Men are dying at higher rates from COVID-19 than are women, and there are likely many reasons for that trend, from potentially weaker immune systems to riskier choices surrounding alcohol and tobacco use. But the pandemic is putting the spotlight on another issue disproportionately affecting men: mental health.
COVID-19 is having a profound impact on the mental health of scores of Americans, raising concerns about a heightened risk of suicide. This applies to all Americans regardless of gender, but men specifically tend to be much more care avoidant, according to the Journal of Health Psychology, and struggle more with the stigma associated with seeking mental healthcare.
As of March 1, the American Foundation for Suicide Prevention found that men died by suicide roughly four times more than women, and since the start of the pandemic, one county in Washington reported a large surge in suicides, mostly men in their 30s and 40s.
Large-scale data has yet to exist on the extent to which the coronavirus is exacerbating the problem, but Dr. Judith Feld, a psychiatrist with 20 years of clinical experience and 10 years of managed care experience, anticipates significant issues related to COVID-19 over the long term, including increases in anxiety. With such a dynamic situation, the healthcare industry would do well to anticipate some of the problems this could cause.
Feld, who recently joined Catasys, which seeks to improve health and reduce claims costs for health plan members with behavioral health disorders, said that men are typically less likely to seek behavioral healthcare due to how society has conditioned them to value themselves, and their sense of that value.
"Especially in our culture, men are supposed to be tough, self-sufficient, and going to a healthcare provider or admitting there could be a mental health concern is often seen as a vulnerability," she said. "It's not really comfortable for men in our country to deal with. There are cultural and socio-psychological issues around why they avoid care, and they don't talk about it."
A SYSTEMIC PROBLEM
That stigma creates headwinds that can make addressing behavioral health a challenge for men and for the healthcare system itself. Even before the pandemic, there was a severe shortage of mental health services, in rural areas in particular, and that's due partly to mental health being treated differently from primary care in terms of reimbursement. The Centers for Medicare and Medicaid Services has ensured parity on copayments and cost-sharing for primary care services, but an equivalent framework for mental health treatment has yet to emerge.
Meanwhile, reimbursement is paltry. Mental health providers are paid at close to 5% below the Medicare allowable, according to Revel Health. By comparison, acute and hospital-based procedures are typically paid at 200% the allowable for commercial services – a stark difference.
Because of a lack of providers and poor coverage, many people have to go outside of their networks to find a provider. That makes addressing mental health a potentially costly proposition, and, in fact, people do spend more on behavioral health providers than on regular acute or primary care.
In addition to those challenges, men face a stigma that has been baked into society over decades.
"Men have had very focused gender roles, historically," said Feld. "Luckily these are changing, but men have always been seen as the providers, seen as strong, who can be depended upon to take care of things for other people. It has been a culture that has not invited men to be vulnerable. And that individualism has really played out in our country for decades. We've had roles that have enforced this, and a culture that has valued this. It's very connected to men's self-esteem and how they see themselves."
WHAT HEALTHCARE CAN DO
Engagement and prevention are the main areas in which the healthcare system can make a dent. Since the industry focus has traditionally centered more on acute and primary care, mental health sufferers are often left to wait until they have the cognitive or emotional equivalent of a heart attack before being treated. The prescription for the industry is to shift the emphasis to preventative mental healthcare so patients don't find themselves in dire situations.
In that way, health plans can have a role in shaping the discussion, in part by acknowledging and highlighting the reality that mental health is the top medical condition that results in disability.
Health plans can also play a role in implementing mental health "extenders," such as health coaches, who work tactically to help a person through a difficult situation. It's not a long-term solution, but at the very least would provide a stopgap of sorts.
Feld stressed the importance of engagement, which is something the healthcare industry has historically not done well when it comes to mental health.
"There's an assumption that people will want healthcare and come to healthcare, and we know that isn't true, and it's certainly not true for men who are care avoidant," she said. "We need to be focused on care avoidant behaviors, reaching out to those individuals in a targeted, personalized way, understanding the population health issues, but being tailored and individual in approach. We need to reframe what it means to reach out and get the healthcare you need."
The "extenders" – the engagement specialists and health coaches – have a massive role to play in communicating not just the importance of receiving care, but what a person's goals are, and what their barriers to self-care might be. There's also a need, said Feld, for more behavioral health providers, and for more providers to be available through technology platforms such as telehealth.
Any industry shift that takes place would happen at a time when almost half of all people are experiencing increases in anxiety caused by the COVID-129 pandemic.
"People with previous mental health problems are experiencing exacerbations of their conditions," said Feld. "People are developing new problems. Many people will come out of this with some anxiety and do fine, but we want to focus on people who are at risk and have had previous conditions and maybe developing problems. Social isolation [and] shelter-at-home [are] a risk for mental health, and a lot of people are struggling with that.
"Engaging people earlier will prevent a lot of poor outcomes in the future," she said. "We can make a huge difference if we're proactive now."