There is a growing awareness today that our nation is in the midst of a mental health crisis. Recent tragic events have brought mental health into the limelight, prompting many, including political leaders, to call for changes in our approach to mental healthcare.
Yet as we seek to address the concerns raised by mass shootings, we must keep in mind that by far the majority of people with mental illness pose no threat to society, says Thomas Young, MD, chief medical officer and founder of nView Health in Atlanta, and a long-time vocal advocate for improving mental health in the United States. If we are to meaningfully address our nation’s crisis in mental illness, Young says, our primary focus should be on ensuring all people have access to high-quality mental healthcare, apart from any connection to our crisis around mass shootings.
“We need to treat mental illness the way we treat physical ailments,” Young said, “Our problem is that we don’t treat mental illness as if we’re trying to cure it.”
How would you summarize inherent challenges facing our nation around how we treat mental illness?
First, there’s the problem of equating mental illness with a tendency toward violent behavior. When we are thinking about mass shootings, we need to understand that they are sometimes caused by mental illness, with the emphasis on sometimes. There are certain mental illnesses such as psychopathy that could lead someone to become a mass shooter. But take the recent Uvalde shooter for instance. While the shooter had some behavioral issues, he did not have any history of mental illness. The idea that all mass shooters are mentally ill is a stigma that’s too often unjustifiably applied to mental illness and does nothing to help us move forward in really helping those with mental illnesses.
Number of Americans in the United States (about one-fifth of the population) living with mental illness in the United States as of 2020, according to the U.S. National Institute of Mental Health
How then can we best begin to address the issue?
The reason we are having a mental illness crisis in our country is that we don’t use the same process model to accurately diagnose mental illness as we use for physical illness. We look at mental illness differently and we treat it differently. Most mental illness treatment in this country occurs because of a crisis moment, not because it is seen as a chronic disorder or disease we are trying to cure. We treat it as a crisis that we’re trying to stop in the moment. We treat it because it’s a suicide attempt or because it’s somebody who lost control somehow and has done something socially unacceptable. Those crisis events subjugate mental illness to a momentary disorder that only needs a fix for the specific incident.
Why is this problematic? Let’s look at a physical condition like diabetes. As a country, we work to cure diabetes. When we can’t cure it, we spend millions of dollars to help people keep it in check. Yet we don’t spend millions of dollars to make sure everybody with severe mental illness, such as schizophrenia or some other psychosis, is kept on the medications we know are effective.
Thomas Insel, the former head of the National Institutes of Mental Health, noted that to treat people with mental illness, you need to make sure they have people in their lives.a They need community and people working with them. They also need a place to live, a place to exist and a place of security. And they need purpose in life.
If we’re going to address mental illness, we must address all these facets.
What are some practical steps we can take to address this problem?
For this country to deal with mental illness, we also need to provide early diagnosis, just like we do for physical illnesses. We screen for diabetes, hypertension and cancer. And if you’re female and over forty-five, it’s likely you will receive a flyer from your health system reminding you to get your mammogram. When was the last time you got a flyer reminding you make an appointment for screening to make sure you don’t have depression or anxiety? It just doesn’t happen. And part of that is due to the stigma associated with mental illness. (See the sidebar, “Improving mental healthcare starts with removing the stigma of mental illness,” below.)
We also need to broaden the conversation about mental health. There’s been a crisis in mental health in our country for a long time. If you go back and statistically look at the rise in the number of people that commit suicide, it’s a hockey stick curve that’s been going up. Why? It’s because we have an increased number of factors that can work to undermine mental health, including everything from social media to information overload brought on by smartphone usage, to economic and housing disparities, which have only grown in recent years.
We can’t address that problem without giving everyone involved in promoting mental healthcare — including physicians, schools and workplaces — the resources they need. I hate to sound like a broken record, but it boils down to focusing on mental issues just like we focus on physical issues. We don’t want people having strokes in this country, so we spend a huge amount of money checking for, following and tracking hypertension. If we put the same amount of money into checking for, following and tracking people who have distress from economics, from work or from personal anxiety, we wouldn’t be in the mental health situation we’re in now.
We also need to understand it all ties together, because people with uncontrolled diabetes and hypertension often have underlying and untreated behavioral health disorders. If you’re diabetic and you’re depressed and anxious, you’re not going to get out and exercise or watch what you eat. You’re not going to remember to take all your medicines. Success on the physical side and success on the mental side often go hand in hand.
What are ways we are already making progress toward meaningful solutions for treating mental illness? Can you point to successes?
We have made some progress. We’re developing more resources for providers and patients. We’re training more people about behavioral health issues. Medical schools are focusing a bit more on behavioral illness. We have begun to understand that we need to do more on the front end for individuals with mental illness.
