Mental Health is Public Health
The need is huge and unmet, say experts, and we ignore it at our peril.
In an editorial published at the start of 2014, New York Times columnist Nicholas Kristof argued that mental health is one of the most crucial and “systematically neglected” topics we need to address as a society.
“One-quarter of American adults suffer from a diagnosable mental disorder, including depression, anorexia, post-traumatic stress disorder and more,” Kristof wrote. Such disorders are the leading cause of disability in the United States and Canada, he added, and pose a greater threat to our well-being than Al Qaeda terrorists. But in polite society a code of silence persists, and Kristof called on his peers in the media to do more to break the taboos surrounding mental health. He also noted the unjust burden imposed on both children and racial and ethnic minorities by untreated mental health problems.
Not two weeks after Kristof’s editorial, the New England Journal of Medicine published an editorial calling for increased global access to “evidence-based treatment and care” for people with mental disorders. “Arguably the most important reason for action is the disturbing evidence that people with mental disorders … are subject to some of the most severe human rights violations encountered in modern times,” the authors wrote.
What role can—and should—public health play in meeting this immense and largely unmet need? That’s the question we put to a range of experts. Their answers follow:
- Nicholas Kristof, “First Up, Mental Illness. Next Topic Is Up to You,” The New York Times (January 4, 2014).
- Vikram Patel, F. Med. Sci., and Shekhar Saxena, M.D., “Perspective. Transforming Lives, Enhancing Communities—Innovations in Global Mental Health,” The New England Journal of Medicine (January 15, 2014).
It’s a kind of insanity—a nearly clinical madness—not to provide for mental health needs in public health policy. People whose mental health challenges are being handled well live richer and happier lives, so there’s a moral imperative there. But for the people who are unmoved by that argument, there is an urgent economic one to complement it. Untreated mental illness is terrifyingly costly: those living with untreated illness are more likely to manifest somatic symptoms, are less able to care for themselves, are less likely to participate in the nation’s economy, will struggle to take care of children whose own behavioral issues generate enormous expense, and may be more inclined to commit criminal acts. We ignore these populations at our collective peril.”
Andrew Solomon, PhD, author of The Noonday Demon: An Atlas of Depression (2001 National Book Award; 2002 Pulitzer Prize Finalist) and Far from the Tree: Parents, Children, and the Search for Identity (2012 National Book Critics Circle Award)
If we think about how over 70 percent of our $2.8 trillion health care budget in the U.S. is related to chronic disease, and then we think about how over 75 percent of chronic disease is related to our behaviors and lifestyles and the decisions we make, then you start realizing how important mental health issues are to both physical health and our economy. If public health is truly interested in the root causes of health and disease, we need to adopt a truer definition of health and pay as much attention to mental health issues as we do to physical health issues, rather than separate them as we’ve done up to now.”
Victor Strecher, MPH ’80, PhD ’83, Professor and Director for Innovation and Social Entrepreneurship, U-M SPH; Author, On Purpose: Lessons in Life and Health from the Frog, the Dung Beetle, and Julia (2013)
One issue we have to think a lot about is capacity. We have some recent survey data that shows that a majority of primary care physicians don’t think we have adequate capacity today for adults or children who need mental health services. And inpatient mental health services aren’t exactly places where health systems make a profit. So we have to think a lot about how much we value those services, and make sure those services are available, whether they’re good for the bottom line or not. That’s a complicated piece—and public health is a huge part of it.”
Nancy Baum, PhD ’10, MHS, Policy Analytics Team Lead, Center for Healthcare Research & Transformation; Board Member, Washtenaw Community Health Organization
When I present a statistical analysis involving mental health, I like to say that mental health is the most endogenous variable ever—it is affected by just about everything, and it affects just about everything. If you take a narrow perspective, you are almost sure to miss something important. So a holistic, public health perspective is needed to understand the determinants and consequences of mental health, and how to improve mental health. This presents a major challenge for researchers and practitioners—understanding and influencing mental health is so complicated. The flip side, and the reason I find this area so exciting, is that there is an opportunity for collaborative public health approaches to make a major contribution to societal health and well-being.”
