance use during, and prior to, the COVID-19 pandemic. We highlight populations that were more likely to experience worse mental health and substance use outcomes during the pandemic and discuss some innovations in the delivery of services. We analyze and present findings using the most recent data available at the time of this publication - including the Household Pulse Survey and the CDC WONDER database. Key takeaways include:

Symptoms of anxiety and depression increased during the pandemic and are more pronounced among individuals experiencing household job loss, young adults, and women. Adolescent females have also experienced increased feelings of hopelessness and sadness compared to their male peers.

Deaths due to drug overdose increased sharply across the total population coinciding with the pandemic - and more than doubled among adolescents. Drug overdose death rates are highest among American Indian and Alaska Native people and Black people.

Alcohol-induced death rates increased substantially during the pandemic, with rates increasing the fastest among people of color and people living in rural areas.

After briefly decreasing, suicide deaths are on the rise again as of 2021. From 2019 to 2021, many communities of color experienced a larger growth in suicide death rates compared to their White counterparts. Additionally, self-harm and suicidal ideation has increased faster among adolescent females compared to their male peers.

Several changes have been implemented in the delivery of mental health and substance use services since the onset of the pandemic, including the utilization of telehealth, steps to improve access to treatment for opioid use disorders, expansion of school-based mental health care, and the rollout of the 988 crisis line. As the public health emergency declaration comes to an end, it is possible that some of these changes will be interrupted.

Prevalence of Mental Illness and Substance Use During the Pandemic

Anxiety and depression

The pandemic was associated with a high prevalence of anxiety and depression symptoms in adults. Research suggests that these symptoms increased during the pandemic, but the extent of this increase is unclear. Throughout the pandemic, symptoms of anxiety and depression have been more pronounced among several populations.

For example, individuals experiencing household job loss were more likely than their counterparts to report symptoms of anxiety and/or depression (53% vs. 30%) in February 2023 (Figure 2). Job loss and unemployment - which have long been associated with adverse mental health outcomes - increased substantially early on in the pandemic.

Fifty percent of young adults (ages 18-24) reported anxiety and depression symptoms in 2023, making them more likely than older adults to experience mental health symptoms (Figure 2). Young adults have experienced a number of pandemic-related consequences - such as closures of universities, transitioning to remote work, and loss of income or employment - that may contribute to poor mental health. Additionally, young adults in college settings may encounter increased difficulty accessing treatment.

Symptoms of anxiety and/or depression were also elevated among women (36%) compared to men (28%) in February 2023 (Figure 2). Even before the pandemic, women were more likely than men to report mental health disorders, including serious mental illness.

Concerns about youth mental health further increased with the onset of the pandemic and the recent uptick in gun violence. In a recent KFF/CNN survey, roughly half of parents (47%) said the pandemic had a negative impact on their child's mental health, including 17% who said it had a "major negative impact". Poor mental health has been more pronounced among adolescent females in particular. As shown in Figure 3, the gap in the share of adolescent females and males reporting feelings of hopelessness and sadness - symptoms indicative of depressive disorder - widened from 2019 (47% vs. 27%, respectively) to 2021 (57% vs. 29%, respectively). Many female adolescents also reported adverse experiences in 2021, which can negatively impact mental health.

Substance use and deaths

The pandemic has coincided with an increase in substance use and increased death rates due to substances. In 2021, there were over 106,600 deaths due to drug overdose in the U.S. - the highest on record. This spike in deaths has primarily been driven by substances laced with synthetic opioids, including illicitly manufactured fentanyl.

Further, the overall drug overdose death rate rose by 50% during the pandemic (Figure 4), but varied across states. While drug overdose death rates increased across all racial and ethnic groups, the increases were larger for people of color compared to White people. White people continue to account for the largest share of deaths due to drug overdose per year, but people of color are accounting for a growing share of these deaths over time. In 2021, the highest drug overdose death rates were among American Indian Alaska Native (AIAN) people (56.6 per 100,000), Black people (44.2 per 100,000), and White people (36.8 per 100,000) (Figure 4). Differences in drug overdose deaths by sex were also exacerbated during the pandemic. As shown in Figure 4, the gap in the drug overdose death rates between males and females increased from 2019 (29.6 vs. 13.7 per 100,000, respectively) to 2021 (45.1 vs. 19.6 per 100,000, respectively).

