Estelle Slootmaker | Tuesday, May 3, 2022

Special report: COVID-19's silver linings for mental health care in Michigan

Mental health report
This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

As COVID-19 has exposed inequities and disparities, the result, in many cases, has been innovative responses that will carry on after the pandemic has passed. More robust mental health care delivery and reduced stigma are among the silver linings emerging from the COVID cloud.

In 2019, the Centers for Disease Control and Prevention reported that 10.8% of U.S. adults experienced anxiety or depression. By the end of 2020, that number was 45.6%. While numbers have dropped somewhat since then, 30.9% of Michiganders were still suffering with these symptoms in August 2021. These mental health impacts were especially egregious for Michiganders of color.

"Things that many of us take for granted – basic resources such as food, or worry about having access to food – these things play a critical role in shaping both the mental health and other health factors in underserved [communities] and communities of color," says researcher Wassim Tarraf, associate professor in the Institute of Gerontology and Healthcare Sciences at Wayne State University. 

Tarraf has been examining how race, employment, and socioeconomic status intersect with pandemic-related stress, depression, and anxiety, polling individuals selected using U.S. census data about mental health changes every two weeks throughout the pandemic.  

Wassim Tarraf.
"The social determinants of health ... played a very important role in differentiating the mental health outcomes between groups, particularly when things were most stressful at the start of the pandemic," Tarraf says.

His analysis reveals even higher levels of stress and mental health issues in older adults of color during the first year of COVID. 25% of non-Latino white respondents surveyed reported mental health issues, compared to 33% of Black respondents and 40% of Hispanic/Latino respondents. However, Tarraf does believe that various innovative responses to these disparities have had a positive impact since the pandemic hit. 

“I think those have yielded some positive and productive results," Tarraf says. "I think the Michigan Coronavirus Task Force on Racial Disparities, which continues to operate, is a positive thing, particularly the focus on transparency and reporting data. Continued outreach to underserved populations, and continued funding for efforts that both help understand the needs of adversely affected communities and develop appropriate real-world interventions, [are] key here."

COVID's toll on youth mental health

According to the Michigan Department of Health and Human Services (MDHHS), in 2020, suicide was the second leading cause of death for Michigan's 10- to 14- and 20- to 24-year-olds, and the third leading cause of death for 15- to 19-year-olds. US Surgeon General Vivek Murthy issued an advisory on the youth mental health crisis in December 2021. He wrote, "Mental health challenges in children, adolescents, and young adults are real and widespread. … The COVID-19 pandemic further altered their experiences at home, school, and in the community, and the effect on their mental health has been devastating."

The Michigan legislature had already laid the groundwork for expanded mental health supports in schools in 2018-2019 with a $26 million investment. According to Diane Golzynski, director of the Michigan Department of Education (MDE) Office of Health and Nutrition Services, that amount was increased to more than $50 million in May 2020. 
Diane Golzynski.
"Those funds are specific. [They] expand school-based health centers that are focused on mental health support — and hire mental health providers to work in the schools directly with kids, rather than having a child that needs mental health support and being told to go to a community-based provider and find that person on their own,” Golzynski says. “Now, we can actually hire those providers to be in the school and serve the kids while they are in school."

In 2021, the state invested another $240 million in school-based mental health supports. These funds will reimburse districts that hire in-school mental health providers for 100% of the providers' first-year salaries, 66% of their second-year salaries, and 33% of their third-year salaries. Schools must commit to employing the providers for four years total. In addition, the state also invested $5 million in the TRAILS program, which offers teachers free social-emotional learning (SEL) training and curricula to implement in the classroom. Staff at more than 700 schools have been trained to implement TRAILS programming in 48 of Michigan's 56 intermediate school districts. More than 9,700 teachers and administrators have completed the MDE's online SEL course. 27% of districts have at least two staff per building who have completed the course and more than 99% of districts have at least one educator who has completed it.

"With SEL, we can determine which kids need a little bit more support, a little bit more involvement from a caring adult, and which kids need even more intensive support," Golzynski says. "We've got partnerships with community mental health and others where we can get those kids seamlessly into those supports."

Help for elders

Older adults were more likely to experience loneliness and social isolation even before COVID-19, but pandemic shutdowns exacerbated both, causing anxiety, depression, and other mental and physical health concerns. As a result, the state's Area Agencies on Aging, AARP, and others have created programs and advocated for policies that will empower elders to remain socially connected, even in the face of a pandemic. For example, AARP launched a series of informative online events; MDHHS partnered with GetSetUp to offer Michigan’s elders free online wellness and educational sessions via Zoom; and senior centers are offering intergenerational programming that leverages older adults’ wisdom through healthy social connections with younger folks. 
Lisa Dedden Cooper.
"Isolation also can negatively impact mental health for older adults. People who have good social networks live longer, and they're physically and mentally healthier than people who are socially isolated," says Lisa Dedden Cooper, manager of advocacy for AARP Michigan. "So much of what we had to do in our lives became virtual instead of in-person. Older adults are less likely overall to have access to the internet or to use computers."

