Progress and challenges in mental health care
Dr. Jan Patterson. Published in Invisible Illness
I’m a medical doctor, and although not a psychiatrist, I’ve observed that there are two kinds of people: those who are affected by mental illness, and those who will be. I’m one of those who is affected. I lost a son to suicide, my brother had a difficult-to-control bipolar disorder, and I struggle with depression. Mental health is important to me as well as to society, so I follow the advances and the continued challenges. I’ll review these and share with you how some have affected me.
One in five U.S. adults experience mental illness annually. For example, in 2021, 22.8% of U.S. adults (57.8 million people) experienced mental illness. About 20% of U.S. adults have anxiety disorders and 8% have major depressive episodes annually. Anxiety disorders affect about 34% of Americans during their lifetime. A 2023 Gallup Poll showed that 29% of U.S. adults have been diagnosed with depression at some point in their life; this is 10 percentage points higher than eight years ago. The prevalence of Americans currently treated for depression has also increased during this period, from 10.5% to 17.8% Suicide is among the top nine causes of death for people ages 10–64, and the second leading cause of death for those ages 10–14 and 20–34.
Recognizing these statistics, what advances have been made in mental health in recent years?
De-institutionalization. In the early 20th century, large public mental institutions, designed to segregate mentally ill patients from society rather than treat or rehabilitate them, were neglectful and often abusive. By the 1960’s most of these institutions closed, with the idea of shifting to community mental health centers for support.
Advances in Research. Research changed from a focus on the mind to a focus on the brain. This led to research on the effects of neurotransmitters for treatment, resulting in the approval of many effective pharmaceuticals. The study of genomics led to the field of pharmacogenetic testing. While still in its infancy, such testing could result in genotyping to predict the most effective pharmaceutical treatment for individual persons. A connection between the brain and the gut was discovered and research on the use of probiotics to influence brain health looks promising.
Progress in pharmaceuticals — Anti-depressants. Anti-depressants were developed to reduce the breakdown of neurotransmitters at the neural synapse or to decrease their uptake. Early anti-depressants were effective but had serious side effects. Many consider the approval of the first selective serotonin reuptake inhibitor (SSRI), fluoxetine (Prozac), in 1985 to be the most significant development in the modern treatment of depression. This class of anti-depressants was effective in many people and much safer than previous ones. Neurotransmitters norepinephrine and dopamine were also targeted and options for safe treatment increased.
While safer, the side effects from these agents could be significant and include gastrointestinal complaints, insomnia, weight gain, and effect on sexual function. Newer pharmaceutical versions were modified to be even more selective to targets and decrease side effects.
I required pharmacological treatment for depression at several points in my life: post-partum, peri-menopausal, after the death of my younger son, and after the COVID-19 pandemic. (My husband and I are both infectious diseases doctors working in a busy urban hospital, so the COVID-19 pandemic was a difficult time, mentally and physically.) Except for the first depression, when only Prozac was available, an SSRI or related pharmaceuticals helped me return to normal. I can attest that weight gain was a main problem for me each time, although I was able to lose weight once the courses of treatment were completed.
SSRIs and related agents take time to act, and many patients are treatment-resistant. Ketamine, previously used as an anesthetic, was discovered to have a rapid effect, could treat depression and suicidality in hours and reach treatment-resistant patients. The mechanism of action is not fully elucidated, but it is thought to increase neuroplasticity and act at neural synapses. It can be administered intranasally or intravenously and must be done under observation. A short series of treatments is typically effective. Limiting factors are the dissociative effects that can occur in some patients and the lack of coverage by some insurers.
Research in the use of psychedelics, including psilocybin (magic mushrooms), ayahuasca, and MDMA (methylenedioxymethamphetamine; known as ecstasy), given in controlled and monitored settings looks promising to help patients get a fresh perspective and relief from depression. This research is still underway and not yet near general use, however.
Anxiolytics. The introduction of benzodiazepines like diazepam (Valium), lorazepam (Ativan), and alprazolam (Xanax) was an advance over alcohol and barbiturates for anxiety. They reduce anxiety while preserving physical activity and cognition and act by stimulating the neurotransmitter, gamma-aminobutyric acid (GABA) to lessen arousal. They can produce withdrawal symptoms and are potential drugs of abuse.
For this reason, SSRIs and related antidepressants have been used for many anxiety disorders because they reduce symptoms but do not lead to dependence. However, benzodiazepines have a rapid onset of action, which is often needed and can be more effective than SSRIs.
