The recent killing of UnitedHealthcare CEO Brian Thompson, allegedly by Luigi Mangione, and the trial of Daniel Penny found not guilty in the chokehold death of Jordan Neely, have once again placed mental health—or rather the failure of the mental health care system in the spotlight. The demand for behavioral healthcare services is more prominent than ever, with approximately six out of 10 Americans needing services either for themselves or someone they love. According to the Centers for Disease Control and Prevention (CDC) more than 50% of Americans will be diagnosed with a mental illness sometime in their life. And half of those adults diagnosed with mental health conditions receive no treatment.
There’s enough blame to go around. Marginalized communities can often experience disparities when it comes to accessing quality mental health care. Other obstacles can include geographical limitations, stigma, and the cost of treatment. These are the obvious ones, but there are others. As everywhere else, racism can play a role. Often people of color are dismissed or subject to gaslighting. Stereotypes about certain groups result in misdiagnosis and mistrust leading people to avoid getting help.
People who live in rural areas (60 million) face many obstacles to treatment (travel, inadequate broadband, and internet coverage). Insurance coverage and cost can play a major role. And cultural competence, which often is lacking in healthcare, results in people not getting treatment they need. Feeling understood and respected can be key to effective care, which is often rooted in community and cultural practices. Linguistic needs and translation services are often lacking, thereby preventing quality care.
And one of the most commonly identified reasons for people not getting mental health care is stigma. While we have made significant progress with how we speak about mental health, stigma clearly still exists, resulting in people feeling ashamed to seek help. Historically, mental health services have been viewed as “less prestigious than other health services” and receive less funding.
How can we improve the treatment gap? While many of these barriers are deeply rooted in our healthcare systems, they are not impossible to solve. Each of these items has a price on the access of people to behavioral and mental healthcare. Some of them have simple solutions and others are much more complex.
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits, is periodically under scrutiny to include regulations that expand coverage and address treatment limitations. Certainly, the Affordable Care Act has helped, but even when providers are available, many continue to operate outside the health insurance system, making them out of network, in part because insurers typically pay licensed mental health professionals lower negotiated rates for their services compared to physical health professionals with similar backgrounds and experience. Consequently, only approximately 56% of psychiatrists accept commercial insurance compared to 90% of non-mental health providers.
Focusing on access and the lack of services, data from 2018 showed that only about one-quarter of the country’s mental health care provider needs were being met. Currently approximately 90 million people live in federally designated Mental Health Professional Shortage Areas, as compared to approximately fifty million people who live in similarly designated primary-care shortage areas. Although rural areas often have few or no mental healthcare services, in urban areas, clinics and providers have long waitlists. The advent of more telehealth services since the pandemic has helped somewhat and many insurers, including Medicare and Medicaid, have expanded coverage to include telehealth options. Technology enabling different specialties to work together to create comprehensive treatment plans is helping to bridge the gap between healthcare organizations using different EHR (electronic health record) systems and ePCR (electronic patient care reporting systems).
But the real problem is stigma and the fear that still prevents people from receiving treatment. The stigma surrounding the mentally ill is not new. In fact, in ancient Greece, a “stigma” was a brand used to mark criminals or enslaved people. During the Middle Ages, mental disorders were regarded as a punishment from God. And in Nazi Germany hundreds of thousands of mentally ill people were murdered or sterilized. Stigma exists in two areas: public stigma and self-stigma. We all are aware of public stigma, the general population’s reaction to those with a mental disorder. But there’s also self-stigma, which involves internalizing public stigma, where those with a mental illness turn against themselves.
Organizations like the National Alliance on Mental Illness (NAMI), Substance Abuse and Mental Health Services Administration (SAMHSA) and Connecticut Legal Rights Project, Inc. along with many other organizations around the nation work constantly to address stigma. The list of ways to fight stigma is endless but the most common advice to wipe it out through campaigns and education is relatively easy to follow: talking openly about mental health to educate oneself and others; correcting others who make insensitive comments; correcting others who use mental health conditions as descriptors; treating mental illness like a disease and reminding others that just as we don’t make insensitive comments about cancer, for example, we shouldn’t do that when it comes to mental health; and to be compassionate to those with obvious mental health issues and recognize their humanity. These tips are fairly benign and the awareness they will foster can help people understand that mental illness is not a character flaw or an imagined malady but rather an illness like any other. Raising awareness can change how society views and responds to this complex issue. In short, public awareness reduces stigma and opens opportunities for appropriate community resources.
The harder guidance is more personal—being honest with others about seeking treatment; again, no one hesitates to say they’re going to the dentist. It hopefully will be empowering and help to overcome self-stigma. Mental health stigma is more than an interpersonal issue: it is in fact a health crisis. People with mental health disorders often die much sooner than they should, not because of increased injuries or suicide, but because of poor physical health, caused by lack of exercise, poor diet, smoking, and self-medicating. And then there’s the damage that people who are mentally ill can cause to others as they spiral. See recent events.
So even if one is not moved by the prejudice those with mental health issues experience, we have seen what can happen when those who desperately need help do not get it. Awareness is key to understanding mental health and assisting people get the help they need. Mental health awareness initiatives can help those suffering to understand the symptoms and learn how the disorders manifest. When individuals recognize signs, they can seek treatment before the condition worsens and prevent severe disruptions to their life. They are also more likely to experience fewer complications, have a successful recovery, and even live longer. In addition, education and awareness help the public more readily identify people who may be struggling and help them receive the necessary treatment.
I do not pretend for a moment to appreciate fully what the Nealy and Mangione families are feeling, not to mention the senseless loss to the Thomson family. And frankly, my years as a public defender, judge, justice, commissioner, member of the federal grievance committee, chair of the client security fund, and the countless other committees at which mental health concerns featured prominently only gave me but a window into the struggles of and ramifications for those with untreated mental illness. Hopefully, these recent events will do more to get us to focus successfully on long term systemic and cultural solutions for our mental health crisis than Sandy Hook did on gun control. But little gestures can have an immediate impact on people struggling with mental health issues, including helping to empower these individuals to overcome self-stigma that often impedes their treatment. And at the holidays, when everything gets magnified, and life’s struggles come acutely into focus, we all can help. Happy Holidays.