A Snapshot of the Mental Health Crisis
Significant social problems including bigotry, systemic racism, political turmoil, food and housing insecurities, violence, the opioid epidemic, etc… preceded, and in some cases, were worsening in our communities prior to the arrival of COVID. As COVID spread, every aspect of peoples’ existence on earth was impacted. A National Institute of Health article points out that, “the COVID-19-pandemic-related economic and social crises [led] to huge challenges for all spheres of human life across the globe. Various challenges highlighted by this pandemic include, but are not limited to, the need for global health cooperation and security, better crisis management, coordinated funding in public health emergencies, and access to measures related to prevention, treatment and control.”
#Stayhome [became] an anthem for everyone, writes Barbara Duriau, a Facebook poster and Administrator of the history-making, COVID-inspired global community group, “View From My Window” (VFMW). In her post announcing the discontinuation of the group this week, she goes on to explain that she, like the 3.8 million members of the group, “…was surrounded by millions of people, virtual but isolated. Another member of the group describes that ‘VFMW took me out of fear and into hope. It gave me something bigger than myself to think about. It opened my eyes to other ways of life, to other seasons, to others homes and hearts, to others suffering and dreaming, and to others perspectives & experiences of what we were all going through together. It was (& still could be) a beacon of light in some dark times. Put simply, I miss it.’
In her 1995 article, Hearing the Difference: Theorizing Connection, Carol Gilligan, an American feminist, ethicist, and psychologist, best known for her work on ethics in community and relationships, states “Theorizing connection as primary and fundamental in human life leads to a new psychology, which shifts the grounds for philosophy and political theory.” Atul Gawande, a surgeon, observes, “Human beings are social creatures. We are social not just in the trivial sense that we like company, and not just in the obvious sense that we each depend on others. We are social in a more elemental way: simply to exist as a normal human being requires interaction with other people.”
In many ways, the effects of isolation continue. Many observe that, in part, general cynicism and animus that seemed to be characteristic of our societal adjustment to COVID precautions and defense still remains. Regardless of where they live, nearly half of Americans (47% overall) say the pandemic has divided their communities; relatively few (13%) say it has brought people together. And many see a long road to recovery, with about one-in-five saying life in their community will never get back to the way it was before the coronavirus outbreak.
A particularly alarming major public health issue in the United States is the opioid crisis. In 2021, more than 106,000 people died from drug overdoses, including more than 70,000 from opioids. This is a significant increase from the number of opioid overdose deaths in 1999, which was just over 16,000.
The opioid crisis is driven by a number of factors, including the overprescription of opioid painkillers, the availability of illicit opioids such as heroin and fentanyl, and the stigma associated with addiction. The crisis has had a devastating impact on families and communities across the country.
Almost 22 years ago, on August 28, 2001, during a hearing with Purdue Pharma before the Subcommittee on Oversight and Investigations of the Committee on Energy and Commerce, House of Representatives the Chairman, James C. Greenwood of Pennsylvania stated:
…Today’s hearing is the logical extension of this subcommittee’s ongoing investigation into prescription drug abuse throughout the United States. My staff and I have met on numerous occasions with the DEA, the FDA, and Purdue Pharma in order to investigate the trends of OxyContin abuse and diversion, and well as to explore potential solutions. Sadly, prescription drug abuse is a growing national problem. According to the National Institute of Drug Abuse, as recently as 1999, more than 9 million Americans, aged 12 and older, reported that they used prescription drugs at least once that year for nonmedical reasons. Nor is prescription drug abuse a new problem. For example, from 1990 to 1998, the number of individuals initiating misuse or abuse of pain relievers increased by 181 percent, new initiates to stimulants increased by 165 percent, tranquilizers by 132 percent, and the initiates into sedative use have increased by 90 percent. It is especially disturbing to note that the most dramatic increases have been found in 12 to 17-year-olds and in 18 to 25-year-olds. There is a gentleman in the audience whose 18-year-old son perished after taking OxyContin in combination, I should say, with another drug…Law enforcement officials have criticized the drug’s manufacturer of overly aggressive marketing practices and a failure to swiftly respond once the abuse of OxyContin was first reported in Maine in early in the year 2000. In fact, on August 21, 2001, Pennsylvania Attorney General Mike Fisher accused Purdue Pharma of continuing to use overly aggressive marketing practices, such as using promotional pens and conversion charts, urging physicians, many of whom were clearly not pain specialists, to prescribe OxyContin to their patients. Their campaign also included efforts to persuade doctors to switch patients who were receiving less addictive and less powerful painkillers to OxyContin.
