Brewing beneath the public health threat posed by the coronavirus pandemic, Hawaii health officials are bracing for the beginning of a major mental health crisis.

Mental health providers statewide are reporting heightened levels of anxiety, loneliness, depression and stress in their patients as a result of job loss, financial worries and the psychologically isolating effects of public health safeguards like public mask-wearing and stay-at-home orders.

As a result, many psychiatrists are increasing their patients’ medication dosages or seeing them more often.

Calls to crisis hotlines are on the rise, with some callers reporting long wait times. Hospitals across the state are admitting a greater number of patients with psychiatric symptoms.

“I wouldn’t say we weren’t in a mental health crisis before COVID, but now it’s being exacerbated,” said Eddie Mersereau, deputy director of behavioral health at the Hawaii Department of Health.

“It’s not so much slamming into us like COVID did when it hit like a freight train and all of a sudden everything was shut down,” he said. “The increase in stress and anxiety and depression that we’re starting to see, we think it’s going to be on the rise for the next six to 12 months.”

New Outreach Initiatives

During the pandemic there has been an uptick in hospital admissions for suicidal ideations and attempts, as well as anxiety and depression, at the four hospitals operated by The Queen’s Health Systems on Oahu, Molokai and the Big Island, according to Mia Taylor, director of community and post-acute care services for The Queen’s Health Systems.

Dr. Travis Parker, the emergency room medical director for the Kauai Veterans Memorial Hospital and Samuel Mahelona Memorial Hospital, said he’s also seeing a significant increase in psychiatric admissions, as well as more patients being admitted because they are intoxicated or need medical treatment as a result of violence between families, couples or roommates.

In early May, four young Kauai men hanged themselves in the same week. Although the unusual spate of deaths cannot be directly attributed to the coronavirus pandemic, the suicide cluster is raising public concern about the mental health consequences of the economic upheaval many Hawaii residents now face.

At the same time that the need for psychiatric help is deepening, the public health threat of COVID-19 has forced most mental health providers to limit or eliminate face-to-face programs and services.

The state Adult Mental Health Division has been trying to supplement a lack of in-person services with phone check-ins, Zoom video chat groups and walk-up meal distribution, Mersereau said.

While these new outreach initiatives are no substitute for personal interaction, he said they are helping to engage people who might otherwise be socially isolated now that so many programs and services are being delivered remotely, if at all.

“Behavioral health is essential to the extent that we can provide services safely,” Mersereau said.

A positive consequence of the pandemic is that it has pushed mental health service providers to tear down the walls and silos between them. Mersereau said there’s a lot more communication and collaboration happening between state and private providers, including new partnerships with homelessness outreach groups.

The behavioral health staff at Kokua Kalihi Valley is seeing a 45% spike in need for services, mostly from patients with preexisting psychiatric diagnoses, according to KKV Medical Director Dr. Laura DeVilbiss.

“A lot of our staff is having anxiety, too,” she said. “We’re all going through a pandemic. Our behavioral health staff is reaching out to everybody on staff to make sure that we’re all taking care of ourselves.” 

Mental health patients have voiced an overwhelming preference for telemedicine, DeVilbiss said, because they can receive therapy at home while doing laundry and without having to coordinate child care.

But even with new virtual tools, some providers wonder whether the state has enough resources to support the anticipated onslaught of people in distress.

“I’m concerned that we’re going to have a lot of mental health consequences from the unemployment, the anxiety and the stress that people are experiencing,” said Annie Nguyen, a Kailua psychologist. “The World Health Organization thinks we’re going to have a significant mental health crisis. I don’t know that we are collectively prepared for it.”

Pros And Cons Of Telemedicine

The coronavirus pandemic has rapidly expanded the use of telemedicine for psychotherapy. Many insurance companies are waiving copays for telemedicine visits and mental health providers have overwhelmingly embraced virtual appointments with their patients.

“Therapy is so key, especially when it’s situational depression or anxiety,” Taylor said. “These are people who don’t have a chemical imbalance. When these symptoms are coming up for people because of what’s going on right now with the pandemic, therapy is so important. And the good news is there are lots of therapists available.”

It’s not a panacea.

Telemedicine is not always effective for people with serious mental health diagnoses, such as schizophrenia and major depression.

It’s also not comfortable for people who are unfamiliar with video chat platforms or don’t have access to the technology required to use them.

Fran Inouye, a psychologist in Honolulu, said several of her older clients have opted out of receiving treatment during the pandemic until face-to-face visits start to feel safe again.

