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Overuse, underuse, and inequality in mental health

Several health news stories over the past few weeks illuminate the crisis in mental health care, marked by overuse and underuse, and inequality. 

As income inequality and health disparities have grown, low-income Americans are also bearing a larger burden of mental illness. A recent analysis of mental health and well-being from the mid-1990s to the early 2010s finds that “declines in mental health have occurred unevenly across the socioeconomic spectrum.” Measures of distress and depression increased and measures of well-being decreased among low-income adults of all ages over this time.

Sadly, low-income Americans often have less access to needed mental health care compared to wealthier people, even in regions with an abundance of providers. In Massachusetts, poor and middle-class patients struggle to find mental health care providers at an affordable price. Even though the state has plenty of clinicians that offer mental health services, only about half accept Medicaid or employer-provided insurance, because of lower reimbursement rates and more paperwork.

The behavioral health system in MA “makes services readily available to those with the means to spend $200 an hour for therapy, but can frustrate those without enough money, regardless of how hard they try to find a therapist and how desperate they are for treatment,” Liz Kowalcyzk writes in The Boston Globe.

As we work to increase access to mental health care, we have to keep in mind that medications are only one aspect of treatment. In a recent op-ed in STAT, former state mental health commissioner Robert Nikkel and journalist Robert Whitaker point out that the movement to expand mental health treatment has led to a “dramatic increase” in the use of psychiatric drugs, but the prevalence of mood and anxiety disorders and symptoms has increased, along with disability due to mental disorders. 

Improving the health of mental health patients does not just mean improving access to mental health care, but also doing better at treating chronic conditions like hypertension and diabetes. People with serious mental health illness have an average life expectancy 10-25 years shorter than people without mental illness, largely because they do not get treatment for preventable diseases. We need to improve primary care access for all, recognize the relationship between mental health disparities and income inequality, and remain wary about using antidepressant medications alone as a long-term treatment.