Maintaining mental health in pandemic times: how insurance can help

COVID-19 has inflicted physical, financial, and economic hardship on many millions of people around the world. Perhaps less visible but no less concerning, it has also taken a toll on people's mental health. After more than 18 months of the pandemic, many studies are yielding a consistent theme of rising incidence of anxiety, depression, and even post-traumatic stress disorder on account of the ongoing health crisis that the world is still coming to terms with. Simultaneously, there may be a widening gap due to lack of accessibility, affordability, and insufficient recognition of difficult-to-diagnose mental health conditions. Insurance can be part of the solution bridging the gap between needs and available resources through early engagement, targeted intervention, and flexible solutions.

Depression, anxiety and COVID-19

A variety of studies and surveys find that the COVID-19 experience has led to a worsening in mental health conditions for many people across the world. For instance, a recent study by the University of Oxford found that 34% of patients with acute COVID-19 infection experienced mental health or neurological conditions after recovery1.  Meanwhile in the US, a study published in the Journal of the American Medical Association found that the prevalence of depression symptoms rose by 3-fold from 8.5% before COVID-19 to 27.8% during COVID-19. Also, lower income groups were at significantly greater risk of depression symptoms than higher income groups2.

Another study found that the share of adults reporting symptoms of anxiety disorder or depressive disorders more than tripled from 11% between January and June 2019, to 41.1% in January 2021. The increase was most pronounced among adults between 18 and 44 years old3.  Elsewhere, a survey by the Organisation for Economic Co-operation and Development showed people between 15 and 24 years reported worsening of their mental health as social restrictions disrupted access to mental health services, closed schools and fueled a labor market crisis4.  

In many countries, increased rates of depression and anxiety have been associated with job losses or a reduction in household income5.  The probability of debilitating symptoms seems to have been higher for women and youth, as well as those with a personal history of mental health issues or who experienced the trauma of seeing family members and friends become ill with COVID-196.

COVID-19 and post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD) is a psychiatric condition that can occur in those who witness or experience a traumatic event. Symptoms include flashbacks, emotional instability and feelings of detachment. PTSD is generally associated with conflict or war, but there have also been cases linked to past outbreaks of diseases. For example, with respect to SARS, a study in Hong Kong found that PTSD occurred in a significant percentage of those people who had recovered from the illness. The study also found that for some people, PTSD manifested in persistent psychological distress and diminished social functioning in the four years after infection7.  

A meta-analysis of 88 studies on PTSD occurrence after large-scale infectious disease outbreaks such as SARS, H1N1 and Ebola found the prevalence of PTSD across populations was 22.6%, higher than after major traumatic events (~20%). The prevalence was highest among healthcare workers (26.9%) and infected patients (23.8%) but was also significant among the general public (19.3%)8.  In COVID-19 times, early signs of mental distress are already showing, with one study indicating that the prevalence of PTSD among the general population was already as high as 15%9.   

More vulnerable groups include the following:

  • Patients who have suffered severe COVID-19: Acute infection requiring hospitalization is associated with increased psychiatric disorders, often observed with a post-recovery delay. One study found a PTSD prevalence of 30.2% after acute COVID-19 infection10.  Patients who required urgent hospitalization or ICU treatment on account of COVID-19 may experience direct trauma that puts them at increased risk of developing symptoms of PTSD. The study suggests that psychosocial support and strong family and community networks can play an important role in preventing PTSD symptoms following recovery from acute disease.
  • Frontline workers: Healthcare workers, in particular those in emergency settings, are at elevated risk of PTSD given their increased exposure to suffering, death and trauma. In the US alone, more than 36% of all public healthcare workers have reported symptoms of PTSD during the current pandemic11.  Some studies indicate that non-clinical workers or frontline workers without formal medical training may be less resilient to trauma than healthcare professionals with advanced training. For instance, research carried out in Turkey during the pandemic indicates that PTSD rates for non-physician health workers was 49.5%, notably higher than 36% for physicians12.  
  • Pregnant women and new mothers are also vulnerable to PTSD. Pre-pandemic, up to 3% of women developed a stress disorder after giving birth13.  Given the special social circumstances triggered by the pandemic, and the documented increase in symptoms of anxiety and depression in new mothers, it is not unlikely that that percentage may rise14.  

Treatment gap exacerbates the crisis

Accessibility and affordability remain the biggest barriers to adequate treatment for mental health conditions. For example, in the US less than half of sufferers receive treatment15.  Pandemic-related disruptions and barriers that have emerged for those seeking care, as well as reduced care capacity during the crisis, may also lead to more undiagnosed cases and lower rates of adherence to treatment. These factors could see a rise in the number of instances of mental health that prove more difficult to treat over the longer term.

Expansion of telemedicine and virtual care, especially in an environment where traditional care models face disruptions, is one tool to bridge the gap between need and delivery of mental health services. Data from the US suggests that telehealth usage has increased 38-fold since the onset of COVID-19. More than 60% of the respondents in a recent McKinsey consumer survey conducted in pandemic times indicated that they opted for virtual instead of in-person appointments with a psychologist or psychiatrist16.  Telehealth is now not just an acceptable, but is in many cases the preferred means for receiving treatment, especially in an environment where people are isolating on account of social restrictions17.  In the US, a growing proportion of telehealth insurance claims - overall, as well as those driven by mental health conditions - further supports this hypothesis18.

Bridging the protection gap

Mental health insurance solutions are still developing, partly due to difficulties in diagnosis of associated conditions and also because of the interconnectedness of physical and mental health. The latter poses challenges to the design and scope of mental health covers. The presence of co-morbidities, lack of data, reliance on self-reporting and limited availability of facilities to treat sufferers are additional obstacles.

