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    How, Exactly, Could We Improve Mental Healthcare? Here's a Start

    Written by

    Adam Clark Estes

    It's been almost a week since the Newtown shootings, and at this point, pretty much everybody with Internet access has weighed in on how to keep this from happening again. Predictably, the majority of the bandwidth for public dialogue has been consumed by the ever-impassioned debate about how to deal with our country's gun problem. The president created a task force on gun control, and put Papa Biden in charge of it. Senator Diane Feinstein loudly announced her intentions to introduce a bill banning assault rifles when Congress reconvenes in January. Even the National Rifle Association said it's "prepared to offer meaningful contributions to help make sure this never happens again." What "meaningful contributions" means is a total mystery to me.

    The more difficult topic to comprehend is that of mental health. Newtown shooter Adam Lanza had some mental health issues, the extent and specific details of which remain unclear. The same can be said about Aurora shooter James Holmes, Tucson shooter Jared Loughner and Virginia Tech shooter Seung-Hui Cho, leading many to the conclusion that our country's mental health system is in dire need of repair. Now there's a serious correlation-does-not-equal-causation problem with that line of thinking, which I'll come back to in a second, but there's also been an utter lack of focus in putting together a plan of action. So I just went ahead and made one based on what people are saying about the need for better mental healthcare in the wake of Newtown and what people have been saying about the need for better mental healthcare for years.

    Step One: Don't Get Confused

    It's both bad and good that the promised conversation about mental health after Newtown is taking some time to launch. It's bad because the conversation needs to happen soon, and this is an opportunity to get it off the ground. However, it's good that nobody's rushing because, as I argued earlier this week, there's a distinct danger in drawing too many connections between gun violence and mental illness, quite simply because those connections don't exist. Sure, there's plenty of correlation between young men with mental illness and the rash of mass shootings in America over the past few years. But when you zoom out and look at the issue broadly, people who have mental illness are just about as likely to commit a violent crime as those who don't.

    It would be foolish to think that we could solve our nation's gun problems with better mental healthcare and nothing else. Statistically speaking, you'd be better off tackling the nation's substance abuse problem or crime problem, as those with history of either are much more likely to be violent. Dr. Richard Friedman expressed this reality well in a New York Times column a couple days after the shooting. "All the focus on the small number of people with mental illness who are violent serves to make us feel safer by displacing and limiting the threat of violence to a small, well-defined group," he wrote. "But the sad and frightening truth is that the vast majority of homicides are carried out by outwardly normal people in the grip of all too ordinary human aggression to whom we provide nearly unfettered access to deadly force." So if you want to talk about gun control, go talk about gun control — for everyone. We're talking about mental healthcare — for everyone.

    Step Two: Lower Cost

    To put it bluntly, mental health care is really expensive. Like, new car expensive. This is not a big new revelation. Health care in general is expensive in the United States, often prohibitively so. Mental healthcare works differently than regular healthcare, though.

    A large portion of general healthcare needs go to very temporary conditions like illness or injury. If you break your arm, you go to the hospital, get an awesome cast and go wait for it to heal. A few weeks later, the cast comes off, and your task of paying for healthcare is probably done, at least for a little while. With most mental health issues, the treatment lasts a lifetime. Treatment for bipolar disorder, for instance, generally calls for monthly visits to a psychiatrist for med management, weekly visits to a psychologist for therapy and, god forbid, occasional trips to the hospital for in-patient treatment that tends to last at least a week. Each of those visits comes with significant out-of-pocket costs, even if you have health insurance. If you don't, a single trip to the hospital can put you tens of thousands of dollars in debt.

    Now let's talk about the numbers for a second. Spending on mental health care in the United States added up $113 billion in 2011, which amounts to about 5.6 percent of total healthcare spending. This is lower than it should be, though, because 45 percent of Americans don't seek mental health due to the prohibitive costs. (This is the very definition of "prohibitive costs.") When you consider the fact that about one if four Americans have a diagnosable mental illness, thing should start coming into focus. Just do the math. For every single American with a mental illness that's getting treatment, there's at least one who isn't due to costs alone. As many have pointed out, it's cheaper to buy a gun than it is to get mental health care.

    Step Three: Improve Access

    Besides mental health care being really it's expensive, it's also really hard to get. This is due to some institutional shortcomings, but the access issue, in a way, is also attributable to the way that we think about mental health. On the institutional front, there literally aren't enough beds in the hospitals.

    More beds are disappearing at an alarming rate, too. The National Association of State Mental Health Program Directors told ABC News that there are 3,222 fewer beds in psychiatric hospitals than there were in 2009, and another 1,249 are due to disappear soon — a 10 percent reduction in total. "This is the worst I've seen it," said Dr. Robert Glover, the association's director. "They are painful, and unbelievably tough. I am incredibly worried about future cuts with the fiscal cliff and state budgets not getting better." The cuts have already started, though, to the tune of $4.35 billion nationwide.

    Not all mental healthcare happens in a hospital, but outside the hospital, it's simply hard to find good mental healthcare. "We have very good treatments for mental illness that are highly effective," Dr. Jeffrey Lieberman, president-elect of the American Psychiatric Association said in the wake of the Newtown shootings. "But they're not widely available. People don't have ready access to them." Poor treatment discourages a large swatch of patients who need treatment but don't get it. A lot of people don't even realize they qualify for care, and some just don't think they need it. In a 2007 study, 66 percent of those surveyed said they thought they could get better treatment on their own, while 71 percent agreed with the statement: "I wanted to solve the problem on my own."

    Step Four: Change Attitudes

    America's mental health crisis isn't going to solve itself, though. Neither is the gun problem. The fourth step is inevitably the hardest one, because it's very hard to change perceptions about mental illness as well as its treatment. Mental healthcare doesn't amount to throwing people in the psych ward for months on end any more, and it's also not going to result in doctors strapping electrodes to your skull. Mental healthcare has actually been moving in a very positive direction, one that favors community-based treatment over institutionalization.

    Mental illness is still a tremendous struggle, though, and a struggle that many Americans are left to brave on their own. If we're going to change how we help these people, we have to change how we think about the system and the illness itself. There's enough stigma attached to mental illness already. So there's no need to add more by stirring up fear and inserting mental health into a conversation about gun control. A better idea: stir up action by addressing mental healthcare funding, improving access to care, and changing how we think about the mentally ill. One in four Americans will thank you.

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