Last month, the U.S. Centers for Disease Control and Prevention (CDC) announced troubling findings of the Adolescent Behaviors and Experiences Survey (ABES) administered during the first half of 2021: during the 12 months prior to the survey, 37.1% of teens reported poor mental health, 44.2% had “experienced persistent feelings of sadness or hopelessness,” and 19.9% had “seriously considered” suicide[1]. This was not the first bad behavioral health news to come out of the pandemic. Multiple children’s hospitals and pediatric health organizations declared a national state of emergency in children’s mental health in October 2021, citing rising rates of emergency and hospital use for mental health emergencies, including suicide attempts, and implicating “the stress brought on by COVID-19 and the ongoing struggle for racial justice” as causal factors, particularly for children of color[2]. Also disproportionately affecting people of color, especially youth, were skyrocketing rates of psychoactive substance use, misuse, and overdose deaths[3,4].
Social isolation was an important risk factor for these
problems in the ABES, as in previous work[4-8]. In the ABES, feelings of being
close to people at school were associated with lower rates of all the mental
health problems measured, including serious consideration of suicide (14.0% for
those connected versus 25.6% for those not connected). Virtual connection was
also associated with somewhat reduced rates (18.4% vs. 24.9%). A growing body
of evidence has linked these trends, which were rising prior to the pandemic,
with public safety measures for COVID-19 mitigation, such as lockdowns and
school closures[4-6]. Similarly, loneliness and lack of access to treatment
have long been recognized risk factors for substance misuse and its consequences[7,8].
Were these pandemic-period increases in mental health and
substance use disorders unavoidable, the combination of trends in place prior
to the pandemic and completely necessary, life-saving governmental “lockdown” actions?
Or were they avoidable, the results of governmental decisions unsupported by
scientific evidence? Likely, you have formed an opinion on these issues. Many
of us have.
The truth is, though, that from an evidentiary perspective,
we don’t know the answer to these questions. To answer them adequately would
require calculating the net benefits versus harms of “lockdowns.” We need a
comprehensive assessment of death and illness from multiple causes—substance
misuse rates, overdoses, mental health problems, deaths from infectious
disease, and deaths from other causes—comparing regions with varying pandemic
policies. This evidence does not exist[9,10]. More importantly from an
evidentiary perspective, though, is what may be an underlying process failure
in research practice: scientists from different disciplines generally do not
work together but work in their own professional silos.
For example, a highly publicized study finding that
pandemic lockdowns “had little to no effect on COVID-19 mortality” was
conducted entirely by a team of economists[11]. Other studies of COVID-19
policies and effects were conducted by teams of behavioral scientists, with no
biomedical scientists, or vice versa, even when the work is labeled
“multidisciplinary” by its authors[4,12-14]. And, as I point out in a
historical review and commentary published in the Annals of Epidemiology,
federal public health leadership, both on the White House COVID-19 Task Force
and at the CDC, consisted—and still consists—almost entirely of infectious
disease specialists, with no specialists in behavioral health or education[15].
What if we approached public health science differently? What
if we recognized that, just as health itself is holistic, public health science
should also be holistic? What if we applied to public health science the same
standards of multidisciplinary engagement already in use in medical care for
chronic diseases[16,17]? What if we put into practice a recognition that specialists
in behavioral health, education, and biomedicine each have unique areas of
expertise and efficiencies in identifying, measuring, and interpreting health
outcomes?
The result, I believe, would be use of multidisciplinary teams
to formulate and study proposed public health policies, producing better
quality evidence—and better policy. In my experience working as a behavioral
health researcher in conjunction with an exceptional clinical team at the Midwestern
University College of Pharmacy, the research product always benefits
from different professional points of view. If you get an opportunity to work
with a person in a discipline whose vocabulary and methods are very different
from your own—please consider it. I promise you and your work will both
benefit.
Read my article suggesting a need for multidisciplinary approaches to public health science: Pandemics, policy, and the power of
paradigm: will COVID-19 lead to a new scientific revolution? at this
link.
1. Jones SE, Ethier KA, Hertz M, et al. Mental health,
suicidality, and connectedness among high school students during the COVID-19
pandemic—adolescent behaviors and experiences survey, United States,
January-June 2021. MMWR Suppl.
2022;71(3):16-21. Available at: https://www.cdc.gov/mmwr/volumes/71/su/su7103a3.htm.