Daniel Eisenberg, PhD, Associate Professor, Department of Health Management and Policy, U-M SPH
Depression afflicts one in every six people. It’s the second costliest disorder in the United States, and according to the World Health Organization, the costliest disorder in most of the developed world. When you have something like this that is prevalent, disabling, costly, and potentially lethal, you should be doing something about it. So it is a public health issue.
Study after study shows that we should be screening for depressive illnesses at the age of onset, which is typically between 15 and 24, rather than waiting for them to get progressively worse. Almost always, major medical illnesses are best treated in the early stages—look at diabetes. If you ask where a marriage between health care delivery and public health has really shined, it’s in diabetes prevention and management.
If we’re going to have breakthroughs in mental health, we have to shift to an epidemiological perspective and find out where the people are who need the help. We need to recognize early onset and intervene when it can be most helpful. We need to develop biomarkers and lab tests to identify who is at risk. This is a quintessential public health problem—but it’s also a pediatrics problem, an internal medicine problem, a school and a workplace problem. This is why we need an integrative model, which is a public health model. If anything, public health people are leading the charge, saying we can do this differently. I don’t hear much of that coming from the general health care delivery system.”
John F. Greden, MD, Rachel Upjohn Professor of Psychiatry and Clinical Neurosciences, U-M; Executive Director, U-M Comprehensive Depression Center; Founding Chair, National Network of Depression Centers
It’s been clear to me since I began doing my early work in psychiatric epidemiology that many of the things that cause emotional distress or pain are the large social factors that impinge upon people’s lives. Something as basic as exposure to stress or to stressful life events—including social problems—is an obvious precursor to what we call mental health and well-being. And those are all very much in the public health paradigm. When one thinks about prevention in public health, social stressors are some of the primary targets if you want to try to create a better sense of emotional well-being for people—especially vulnerable populations.”
Harold W. Neighbors, MA, PhD, Professor, Department of Health Behavior and Health Education, U-M SPH; Associate Director, Center for Research on Ethnicity, Culture and Health
In 2009, I had the privilege of serving on an Institute of Medicine committee that issued a report on the prevention of mental illness and problem behaviors in children, youth, and families. We found that across the developmental span of childhood, from preconception on, there are effective interventions that can have a lifelong impact. Early in life, home nurse visitation, high-quality center-based care such as Head Start, and high-quality pediatric care make a huge difference, as do targeted interventions during the school years. Moving into adolescence, there’s good evidence we can prevent substance abuse and episodes of depression and even possibly stave off psychotic episodes and schizophrenia through community awareness and by heeding very early warnings signs, or in some cases using cognitive behavior therapy and antipsychotics.
When you see so many kids already addicted to drugs or attempting suicide, you say to yourself, we have to go further upstream. We have to intervene before things become so terrible. Kids who have poor physical and mental health outcomes very often have parents who are depressed, so we can also intervene effectively to strengthen parenting. Investing dollars in prevention makes sense. There’s a lot that we could do if we include mental health in the broad public health framework. Public health needs to embrace mental health issues the way it has physical health issues.
William Beardslee, MD, Director, Preventive Intervention Project, Judge Baker Children’s Center; Chairman Emeritus, Department of Psychiatry, Boston Children’s Hospital; Gardner-Monks Professor of Child Psychiatry, Harvard Medical School
One of the things we learn about in public health is that if you test for it, you have to do something about it—you don’t just test and do nothing. With so many health care organizations now embracing the patient-centered medical-home model of care, pediatricians and primary care physicians are doing more screening. But there aren’t enough psychiatrists to go around, so we need an integrated, interdisciplinary, public-health approach to not only treatment, but above all prevention—screening, education, and outreach.”
