Earlier this month, Dr. Atul Gawande posted a graphic from Johns Hopkins University that overlaid daily COVID-19 growth in Italy and the United States. The two paths were eerily similar. We at #CrisisTalk began using the same framework and adding in China’s trajectory to gain insight into our likely future in the United States. By aligning the first day each country reported over 100 cases (March 2nd in the U.S.), we aspired to project 8 and 45 days into the future. This approach could assist in planning the mental health and substance use crisis response needed for communities across the nation.
If we follow China’s trajectory, we might expect a four to six week period of major impact followed by a flattening of the curve when it comes to the number of individuals diagnosed with COVID-19. Wuhan is starting to relax restrictions and see days without any new reported cases. Unfortunately, the U.S. line is not yet bending and has pushed to the highest level of any country in the world with no sign of slowing down. We’re in uncharted territory and have not yet engaged in the massive testing and social distancing that Dr. Gawande says it is necessary to flatten the curve.
Seattle, Southern California, New York City, and New Orleans have seen the highest concentrations of domestic COVID-19 cases, but even states like Arizona, with far fewer diagnosed cases, have declared the virus to be widespread, according to Dr. Cara Christ, the state’s Director of Health Services. She projects that the virus’ peak will start in the middle to end of April with peak hospitalizations to follow in May. Across the U.S, we must prepare for an extended battle! National Geographic and many other publications have drawn parallels between COVID-19 and the Spanish flu, an H1N1 virus that spread globally starting in the spring of 1918 with a very significant impact through the spring of 1919.
For behavioral health crisis responders, we must anticipate the possibility that this national emergency might have waves that aren’t counted in weeks but months. What is the impact and how do we innovate to meet the evolving needs of our communities as our resources are strained, some to the point of exhaustion?
Disaster Mental Health Crisis Response
Over the past 20 years, we’ve seen multiple national disasters with 9/11 and Hurricane Katrina, both requiring robust disaster mental health crisis response to support individuals recovering from the psychological effects of natural and human-caused disasters. FEMA’s Crisis Counseling Assistance and Training Program (CCP) has provided supplemental assistance to local community efforts. SAMHSA’s Disaster Distress Helpline and the National Suicide Prevention Lifeline have also engaged in partnerships with state-level behavioral health and public health efforts. FEMA is now working with DHHS to execute a “whole of government response.”
Unlike 2001 and 2005, we’re now seeing the emergence of a national infrastructure of behavioral health crisis response, crisis call center hubs, community outreach mobile teams and local mental health, and substance use crisis receiving and stabilization facilities that serve as alternatives to jail and inpatient acute care. Increasingly, the response of these services and supports is one of crisis care now: available to anyone, anytime, anywhere (see SAMHSA’s National Guidelines for Behavioral Health Crisis Care: A Best Practice Toolkit). These are substantial supports to mitigate the impact on hospital emergency departments, which are the front line in the COVID-19 battle. They also represent locations of high risk to spread the virus, so we must solidify other locations for care when someone is experiencing a mental health or substance use crisis.
In the days ahead, we’ll see increased coordination of state, local, tribal, and territorial governments to mobile their resources to address evolving community needs. Alternative service delivery models that leverage technology will become more prevalent, and it will become clearer than ever that behavioral health cannot lean on emergency departments to manage the front door to acute or crisis care. We do not have enough no-wrong-door crisis care resources to tackle our existing demand, and demand is most certainly going to rise.
Now and Later
The challenges of our disaster mental health crisis response are equal parts now and later. First up, shoring up our U.S. healthcare system’s ability to provide ICU and ventilator care for those with critical respiratory distress while solidifying an adequate supply of personal protective equipment (PPE) for healthcare workers are the top priorities.
On March 11, 2011, the world’s deepest and largest sea wall at 18 feet was overwhelmed by the tsunami created by a 9.0 earthquake that occurred eighty miles offshore of northern Japan. Alarms went off, and people were warned to get to higher ground. The wall was simply not high enough for the magnitude of this disaster, and the water flowed over the top and destroyed wherever it flowed next. More than 28,000 people were confirmed dead.
In like manner, approximately 14% of individuals infected with COVID-19 require hospital care, and about 30% of these patients will need intensive care and/or ventilator support to survive.
In the U.S., our sea wall of ICU beds is the deepest and most extensive in the world (per capita) at nearly 97,000. The American Hospital Association dataset does not record the proportion capable of negative pressure isolation, but it does add that there are another 25,000 step-down beds and nearly 1,200 burn beds, some of which might be repurposed for this disaster. Acute care hospitals are estimated to have 62,000 ventilators. Any volume that exceeds our available capacity will lead to lives that are unnecessarily lost… we will simply be exceeding the height of our sea wall and lose our ability to fend off the full force of the attack. We must evolve! We must develop solutions that reduce the amount of water coming at our sea wall or lives will be lost.
The SAMHSA National Guidelines described above call for a system of core no-wrong-door, behavioral health crisis care continuum services (crisis call center, mobile crisis teams, and crisis receiving and stabilization facilities) deployed directly to those in need, which can reduce hundreds of thousands of emergency room visits for people in psychiatric distress. Behavioral health crisis care has the unprecedented opportunity to supply important emotional support and engagement in a manner that frees up hospitals to maximize their capacity to serve those in COVID-19 distress, but this will only occur when crisis providers and acute mental health hospitals remove the default steps of medical clearance and screening in emergency departments. Our communities would never accept the inverse practice of emergency departments delaying access to needed physical health care until a person completed a mental health stability check by a behavioral health professional, so let’s put an end to this equally unacceptable practice. Last month, SAMHSA delivered the toolkit, and now is the time to exponentially expand access to true crisis care services that serve all individuals in need, much like their physical health counterparts of 911 call centers, ambulances, and emergency departments.
As for the later… Part 2: COVID-19: The Physical Health Impacts of Isolation will be posted later this week.