World mental health day was Oct 10, but given the state of the nation, and the world, every day should be mental health day.

     Mental illness is quite common, affecting 1 in 5 US adults, or 51.5 million people in 2019. That means almost all of us know at least one person, probably many people (whether we know it or not) who suffer from some type of mental malady. The Covid-19 pandemic has made the situation worse. A June 2020 survey published by the CDC reported that 40% of US adults were struggling with mental health or substance use. A survey from the Commonwealth Fund using data from March to May 2020 revealed that 1 in 3 US adults were experiencing stress, anxiety, or great sadness. This is hardly surprising. The pandemic has caused disruption of our normal routines, loss of social support, upheaval in schooling, and severely diminished in-person contact with anyone who resides outside of our homes, including family, our closest friends, our work colleagues, and even casual, but rewarding brief interactions-the mail person, the clerk at Kroger’s, or our favorite waitperson at our regular restaurant. Family and holiday celebrations have been scaled down, cancelled, or postponed indefinitely. Mourning rituals, which provide structure and comfort to our grief, have been attenuated or vanquished altogether. None of these life-altering changes are advantageous to our mental health and are likely to have reverberations far into the future.

     In addition to its solitary burden, mental illness is also closely associated with other co-morbidities (illnesses or conditions which compromise our health) and toxic coping strategies. 37% of adults with any mental illness, such as severe anxiety, depression, or schizophrenia, also use illicit drugs, and 31% are binge consumers of alcohol, often in a self-help attempt to feel better. The contributing substance abuse then leads to further fall out, such as job loss or homelessness. Patients with mental illness are more likely to miss work or school, have legal and financial problems, inadequate social support, live in poverty, and have other general medical conditions. Both mental illness and substance abuse are associated with impaired judgement and high risk behaviors, including sexual promiscuity, and may result in suicide

     A substantial proportion of mental illness is insufficiently treated. The 2019 National Mental Health Services Survey showed that in 2018, less than half of adults with any mental illness (43%) received mental health services. This translates to nearly 60% being untreated.

     The single largest reason for unmet care was cost.  Historically, insurance companies have reimbursed for mental health services at much lower levels than for physical illness. The carriers imposed separate copay charges for mental health services, separate limitations on lengths of stay in in-patient facilities, and separate ceilings on mental health coverage, as compared to other medical and surgical services. These disparities were partially addressed with the Mental Health Parity Act of 1996 and the Mental Health Parity and Addiction Equity Act of 2008, which required large group employer-based insurance policies to cover mental health services at the same levels as medical and surgical services. The Affordable Care Act (ACA) expanded coverage further by requiring individual, small group, and Medicaid expansion plans to do the same.

     Another reason for lack of mental health care is widespread bias against mental health, internalized by those who are affected, as well as their families. I saw these biases reflected in my patients’ dismissal of recommendations for treatment in favor of the idea that resolution of their symptoms was within their control: “I can will my depression away,” “I won’t have debilitating anxiety if I get more sleep, meditate more, change jobs…” Meanwhile, the symptoms, and disruptions to their quality of life persisted. I highlighted one example of this prejudice in my video discussion on social determinants of health.  Janet*, was depressed, and initially refused both counseling and medication. After considerable cajoling, she finally agreed to try an anti-depressant medication, following which her symptoms notable improved. We were both pleased with her success.  Unfortunately, her husband did not believe in treatment for depression, and Janet discontinued pharmacologic therapy at his insistence.  When I saw her in follow up, she was depressed again. While admitting that she felt better with treatment, she was unwilling to override her husband’s objections and resume her medication. Her demonstrable improvement was insufficient to overcome the negative beliefs surrounding mental health.

      Yet a third obstacle to care is the dearth of mental health providers, particularly in non-metropolitan and rural areas. Given the number of patients requiring treatment, the limited number of mental health professionals, and the stigma attached to engaging the services of specialized mental health professionals, many patients with depression and anxiety are managed by primary care providers, such as internists and family practioners, as well as by pediatricians and OBGYNs. However, when we “non-psychiatrists” have reached the limits of our psychiatric expertise, it can be difficult to convince our patients to pursue expert consultation. The patients protest-they are comfortable with me, they do not want to start over with someone new, it would be too expensive, the location/appointment times of the (referral) aren’t convenient, they are fearful of change. The net result is the same-suboptimal control of their symptoms.

     A facet of mental illness that is not always acknowledged is the impact that certain personality disorders, and mental conditions, particularly if they are untreated or inadequately controlled, have on  communication and compliance as patients interact with the medical system.  Patients’ anxiety can affect their ability to absorb, retain and process information accurately.  Depression may affect judgement and decision-making.  Psychosis can preclude rational discussion. Borderline personality can alter inter-personal relationships. When mental health issues affect medical or surgical management in the in-patient setting, it can be extremely challenging to obtain urgent psychiatric evaluation, not to mention appropriate post-discharge care. Our healthcare system does not provide adequate tools or resources to address these issues.

     Medical management of psychiatric conditions is often imprecise.  Although testing is becoming available to predict individual responsivity to classes of psychotropic medications, historically trial and error methods have been used in the effort to control symptoms. A number of these medications, especially anti-psychotics, can produce undesirable side effects, such as grogginess, sleepiness, seizures, and problems with sexual function, as well as life threatening problems such as heart arrhythmias and sudden death. Unpleasant side effects reduce compliance with therapy, and consequently, suboptimal control of the mental illness. Conversely, some patients, when they are successfully treated and feel well, decide that they no longer require medication, discontinue treatment, and relapse, setting up a vicious cycle of affliction and remission. This is a frustrating and exhausting situation for patients, their families, and their providers.

     Attitudes toward mental illness, as well as the US health system’s incentives and structure, fail these patients, and will continue to do so until we value health and healing over profit and expediency. The protections afforded by mental health parity laws, and the ACA,  have improved the quality of life for many people. However, the ACA’s benefits are currently threatened by litigation currently before the US Supreme Court. Having a substantial proportion of Americans untreated, or inadequately treated for mental illness is deleterious not only for the affected individuals, but for their families, their employers, and for society as a whole. We must provide adequate pharmacologic, psychologic, and social support to those who are affected. We must de-stigmatize and address mental illness socially, financially, and operationally to have a happier and healthier population.

*Name changed to protect the patient’s privacy