As a Certified Mental Health Nurse as well as a recovery advocate, I was invited to and further testified:
In considering the escalation of the number of people becoming addicted to, and dying from, the misuse of OxyContin, it is important to realize that its respiratory depressant effects can be lethal with any, including the initial use, that is not monitored by a physician. The likelihood of death is increased because when used in conjunction with alcohol and other sedatives, as is the practice among many teenagers, the respiratory-depressant effects are potentiated. The rapid increase in the number of young people able to access and consequently abuse OxyContin [and other opioids] is intensely apparent in my daily practice. Many, if not most, of the adolescents I come in contact with are well aware of how “good” the “Oxy’s” are. When I ask my young patients if they realize that OxyContin is just as, if not more, deadly than heroin, they respond with great skepticism and apathy because they view OxyContin as a medicine, not a street drug, making it more attractive to a wider variety of teens. These young people consider OxyContin to be a cleaner, prettier, more powerful form of heroin. Although they are vastly informed of the positive euphoric potency of OxyContin, they have little, if any, information about its often fatal respiratory depressant and other side effects, and the eventual withdrawal syndrome. This lack of knowledge and lack of concern for their own existence is evident as they freely admit to, and even brag about, supplementing OxyContin use with alcohol and other opioids, a practice that has proven to have detrimental consequences. Upon entering treatment, often as a result of legal or familial force, adolescents are resistant to intervention or education. This opposition is not only a result of their inherent developmental ideology of independence, omnipotence, and immortality, but also because OxyContin provides the ultimate in escapism. I have watched young people walk out of treatment centers, risking imprisonment, homelessness, the loss of families, including the loss of their own small children, and even the loss of their own lives, rather than face the prospect of life without OxyContin and other drugs.
As we search for healing, the ideal solution in coping with and eventually remedying the individual angst and community division of our mental health emergency, should be our medical and behavioral health system. However, healthcare is a complex and challenging system, and has not been available to meet the challenge of our current mental health crisis. Here are a few of the most common reasons:
One of the biggest challenges facing the healthcare system is the high cost of care. Healthcare is expensive, and the costs are constantly rising. The United States spends more on healthcare than any other developed country, both as a percentage of GDP and on a per capita basis. This is due to a number of factors, including the high cost of medical technology, prescription drugs, medical devices, hospital stays, the increasing complexity of medical care, and the aging population. There is a lot of waste in the system, and this drives up costs.
Another challenge is the fragmentation of the healthcare system. The healthcare system is complex, disorganized, and inefficient. There are many different players in the system, including hospitals, doctors, insurers, and pharmaceutical companies. There are many different types of insurance plans, and each plan has its own set of rules and benefits. This can make it difficult for patients to navigate the system and get the care they need.
Adding to this, the healthcare system is facing a shortage of providers, especially in primary care. This is due in part to the low pay for primary care doctors, the high stress of the job, and the increasing number of people who are uninsured or underinsured.
The system is also inequitable. Health inequities are a serious problem in the United States. They can lead to poorer health outcomes for people who are already at a disadvantage. It is important to address these inequities so that everyone has the opportunity to live a healthy life. There are many factors that contribute to health inequities, including race, ethnicity, socioeconomic status, and geographic location. Not everyone has access to quality healthcare, and those who do often have to pay high prices.
Finally, the emerging trend of private equity firms acquiring healthcare systems must be considered. It is often not in the best interest of patients, staff, or the community for private equity companies to own hospitals.:
- First, private equity companies are focused on making a profit, and they may make decisions that are not in the best interest of patients or the hospital staff. For example, they may cut costs by reducing the number of nurses or doctors, or by closing down essential services.
- Second, private equity companies often have little experience in the healthcare industry, and they may not have the expertise to manage a hospital safely or effectively. This can lead to problems such as poor patient care, financial mismanagement, and regulatory violations.
- Third, private equity companies often use debt to finance their acquisitions, which can make the hospitals they own more vulnerable to financial problems. If a hospital is unable to make its debt payments, it may have to file for bankruptcy, which can disrupt patient care and put jobs at risk.
The status of healthcare in America today is multifaceted and convoluted. On the one hand, the United States has some of the best medical care in the world, with cutting-edge technology and highly skilled doctors. On the other hand, the healthcare system is also expensive and fragmented, and many people struggle to afford the care they need.
More specifically, availability of necessary quality mental health care is severely lacking. In a March 23, 2023 article entitled, “Medicaid Data Show Wide Differences in Mental Health Care in the United States”, the National Institute of Mental Health writes, “the findings highlight the nationwide use of emergency departments for mental health care, while emphasizing wide variations in rates of use between states and between mental disorders. The frequent use of emergency services for mental health care shown in this study might, in some cases, indicate a high degree of unmet need or a lack of access to outpatient mental health services.”