AARP is asking the Michigan legislature to bridge this digital divide.

"One of the things we're advocating for is greater access to broadband, including both infrastructure and computer literacy for older adults," Cooper says. "And, on the topic of silver linings, there is a renewed look at the long-term care system in Michigan. People who work in this field know that there are systemic deficiencies when you look at traditional nursing homes. What we saw with COVID opened a lot more people's eyes to this."

Telehealth and helplines

Another of COVID's silver linings for mental health care was the expansion of virtual care, telehealth, Zoom-based support groups, and the expansion of helplines.

"For many, telehealth has been an absolute lifeline," says Kristin Gietzen, president and CEO of Arbor Circle, a West Michigan provider of mental health counseling, substance use treatment, and family services. "It has increased access to services. It has allowed people to continue services that they had started before the pandemic that would have otherwise been interrupted. And it has allowed a giant step forward in technology for mainstream mental health and behavioral health services. Telehealth would not have emerged as a primary method for delivering behavioral health services if it had not been for the pandemic." 
 
Kristin Gietzen.
Thanks to telehealth, Arbor Circle maintained connections with 80% of its clients during COVID shutdowns.

"For a good chunk of the pandemic, about 90% of the services that we were providing were through telehealth," Gietzen says. "A little bit more than a third of our services are still being provided through telehealth. And that's primarily the client's choice. There's a lot of fluidity in the kinds of things that we can do as a provider now that we couldn't do before. And that's really been a game changer."

Arbor Circle therapist Marvin Mckenzie simulates a telehealth visit with a colleague.
COVID also resulted in insurers reimbursing providers for telehealth services.

"I think that we have undergone a significant culture shift," Gietzen says. "Clients are expecting telehealth and our employees are expecting to use it. It's not a new phenomenon anymore. It's within the norm."

During the pandemic, the state of Michigan also rolled out virtual mental health via websites and helplines. The state's mental health warmline, launched in April 2020, continues to offer residents experiencing mental illness help from certified peer support specialists who speak from their own experience. Meanwhile, MiCal, the Michigan Crisis and Action Line, kicked off in Oakland County and Michigan's Upper Peninsula in April 2021, and it will soon be up and running in all of Michigan.

"It's already in 50% of the state," says Dr. Debra Pinals, MDHHS medical director for behavioral health and forensic programs. "I believe we are putting in some really good support to help people who might be in crisis."

In its first year, MiCal fielded 50,000 calls for help.
Jill Smith.
"We're there on the other end of the phone when people need us," says Jill Smith, MiCAL program director for Common Ground, the helpline's administrator. "We stood ourselves up during the pandemic. We're there to listen. We're there to provide support. We're there to provide referrals and resources to individuals."

Fresh approaches to substance use disorders

As depression, anxiety, and stress increased during the pandemic, substance use disorders rose as well. Between April 2020 and April 2021, opioid-related drug overdoses killed more than 2,900 Michiganders — a 19% increase over the preceding year. The state also is expanding harm reduction programs that keep people with substance use disorders alive until they are ready to seek treatment and sobriety.

Another innovative health care response, community integrated paramedicine, has become a trusted source of help for Michiganders living with substance abuse disorders. These paramedics perform basic, non-emergent, clinical tasks on site in people’s homes or connect them to appropriate resources.
Dr. Debra Pinals.
"On the substance use disorder front, we still are tackling many of the issues," Pinals says. "We're hiring a person to look at why there's a disproportionate impact of the opioid overdose rates on Black and Hispanic populations. We are continuing strongly in our effort to combat the opioid overdose death rates and to turn those numbers around."

Reduced stigma amplifies expanded services

Perhaps the brightest silver lining for Michiganders' mental health is that the pandemic has reduced stigma that prevents people of all ages from getting help when they need it.

"More people are speaking about mental health and wellbeing. We see that in prominent people throughout our community. We see that in entertainers who are coming out and speaking on it," says Judy Gardner, executive director of the National Alliance on Mental Illness (NAMI) Washtenaw County. "We all were in this collective with COVID. More people are experiencing, for the first time in their life, what it feels like to have anxiety. And for those that had an underlying anxiety disorder, it made things worse."

Gardner has been thrilled with additional requests for NAMI's help, not only from individuals but also from communities, businesses, and school districts. In response, NAMI Washtenaw has grown its family education programs, peer-to-peer supports, and support groups to meet demand.