In this environment, some key opportunity areas for insurers include:

  • Offer preventive solutions: Minimally disruptive, low-cost interventions can be offered to initially offset or mitigate more disruptive, higher-cost claims later. The ability to engage early is important. If prevention is not possible, obtaining a timely diagnosis for the individual and the creation of a comprehensive, personally tailored package of care can help successful treatment and positive outcomes.
  • Design flexible customer-centric offerings: The specific areas where consumers are seeking insurer support include mental wellness counselling, hospitalisation support and rehabilitation. Some consumers may also be open to flexible mental health add-ons to existing critical illness or medical insurance covers, rather than a stand-alone policy.
  • Continue to gauge future trends in disability insurance: While headlines have focused on excess mortality rates and symptoms associated with long COVID, a longer-term challenge will be to assess trends in disability insurance, these in turn driven by changing levels of mental illness, musculoskeletal or back pain, and long COVID across the population. This is not the only challenge: insurers and the medical community alike will need to understand the relationship between mental and physical health conditions associated with COVID-19. The likelihood of being diagnosed with a mental health condition increases with certain physical conditions, while the presence of a pre-existing mental health condition as a co-morbidity is also an indicator, in some cases, for poorer outcomes.
  • Identify vulnerable population groups: Insurers can design targeted intervention solutions for those with higher susceptibility towards mental ill-health on account of COVID-19, such as medical personnel, expectant and new mothers, and the millennials and generation Z.

Given uncertainty over the still-emerging challenge of COVID-19, the natural inclination would be to observe and wait before insuring longer-term health outcomes. This would be a mistake, in our view. Life and health insurers, and their reinsurers, can engage now, tailoring interventions to where they can have the greatest impact: disseminating information and supporting prevention. The pandemic has erected additional barriers between patients and care providers. Insurers can be part of the solution on the route back to “normal”, delivering value to customers and enhancing customer engagement, as well.

References

1 M Taquet, J R Geddes, M Husain, et. al., "6-month neurological and psychiatric outcomes in 236 379 survivors of COVID-19: a retrospective cohort study using electronic health records", The Lancet Psychiatry, 06 April 2021.
2 C K. Ettman, S M. Abdalla, G H. Cohen et. al., "Prevalence of Depression Symptoms in US Adults Before and During the COVID-19 Pandemic", JAMA Network, 02 September 2020.
3 N Panchal , R Kamal , C Cox et. al., "The Implications of COVID-19 for Mental Health and Substance Use", Kaiser Family Foundation, 10 February 2021.
4 Supporting young people’s mental health through the COVID-19 crisis, OECD Policy Responses to Coronavirus (COVID-19), 12 May 2021.
5 C Ruengorn, R Awiphan, N Wongpakaran et. al., "Association of job loss, income loss, and financial burden with adverse mental health outcomes during coronavirus disease 2019 pandemic in Thailand: A nationwide cross-sectional study", Depression Anxiety, PubMed.gov, 2021.
6 K Wanigasooriya, P Palimar, D N. Naumann, et. al., "Mental health symptoms in a cohort of hospital healthcare workers following the first peak of the COVID-19 pandemic in the UK", Cambridge University Press, 29 December 2020.
7  X Hong, G W Currier, X Zhao, et. al., "Post-traumatic stress disorder in convalescent severe acute respiratory syndrome patients: a 4-year follow-up study", General Hospital Psychiatry, PubMed.gov, 2009.
8 Yuan, K., Gong, YM., Liu, L. et al. "Prevalence of posttraumatic stress disorder after infectious disease pandemics in the twenty-first century, including COVID-19: a meta-analysis and systematic review", Mol Psychiatry, 2021.
9 L Zhang, R Pan, Y Cai, J Pan. "The Prevalence of Post-Traumatic Stress Disorder in the General Population during the COVID-19 Pandemic: A Systematic Review and Single-Arm Meta-Analysis", Psychiatry investigation, PubMed.gov, 2021.  
10 D Janiri, A Carfi, G Kotzalidis, et. al., "Post-traumatic Stress Disorder in Patients After Severe COVID-19 Infection", JAMA Psychiatry, 18 February 2021.
11 J Bryant-Genevier, C Y. Rao, B Lopez-Cardoso, "Symptoms of Depression, Anxiety, Post-Traumatic Stress Disorder, and Suicidal Ideation Among State, Tribal, Local, and Territorial Public Health Workers During the COVID-19 Pandemic — United States, March–April 2021", Morbidity and Mortality Weekly Report, 2 July 2021.
12 L Baertlein, ”Each COVID-19 surge poses a risk for healthcare workers: PTSD” Reuters, 5 September 2021.
13 S Ayers, R Bond, S Bertullies et. al., "The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework", Psychological medicine, PubMed.gov, 2016.  
14 A M Kotlyar, O Grechukhina, A Chen, et al., "Vertical transmission of coronavirus disease 2019: a systematic review and meta-analysis", American Journal of Obstetrics and Gynecology, PubMed.gov, 2021.
15 Brother, You're on my mind, National Institute on Minority Health and Health Disparities, accessed on 31 August 2021.
16 Telehealth: A quarter-trillion-dollar post-COVID-19 reality?, McKinsey & Company, 2021
17 J Tse, D LaStella, E Chow, et. al., "Telehealth Acceptability and Feasibility Among People Served in a Community Behavioral Health System During the COVID-19 Pandemic", Psychiatry Online, 7 May 2021.
18 R Gelburd, "The Growing Connection Between Telehealth and Mental Health During COVID-19", U.S. News, 16 April 2021.

  

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