There are a number of reasons why access to mental health care is so limited, especially in states like Pennsylvania. Like healthcare in general, the most common reasons for the inadequacy includes cost, lack of providers, and inefficiency. Adding to these circumstances, are the problems of parity and stigma.
Mental health parity is the idea that people with mental health conditions should have access to the same quality of care and coverage as people with physical health conditions. Parity laws require health insurance plans to cover mental health and substance use disorder (SUD) benefits in the same way they cover medical and surgical benefits. Though the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires health insurance plans to provide parity for mental health and SUD benefits, there are some exceptions to these requirements. For example, MHPAEA does not require health insurance plans to cover inpatient mental health care for more than 15 days per year. Additionally, MHPAEA does not require health insurance plans to cover all mental health and SUD services. Many insurance plans do not cover mental health care, or they only cover a limited amount of mental health care. This can make it difficult for people to afford the care they need.
There is still a lot of stigma associated with mental illness, which can prevent people from seeking help. People may be afraid of being judged or discriminated against if they talk about their mental health problems. First, stigma can lead to shame and embarrassment. People may feel ashamed of their mental health condition and may not want to talk about it. Second, stigma can lead to fear of discrimination. People may worry that they will be treated differently if they disclose their mental health condition. They may worry that they will be fired from their job, denied housing, or even shunned by their friends and family. Third, stigma can lead to self-stigma. People may internalize the negative stereotypes about mental illness and believe that they are not capable of living a normal life. They may also believe that they are to blame for their mental health condition and that they should be able to “just get over it.”
These are just a few of the reasons why access to mental health care is so limited. It is a complex and challenging issue, and there are no easy solutions. Despite these challenges, there are also some positive trends in the healthcare system. There are a number of people working to improve access to mental health care and make it more affordable, accessible, and equitable.
One source of remedy may be funding and resources made available by the National Prescription Opiate Litigation (NPOL). It is a multidistrict litigation (MDL) that was created in 2017 to consolidate thousands of lawsuits against opioid manufacturers, distributors, and pharmacies. The NPOL is being overseen by a federal judge in Cleveland, Ohio. The lawsuits in the NPOL allege that the defendants were responsible for the opioid crisis by overprescribing opioid painkillers, failing to adequately monitor the use of these drugs, and engaging in deceptive marketing practices. The plaintiffs in the lawsuits are seeking damages for the harm that they have suffered as a result of the opioid crisis.
In their article, “Opioid crisis settlements have totaled over $50 billion. But how is that money being used?,” CBS reports that Christine Minhee, attorney by training and founder of OpioidSettlementTracker.com, has compiled data on the settlements tracking the amount of money allocated and where states have decided to spend it. According to her data, which is used by state governments and the Centers for Disease Control and Prevention, the total pot of funds available from the settlements has reached around $54 billion dollars, with nearly half of the money coming from a $26 billion dollar 2022 settlement with drug manufacturers and distributors, and more funds expected from ongoing legal battles. States are required to spend 85% of their settlement funds on opioid remediation, with 70% of that allocated to future remediation, Minhee says, to prevent a repeat of the 1998 tobacco settlement controversy, when just 3% of billions of dollars was used for treatment and cessation of smoking. Remediation can include funding harm reduction, treatment options and more. States have wide discretion over how they choose to spend the money.
The settlement funds could be used to prevent opioid addiction by funding education and awareness campaigns, as well as harm reduction programs. This would not only understand the science of the disease, hopefully decreasing stigma, but also help people understand the risks of opioid addiction and make better informed decisions about their health. Further, the funds could be used to increase access to evidence-based treatment and recovery services such as addiction medications and counseling. The money may also support research into new treatments and prevention strategies. This would help finally focus efforts on developing more effective ways to help people who are struggling with opioid addiction. Finally, the funds could be used to hold opioid manufacturers and distributors accountable for their role in the opioid crisis. This could include funding lawsuits against these companies, as well as supporting efforts to change the way they do business.
The Affordable Care Act assisted in helping to reduce the number of uninsured Americans. It has had a number of benefits for Americans, including expanding health insurance coverage, improving the quality of care, and reducing the costs of health care. Another piece of legislation positioned to greatly improve the state of mental health care is The Consolidated Appropriations Act, 2023. It is an omnibus spending bill that includes a number of provisions that will impact mental health and substance use disorder treatment. It was signed into law by President Biden on December 27, 2022.