Research suggests that substance use among adolescents has declined, yet drug overdose deaths have sharply increased among this population, primarily due to fentanyl-laced substances. Among adolescents, drug overdose deaths have more than doubled from 2019 (282 deaths) to 2021 (637 deaths) following a period of relative stability. Male, Black, and Hispanic youth have experienced the highest increases in deaths due to drug overdose.

During the pandemic, excessive drinking increased along with alcohol-induced deaths. Alcohol-induced death rates increased by 38% during the pandemic, with rates the highest and increasing the fastest among AIAN people. AIAN people died of alcohol-induced causes at a rate of 91.7 per 100,000 in 2021, six times more than the next highest group - Hispanic people at a rate of 13.6. Black people also experienced significant increases in alcohol-induced deaths during COVID, with rates increasing more than 45% (Figure 5). Both rural and metropolitan areas experienced an increase in alcohol-induced deaths during the pandemic, but rural areas saw the largest increase (46% increase compared to 36%).

Suicidal ideation and deaths

Concerns about suicidal ideation and suicide deaths have also grown during the pandemic. Notably, self-harm and suicidal ideation has increased among adolescent females. Thirty percent of adolescent females seriously considered attempting suicide in 2021 compared to 14% of their male peers (Figure 6). Other analyses found that as the pandemic progressed, emergency department visits for suicide attempts increased among adolescents, primarily driven by females.

Suicide deaths in the U.S. began to increase in 2021 after briefly slowing in 2019 and 2020, although some research suggests that some suicides may be misclassified as drug overdose deaths since it can be difficult to determine whether drug overdoses are intentional. From 2019 to 2021, many communities of color experienced a larger growth in suicide death rates compared to their White counterparts. In 2021, suicide deaths by firearm accounted for more than half ( 55%) of all suicides in the U.S., but varied greatly across states.

The pandemic has also raised concerns about mental illness, suicide, and substance use among other populations. Essential workers and people with chronic health conditions may have experienced worsened mental health due to increased risk of contracting or becoming severely ill from COVID-19. Many of these individuals, particularly those with chronic conditions, were already at-risk of experiencing poor mental health outcomes prior to the pandemic. LBGT+ people have historically faced mental health problems at higher rates than their non-LGBT+ peers. The pandemic has continued to negatively impact LBGT+ people's mental health in disproportionate ways. In addition, people experiencing prolonged COVID-19 symptoms, or long COVID, may be more likely to develop new mental health conditions or to experience worsening of existing ones.

Changes in the Delivery of Mental Health and Substance Use Disorder Services

Leading up to the pandemic, many people faced barriers accessing mental health and substance use disorder services for reasons including costs, not knowing where to obtain care, limited provider options, and low rates of insurance acceptance. Young adults, Black adults, men, and uninsured people were less likely to receive services compared to their peers.

In recent years, access to care barriers may have worsened due to pandemic disruptions and closures, workforce shortages, and increased demand for services. In response to growing need, some policies and strategies were implemented to address access challenges, such as growth of telehealth, improved access to opioid use disorder treatment, the expansion of school-based mental health services, and the rollout of 988; however, challenges remain.

The delivery of mental health and substance use disorder services via telehealth grew sharply during the pandemic. By 2021, nearly 40% of all mental health and substance use disorder outpatient visits were delivered through telehealth. These behavioral health services via telehealth have also been more utilized in rural areas than urban areas during the pandemic. This underscores the role telehealth can play in improving access to behavioral health services in rural areas, which often face additional provider and resource shortages. Further, community health centers - which serve low-income and medically underserved communities, including communities of color and those in rural areas - experienced a large increase in behavioral health visits in 2021, largely driven by telehealth. During the pandemic, many state Medicaid programs expanded coverage of behavioral health telehealth services. This includes broadening the range of behavioral health services offered virtually and allowing for more provider types to be reimbursed for telehealth services. Many state Medicaid programs reported that telehealth has helped maintain and expand access to behavioral services during the pandemic. Some private payers have also improved coverage for mental health and substance use services by removing pre-pandemic telehealth coverage restrictions. Although telehealth can broaden access to care, in-person care may be necessary or preferred for some or for those experiencing challenges with technology and digital literacy.