For Robert Brown, a Kauai psychologist who has been practicing for 50 years, the thought of transitioning to telemedicine — something brand new to him — was so unappealing at this late stage in his career that he decided to retire three weeks ago.

Brown said it was difficult to find new providers for his former patients, especially those who have a serious mental illness. He also struggled to find providers willing to treat new patients covered by Med-QUEST, the state’s public health insurance for low-income people.

Brown’s retirement might be short-lived, however. He said he would return to work out of a sense of duty if the need for coronavirus-related mental health services outweighs the available resources.

There is some concern that the greater patient access afforded by telemedicine could lead to burnout for some providers.

To keep up with the surge in demand, Tanya Gamby, a Kauai psychologist, said she has been regularly taking virtual appointments with her patients on evenings and weekends.

With telemedicine, Honolulu psychiatrist Sonia Patel said she’s learning that it’s harder to detect subtle cues from her patients’ body language that might give her insight into how well they’re doing.

But by meeting patients virtually in their bedrooms and living rooms, she said she’s gaining access to a whole new set of environmental cues: art on the wall, clutter in a room, a pet cat slinking across the screen.

Telemedicine has also given Patel the flexibility to check in more frequently with patients she’s concerned about, such as an 11-year-old girl who was having suicidal thoughts that worsened when COVID-19 forced her to stay sequestered at home.

With telemedicine, Patel said she was able to meet with this patient twice a week, plus a third appointment with the patient’s mother. Patel said the girl’s symptoms have eased with the aid of these more frequent visits and medication.

“This might shift my practice,” Patel said. “Especially for patients that live on the other side of the island or for patients that I’m not seeing every week for hardcore psychotherapy, just medication checks, they don’t need to drive all the way down to Kaimuki and look for parking when we can just do this.”

For some people the pandemic is relieving mental health symptoms, Patel said.

“An interesting thing is that a lot of my patients who are introverts are really loving this time,” Patel said. “They don’t want it to end because they are finding that there’s no pressure on them right now to interact.”

Some people are having breakdowns because they are overwhelmed with the pressure to juggle working from home while also acting as a pseudo-school teacher to their children who are adjusting to distance learning, Patel said.

The husband of one of Patel’s patients is applying for the federal Family and Medical Leave Act so that he can have the flexibility to stay home to help his wife with schooling and rearing their kids because the stress of these new responsibilities on top of her day job is causing her to become suicidal.

While there is a shortage of psychiatrists in Hawaii, some primary care physicians are well-equipped to help their patients manage mild to moderate anxiety and depression by prescribing psychiatric medications.

Free Help Is Available

Another problem is that some people who’ve lost their health insurance along with their job will not be eligible for free coverage from Medicaid through the state’s Med-QUEST insurance program because they are taking in too much money through unemployment benefits.

“So now we’re saying, ‘OK, you’re going to have to drain your entire bank account before you can qualify for Medicaid?’” Taylor said.

“We’re very, very worried about that,” she added. “We’re starting to see a trickle of this happening now, but it’s not yet the big wave that I think is coming.”

People who don’t have health insurance can get services for free through the Hawaii Mental Health Pro Bono COVID-19 Project, which launched last week.

Honolulu psychologists Lawrie Ignacio and Graham Taylor assembled a team of about 100 psychologists, marriage and family therapists, social workers and mental health counselors across Hawaii to provide services by phone or online video platforms.

“It’s going to be the mental health professionals putting our nation back together.” — Graham Taylor, psychologist

The program will continue for the foreseeable future as Ignacio and Taylor said they suspect that the need for mental health services will continue to rise as the fallout of job loss and financial upheaval sets in.

“This virus has taken away things from people in ways that it’s affecting their identity,” Taylor said.

Another resource for people in the throes of a mental health emergency is the state-run Crisis Line of Hawaii.

The hotline is experiencing a significant increase in calls, according to Yara Sutton, program support services manager at the state Health Department’s Adult Mental Health Division.

In March through mid-April, Sutton said callers were primarily concerned that they might be infected with COVID-19 or they were worried about their risk of contracting it.

The conversation shifted from mid-April through May, when most people were calling the hotline for help dealing with anxiety stemming from financial losses and economic stressors.

Taylor said she’s fielded complaints from patients who are having trouble getting help from Aloha United Way 211, which she said has been backed up by a flood of calls.

The hotline connects people to information and services that can help them find food, shelter, drug treatment, child care, elderly care and job training.

Many of the same resources available from the hotline by phone are also listed on the 211 website.