Patrice Harris, MD, MA, discusses the pandemic's impact on children & teens

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

AMA Immediate Past President Patrice Harris, MD, MA, discusses the growing concerns with mental health issues in children and adolescents, access to care and the AMA's Behavioral Health Collaborative.

Learn more about AMA's Behavioral Health Collaborative. If you or someone you know is struggling, contact the National Suicide Prevention Lifeline at (800) 273-8255.

Find additional information on COVID-19 at the AMA COVID-19 resource center.

Speakers

• Patrice A. Harris, MD, MA, immediate past president, American Medical Association.

Unger: Hello, this is the American Medical Association's COVID-19 Update. Today, we're talking to Dr. Patrice Harris, AMA's immediate past president, as well as a psychiatrist and former county health director in Atlanta about mental health issues in kids, teens and young adults. I'm Todd Unger, AMA's chief experience officer in Chicago.

Dr. Harris, we're closing in on a year since our first lockdown, and we're seeing the numbers come down and good news on the other one with vaccines, but we're also seeing growing concern with mental health issues, especially in young people, children, adolescents and young adults. Can you talk about the impact that that pandemic has had on these folks?

Dr. Harris: Well first, Todd, of course, as a child and adolescent psychiatrist, I always am glad for the opportunity to elevate mental health issues because we just don't talk about them enough. But I think that you know from what we're seeing regarding the number of adolescents who are reporting more symptoms of depression and anxiety, we've seen an increased number of suicides. Actually, adults are endorsing symptoms of anxiety and depression. Everyone really wants to, and I'm glad, talk about mental health, but these are certainly worrisome signs. It's been a year. People are using all types of terms, "COVID fatigue," "hitting the wall," but at any rate, this is something that we need to think seriously about, talk seriously about and act seriously about.

Unger: When you think about kind of on the younger end of the spectrum, and we have ... let's say children, adolescents and young adults, and you think about the drivers of what is causing this, the issues around mental health. Do you see kind of differences between those groups?

Dr. Harris: I think the drivers are the same, right, and many of these drivers were the same pre-COVID. It's just that COVID has amplified issues around loneliness, disruption in lives, but have certainly before, there were opportunities for that human connection to be with friends, to be with family members. COVID has certainly disrupted that. COVID has disrupted a sense of safety.

I've talked to young folks, and they feel that they aren't as safe. They feel vulnerable. Again, parents are losing jobs, and so there's economic stressors. And folks, unfortunately, have ... some folks have personal experience with illness or death in loved ones. And even in that, the normal rituals that some people had in this country to grieve that and have that opportunity then to not resolve grief, but at least say goodbye to people that we love, we don't even have the ability to do that. And so all of these stressors, we are seeing these increased incidences of depression, anxiety and suicide.

Now I do want to say this, Todd, we, always, at the AMA say we need to rely on the science and the data. So what we don't want to do is draw any cause and effect lines here, right? But we do know that people are tired. They're exhausted. They are feeling emotionally disconnected. Some folks are using alcohol and drugs to connect. So all of this certainly raises this as a critical issue that we have to address, really, not just in the medical community, but across our society.

Unger: Well, I read a pretty incredible statistic over the weekend that said about a quarter of 18- to 24-year-olds said they had seriously thought about or considered suicide. That's an astounding statistic. Can you talk more about mental health issues for young adults?

Dr. Harris: Well, and I will say we had seen the number of suicide attempts and suicide increase over the last several years. And by the way, as we've centered equity into all of our conversations right around COVID and around mental health, those numbers were increasing in greater numbers, Todd, for African American male youth. And so as we think about the disruption in lives and the loneliness, we do see, and if you have noted from this study, more young folks talking about suicide. And so we really do need to make sure support services are available.

Any time I'm talking about mental health, I want to make sure that we display text lines or 1-800 numbers where folks can get the help that they need because we want to make sure that everyone knows that it's okay, first of all, not to be okay. You don't have to pretend, but we also want to make sure that folks know where they can go to get help.

Unger: Are there any particular signs for physicians to watch for, to recognize when a specialist might be needed?