Rosalind García-Tosi, ScD, MSW, MPH ’96, Associate Director of Administration, U-M Comprehensive Depression Center
My father struggled with bipolar disorder for ten years. When he finally got the treatment he needed, he was able to lead a happy and successful life again. To help ensure people get early treatment, we must reduce the stigma around mental illness and increase the funding for services in the community. That’s why I authored the ENHANCED Act to establish national centers of excellence, based on the great work already underway at the U-M Comprehensive Depression Center, to increase the focus on critical research and better treatment of depression and bipolar disorders. My Excellence in Mental Health Act would go even further to help increase the availability of treatment in communities and improve the quality of care offered. Public health has a vital role to play in all of these efforts.”
U.S. Senator Debbie Stabenow (D–Michigan)
First, some of the best epidemiologic studies say that in any one year, approximately 40 percent of the U.S. population may be affected by significant psychiatric illness—including anxiety disorders, depression and bipolar disorder, schizophrenia, and alcohol/drug abuse or addiction. The numbers are more or less the same in the rest of the developed world.
Second, access to treatment is inadequate. Even in the U.S., only about 20 percent of the people who have depression—to take just one example—receive adequate treatment. As with many illnesses, the first treatment does not necessarily produce the desired outcome. So treatment adherence and good follow-up are major needs—and both are directly linked to outcomes and costs.
Third, psychiatric illnesses like depression frequently go undiagnosed. In primary care settings, 50 percent of cases are missed.
Fourth, the World Bank predicts that by 2020 depression will be the number one global eco- nomic burden of any disease.
Fifth, it’s not uncommon for patients who present to a physician or are admitted to an emergency room to have both a medical and a psychiatric problem. And when that happens, the psychiatric component of the patient’s clinical picture is generally not addressed at the same level as the medical component.
So mental health is a major health problem, which means it’s a public health problem. But it’s not generally viewed as a public health priority, in large part because of stigma, I believe, but also because many health professionals are unaware of data like this.
Allan Tasman, MD, Professor and Chair, Department of Psychiatry and Behavioral Sciences, University of Louisiville Medical School; Treasurer, National Network of Depression Centers; Past President, American Psychiatric Association
Only in the last six years have international and national health organizations recognized that:
- Mental illnesses are the second largest contributor to the worldwide disease burden;
- Mental health conditions should be provided with the same out-of-pocket costs to individuals as traditional medical conditions;
- The provision of mental health services is an essential benefit under the Affordable Care Act.
Public health has always taken a lead in community education, screening for illness and at-risk behaviors, linking individuals and communities to care, helping to measure the acute and chronic disease needs of communities, and implementing short- and long-term interventions to mitigate the resulting harm. Public health has also promoted the innovative use of health information technologies for the exchange of critical data on disease and its social determinants. By viewing mental health as a key component of public health, one can see the immense potential for rapid, integrated, coordinated mental health care within the context of primary care.
Kyle Grazier, MS, MPH, DrPH, Chair and Richard Carl Jelinek Professor of Health Services Management and Policy, Department of Health Management and Policy, U-M SPH; Professor, Department of Psychiatry, U-M Medical School
As advances in U.S. public health grow and progress, it is critical that we embrace mental health conditions as matters of public health, rather than simply as clinical concerns. Just as we encourage individuals to pursue treatment for common or chronic diseases, we should advocate to change attitudes and help-seeking behaviors related to mental health—for the benefit of society as a whole.
A prime example is the U.S. Department of Veterans Affairs’ Make the Connection initiative (maketheconnection.net), a public health education campaign to connect veterans and their families with mental health information and services—and help them discover ways to live more fulfilling lives. On the website’s educational pages, veterans and civilians can learn about the types of symptoms and conditions veterans may experience, without unnecessarily labeling or stereotyping veterans.
While Make the Connection encourages veterans to reach out and overcome their life challenges, the campaign also inspires cultural change by showing all viewers that treatment is available—and it works. On both an individual and a population level, Make the Connection is designed to change perceptions about mental health treatment and is leading the charge to move beyond mental health stigma to promote health and wellness.