We’ve created a few better treatment options and are looking at new treatment options, such as transcranial magnetic stimulation and ketamine therapy. We’re achieving advancements in some of our treatment programs. These are all good developments, and we need to keep at it and build on them.
We’re using technology to provide tools to our providers that help them get the right information for screening and accurately diagnosing patients with behavioral health issues. We’re starting to see that by giving physicians tools for behavioral health, just as with physical wellness, we can improve the quality of behavioral health outcomes.
We’ve also been able to use technology to provide patients with better access to help. For example, patients can get therapy through online cognitive behavioral therapy, or CBT, which does not require a person-to-person conversation. We’ve been able to advance telehealth, which helps get services to people in different locales at the right time. And people have created interesting solutions like chatbots and other technologies that can at least give people some immediate support. There is the opportunity to use more advanced technology like AI [artificial intelligence] to provide a virtual therapy experience, and I see that opportunity only improving over time.
There also is a move toward combining objective data with patient-reported data to get a more complete picture of what is going on with patients. A large psychiatric facility in Texas, for example, is studying the use of wearable technology to improve diagnosis and outcome tracking. Early results have shown the wearable data can have a positive impact on patient safety and outcomes in inpatient psychiatric treatment.
What specific message or advice or do you have for healthcare financial leaders around this issue?
Healthcare finance leaders should educate themselves about the science of mental health.
They should understand the logic of embracing the science of the right treatment for mental illness just as they do for physical illness and then applying the same financial commitment with the same financial processes. They should see that funding the improved delivery of behavioral health services is actually a value proposition that can help keep people from developing chronic diseases that are even more costly to treat.
It all comes back to money. Finance leaders of hospitals and health systems should be advocates for better payment for mental health services, working with their health plan counterparts to underscore the importance of this issue and to develop plans that provide adequate coverage for behavioral healthcare.
And it’s in their organizations’ interest to do that because mental illness can often be the root cause of physical illness.
Consider readmission rates, for example. Some studies demonstrate that more than half of the causes for readmissions inside 30 days are tied to behavioral health issues. Consider someone with congestive heart failure who is discharged but then readmitted. The reason their congestive heart failure may have worsened might be that when they were discharged, they had major depression. They had no support services at home. They didn’t have any way to get what they needed — somebody who could watch their back and keep them focused on recovery. So they stopped taking their medications appropriately, and they didn’t watch their salt or track and follow their blood pressure. They waited too long to call their doctor when they were short of breath, at which time they couldn’t get out of bed.
Why were they readmitted? The easy answer is that they failed to take their medicine properly. But the actual answer may be that it was because they were depressed.
The simple fact is that nobody should leave a hospital for any reason who isn’t screened for a mental health disorder. Failure to do so is to be flagrantly irresponsible with the economics of a hospital system. You need to make mental health care an integral part of how you deliver healthcare, and you need to make sure your behavioral health specialists are being compensated appropriately and are receiving the same tools and the same attention to technology, data collection and tracking as the physical health world has received. If you’re going down the value-based payment route, you have a responsibility to make available the tools and payments required to measure value.
a. Insel, T., “What American mental health care is missing,” The Atlantic, Feb. 13, 2022.
Improving mental healthcare starts with removing the stigma of mental illness
The enormous stigma behind mental illness remains one of the biggest obstacles to ensuring Americans have access to high-quality mental healthcare, said Thomas Young, MD, chief medical officer and founder of Atlanta-based nView Health.
“There are still too many people who see someone struggling with mental health who ask, ‘Why are they having that problem? Why can’t they just act differently?’” Young said. “We don’t look at somebody who has a heart attack, gets brought to a hospital by an ambulance and spends a lot of community resources and say, ‘You ate all that meat. You drank all that alcohol. You didn’t watch your weight. You didn’t exercise. We’re spending all this money on you. What’s wrong with you? Why didn’t you just not do those things?’”
Young decried the all-too-common readiness of many people to cast blame for mental illness – or to shame them.
“I don’t know that we can look at ourselves and confidently say there’s a strong societal will to do what’s necessary to help provide patients with mental illness receive the kind of care they need,” he said.
Neither is there the adequate political leadership on this front, Young said.
“The will is certainly not there from what we see in our representatives in the legislative branch,” he said. “We don’t see adequate funding coming to mental illness. We see some funding, but is it enough? Absolutely not. The concept of giving people things that aren’t pills or operations to help them get better is foreign to too many on the political side.”
To make headway in addressing this challenge, Young called for increased advocacy.
“We need people to advocate before legislators, with the message that mental health legislation must follow the science, just as it does with legislation regarding physical healthcare,” Young said. “And we need people to message the American public to change the prevailing ideas and attitudes toward mental health. That’s not happening nearly enough, whether it’s on the national level, state level, local level.”