While benzodiazepines are not recommended as first-line therapy in anxiety disorders because of the concern for dependence, they may be necessary for some who do not respond to first-line treatments. In addition, they may have a role in the treatment of anxious depression.
Antipsychotics. The introduction of chlorpromazine (Thorazine) in the mid-20th century reduced symptoms of psychosis in schizophrenia and revolutionized treatment because it decreased the need for hospitalization. Schizophrenia affects about one percent of people globally. Anti-psychotics treat the disorganized behavior, hallucinations, and delusions that occur with this disease. The newer generation anti-psychotics, including olanzapine (Zyprexa) and others, are of greater benefit and have less unpleasant side effects, although metabolic changes including weight gain are a problem.
Medications can control the symptoms of schizophrenia but do not cure the disease, so people who discontinue these medications typically relapse. This can often be the problem with mentally ill people who are unhoused or incarcerated.
Mood Stabilizers. The first and classic mood stabilizer is lithium carbonate. It can be effective for bipolar disorder, in which both depression and mania occur. The mechanism of action is not well-delineated. Higher levels cause toxic effects, so drug monitoring is required. Side effects include weight gain, thyroid, and kidney toxicity. Anticonvulsant drugs such as carbamazepine (Tegretol) and valproate (Depakote) have also been used. Newer anticonvulsants such as gabapentin (Neurontin) and lamotrigine (Lamictal) have been used because they are better tolerated although efficacy is not as well-established.
An uncommon variant of bipolar disorder is the rapid-cycling form. This form has increased numbers of episodes of mania and depression and is typically more resistant to treatment. Lithium is often not effective. Antipsychotics and or a combination of agents are often used, but the optimal treatment has not been established.
Sadly, this was the type of bipolar disorder that my brother had. Lithium was not effective for him. Antipsychotics were more helpful, but his illness was never adequately treated.
Changes in Psychotherapy. The mid-20th century saw the decline of Freudian psychoanalysis due to a lack of evidence for its effectiveness. Psychodynamic therapy, using self-reflection and self-examination to enlighten present circumstances and relationships, became more commonly used. Cognitive behavioral therapy, a shorter-term, goal-directed therapy to identify and replace negative thoughts and behaviors with positive ones, was also introduced. The use of psychotherapy along with medication for conditions such as anxiety and depression can add the benefit of developing coping skills and insightful self-assessment.
Psychodynamic therapy after my son’s suicide helped me realize that his death was not my fault. It has been a place to express outpourings of grief in a safe and reflective setting. Objective and active listening about situations from a trained professional is valuable for developing insights and self-understanding.
Telehealth. The pandemic has exponentially increased the use of telehealth, and it is popular with both patients and mental health professionals. Insurance coverage of this innovation was essential to its widespread use. Research indicates it is as effective as in-person therapy most of the time. This innovation has made mental health professionals more accessible to those in rural areas and those unable to travel or commute to sessions.
Improved Insurance Coverage. The Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008 elevated insurance coverage of mental health and addiction treatment to the same level as other medical and surgical care. That did not help the uninsured, but the Affordable Care Act in 2014 helped to guarantee some type of insurance coverage for many.
Accessible resources. Many resources have become readily available, such as those found on the National Alliance on Mental Illness (NAMI) website, the Crisis Text Line, and the 988 National Suicide Lifeline, the first federally-recognized national telephone number for suicide prevention.
Many challenges in the treatment of mental illness remain, however.
Community-based treatment. While the intent of closing large psychiatric institutions was to shift care to community centers, community-based mental health treatment has been inadequate. As a result, many mentally ill people are unhoused or incarcerated. The Treatment Advocacy Center is a non-profit organization advocating for community-based treatment for those who struggle with voluntary treatment compliance. The group keeps “The Preventable Tragedies Database” on its website, documenting violence in the community because of mental illness in both victims and perpetrators. The recent Jordan Neely tragedy will no doubt be added to this database.
In the meantime, most communities have woefully inadequate community mental health infrastructure. As Thomas Insel, the former director of the National Institute of Mental Health has discussed, there are great breakthroughs in research and psychopharmacology, but the affected individual needs people, a place for support, and meaning in life.
Holistic Approach to Treatment. In addition to the need for traditional treatment in a community-based setting, there is also a need for a whole-person approach to treatment. There is increasing evidence that exercise and nutrition benefit mental health, but these approaches are generally overlooked.
