From 2008 to 2019, the number of adults with any mental illness in the US increased from 39.8 million to 51.5 million - a 30% increase. However, the latest estimations show closer to 60 million. Of this number, less than half of those with mental health and less than 10% of those with substance abuse disorders conditions received treatment. The treatment shortfalls might come from insufficient resources to provide mental health services. In most states, there are fewer than 40% of the mental health professionals needed. To see the functioning of this number in practice, there are 340 people for every 1 mental health provider in the US.
The US behavioral healthcare system is in a time of change. Historically, care for mental health was managed on a community basis, separated from the general healthcare system. Early debates considered whether mental health should be dealt with biologically or socially, and the past century has worked to holistically integrate behavioral healthcare into the larger medical system. In recent years, the US has begun to face a ‘mental health crisis’ - which Pew Research Center claims would be the crisis of the century, if not for the recent pandemic. The issue is threefold: a youth mental health crisis, ongoing substance abuse disorder, and serious mental illness (SMI). Each of these requires drastic policy reforms and medical reconceptions to provide adequate care to the numerous individuals affected.
The mental health crisis unevenly impacts American Indian or Alaskan Native youth, LGBTQIA+ youth, and those of low-income or houseless individuals, and these equity considerations must be taken into policy initiatives. Those with SMI, including schizophrenia, bipolar, or other severe mood and anxiety disorders experience a series of lifelong social challenges. These include a 20 to 25 year shorter life expectancy, a ten-fold incarceration rate, and being sixteen times more likely to be killed by police. These stem from lack of treatment, training issues, and lack of awareness on behalf of officers. Moreover, many with SMI conditions are only treated when in jail or prison, and many experience homelessness due to high unemployment rates from career exclusion.
The American mental health crisis has pushed policymakers to grow the system to a nationwide initiative and reform the system through accessibility and equity. While, at the same time, expanding care and acknowledging the validity of mental healthcare at the level of physical healthcare. One of the first significant measures passed was the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA). The federal law ensures that group health plans and health insurance issuers cannot impose less favorable benefit limitations on those using the plan for mental health or substance abuse disorders (MH/SUD) versus medical or surgical benefits. As the issue has become of interest to the Biden-Harris administration, in September of this year, final rules were added to the Act to be implemented on January 1st including making clear the protections afforded under MHPAEA, requiring plans and insurers to collect data and address material differences between MH/SUD and medical or surgical care.
In addition to these reforms emphasizing the importance of mental healthcare and its handling at the same level as medical or surgical care, other improvements on a smaller scale are vital. First, access issues might arise from the fact that conditions might preclude their own treatment, so the openness of services, early intervention, and trust building all become important.
Second, choice of care and written designation of treatment preference ensure individuals can have autonomy in creating a treatment plan that works best for them. Next, primary care physicians, who are the providers of medicine but not psychotherapy, limit patient care to merely medicinal forms rather than holistic. To combat this, there needs to be a change in focus from reduction of symptoms to recovery through social support and a safe, nurturing environment. California’s new Medicaid waiver does just this by covering food or rent as a written prescription as well as ‘clubhouses’ - important spaces where those with SMI can form community. Taken together, each initiative can better ensure adequate patient care is reflected in legal regimes.
The American healthcare system continues to lack affordability -particularly with issues of employability and houselessness - which often impacts those with SMI or other mental health conditions, and these barriers need to be considered in further reform. Generally, appointment wait times are also high, and treatment options require far more innovation to deliver satisfactory care. As many are affected by mental health crises, ensuring that treatment is affordable, available, and catered to the needs of those impacted is necessary.
Image by Office of Maggie Hassan via Wikimedia Commons