Express Scripts recently reported a spike in prescriptions for medications targeted to the treatment of anxiety, depression, and insomnia as the COVID-19 crisis was gathering steam, a development that should not come as a surprise to anyone. In the face of ambiguity people tend to become more fearful, anticipating the worst possible scenario. This reaction reflects a natural defense mechanism — the fight or flight response — in the face of real or imagined danger.
When people do not feel they can do anything to control their situation, they often grasp at other things aimed at making sense of their environment and exerting some element of control over something. It is one of the reasons we saw a run on toilet paper and paper towels after the news of coronavirus hit, even though there was no evidence that either of these products would be particularly valuable in dealing with the crisis. It gave people a sense of doing something and therefore, some measure of control even though it was not grounded in a realistic assessment of the facts or data.
Add to this the daily drumbeat of often sensationalist news or partial information without adequate context (e.g. stories that suggested major cities like New York would run out of beds). This only adds to people’s experience of not being in control and dreading an uncertain future. To add fuel to the proverbial fire, conflicting information from National leaders leaves people with the deeper sense of things being out of control. Take for example, reports that we have enough tests and reports that we do not have enough tests. Or other reports touting that we have enough personal protective equipment and other stories that point out the lack of PPE for healthcare workers. The reports pertaining to the stock of ventilators paints the same picture — we have enough, we do not have enough. The natural question for the public is ‘who can I trust?’ In the absence of public trust, anxiety rises.
The hard reality is that people are understandably afraid of a virus we do not fully understand. Our nation’s response was inadequate; we failed to prepare in the months before the virus hit our shores; we lacked coordination once it confronted our homeland. We have seen a precipitous loss of approximately 22 million jobs in a month — more than the total job growth since the great recession of 2008-2009. So, there should be a healthy dose of anxiety. For those who have lost jobs and are unsure when the unemployment checks will kick in, or for business owners who are struggling to keep the lights on, there is real, palpable anxiety. For others, personal fortunes are on the brink of collapse.
Anxiety that cannot translate into purposeful action tends to feed on itself, snowballing and spiraling out of control. Generalized, overwhelming anxiety can lead to a sense of helplessness and emotional paralysis, and when this happens taking any action becomes harder to do and anxiety clouds people’s ability to think clearly and logically. There can be a sense that everything is spinning out of control.
These emotional responses have the unfortunate effect of undermining sleep patterns, negatively effecting eating, and creating havoc with the immune system. This makes people more susceptible to illness and exacerbates underlying health conditions which are likely to worsen the effect of COVID-19 in the event people do contract the virus.
Against this backdrop, is it any wonder we see an increase in anti-anxiety, anti-depressant, and anti-insomnia medications? These medications all have a place, especially if they are taken on a time-limited basis in the case of acute onset, and they can be helpful in improving short-term cognitive functioning that enables people to take constructive action to create a path forward in the face of the crisis. They can also be addictive.
Anxiety is a normal, healthy human reaction to the health and economic crisis brought about by the coronavirus. The extent to which individuals develop coping skills to deal with the anxiety will have a profound effect on their overall well-being, both short and longer term. Insurance companies and PBMs have data available to identify members who are at risk and can offer counseling and support. Having access to trained professionals to talk through the anxiety associated with the current crisis is clearly an important resource. But behavioral and mental health services are too frequently not adequately covered, and more importantly, come with a stigma attached to their use. So, services which could be effective often are not used even when they are covered by insurance.
By failing to adequately provide ‘talk therapy’, particularly to those most at risk, we are likely to see an increase in overall healthcare costs long after the peak of the COVID-19 crisis has ended. And talk therapy is relatively easy to do remotely. Cognitive behavioral counseling and support can be easily and effectively delivered telephonically — even without a video visit.
One of the outcomes of the pandemic may be greater tolerance for and an appreciation of the anxiety associated with uncertainty. Normalizing this would help bridge the gulf that has long existed between the realm of physical and emotional health. Taking a more holistic view would go far in improving outcomes associated with a wide range of chronic conditions.
In the meantime, there are simple steps we can all take to maintain better balance and perspective in the face of uncertainty.
1. Taking some deep breaths helps to get more centered and think clearly.
2. Talking to someone we trust is helpful in getting perspective.
3. Putting things on paper gives us a sense of control and helps with perspective.
4. Getting regular exercise, even if it means taking laps around the apartment, helps.
5. Taking health precautions — social distancing, using a face covering when going out, practicing good hand hygiene, disinfecting surfaces (without going crazy), coughing into your elbow, and refraining from putting your hands on your face — all help to keep us safe.
We will come out of this on the other side, hopefully a lot smarter. One perspective worth noting is that approximately 80% of the people who actually contract COVID-19 have mild symptoms; some apparently do not even know they have had it.
It’s time for each of us to take our own emotional health seriously, and it’s time that payers do as well.