[2] American Academy of Pediatrics, American Academy of
Child and Adolescent Psychiatry and Children’s Hospital Association.
AAP-AACAP-CHA declaration of a national emergency in child and adolescent
mental health. October 19, 2021. https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/?_ga=2.249206535.1219731009.1653672604-2027483972.1649716825
[3]
American Medical Association. Issue brief: nation’s drug-related overdose and
death epidemic continues to worsen. May 12, 2022. https://www.ama-assn.org/system/files/issue-brief-increases-in-opioid-related-overdose.pdf
[4] Ross JA, Malone PK, Levy S. The impact of the
SARS-CoV-2 pandemic on substance use in the US. Clin Infect Dis. 2022;ciac311. Online ahead of print. Available at:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9129126/pdf/ciac311.pdf
[5]
Viner R, Russell S, Saulle R, et al. School closures during social lockdown and
mental health, health behaviors, and well-being among children and adolescents
during the first COVID-19 wave. JAMA
Pediatr. 2022;176(4):400-409. Available at: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2788069
[6] Benton T, Njoroge WFM, Ng WYK. Sounding the alarm for
children’s mental health during the COVID-19 pandemic. JAMA Pediatr. 2022;176(4):e216295. Available at: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2788911?resultClick=1
[7]
Ingram I, Kelly PJ, Deane FP, et al. Loneliness among people with substance use
problems: a narrative systematic review. Drug
Alcohol Rev. 2020;39(5):447-483. Available at: https://onlinelibrary.wiley.com/doi/10.1111/dar.13064
[8]
Bolinski R, Ellis K, Zahnd WE, et al. Social norms associated with nonmedical
opioid use in rural communities: a systematic review. Transl Behav Med. 2019;9(6):1224-1232. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6875642/
[9]
Haber NA, Clarke-Deelder E, Feller A, et al. Problems with evidence assessment
in COVID-19 health policy impact evaluation: a systematic review of study
design and evidence strength. BMJ Open.
2022;12(1):e053820. Available at: https://bmjopen.bmj.com/content/12/1/e053820.long
[10] Cristea IA, Naudet F, Ioannidis JPA. Preserving
equipoise and performing randomized trials for COVID-19 social distancing
interventions. Epidemiol Psychiatr Sci. 2020;29:e184. https://doi.org/10.1017/S2045796020000992
[11] Herby
J, Jonung L, Hanke SH. A literature review and meta-analysis of the effects of
lockdowns on COVID-19 mortality. Studies
in Applied Economics. January 2022. https://sites.krieger.jhu.edu/iae/files/2022/01/A-Literature-Review-and-Meta-Analysis-of-the-Effects-of-Lockdowns-on-COVID-19-Mortality.pdf
[12] Chams N, Chams S, Badran R, et al. COVID-19: a multidisciplinary review. Front Public Health. 2020;8:383. Available at: https://www.frontiersin.org/articles/10.3389/fpubh.2020.00383/full
[13] Holmes EA, O’Conhor RC, Perry VH, et al.
Multidisciplinary research priorities for the COVID-19 pandemic: a call for
action for mental health science. Lancet Psychiatry. 2020;7(6):547-560.
Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7159850/
[14] Woolf SH, Chapman DA, Sabo RT. Excess deaths from
COVID-19 and other causes in the US, March 1, 2020, to January 2, 2021. JAMA.
2021;325(17):1786-1789. Available at: https://jamanetwork.com/journals/jama/fullarticle/2778361
[15]
Fairman KA. Pandemics, policy, and the power of paradigm: will COVID-19 lead to
a new scientific revolution? Ann
Epidemiol. 2022;69:17-23. Available at: https://reader.elsevier.com/reader/sd/pii/S1047279722000230?token=937D66A3B192E124236DFC7133F0DCEC0BF147BDCA80BF302A17A7B686856E2F60CBC363052290C8D6D0135656EE5953&originRegion=us-east-1&originCreation=20220530173333
[16] American
Diabetes Association. Standards of medical care in diabetes—2021. Available at:
https://care.diabetesjournals.org/content/diacare/suppl/2020/12/09/44.Supplement_1.DC1/DC_44_S1_final_copyright_stamped.pdf.
[17] National Kidney Foundation. Clinical practice guidelines for chronic kidney disease. evaluation, classification, and stratification. 2002. Available at: https://www.kidney.org/sites/default/files/docs/ckd_evaluation_classification_stratification.pdf.
