The COVID-19 pandemic has reshaped our lives in countless ways, but perhaps one of the most profound impacts has been on our mental health. Across the globe, individuals have faced isolation, fear, loss, and uncertainty. In the United States, the rate of psychological distress soared as the pandemic unfolded, with millions of Americans grappling with heightened levels of anxiety, depression, and other mental health struggles. However, while the need for mental health services has sharply increased, access to care has not kept pace, with significant gaps remaining—particularly when it comes to outpatient mental health services and telehealth mental health care.
A recent study, led by Dr. Mark Olfson from Columbia University Mailman School of Public Health and Vagelos College of Physicians and Surgeons, explores how the pandemic exacerbated disparities in mental health care access. The findings highlight that, despite the increase in psychological distress, the utilization of outpatient mental health services decreased for individuals experiencing serious psychological distress. This concerning trend underscores the challenge of ensuring that all individuals, especially those in greatest need, can access the mental health care they require, including telehealth mental health care.
The Surge in Psychological Distress
One of the key takeaways from this study is the sharp rise in psychological distress during the pandemic. The research analyzed data from the 2018–2021 Medical Expenditure Panel Surveys (MEPS), which are overseen by the Agency for Healthcare Research and Quality (AHRQ). According to the study, the proportion of American adults experiencing serious psychological distress grew from 3.5% in 2018 to 4.2% in 2021—a notable increase in just three years.
This uptick in distress reflects the broader mental health crisis spurred by the pandemic, which has been linked to an increase in mental health conditions such as depression, anxiety, and stress. According to Dr. Olfson, “The trends and patterns we observed in the United States align with reports globally concluding that several mental health problems, including depression and generalized anxiety disorder, have become more prevalent during and after the pandemic.”
At the same time, there were shifts in the overall distribution of psychological distress in the population. The rate of individuals with less serious psychological distress rose from 56.1% to 58.6% between 2018 and 2021, while the proportion of adults reporting no psychological distress dropped from 40.4% to 37.2%. These figures reflect the far-reaching impact of the pandemic on mental well-being, as even those not previously struggling with serious distress began to experience some level of psychological burden.
Diminishing Access to Outpatient Mental Health Services
While the rate of psychological distress increased during the pandemic, access to outpatient mental health care for those experiencing serious distress actually declined. The study found that, despite the growing demand for mental health services, the overall utilization rate of outpatient care increased only slightly—from 11.2% in 2018 to 12.4% in 2021. However, the rate of individuals with serious psychological distress accessing outpatient care decreased by nearly 6 percentage points, from 46.4% in 2018 to 40.4% in 2021. This marks a troubling drop in access for those who were arguably the most in need of care.
In contrast, the rate of individuals with less serious distress seeking outpatient mental health care increased, from 14.8% in 2018 to 16.4% in 2021. While this increase in care utilization is a positive development, the decline in care for those with serious distress highlights the systemic barriers that prevent many individuals from accessing the help they need. This includes challenges related to availability, affordability, and the ability to navigate mental health systems—issues that were only amplified by the pandemic.
The study also points out that certain demographic groups faced particular challenges in accessing outpatient mental health services. For example, young adults (aged 18 to 44) saw a significant increase in treatment rates, with utilization rising to 15.2% in 2021, compared to 12.4% in 2018. This was in contrast to the middle-aged (45-64 years) and senior (65+ years) cohorts, who did not experience similar increases in treatment rates. Employed individuals were also more likely to access care than their unemployed counterparts, and college graduates saw a notable increase in utilization, while those with less education did not.
The Telehealth Divide: A Double-Edged Sword
One of the most significant changes in healthcare delivery during the pandemic was the widespread shift to telehealth, including virtual mental health services. While telehealth provided a necessary solution to ensure continued access to care during lockdowns and social distancing measures, it also revealed significant disparities in how different groups were able to benefit from these services.
The study revealed that, in 2021, 33% of individuals receiving outpatient mental health care had at least one video visit. However, access to video-based telehealth mental health care was not equally distributed across demographic groups. Younger adults were far more likely to use video visits than older adults, with video visits occurring at twice the rate for young adults (18-44 years) compared to middle-aged adults (45-64 years), and about six times the rate for younger adults compared to seniors (65+ years).
Additionally, the use of video telehealth was higher among women, those with higher incomes, college graduates, and employed individuals. Conversely, individuals with lower incomes, less education, and those who were unemployed were less likely to utilize video-based telehealth mental health care. This divide is particularly troubling, as it highlights the gap in access to virtual care for vulnerable populations, who may be most in need of mental health support.
For those experiencing serious psychological distress, telephone-based mental health services were more commonly used than video or in-person care. This suggests that, even within the group of individuals facing the most severe mental health challenges, access to preferred forms of care (such as video visits) was limited, likely due to barriers such as technology access, digital literacy, and affordability.
Unequal Access to Care: A Call for Change
The findings from this study paint a stark picture of the disparities in access to mental health care during the pandemic. While the need for care has increased, many individuals—particularly those with serious psychological distress, older adults, those with lower incomes, and individuals with less education—have faced significant challenges in accessing care. Dr. Olfson emphasized that “these patterns underscore critical challenges to extend the reach and access of telehealth mental health care services via easy-to-use and affordable service options.”
The pandemic has exposed the need for urgent action to address these disparities and make mental health services more accessible and equitable for all. Policymakers, healthcare providers, and insurance companies must work together to eliminate barriers to telehealth access, such as high costs, lack of internet access, and inadequate digital literacy. Moreover, healthcare systems must take a more holistic approach to care that accounts for the unique needs of vulnerable populations and ensures they can receive care regardless of their socio-economic status, age, or education level.
The national profile of those receiving outpatient mental health care via telehealth mental health care—typically younger, employed, higher-income, and privately insured individuals—raises significant concerns about equity in the delivery of virtual mental health care. If these disparities are not addressed, clinicians will continue to face challenges in connecting their older, unemployed, and lower-income patients to video-delivered outpatient care, further exacerbating mental health inequities in the U.S.
Conclusion: A Path Forward
As we continue to navigate the mental health repercussions of the COVID-19 pandemic, it is clear that the gaps in care are not only a result of increased demand but also systemic barriers that prevent equitable access. The growing demand for mental health services is undeniable, but it’s equally important to ensure that all individuals, regardless of their demographic background, have equal access to the care they need, including telehealth mental health care.
To move forward, we must prioritize the development of inclusive, accessible, and affordable mental health services—both in-person and virtual. The pandemic has shown us the critical role that telehealth mental health care can play, but it has also illuminated the disparities that must be addressed. Only by addressing these inequities can we ensure that the mental health system serves all people effectively and equally.