"I am also encouraged by the amount of legislation that's being moved at the federal level around mental health. That hasn't happened in many, many, many years," Gardner says. "We still have a long way to go around stigma, but I think COVID has increased the dialogue between people, so I'm happy about that."

Judy Gardner.
While all Michiganders anticipate the day when the pandemic is fully in the past, many will continue to benefit from the innovative mental health care responses that arose during the crisis.

"COVID has shined a light on things that have often been hidden, things that we don't talk about. One of those things is mental illness," Gardner says. "That is a good thing because we need to expose, and we need to talk about, mental illness and trauma and stress."

Estelle Slootmaker is a working writer focusing on journalism, book editing, communications, poetry, and children's books. You can contact her at [email protected] or www.constellations.biz.

Lead image designed by Jay Hero.

Sheila Marcus photo by Doug Coombe. Wassim Tarraf photo by Nick Hagen. Kristin Gietzen and Marvin Mckenzie photos by Bud Kibby. All other photos courtesy of the subjects.
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Q & A: Dr. Sheila Marcus
Q & A: Dr. Sheila Marcus
On pediatric mental health


Michigan Child Collaborative Care (MC3) helps primary care providers address their young patients' mental health by offering same-day phone consultations with psychiatrists as well as telepsychiatry visits with patients. These services have proven vital during the pandemic, both initially, as shutdowns limited access to in-person mental health supports; and on an ongoing basis, as the number of Michiganders with mental health issues has soared. Dr. Sheila Marcus, a clinical professor at the University of Michigan and section chief for child and adolescent psychiatry at Michigan Medicine, helped launch MC3 in 2012.

This interview has been edited for length and clarity.

Q: Why is it important that we focus mental health efforts on children and teens?

A: We are beginning to discover what was a substantial problem in the state of Michigan before the pandemic has become a tsunami of need during and following the pandemic. About 20% of children and adolescents will have some sort of mental health issue, depression, anxiety, ADHD, autism, trauma, OCD, and a whole host of issues. That has increased during the pandemic. The data now is something like 40% of adolescents report mood and anxiety symptoms during and following the pandemic.

In places where there exist child-mental-health-trained or child psychiatrists, the wait times are anywhere between four and six months. The vast majority of the counties in the state of Michigan don't have any trained children's psychiatrists. So there's no wait time because there's no line to wait in. In those cases, generally, children are being cared for by pediatricians, family medicine physicians, or nurse practitioners.

Q: What kinds of mental health challenges does MC3 help pregnant women and new mothers overcome?

A: The most common complication of pregnancy is postpartum or pregnancy-related depression. The postpartum period is often a time when women who have bipolar illness have their first episodes. The other big issue in pregnancy and postpartum is trauma. So many women are victimized during their pregnancies. In the case of women with domestic violence histories, there often are uses of substances including marijuana and alcohol, sometimes opiates. 

We're very mindful that when we're caring for pregnant moms, we also have to care for the babies, even during the pregnancy. If we have a victimized, traumatized, substance-abusing, depressed mom, simply treating the mom’s disorders will be insufficient. You have to make sure that mom and baby get into infant mental health services to give mom the skills that she needs to form a healthy attachment relationship to the infant. We sometimes call this ‘the dance of early childhood,’ moms looking at babies, babies looking back at moms, and falling in love with one another.

Q: What role can primary care providers play in meeting the mental health needs of these women and their infants?

A: Many obstetricians are doing a screening for depression, anxiety, and trauma during pregnancy. They're more likely than anybody to pick up on signs and symptoms of some of these disorders. They may have followed the mom in other pregnancies and have a sense of whether there have been other issues. In family medicine [practices], doctors are following moms during pregnancy and postpartum as well as their children. They're really connected to the family, sometimes for many generations.

Q: How is MC3 engaging these PCPs?

A: Our role is to support and scaffold the primary care docs in caring for the children that are already in their panels for primary care. After they've called us once or twice, they realize that we're here to support them and here to validate that the work that they're doing is incredibly difficult — not chastising them for not being able to do things that they weren't trained to do. 

We also do "brown bags," clinical case consultations, where a group gets together and presents a case or two to discuss cases over lunch. We have a variety of recorded modules available to practitioners on a whole host of topics like depression, anxiety, eating disorders, LGBTQ issues, and suicide. We've begun a specific suicide prevention and safety planning [module], which we're delivering to 60 or 70 practitioners several times a year. Since COVID, there are now billing codes that allow them to bill for consultations, report writing, tests, or multidisciplinary meetings that happened on the same day as a [patient] visit.
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