While material well-being improved at the top, America’s emotional distress climbed to crisis levels.
by Cynthia Koons edited by O Society July 3, 2019
So many statistics say that life in the U.S. is getting better. Unemployment is at the lowest level since 1969. Violent crime has fallen sharply since the 1990s—cities such as New York are safer than they’ve ever been. And Americans lived nine years longer, on average, in 2017 than they did in 1960. It would make sense that the psychic well-being of the nation would improve along with measures like that.
Yet something isn’t right. In 2017, 47,000 people died by suicide, and there were 1.4 million suicide attempts. U.S. suicide rates are at the highest level since World War II, said the U.S. Centers for Disease Control and Prevention on June 20, when it released a study on the problem. And it’s getting worse: The U.S. suicide rate increased on average by about 1% a year from 2000 through 2006 and by 2% a year from 2006 through 2016.
Although suicide is the starkest indicator of mental distress, others abound. Drug overdoses claimed 70,000 lives in 2017, and 17.3 million, or 7%, of U.S. adults reported suffering at least one major depressive episode in the past year. Life expectancy, perhaps the broadest measure of a nation’s health, has fallen for three straight years, in part because of the rise in drug overdoses and suicides. That’s the first three-year drop since 1915 to 1918.
The problems may have different and varied causes, but what they add up to is a national mental health epidemic. The damage is on the scale of the global financial crisis, yet we lack the institutions, policies, and determination to address it. The government’s response has been inadequate, says Paul Gionfriddo, president of Mental Health America, an advocacy group. “The dollars have gone more to deep-end services in jails and prisons. It’s a really bad idea to put the money into jails because the people don’t belong there.”
“I’d like to say things have improved a lot, but they haven’t”
Mental health problems manifest in a number of ways and encapsulate a wide range of conditions, including substance abuse disorders, crippling anxiety, schizophrenia, and suicidality. A person’s susceptibility depends on genetic, social, and environmental factors. These contributors are believed to be intertwined; psychological stressors can activate a genetic predisposition, so life circumstances matter a lot. And the U.S. is home to some particularly challenging ones: stagnant wages; rising health-care costs; the proliferation of highly addictive opioids after a marketing push from major drug companies; the disappearance of well-paid blue-collar jobs and the emergence of the gig economy; the lack or limited availability of treatment and services. The destructive powers of technology, be it in the form of social isolation or cyberbullying, have been cited in the rising number of teens killing themselves. Suicide is the second-leading cause of death for 10- to 34-year-olds. Then there’s the prevalence of guns, which are used in half of all suicides.
Whatever the causes, mental illness and substance abuse are social and economic catastrophes. They cost U.S. businesses $80 billion to $100 billion annually, according to a literature review put out by the Center for Workplace Mental Health, which also showed that some two-thirds of people suffering from either mental health or substance abuse disorders don’t receive any treatment for their conditions. Unchecked mental health conditions can result in violence. In America, workplace shootings have become almost routine. The latest: On the afternoon of May 31, 2019, a disgruntled city employee killed 12 people at a municipal building in Virginia Beach, Va.
Some federal actions have contributed to the crisis. Out of concern that patients were trapped in mental hospitals without a path out, President John F. Kennedy signed the Community Mental Health Act in 1963 to provide funding for new services in the community. The law “drastically altered the delivery of mental health services and inspired a new era of optimism in mental health care,” according to the National Council for Behavioral Health. It also came at a time when new psychiatric drugs were emerging, supporting the hope that the future was going to be brighter for people in need of care.
Almost 60 years later, it’s clear things haven’t worked out that way. “People with severe mental illness can still be found in deplorable environments, medications have not successfully improved function in all patients even when they improve symptoms, and the institutional closings have deluged underfunded community services with new populations they were ill-equipped to handle,” Daniel Yohanna wrote in “Deinstitutionalization of People with Mental Illness: Causes and Consequences” in the AMA Journal of Ethics in 2013.
This leaves people without the comprehensive care they would need to recover from drug addiction or suicidal thinking. Yohanna cites a poll of experts who say 50 beds per 100,000 would meet Americans’ acute and long-term care needs. In some states the number is as low as 5 per 100,000. “I’d like to say things have improved a lot, but they haven’t,” he says today.
