What’s Wrong With Mental Health Care in America?

Just about everything.

I can sum up our country’s mental health care problem in one sentence: Failure to provide local, high-quality, comprehensive, affordable, evidence-based mental healthcare for every American citizen, at the appropriate level of intensity, for as long as necessary for full recovery and relapse prevention.

Few Americans have access to local high-quality, evidence-based mental healthcare. Some people find mental health care cost-prohibitive. Others struggle to make ends meet, dipping into their savings, wiping out their retirement accounts or college funds in order to afford appropriate mental health treatment for themselves or their loved ones.

Societal ignorance is partially to blame for this problem. Although “the stigma” of mental illness has allegedly been reduced in recent decades, I see it all around. Like racism and sexism, the stigma of mental illness is perhaps less overt now than it was in previous generations, but it is alive and well today in all of its subtler forms. Many insurance plans do not provide coverage for mental health care. This conveys the message that mental health treatment somehow optional, unimportant, or extracurricular. The brain is arguably the most important part of the body, so why should treatment of brain diseases be viewed as less essential than ophthalmology, endocrinology, or dermatology?

Even more infuriating to me is the reality that mental illness itself is not nearly as stigmatizing as GETTING TREATMENT FOR MENTAL ILLNESS. Consider the following:

• As a graduate student, I read about a medical insurance policy that parents of college students can take out for their children. This policy allows parents to receive a full tuition refund if their child withdraws from school mid-semester for medical reasons. However, the policy specified that, if the student withdraws due to “a nervous or mental disorder,” the parents would receive only a 60% refund. The implication here, as I see it, is that students with mono or renal failure or cancer have “legitimate” illnesses that are neither their fault nor their choice, whereas students with bipolar disorder or anorexia nervosa or major depression are at least partially to blame for their problems, which are seen as less “real,” and they could stick it out for the rest of the semester if they really wanted to. This policy creates a situation in which students struggling with severe mental illnesses feel pressured to remain at school, away from their primary support system, with inadequate treatment, for the duration of the semester, rather than returning home to their families to recover and pursue more intensive treatment.

• Many universities require students who have been out on medical leave for mental health reasons to have a readmission assessment with a mental health professional before being permitted to matriculate once again. Students who were out on medical leave for physical illnesses are not required to submit to a physical exam upon their return to school.

• In the state of Florida (and perhaps in other states), aspiring attorneys must answer a question on their bar application asking whether they have had treatment for a mental disorder. [OBJECTION, YOUR HONOR! RELEVANCE?] If they answer “yes” (and they must answer truthfully under penalty of perjury, they must submit a letter to the bar from their treatment provider describing the nature of their symptoms and course of treatment. Law school is a virtual breeding ground for depression, anxiety, substance abuse, and various stress-related ailments, but many law students will not seek treatment because they don’t want their law careers to be jeopardized by answering “yes” to that question. And I can’t say that I blame them.

• Some adoption agencies, particularly those that deal with international adoptions, categorically refuse to consider individuals who have been diagnosed with or treated for any mental disorder as potential adoptive parents. For example, taking medication for any mental illness, including anxiety or depression, automatically disqualifies hopeful adoptive parents from adopting Chinese orphans. Because, of course, isn’t it better for a child to grow up in an impoverished orphanage without access to modern medical care or higher education, rather than in a loving, stable home with a dad or mom who has responsibly sought treatment for A VERY COMMON, VERY TREATABLE MEDICAL CONDITION? Notably, having an undiagnosed, untreated mental illness does not disqualify potential adoptive parents from adopting Chinese orphans. This policy clearly discriminates against those who have sought treatment.

• Receiving mental health treatment is potentially damaging to a soldier’s military career. This creates a catch-22, because the very act of serving in the military during times of war is a huge trigger for mental illnesses like PTSD, depression, and substance abuse. Few people escape from deadly combat without some mental scars. Yet seeking treatment and risking a diagnosis of a mental disorder is too risky, and too humiliating, for those who have made a career out of protecting and defending our country.

In each of these instances, people who do not seek treatment for their symptoms seem to have a distinct advantage over those who do. For what other disease is it preferable to stay sick than to get healthy? People with mental illnesses who receive good treatment obviously fare better, on the whole, than those who receive no treatment or insufficient treatment. The ultimate irony here is that many people who have been treated for mental illnesses are at least as “mentally fit” as people without mental illnesses, if not more so, BECAUSE they have been through treatment. In general, those who seek out and receive good mental health treatment tend to develop more self-awareness, better coping skills, and a more positive perspective. Certainly these qualities are beneficial to a student, an attorney, a parent, or a soldier.