Victor and Lynne Brick established the John W. Brick Mental Health Foundation in memory of Victor’s brother who suffered from schizophrenia and died from complications. John had received excellent conventional treatment, but not a program in healthy lifestyle practices. The Foundation promotes the integration of nutrition, exercise, and mind-body practices with traditional therapies The My Well-Being Ecosystem handout is a resource provided as a tool to an integrative approach.
Spirituality has also been neglected as a dimension of holistic care and can improve the quality of life in those to whom it is meaningful.
Shortage of Mental Health Professionals. More than half of U.S. counties lack a single psychiatrist. Almost half of the U.S. population lives in an area with a shortage of mental health professionals. There are many reasons for the shortage: poor reimbursement rates, an aging workforce, low professional retention, and an increased need for services.
Uninsured Populations. Although insurance coverage for mental health has improved, many people remain uninsured or underinsured. And, despite the improvements in insurance coverage for treatment, many times it is still denied. Overall, the rate of uninsured in the U.S. is around 10%. In Texas, the rate is 18%. So, it is not surprising that Texas is rated as the worst state for mental health care. In my state, 41% of adults with a cognitive disability did not seek medical care due to expense. The state also had the highest proportion of youth (73%) with a major depressive episode in the last year who did not get treatment. This is ironic because Texas Governor Greg Abbott calls for mental health care to address gun violence.
Lack of Acceptance of Insurance. Almost half of psychiatrists do not accept insurance, which can pose a barrier even for the adequately insured. There are multiple reasons for this, including the poor reimbursement rate for psychotherapy, the shortage of psychiatrists resulting in heavy demand for services, the need for a bureaucratic infrastructure to deal with insurance companies which proves impractical for solo practice, and the concern by patients about the privacy of reports to insurance companies.
Stigma. While mental disorders affect 1 in 5 Americans, there is still a perception that these disorders occur in those who are weak in character, incapable or threatening. NAMI has a StigmaFree campaign to decrease the barriers for those affected by mental illness.
In addition, there is a stigma about taking psychoactive medications. There may be a perception that medications are unnatural “chemicals” which are harmful, and natural products or approaches may be preferred. Of course, natural products such as botanicals and supplements are also chemicals. And many of the pharmacological medications simply enhance the effect of already-existing neurotransmitters and chemicals in the brain.
As an integrative medicine physician, I am all for using natural therapies and products whenever possible. I instruct patients and families on the use of breathwork, guided meditations, mindfulness, exercise, nutrition, aromatherapy, and use of botanicals and supplements. I am the lead author of a book about self-care steps to wellness that entails many of these approaches. I also believe, however, in using all the tools in the toolbox. Evidence-based treatment with medications is often an important tool in treating mental illness and can be lifesaving. Discuss with your healthcare professional what is right for you.
Suicide is increasing. The rate of suicide climbed 37% between 2000 to 2018 — an unprecedented increase. My son was 18 years old when we lost him to mental illness and suicide during this time. In 2021, the rate is again close to the 2018 peak. I have not known of a greater heartache than losing a child. And a loss due to a preventable death is excruciatingly painful. Recently, I wrote an article about how I have dealt with the devastating effects of my child’s suicide.
Because I have been in the wake of suicide and experienced the pain, I am very aware of the importance of preventing this tragedy.
A recent study has looked at risk factors for ‘deaths of despair’ that include drug, alcohol, and suicide mortality. Not surprisingly, they found that disability, ethnicity, rurality, unemployment, less education, and lack of health insurance were social determinants of risk factors for these deaths.
There is a crying need for research and intervention for suicide. Research in psychopharmacology, pharmacogenetics, and neural mechanisms proliferate, yet research for practical intervention and prevention of suicide lags.
In addition, comprehensive strategies to address social determinants of health are needed to decrease deaths of despair.
What can we do?
The directive of Patrick Geddes to “Think globally, act locally” is a strategy that applies to ailing mental health. At a community level, we can raise awareness of the need for funding and infrastructure to support community-based mental health centers. At a state and national level, we can make our elected representatives aware of the need for funding of mental health infrastructure, research and intervention to prevent suicide, and universality of health insurance that covers mental health benefits.
I have lost a child and watched a brother suffer due to mental illness. I know many of you have also experienced tragedies due to mental illness. Let’s do what we can to change things.
This article is intended to provide useful information on the topic of mental health. It is not intended to treat or diagnose any medical condition. Please be sure to discuss your health decisions with your own health care professional.
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