Shifts in how Americans perceive risk, access healthcare, and parent their children underlie many mental health trends. The following article sheds light on causal societal, cultural, and industry trends that are changing the way mental health (including addiction services) is delivered and paid for.
A few years ago, while speaking with a colleague on the phone, I shared my sorrow over the death of a young friend who had just turned 21. My colleague, instantly supportive, asked me what she had died of. When I confessed that it was a heroin overdose, my colleague’s voice hardened and she said in an accusing tone, “Well you know more people like that.”
What I didn’t say then was that we all do. Drug overdoses in the U.S. are now the leading cause of accidental deaths. In 2013, that was close to 44,000 Americans, far more than the 35,000 who died in auto crashes that year or the 16,000 who were murdered.
Many of us, like my former colleague, hold stereotypes about what heroin users are like and may even assume that their overdoses are morally deserved. But in reality, people who abuse medications or illegal drugs look and sound like you – no matter who you are. Data from the Centers for Disease Control and Prevention (CDC) shows that every demographic slice is affected and that most of those who died from an opiate overdose were white, suburban (often middle class) people between 25 and 54 years old. At least half of those who died overdosed on prescription analgesics.
The fast rise in drug and alcohol abuse has been influenced by economics and societal trends. “Popular” drugs trend with availability and price. For example, heroin’s popularity was bolstered by the last decade’s influx from Afghanistan that drove its price well below the street value of prescription drugs. Meanwhile, we saw (and are still seeing) substantial leakage out of our medical system as U.S. prescribers write more scripts for opiate painkillers each year than there are adults in the country. At multiple places in our healthcare system, insurers, physicians and administrators are discussing and implementing changes to their policies including how to incentivize healthcare providers. Their goal is to safely address a systemic over-reliance on pain killing medicines.
Even as access to pharmaceutical drugs tightens and street drugs get cheaper, we see a confluence of social and cultural trends that conspires to make younger generations more vulnerable to addiction. Surveys by the Substance Abuse and Mental Health Services Administration (SAMHSA, the Federal agency charged with improving the quality and availability of prevention, treatment, and rehabilitative services) show teens and twenty-somethings’ perception of harm from misusing drugs and alcohol declining while the consequences as measured in related deaths, emergency room visits, and arrests soar. The thinking goes something like, “if it’s legal (somewhere) it must be safe to use.” And, by extension, “if one pill makes me feel good then more pills will make me feel even better.”
Many of the parents of these children are conflicted about the harm of drug abuse and drinking – after all, they did it too. Often referred to as “helicopter” parents, many have over-protected their children from failure, unhappiness, and consequences. The ramifications of being protected from disappointments, of not hearing the word “no,” and from being given “every opportunity” has resulted in “gifted” teens and young adults who don’t know how to internally manage the natural bouts of anxiety, performance stress, frustration, and sadness that are part of growing up.
Some channel their feelings of chronic stress into getting better grades and gaining acceptance to top schools with a soul-numbing, tunnel-vision focus that Yale professor William Deresiewicz writes about in his book, “Excellent Sheep.” About 20% use mood-altering substances to manage feelings or to “self-medicate.” SAMHSA’s 2013 survey measures the use of illicit drugs at 21.5% among young adults aged 18 to 25 versus 9.4% for all Americans over age 12.
Marijuana is the most popular and fastest-growing drug. Because today’s marijuana plants have been bred to contain levels of THC (marijuana’s main psychoactive ingredient) 10 times higher than plants did 20 years ago, mental health professionals are seeing a rash of marijuana-induced anxiety and psychoses. We might expect to see some push back from health providers as states expand legalization of marijuana.
Stress, Challenges, and the Medical Treatment Model
Perspectives on mental health trends run hot – and in researching underlying causes and implications, explanations vary in scope and inflammatory tone. For example, changes to diagnostic criteria have some parents fearful that their children will no longer qualify for special services, while some providers and their patients worry that only pharmaceutical solutions will be reimbursable. Here is how I see it at the moment, but stay open and draw your own conclusions.