People with less severe issues also face hurdles when they need help. Most people are at the mercy of their company’s health plans when it comes to seeking care; a person with fewer benefits simply wouldn’t have access to the best resources for either crisis care or chronic mental health treatment. Even for those fortunate enough to be able to pay out of pocket, availability of providers ranges wildly across the U.S., from 50 psychiatrists per 100,000 people in Washington, D.C., for example, to 5.3 per 100,000 in Idaho, according to research from the University of Michigan’s School of Public Health Behavioral Health Workforce Research Center. And despite laws requiring insurers to offer mental health benefits at the same level as other medical coverage, many make it difficult to find appropriate treatment and limit residential care. In a major class action, Wit v. United Behavioral Health, one of the country’s biggest health insurers was held liable for denying mental health benefits. The company says it’s changed its guidelines.
“What we measure affects what we do, and if we measure the wrong thing, we will do the wrong thing”
This isn’t a uniquely American experience. In India and China, which combined are home to one-third of the world’s population, more than 80% of people with mental health or substance abuse disorders don’t seek care, according to a report by the Lancet commission on global mental health released in October 2018. In South Africa the closure of a 2,000-bed mental hospital sent patients to unlicensed community facilities and resulted in more than 140 deaths, the report shows. The study also poked holes in the idea that drugs have helped solve the problem: The use of antidepressants in Australia, Canada, England, the U.S., and other wealthy countries didn’t lead to a decline in the prevalence and symptoms of mood disorders despite substantial increases in the use of the drugs from 1990 to 2015. The Lancet commission warns that mental health disorders could cost the global economy as much as $16 trillion from 2010 to 2030 if governments and businesses don’t do more to address them.
Some countries have started to grapple with the problem. New Zealand Prime Minister Jacinda Ardern unveiled the world’s first Wellbeing Budget in May, earmarking NZ$1.9 billion ($1.2 billion) for mental health, which should also improve services for people living with the type of anxiety and depression that doesn’t require hospitalization but still has a major effect on their everyday life. “You have a limited budget, and you have to try and balance the need to grow the economy, create jobs, balance the books, and look after our people and our environment,” Ardern said in comments reported in the New Zealand Herald. “This budget shows you can do all of those things.”
Only weeks after more than 50 people were killed on March 15 in mosque shootings in Christchurch, Ardern demonstrated her willingness to tackle problems other governments have sidestepped by banning almost all military-style guns in the country. Shortly after the Virginia Beach shooting, President Donald Trump’s acting chief of staff, Mick Mulvaney, warned against wading into the politics of gun control “too soon.” U.S. lawmakers fail to enact meaningful gun control measures despite an onslaught of mass shootings in the past five years.
The spending proposed by Ardern’s government far outpaces what the U.S. spends on its Substance Abuse and Mental Health Services Administration, the main agency that provides funding for states to implement services that address these types of problems. Ardern’s proposed outlay is 15 times as high as SAMSHA’s $5.6 billion budget request for the U.S. in 2020 on a per-capita basis.
In the U.K., the Office for National Statistics released data for the first time in February that combine personal and economic well-being, showing measures of “happiness” and “life satisfaction” in addition to more traditional metrics such as household debt and disposable income. The data collection effort dates to 2010, when Prime Minister David Cameron announced the government was going to start measuring people’s well-being. That directive spawned initiatives such as the Green Book, which is used to evaluate new policies to ensure they improve not only economic output but also social welfare and well-being, says Gueorguie Vassilev, who heads the economic well-being and digital transformation team at the Office for National Statistics. The country also created a Minister of Loneliness in January 2018 in response to its findings on social isolation. This month the government announced a campaign to alleviate the stigma of loneliness.
These countries are saying that improving the physical well-being of their citizens isn’t enough. Seeing the limitations of traditional statistics, economist Joseph Stiglitz published “Beyond GDP” in the magazine Project Syndicate in December, a decade after Stiglitz co-authored the report “Mismeasuring Our Lives: Why GDP Doesn’t Add Up.”
“What we measure affects what we do, and if we measure the wrong thing, we will do the wrong thing,” Stiglitz wrote. “If we focus only on material well-being—on, say, the production of goods, rather than on health, education, and the environment—we become distorted in the same way that these measures are distorted; we become more materialistic.” Traditional numbers have failed us. It’s time for a new approach before America’s mental health deteriorates even further.