Some of the most notable provisions include: Expansion of Medicaid coverage. The bill expands Medicaid eligibility to cover more low-income adults, including those with mental health and substance use disorders. This will help to ensure that more people have access to affordable treatment. It also Increases funding for mental health and substance use disorder programs. The bill includes $11 billion in new funding for mental health and substance use disorder programs. This funding will be used to support a variety of programs, including prevention, treatment, and recovery support services. Additionally, The bill helps reduce barriers and makes it easier for people to access mental health and substance use disorder treatment through telehealth. This will be especially helpful to people in rural areas.
The bill supports research and includes $1 billion in new funding to support a variety of research projects, including studies on new treatments and prevention strategies to support mental health and recovery from substance use disorders. Furthermore, the bill includes $10 million in new funding for innovation programs in the mental health field. This funding will be used to support the development and implementation of new mental health interventions and clinical programming.The Consolidated Appropriations Act, 2023 (Pub.L. 117–328, 147 Stat. 814, enacted December 29, 2022) includes a number of provisions that impact community mental health.
One provision provides $10 billion in funding for mental health services, including $5 billion for the Substance Abuse and Mental Health Services Administration (SAMHSA) and $5 billion for the Department of Health and Human Services (HHS). This funding will be used to support a variety of programs, including:
- Crisis stabilization services
- Mobile crisis response teams
- Community-based mental health treatment
- Suicide prevention
- Substance abuse treatment
Another provision provides $1 billion in funding for the Children’s Mental Health Services Block Grant (CMHSBG). This funding will be used to support a variety of programs, including:
- Early intervention and prevention services
- School-based mental health services
- Pediatric and adolescent inpatient and residential mental health services
- Family support services
The Consolidated Appropriations Act of 2023 includes $50 million in new funding for workforce development programs in the mental health field to address the staffing shortage. This funding will be used to train new mental health professionals and support the professional development of existing mental health professionals. The bill also has a number of provisions that will increase systemic collaboration and efficiency by supporting the integration of mental health care with primary care.
The legislation provides $5 million in new funding for coordination programs in the mental health field. This funding will be used to support the coordination of mental health resources, personnel, and services across different settings and systems. These provisions include: Funding for training and technical assistance for primary care providers on how to integrate mental health care into their practices, funding for research on the effectiveness of integrated mental health care, and support for the development of sustainable models of integrated mental health care. These provisions are designed to help primary care providers better identify and treat mental health conditions in their patients. They also aim to improve access to mental health care by making it more readily available in primary care settings.
Integration of mental health care with primary care can have a number of benefits for patients. It can lead to earlier diagnosis and treatment of mental health conditions, which can improve outcomes. It can also reduce the stigma associated with mental health care, as patients are more likely to seek help if they can receive it in a familiar setting. Integration of mental health care with primary care can also be beneficial for providers. It can help them to more cohesively work together in better understanding and managing the mental health needs of their patients. It can also save time and money, as providers can address both physical and mental health needs in a single visit.
As unprecedented rates anxiety, depression, violence, substance misuse, overdoses, and suicide continue, global, national, and local communities must continue to work toward recuperating and healing. The efforts to (re)gain peace and mental health should be intentional and organized. Official structures such as The Consolidated Appropriations Act of 2023 are long overdue and much needed positive steps for establishing and maintaining individual and community mental health through continuing expansion of access to care, improvement in the quality of care, as well as supporting research, workforce development, innovation, and meaningful coordination of resources.
Theresa M. Drass
TheresaDrass4@GMail.com
Gilligan, C. (2003). Hearing the difference: Theorizing connection. Anuario de Psicología, 34(2), 155–161.
Medicaid Data Show Wide Differences in Mental Health Care in the United States: https://www.nimh.nih.gov/news/science-news/2023/medicaid-data-show-wide-differences-in-mental-health-care-in-the-united-states
Opioid crisis settlements have totaled over $50 billion. But how is that money being used?: https://www.cbsnews.com/news/opioid-crisis-settlements-have-totaled-over-50-billion-how-is-that-money-being-used/
Panneer S, Kantamaneni K, Palaniswamy U, Bhat L, Pushparaj RRB, Nayar KR, Soundari Manuel H, Flower FXLL, Rice L. Health, Economic and Social Development Challenges of the COVID-19 Pandemic: Strategies for Multiple and Interconnected Issues. Healthcare (Basel). 2022 Apr 21;10(5):770. doi: 10.3390/healthcare10050770. PMID: 35627910; PMCID: PMC9140679.