Sonja V. Batten, PhD, VA Mental Health Services, U.S. Department of Veterans Affairs
We know that those who suffer from mental health issues have high rates of co-morbid conditions, such as cardiac disease, and are high utilizers of the medical care delivery system. And, more and more, we know that there is a significant biological component to many mental health conditions.
And yet the media and others, including many health professionals, persist in making an artificial distinction between “mental health” and “physical health.” It is time that we stop making this distinction.
Mental health parity is a step in that direction. But, until we end the way those of us who work in health care speak about these conditions, stigma related to mental illness will continue. Until we end the artificial distinction between physical and mental health, research into causes and cures will be limited, and not enough practitioners will choose to work in this field. As long as some see mental health issues as a sign of “weakness” and not a clinical condition, people most in need will not seek care. Isn’t it time for public health to lead the way in changing how we view and talk about these devastating diseases?
Marianne Udow-Phillips, MHSA ’78, Director, Center for Healthcare Research & Transformation
When it comes to mental health, we’re more or less where the war on cancer was in the early 1970s. The brain is the most complicated of all of our organs by many orders of magnitude, and we are just now getting the biological tools to allow us to interrogate it at the molecular level and to use imaging techniques to see the brain in action. So the opportunity to make progress against major psychiatric disorders is at hand. That doesn’t mean it’s going to happen quickly, but it means hard science has a beginning foothold in our field. Up to now we’ve been developing treatments by chance and learning to use them by experience, but we haven’t had a rational understanding of what goes on in the brain. Now that we’re getting that understanding, we have the potential for more rational treatment. Eventually we’ll get to prevention.
If you care about public health, you’ve got to care about mental health. As a group, psychiatric disorders cause more social and financial cost worldwide than any other group of disorders—and they’re closely related to such major causes of disability and death as heart attacks, strokes, diabetes, and Alzheimer’s disease.
J. Raymond DePaulo Jr., MD, Henry Phipps Professor and Director, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine; Psychiatrist-in-Chief, The Johns Hopkins Hospital
With the Affordable Care Act, we’re going to see more people coming into the system. What’s it going to mean? We’re going to need to figure out new and collaborative models of care—the idea of a therapist sitting with an individual patient may no longer be the norm. Public health could help us make the shift to a more population- and prevention-based approach to mental health.
Michelle Riba, MD, Professor of Psychiatry and Associate Chair, Integrated Medical and Psychiatric Services, U-M Department of Psychiatry; Past President, American Psychiatric Association
FactCheck: Mental Health Services Capacity in Michigan
- 20 percent of Michiganders report being diagnosed with depression, as compared to 18 percent of Americans.
- 59 percent of those on Medicaid and 33 percent of the uninsured report depression and/or anxiety symptoms in Michigan.
- 57 percent of primary care physicians in Michigan report that the availability of mental health services in their community is inadequate for adults.
- 68 percent of primary care physicians in Michigan report that the availability of mental health services in their community is inadequate for children.
- 42 is Michigan's rank among the 50 states and the District of Columbia in availability of inpatient psychiatric beds.
Source: Mary Smiley; Danielle Young; Marianne Udow-Phillips; Melissa Riba; Joshua Traylor. Access to Mental Health Care in Michigan. Cover Michigan Survey 2013. December 2013. Center for Healthcare Research & Transformation. Ann Arbor, MI.
Who's Mental Health Action Plan
Adopted in May 2013 by the 66th World Health Assembly, the World Health Organization's Comprehensive Mental Health Action Plan 2013–2020 sets new directions for mental health, among them a central role for the provision of community-based care and a greater focus on human rights. The plan's four main objectives are:
- Strengthen effective leadership and governance for mental health
- Provide comprehensive, integrated, and responsive mental health and social care services in community-based settings
- Implement strategies for promotion and prevention in mental health
- Strengthen information systems, evidence, and research for mental health
Source: World Health Organization Comprehensive Mental Health Action Plan, adopted by the World Health Assembly, May 2013