200x200-ward Since the beginning of the COVID-19 pandemic, its consequences have had a severe effect on mental health (Czeisler et al., 2020; Sher, 2020). Factors such as economic anxiety, social isolation due to necessary social distancing regulations, anxiety and fear regarding the virus, and chronic stress are factors that have contributed to the increase in mental health symptoms (Sher, 2020). Since the start of the pandemic, there have been notable increases in depression and anxiety and increased psychological distress in both the general population and among healthcare professionals (Sher, 2020). A large survey of adults in the U.S. found that there was a substantial increase in anxiety and depressive symptoms endorsed compared to the same time the previous year (Czeisler et al., 2020). This survey also found that in June 2020, 40.9% of participants endorsed at least one adverse mental health condition, including anxiety and depression symptoms (30.9%) and PTSD symptoms (26.3%). Worryingly, the survey also found that 10.7% of participants had seriously considered suicide over the past 30-days (Czeisler et al., 2020). This is in line with case reports of COVID-related death by suicide (Sher, 2020). Survivors of COVID-19 also appear to be at increased suicide risk (Sher, 2020).

Unsurprisingly, there has also been a corresponding rise in heavy substance use and substance use disorders alongside the increased rates of other mental health symptoms (Sher, 2020). In the same large survey, 13.3% of participants endorsed starting to use substances or increasing substance use to cope with the emotional burden of the pandemic (Czeisler et al., 2020; Ornell et al., 2020). In the week ending March 21, 2020, there was a 55% increase in alcohol consumption compared to the same time last year and a 243% increase in online sales of alcohol (Sher, 2020). Recently, the Center for Disease Control (CDC) released a report about the increase in drug overdose over the course of the pandemic. The data suggests that drug overdoses have accelerated, with synthetic opioids driving the overdose increases (Center for Disease Control, 2020). Alarmingly, the increases seen in February, March, April, and May 2020 are the highest increases seen since the 12-month overdose estimates began in January 2015 (Center for Disease Control, 2020).

The rising rates of mental health issues are occurring alongside an increased difficulty providing and accessing mental health care, particularly for vulnerable and at-risk populations. This is particularly true for residential treatment programs for substance use, many of which closed due to physical distancing requirements within days of the pandemic declaration (Melamed et al., 2020). The centers that remained open had reduced admission capacity due to social distancing requirements, decreasing the ability of clients to access care. For example, across 20 different residential substance use treatment facilities in California, the pandemic resulted in severe changes in functioning during initial shelter-in-place (SIP) orders (Pagano et al., 2020). Clients often experienced delayed treatment or early discharge during the SIP orders (Pagano et al., 2020). Clients who were able to receive treatment suffered from isolation, receiving fewer services overall, technological challenges with accessing telehealth (e.g., no phone with internet, insufficient internet bandwidth), and experiencing increased economic and psychosocial barriers upon re-entry to society from the program (Pagano et al., 2020). These difficulties are in addition to facilities often struggling to access PPE and obtain sufficient resources for infection control measures during the initial SIP orders (Pagano et al., 2020).

Many programs have substituted providing in-person services with remote care via telehealth, including traditionally residential facilities (Melamed et al., 2020). Telehealth is currently being used for outpatient treatment and group-based programs for substance use and for support groups such as alcoholics anonymous and narcotics anonymous (Oesterle et al., 2020; Shelton et al., 2020). These resources are a mix of telephone-based recovery support, telephone-based therapy, video-based therapy, and smartphone apps (Oesterle et al., 2020). However, telehealth has specific barriers, such as training staff to use telehealth services, lack of reliable internet, and lack of required equipment (e.g., phone, tablet, computer; Oesterle et al., 2020; Shelton et al., 2020).

Veterans may be particularly vulnerable to experiencing pandemic-related stressors, including economic issues, exacerbation of mental health symptoms, and lack of social support (Gerber, 2020; Murphy et al., 2020; Ramchand et al., 2020). The mass societal upheaval caused by the pandemic can be re-traumatizing for veterans, who have had more trauma exposure than the general population and thus have more psychiatric comorbidity, including substance use disorders (Gerber, 2020; Murphy et al., 2020; Ramchand et al., 2020). A study in the U.K. found that veterans reported increased anxiety, depression, and PTSD symptoms, along with increased anger and alcohol misuse due to the pandemic (Murphy et al., 2020). Additionally, veterans are more likely to be economically impacted by the pandemic (Ramchand et al., 2020). In the U.S., approximately 15% of veterans work in industries that have been hard-hit by the pandemic (Ramchand et al., 2020). Veterans also often have more limited savings compared to their civilian counterparts (Ramchand et al., 2020). Moreover, the social isolation caused by the pandemic may increase the already high veteran suicide rate and increase demand on an already taxed mental health care system (Ramchand et al., 2020).

To help address the needs of veterans, the Veteran's Health Administration (VA) has worked to exponentially increase access to and feasibility of telehealth services for veterans receiving care at the VA (Connolly et al., 2020; Rosen et al., 2020). This includes those who access substance use treatment. By June 2020, after the initial pandemic declaration, the VA as an organization experienced an 11x increase in encounters using direct-to-home video and a 5x increase in telephone contacts relative to before the pandemic (Rosen et al., 2020). Over 550,000 veterans have received virtual mental health care, scaling up telehealth services in the first four months of the pandemic by 80% (Rosen et al., 2020). In line with this, a survey found that VA psychologists reported a 7x increase in using telehealth methods for providing psychological services (Pierce et al., 2020). The VA also expanded existing programs to enable closer monitoring of veterans at risk of suicide, with a focus on veterans who have screened positive for COVID (Rosen et al., 2020). These remarkable increases in expanding access to telehealth and taking steps to ensure continuity of care will likely help to mitigate some of the expected mental health fall-out of the pandemic. However, as the pandemic continues, more research will be needed on the impact of pandemic-related stressors on veterans and how these adaptations can be improved to continue providing quality services to our nation's veterans.


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