Dr. Harris: Well, let's start with family members, right? Because let's start with most folks are at home. And what I've been encouraging parents to do is certainly try to differentiate between those sort of normal expected reactions to what we're going through. We don't want to pathologize every little bit of stress and anxiety and worry, right? We want to routinize that and say, "Yes, these are normal human emotions that you are experiencing."

But I tell parents, and I would say the same to physicians, but if there are children or adolescents or young adults who are becoming more withdrawn, right? If they are not eating, if they are not sleeping, if they are talking about feeling hopeless about the future and sometimes even endorsing, yes, some people might say, "I'm feeling like perhaps I don't want to live anymore." Of course, you want to get those folks immediate help, but those are some of the signs and symptoms that I would watch for and a particular drop-off in ability to function.

Now we know, let's say this, that there has been some drop-off in all of us, right, in our normal productivity. So we don't want to say that that is necessarily indicative of someone who may be depressed, but we certainly want to look at the rate or the level of drop-off and if they are not functioning, even in normal daily activities, that's when parents should ask for help.

Unger: All right. Well, you've led efforts to integrate public health, behavioral health and primary care even before the pandemic. Why is that integration so important in addressing these concerns and how to physicians, including pediatricians, help make this happen?

Dr. Harris: Well, Todd, unfortunately, as we are talking about mental health issues more, there's still a lot of stigma, but there are also issues around accessibility, right, to services. And so we found that there should be no wrong doors to getting services, right? And so when our services are integrated and so when someone can go to the pediatrician and be able to or feel free to and confident and the pediatrician has the tools and resources needed to deal with that. When the primary care doctor feels that they are supported and has the tools and resources and perhaps even a collaborative relationship with the psychiatrist, we believe that leads to that no wrong doors approach.

And so you don't have to necessarily see a psychiatrist as your first step. You can talk with your primary care physician. You can talk with the pediatrician as a first step, and there's a collaborative care there as needed. That's, I believe, a good system. Again, there's no, by the way, one size fits all system, but it's about having a system of no wrong doors and collaborative care. That's about meeting people where they are, meeting our patients where they are, giving them the care that they need, and then making sure that they get referred to other levels of care as appropriate.

Unger: I really liked the way that you stated kind of that no wrong doors as being kind of a paradigm. You also mentioned collaborative. Can you talk a little bit about the Behavioral Health Collaborative and where that fits in here?

Dr. Harris: Yes, and I can't tell you how personally excited I am, of course, as you said, coming into my role at the AMA, knowing the importance of collaborative care, integrated care because, again, people come to care. They may come to an institution for help with rent, right? But we know that there are psychological stresses related to housing and stability. And so it's about making sure that we are doing all that we can to integrate that care. And the AMA has been a leader in this, bringing together a group of people and answering the question. And I can tell you from my primary care colleagues over the years, they all would say, "Absolutely, Patrice. We want to do this, but can you develop any tools for us to make this successful, make this work for our practice and our patients?" And of course, the AMA, as usual, stepping in and has developed this initiative regarding primary care and a behavior health integration where we have developed a toolkit and resources and information for primary care physicians to make this work for their practices and their patients.

Unger: Well, as we move, hopefully, into what would be considered the recovery phase of the pandemic, what have we learned about the fixes that need to happen in our healthcare system to better address mental health issues, and should we expect, I guess, this problem to decrease in severity once these kinds of restrictions in our lives are eliminated?

Dr. Harris: It won't be that simple, Todd. And in fact, as it relates to mental health, we might expect more issues. After we get over the acute phase of the pandemic, I think we will be talking more and thinking more about perhaps post-traumatic stress disorder. This has been traumatic. And then there have been some experiences within the COVID-19 pandemic that has even further led to increased trauma. But now is the time, right? And so, I'm so glad to have this conversation, and so we should be thinking now about a solid mental health infrastructure. It's been woefully underfunded for decades, but now is the time to be prepared, now is the time to think about making sure schools have resources to deal with this, now is the time to make sure that there are resources for community-based organizations to deal with this.