As opioid-related overdose deaths have sharply increased, measures to improve access to treatment have been implemented. Following the onset of the pandemic, the federal government allowed for new flexibilities in opioid use disorder (OUD) treatment to ease access barriers, for example allowing for take-home methadone doses and covering telehealth treatment, and the Biden administration has proposed making these flexibilities permanent. Further, the 2023 Consolidated Appropriations Act eliminated the X-waiver requirement for prescribing buprenorphine, which substantially increases the number of providers who are authorized to prescribe buprenorphine to treat OUD. Voluntary guidelines for providers have also been issued to help reduce opioid overprescribing and misuse. At the same time, the Drug Enforcement Agency recently proposed returning to previous rules that required in-person visits before prescribing controlled substances to patients via telehealth, though there are some exceptions.

In response to growing mental health concerns among youth, integration of mental health services in school-based settings became a priority. Recent legislation aims to expand mental health care in schools - a setting that is easily accessible by children and adolescents. Specifically, legislation provides funding to expand and train mental health providers in schools; implement suicide, drug, and violence prevention programs; and provide trauma support services, among others. Further, recognizing Medicaid's importance in covering and financing behavioral health care for children, CMS is now required to provide updated guidance on how to support and expand school-based behavioral health services. The recently passed Consolidated Appropriations Act (CAA) continues to build on prior pandemic-era legislation that promotes access to behavioral health care for children. For example, to ensure more stable coverage for low-income children the CAA requires states to provide 12 months of continuous eligibility for children in Medicaid and CHIP.

An easy-to-remember number for the suicide and behavioral health crisis hotline, 988, was launched in 2022. On July 16, 2022, the federally mandated crisis number, 988, became available to all landline and cell phone users, providing a single three-digit number to access a network of over 200 local and state funded crisis centers where those in need may receive crisis counseling, resources and referrals. After 988 implementation, national answer rates increased alongside increases in call volume. Long-term sustainable funding of local 988 crisis call centers remains uncertain in many states. In addition to 988, some states are developing behavioral health crisis response systems, such as mobile crisis or crisis stabilization units, which will enable a specialized behavioral health response for behavioral health crises that require intervention. The CAA included provisions aimed at strengthening and evaluating 988 and the developing behavioral health crisis continuum.

Despite steps taken to improve the delivery of mental health and substance use services, challenges remain. Provider workforce challenges are widespread, with nearly half of the U.S. population ( 47%) living in a mental health workforce shortage area. Shortages may contribute to access challenges and contribute to increases in psychiatric boarding in emergency rooms. Additionally, provider network directories are often outdated, further contributing to access challenges. While recent legislation has taken steps in response - including funding for at least 100 new psychiatry residency positions, grants for mental health peer support providers, and improvements to provider directories through the CAA - these are relatively small measures in the face of big access challenges. The lack of a diverse mental health care workforce may contribute to limited mental health treatment among people of color. Separately, even with insurance coverage, individuals with mental health needs face challenges accessing care. While Medicaid enrollees have limited out-of-pocket costs there is variation in who is eligible and the range of services covered across states. Additionally, the end of Medicaid's continuous enrollment provision - on March 31, 2023 - could result in millions of disenrollments over the next year which could disrupt access to behavioral health services. Among private insurance enrollees, enrollees, with mental illness face high out-of-pocket costs; and these costs vary substantially across states. While most adults with mental illness have private insurance, rates of mental illness and substance use disorders are most prevalent among nonelderly adults with Medicaid.

Looking Ahead

Although steps have been taken to address negative mental health impacts stemming from the pandemic, mental health and substance use concerns remain elevated. Heightened racism and increasing gun violence may also contribute to poor mental health outcomes. Further, negative mental health impacts have been more pronounced among several populations, including communities of color, young adults and children - populations which have historically experienced increased barriers to care. Additionally, despite renewed discussions and new federal grants for state parity enforcement under the CAA, challenges with mental health parity persist - including lack of clarity on specific protections, low compliance rates, and slow federal enforcement. Finally, the COVID-19 public health emergency will end in May 2023, which may at least partially unravel steps taken toward delivering mental health services via telehealth and improving access to substance use disorder services.