According to the well-respected National Alliance of Mental Illness (NAMI), the percentage of the U.S. population suffering from anxiety disorders such as PTSD, obsessive-compulsive disorder or specific phobias runs about 18% (or 42 million people last year). Just under 7% of adults (or 16 million) live with a major depression, while 6.1 million live with bipolar disorder and 2.4 million with schizophrenia.
Two significant challenges in the industry are:
- Delivering treatment to those in need. The majority of those who suffer do not get treatment. NAMI reports that close to 60% of affected adults and 50% of affected children did not receive mental health treatment in the previous year. Federal requirements for parity of coverage with medical and surgical services in new healthcare plans should help increase access to needed mental health and substance abuse treatment.
- Differential diagnosing. Diagnostic manuals such as the DSM-V help clinicians diagnose by clustering symptoms – not an easy task when almost every mental health issue includes anxiety as a symptom.
In a typical medical model, the physician attempts to promote healing and cure ailments. For example, she might set a broken limb or treat an infection with antibiotics. The treatment model in mental health is notably different. Here, physicians and other clinicians use medications and in-office therapies to improve a patient’s quality of life – they acknowledge that their patients might always be addicts or might always struggle with recurring depression, but behavioral and/or pharmaceuticals therapies can help them manage their symptoms and lead fulfilled lives.
Indeed, most mental illnesses are not cured by pharmaceutical drugs, but the illnesses can be managed and symptoms treated. In fact, medical science doesn’t truly know how or why these drugs work. In a 2014 report on mental health medicines under development, PhRMA (a pharmaceutical advocacy group) acknowledged that developing effective treatments for mental disorders “has been hindered by many factors, including a limited understanding of how current treatments work in the brain.”
Still, exciting advances in neuroscience research are shedding light on the brain’s mechanisms for some kinds of depression, which ultimately may turn into breakthrough pharmaceutical approaches. In the meantime, new understandings about our brain’s neuroplasticity coupled with Stephen Porges’ groundbreaking Polyvagal Theory (that a key part of our central nervous system serves different evolutionary stress responses) is leading to alternative treatments of anxiety, depression, trauma, and autism. These non-pharmaceutical therapies include yoga, mindfulness, neurofeedback, and play therapies – many of which are not yet covered by health insurance plans.
20 Minute Psychiatric Visits
The relatively low cost and effectiveness of mental health medications has made it tempting for healthcare insurers to view mental health inside a medical model (perhaps parity of coverage between medical and mental health services is also fueling this trend). A drug like Celexa can reduce anxiety symptoms and with tweaking can help a patient manage anxiety for years. However, cognitive behavioral therapy (CBT) and relaxation techniques have proven to be a more successful long-term treatment, allowing a patient to live symptom free. Indeed, treatment for many anxiety disorders that includes therapy is more effective than medication alone. But in the short term, drug treatment is less expensive for the patient and his insurer.
In addition, with insurers often capping medical evaluations at 20 minutes for reimbursement purposes (and health systems enforcing those 20 minutes), psychiatrists often do not have the luxury of time to explore everything going on with a patient to fully understand the scope and complexity of the patient’s illnesses. Even so, psychiatrists can cause fast relief by prescribing medication that targets the symptoms.
In The Next Right Thing’s dual diagnosis substance abuse practice, our psychiatrist almost always ends up changing diagnoses and medications of the adolescents she sees. This is a reflection not on the skill of a patient’s previous psychiatrist but on the substantial advantage that comes with having the luxury of a longer time with the adolescents and being able to see how their psychiatric symptoms change when their minds and bodies are free of drug and alcohol use. A three or four day stay at a hospital or an initial 60-90 minute assessment just isn’t enough time to understand what’s going on in adolescents’ brains or their family systems.
Much of the conflict in mental health research, treatment, and even in healthcare insurance comes out of battling paradigms: brain-based or mind-based. And the paradigms are blurring and changing as providers sort through the treatment implications of the neurophysiological (i.e., hardwired) foundations of emotions, social engagement, and self-regulation.
Adapted from an article in VIEWS, Spring 2016. Click here for the original article.