This issue brief was originally published on Student Pugwash USA’s Elections 2012 page (click on the link and go to Issues > Health >Mental Health).
The State of Mental Health in the US and Globally
Mental illness is a term which covers a large number of disorders which can broadly be categorised into five groups: anxiety disorders (e.g. phobias, obsessive-compulsive disorders); mood disorders (e.g. bipolar disorder, depression); schizophrenia; dementias (e.g. Alzheimer’s, Parkinson’s); and eating disorders (e.g. anorexia nervosa, bulimia) . Mental health is as important to wellbeing as physical health – mental illness kills and disables and it causes huge amounts of suffering to individuals and the society at large as well as having enormous economic impact. Furthermore, people with mental illness are also more likely to have poor physical health than those without .
It is difficult to exaggerate the magnitude of the problem of mental illness. In the United States, it is estimated that more than a quarter of adults suffer from a diagnosable mental disorder every year. Depression alone is the leading cause of disability among people 15-44 years old, with more than 21 million cases of major depressive disorder (MDD) annually  and more than 30 billion US dollars lost each year due to lost productive time . There were 37,000 suicides in the United States in 2009 , making it the tenth leading cause of death (this rises to the top three in those aged between 15 and 44). Moreover, the number of suicides in the armed forces far outnumbers the number of soldiers killed in action .
Globally, the picture is even worse. Mental illness directly affects hundreds of millions of people every year; kills about 1 million people; is responsible for 13% of global disability adjusted life years, a measure of disease burden taking into account ill-health, disability or early death; and is estimated to cost upwards of US$2.5 trillion [7-9]. A large number of countries lack a mental health strategy and in many places suicide and attempted suicide are still illegal. However, it should be noted that some disorders, such as schizophrenia, have better outcomes—i.e. higher recovery rates and lower impairment and disability from symptoms— in resource-poor settings such as sub-Saharan Africa  so improvements in mental health treatment and prevention are likely to come from all corners of the globe.
There is still a great deal of stigma around having a mental illness, both from society towards people with mental illness, leading to prejudice and discrimination in employment and opportunities; and stigma that those with mental illness turn towards themselves, leading to low self-esteem and failure to pursue opportunities . Many people’s view of mental illness is shaped by media, where the topic predominantly appears in the context of violent crime. Mental Health America (formerly the National Mental Health Association) identifies a number of different prominent misconceptions about mental illness including: that children don’t suffer from mental illness; that those with psychiatric problems are dangerous, need to be locked away and can never be normal; and that those with mental illness aren’t suited for important or responsible positions . Needless to say all of these ‘facts’ are wrong. By greater education of the general population and greater integration and openness of people with mental illness in society, the lives of people suffering with mental health disorders can be greatly improved.
Mental Health Policy in the United States
Approximately two-thirds of those who have a diagnosable mental illness in the United States do not receive treatment . Historically, the provision of mental health and substance abuse services has largely been by individual states, rather than the federal government, meaning that mental health services can differ greatly in both type and level of care across the country . Perhaps unsurprisingly, poorer and more rural areas tend to have the lowest levels of mental health professionals per capita . Furthermore, the high levels of fragmentation in health services in the United States means that mental health and physical health services are not well integrated. Those who do receive mental health treatment often do not get adequate treatment for comorbid physical conditions, and mental health disorders are often not diagnosed and treated within primary care. There are also large disparities among racial groups. Ethnic minorities have less access to mental health services than white people and when they do receive care it is more likely to be poor in quality .
Major reforms of mental health services in the United States over the last century or so have focused on de-institutionalisation and community-centred care, but have been federally led. This has established a commendable emphasis on community care for the mentally ill, with patients no longer suffering the poor conditions, overcrowding and isolation of past psychiatric institutions. However, these policies have also brought other problems to the fore, with many people with poor mental health having difficulty in accessing these community services as well as housing, resulting in homelessness and/or inadequate treatment .
One of the great difficulties in mental health policy has been attempting to gain parity of mental health and physical health problems. For years, health plans routinely set stricter treatment limits and imposed higher out-of-pocket costs on mental health care than care for any other illness. In 1996, Congress passed The Mental Health Parity Act, which established the principle that mental health benefits should be “on par” with medical and surgical benefits. However, though the use of disparate annual or lifetime dollar limits between mental health coverage and coverage of other illnesses was banned, insurance plans still routinely set arbitrary caps on how many mental health treatment sessions or days of hospital care they would cover regardless of medical need. In 2008, this was supplemented by the Mental Health Parity and Addiction Equity Act (MHPA) which prohibits group health plans from imposing treatment limitations and financial requirements on mental health benefits that are stricter than for medical and surgical benefits.
Mental Health & The Patient Protection and Affordable Care Act
The passage of the Patient Protection and Affordable Care Act (ACA; also known as Obamacare) in 2010 is expected to lead to large improvements in mental health in the United States. Americans with mental health problems are more likely to be uninsured  than those without such conditions. Through its provisions expanding insurance coverage and Medicaid, it is thought that the ACA will lead to an extra 3.7 million Americans with severe mental illness gaining access to care when full implementation occurs in 2019 . This number does not include those with mild to moderate mental health problems. Further numbers should also be covered through the prohibition of denial of insurance based on pre-existing conditions. In terms of the parity mentioned previously, the ACA extends the MHPA’s prohibition of discriminatory limits on mental health and substance use services .
The emphasis within the ACA upon integration should also help reduce problems faced by those with mental illness because of fragmentation of health systems. Those eligible for Medicaid with multiple chronic conditions, including mental health conditions, will be able to have a “health home” option, where all healthcare professionals involved in an individual’s care (e.g. primary care practitioner, psychiatrist, cardiologist etc.) can share information and coordinate treatment . Another benefit included in the ACA is the supported employment programs, which help those with the most severe mental health issues to pursue competitive employment by providing them with support for an unlimited period of time including coaching on self-presentation, forming relationships with colleagues, and identifying and resolving problems at work . This evidence-based strategy [22, 23] allows people to be productive, have a valuable role in their communities, and pay taxes.
However, the ACA still leaves a number of problems for Americans living with mental illness. Even after its full implementation, a large number of people will not be able to gain access to mental health services. This includes people whose employer-sponsored plans don’t offer behavioural health benefits and those people, such as undocumented immigrants, who aren’t eligible for the expansion in coverage .
Mental Health in Political Discourse
Unfortunately, mental health issues do not feature strongly in political discourse. As of 29th July 2012, I cannot find any mention from either of the main presidential candidates on the issue of mental health in the last few years. Perhaps if enough of their constituents can persuade them that this is an issue they feel strongly about, this is something that can change.
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