History has shown that the mental health impact of disasters outlasts the physical impact, suggesting today's elevated mental health needs will continue well beyond the coronavirus outbreak itself. As we emerge from the COVID-19 pandemic and the federal public health emergency draws to an end, it will be important to consider how the increased need for mental health and substance use services may persist long term, even as new cases and deaths due to COVID-19 hopefully subside.

This work was supported in part by Well Being Trust. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

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The Implications of COVID-19 for Mental Health and Substance Use

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This brief explores mental health and substance use during, and prior to, the COVID-19 pandemic. We highlight populations that were more likely to experience worse mental health and substance use outcomes during the pandemic and discuss some innovations in the delivery of services.

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Communities Coming Together: Mutual Aid During COVID-19

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Communities Coming Together: Mutual Aid During COVID-19

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Chronicles how communities organized to support each other during the crisis, demonstrating civic engagement and solidarity.

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‘Let communities do their work’: the role of mutual aid and self‐help groups in the Covid‐19 pandemic response

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How to respond quickly, effectively, and sensitively to large‐scale crises is debated at length in the aid sector. Institutional focuses on projects and outcomes have led to abundant literature on the efficacy of external interventions, while the…

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Federalism Under Fire: State vs. Federal Response to COVID-19

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Federalism Under Fire: State vs. Federal Response to COVID-19

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Analysis of how different levels of government responded to the pandemic and the implications for American federalism.

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COVID and Federalism: Rich Opportunities for Public Accountability

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The COVID-19 crisis offered excellent lessons in the advantages of federalism, the division of power between the federal government and the states. Most COVID policies directly affecting Americans were made and enforced, not by Washington, but by state and local officials.

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Examines the challenges in creating and implementing public health policies during the pandemic.

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Public policy for healthy living: How COVID-19 has changed the landscape

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The coronavirus disease 2019 (COVID-19) pandemic had a transformational impact on public policy as governments played a leading role, working alongside and coordinating with business/industry, healthcare, public health, education, transportation,…

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Explores how democratic institutions and processes adapted during the pandemic and the implications for civic participation.

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COVID-19 and democracy: a scoping review - BMC Public Health

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Background The resilience of democracy is tested under exogenous shocks such as crises. The COVID-19 pandemic has recently tested the resilience of democratic institutions and practices around the world. Aim The purpose of this article is to scope the early research literature that discusses democracy and the COVID-19 pandemic. We review scientific journal articles published during the first two years of the pandemic. We ask three research questions in scoping this body of literature: (1) what are the key topic areas of all published research that associates itself with both democracy and COVID-19, (2) what kinds of conceptual and theoretical contributions has research literature that more specifically discusses democracy under the pandemic produced, and (3) what are the impacts of democracy to the pandemic and vice versa according to empirical research? Methods The scoping review methodology draws on systematic literature search strategies, computational methods, and manual coding. The systematic Web of Science search produced 586 articles for which we conducted a Correlated Topic Model. After technical and manual screening, we identified 94 journal articles that were manually coded. Results The early research on democracy and the COVID-19 pandemic offers a versatile body of scholarship. The topic modeling shows that the scholarship discusses issues of crises, governance, rights, society, epidemiology, politics, electorate, technology, and media. The body of papers with conceptual and theoretical contributions has offered new insights on the difficulties, possibilities, and means to maintain democracy under a pandemic. Empirical research on democracy’s impact on the COVID-19 pandemic and vice versa varies in terms of methodology, geographical scope, and scientific contributions according to the direction of influence studied. Democracy appears to have a significant impact on some aspects of policy responses and epidemiological characteristics of the pandemic. In most parts of the world, the scope, franchise, and authenticity of democracy narrowed down due to the pandemic, albeit in most cases only temporarily. Conclusions A significant number of papers show that the pandemic has accentuated democratic backsliding but is unlikely to have undermined established democracies that have proved resilient in face of the pandemic. But empirical research has also made visible some weak signals of antidemocratic tendencies that may become more accentuated in the longer run.

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International Cooperation and Competition During Crisis

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International Cooperation and Competition During Crisis

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Examines how countries collaborated and competed for resources during the pandemic, highlighting global interdependence.

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The World After: Global Implications of COVID-19

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The World After: Global Implications of COVID-19

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Analysis of how the pandemic has reshaped international relations, economics, and society on a global scale.