The National Institute of Mental Health estimates that more than ¼ of American adults suffer from a DSM-IV diagnosable mental disorder in any given year. Further, mental disorders are the leading cause of disability in the US and Canada for individuals ages 15-44. Most upsettingly, only 41% of Americans with diagnosable mental disorders have received any mental health treatment at all in the previous 12-month period. The vast majority of mental illnesses are treatable and manageable – and some are even curable – when the patient receives appropriate care. Imagine how many lives are destroyed, how much productivity is lost, and how much suffering is perpetuated not by mental illness per se, but by people’s refusal or inability to get proper mental health care.

At times, the state of affairs in mental health care looks so bleak that I ask myself why I have chosen this field. My conclusion: the awful state of mental health care is precisely the reason why I have chosen this field. As I ponder this issue, I am reminded of an inspiring quotation from Neale Donald Walsch: “Be a light unto the darkness, and curse it not.” I’m doing my very best to be a light unto the darkness. It’s the “curse it not” that I find much more challenging.

4 Replies to “What’s Wrong With Mental Health Care in America?”

  1. You tell ’em, Dr. Ravin. I am sharing your post on my Facebook account. The state of mental health care in our country is beyond deplorable.

  2. Yes. To most of this. However, I need to correct something about the adoption part: it is not the agencies that put restrictions on who can adopt, it is the sending countries. For example, to adopt from China, which is the strictest sending country at this particular time, you have to be between of a certain age (under 45, not sure of the lower limit), you cannot have a BMI over 25, you must make a certain amount of money, you may not be on any psychotropic medication, and you must be in a heterosexual marriage. There has been talk of excluding potential adopters with less than above average IQs. Saying that it is the adoption agencies is inaccurate, and yes, it does depend on diagnosis/treatment, but the adoption process involves psychological assessment by at least one qualified professional. There are also other factors that exclude potential adopters that are just as discriminatory, and using this as an example of discrimination against treatment isn’t quite accurate and is also quite out of context. There’s a lot more going on in China around international adoption than you said. And yes, adoption agencies may say on websites that they don’t accept applications to China/certain other countries if one has been treated for mental illness, but it would be unethical for them to accept applications and do homestudies and take incredible amounts of money from people who will just be rejected from the country per the country’s policy.

    1. Grace,

      Thank you so much for the clarification. I apologize for the inaccuracies in my post. I agree with you that the other qualifications from China are equally discriminatory, and I also agree that it would be unethical for adoption agencies to accept applicants who don’t meet the country’s criteria.

      In my opinion, potential adoptive parents sould be screened for psychological fitness on the basis of a psychological assessment alone, rather than automatically ruled out because they have received a diagnosis in the past, or are taking psychotropic medication, or are in psychotherapy. That way, individuals who have been diagnosed and treated and are currently psychologically fit to be parents would be approved, and individuals who have undiagnosed or untreated mental symptoms that render them unable to parent effectively would be ruled out. This policy, I believe, would protect the best interests of the child while also being fair to potential adoptive parents who may have so much to offer to a child despite (or perhaps because?) of mental health diagnosis and treatment.

      As for the BMI <25? That is ludicrous and arbitrary. Weight is an imperfect measure of health. Many people with BMI > 25 are healthy and fit but have higher BMI’s due to having large body frames or being very muscular. I would at least hope that they have a minimum BMI requirement, since underwieght is more immediately dangerous and potentially life-threatening than being slightly overweight. And since when was weight a prerequisite for good parenting?

  3. Dr. Ravin,

    I completely agree with your views regarding psychological assessment of potential adoptive parents. In many (the majority) of instances of adoption (domestic private, domestic public, and some international), this is the policy. There are adoptive parents with well-managed depression/anxiety and even bipolar disorder in this country. It is certainly widespread, at least in the two types of domestic adoption, to be in psychotherapy during the process. It is likely to be beneficial to potential adoptive parents, particularly those who arrived at adoption as a means of parenting via infertility issues, to participate in psychotherapy, and for the vast majority of situations this is completely acceptable.

    And for the BMI requirements…I don’t recall ever hearing of a minimum BMI requirement, although to the best of my knowledge this is a policy of only China at this point.

    Weight has never been, and never will be a prerequisite for good parenting. There seems to be a schema floating around that this is the case, and that is disturbing.

    It is often said in the adoption research world that adoptive parents are the cream of the crop because of all the scrutiny they must pass through. Some of these requirements, however, are just discriminatory.

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