The good news is that there was funding appropriated at the end of last year that will specifically target mental health needs. And certainly there was funding in the CARES Act earlier in 2020, and so now we have to make sure that we are spending that money in ways that gets to the people who need it most.

The other piece that's related here that people didn't hear a lot about in the appropriation bill at the end of 2020 was that payers have been tasked to make sure that they are compliant with the parity laws. That is something that the AMA has been engaged in, and we have particularly been engaged in that as part of the opioid task force because it's not enough to just say these services are available, but patients and doctors have to jump through hoops to get to these services. And oftentimes, payers required some of those additional hoops. So we have to make sure there's parity out there, so that was also good news in that appropriations bill signed into law in December.

So there's good news. There's resources. Resources are needed. Now we have to make sure that we begin the implementation phase of the work.

Unger: Is there... you mentioned earlier that like so many aspects of health care in the pandemic that have revealed real vulnerabilities, especially among minoritized populations. And you mentioned that, in particular mental health in certain communities really need additional look and help here. What's going on in that regard to be able to kind of think about the infrastructure that needs to be built?

Dr. Harris: So it was really about access or lack thereof when it came to communities of color. Now, Todd, there are many reasons for that access. Lack of affordable, meaningful health coverage, right? Oftentimes, I've had so many patients who said they thought they had coverage for their mental health disorder. They thought they had purchased comprehensive coverage, but it really ended up being a sham insurance, particularly when it came to coverage. So it's the access issue.

So from the broader standpoint, we need to continue to fight for Medicaid expansion. We know that so many of our patients were able to get care for mental health and substance use disorders because they had access to Medicaid ... And so we need to look from a broad perspective. We need to look at the barriers to care and parity which I've mentioned already.

But again, this pandemic has exposed so many fault lines, as you noted, of the lack of a well-funded public health infrastructure, the lack of a mental health infrastructure are pre-existing health inequities, and there's some intersection there. And so we have to continue to get the data to see where the access issues lie, where the access to affordable, meaningful coverage, or lack thereof, lies, and then make sure we are targeting interventions and resources to those communities who don't have access.

Unger: You said something really important which is basically we shouldn't expect this to just go away when the pandemic has gone. In fact, we should expect that it could possibly get worse. And when you think about that kind of going forward, are there any things that you would want physicians to keep in mind and think about as we advocate for fixes to a system which was clearly not working before?

Dr. Harris: Well, I hope that physicians take a look at the resources that AMA has developed regarding collaborative care and integration. And by the way, I've been a part of several work groups over the last year where folks are looking at that very thing, looking at integration. And so I hope that physicians take advantage of that. Again, check out those resources. It's no one size fits all solution. Make it work, use the resources that are appropriate for your practice and your patient population. We don't want to ask. Listen, physicians are asked to do so much all the time, right? And so look at the resources and figure out how you can integrate it into the work, really, you are already doing. And I know my primary care colleagues who are listening are saying, "We do so much of that already," but it's just about coordinating it and organizing it in a way that makes it work for your practice and leads to better health outcomes. So I think that's a first step.

Another first step is making sure that we are taking care of ourselves. This has been a very rough time. Whether a physician has practiced on the front lines or in their usual practice site, COVID has disrupted physician practices and our lives as well, both professionally and personally. Already, we're seeing an increase in physician burnout, pre-COVID. And I'm certain that this pandemic has exacerbated that. So the other message to my colleagues is to make sure you are doing what you need to do and practicing self-care and getting help when you need it.

Unger: That's so important. Well, thank you so much, Dr. Harris, for being here today. And it's clear now, more than ever, that we do need physician voices at the table to inform policies and decisions. So thank you for being here, and for those who are looking for resources, please check out ama-assn.org/covid-19. Thanks for joining us. Please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

With an increased number of people reporting worsening mental health in recent years, it is imperative that people are aware of the 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) telephone program.

People experiencing a suicidal, substance use, and/or mental health crisis, or any other kind of emotional distress can call, chat or text 988, and speak to trained crisis counselors. The national hotline is available 24 hours a day, 7 days a week.

The previous National Suicide Prevention Lifeline phone number (1-800-273-8255) will continue to be operational and route calls to 988 indefinitely.