The Future of Public Mental Health: Challenges and Opportunities

Abstract

Policy Points.

• Social policies such as policies advancing universal childcare to expand Medicaid coverage of home‐ and community‐based care for seniors and people with disabilities and for universal preschool are the types of policies needed to address social determinants of poor mental health.

• Population‐based global budgeting approaches like accountable care and total cost of care models have the potential to improve population mental health by incentivizing health systems to control costs while simultaneously improving outcomes for the populations they serve.

• Policies expanding reimbursement for services delivered by peer support specialists are needed. People with lived experience of mental illness are uniquely well suited to helping their peers navigate treatment and other support services.

Mental illness is highly prevalent and a leading cause of disability globally and in the United States. ¹ In the United States, which is the focus of the article, one in five adults and youth ages 9 years old and older and one in six children ages 2–8 years old experience mental illness each year ² , ³ , ⁴ ; about half of the US population experiences mental illness at some point in their lifetime. ⁴ In recent years, the stressors of the COVID‐19 pandemic have increased psychological distress, anxiety, and depression across the globe. In the United States, youth and young adults have been particularly affected. Mental illness was increasing among US children and adolescents in the decade leading up to, ⁵ and then further exacerbated during, the pandemic; in 2021, 44% of US high school students reported that they persistently felt sad or hopeless during the past year. ⁶ Prior to the pandemic, fewer than 5% of young adults ages 18–29 years old experienced serious psychological distress. ⁷ At four time points during the pandemic—April 2020, July 2020, November 2020, and July‐August 2021—between 20% and 30% of US young adults ages 18–29 years old reported experiencing serious psychological distress, ⁸ which has been shown to accurately predict serious mental illness. ⁹ This suggests that the distress experienced during the COVID‐19 pandemic could translate to long‐term psychiatric disorders.

In the wake of the pandemic, mental illness and mental health are garnering increased attention across US society, including among the public, health care leaders and providers, the business community, and policymakers. ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ Although often used interchangeably, “mental illness” and “mental health” differ in meaning. Mental illnesses are diagnosed conditions characterized by a clinically significant disturbance in a person's cognition, emotional regulation, or behavior. ¹⁶ , ¹⁷ Mental health is a broader construct encompassing a person's state of mental or emotional well‐being, including but not limited to mental illness. ¹⁷ Although everyone experiences ups and downs in mental health, not everyone experiences the sustained impairment that contributes to the diagnosis of mental illness. We are experiencing a window of opportunity to reimagine the US mental health “system”—in reality, a set of highly fragmented organizations—and build a true public mental health system that both delivers clinical treatment for mental illness and promotes mental health at the population level. This article summarizes past gains and successes in US mental health, outlines failures and continuing problems, and discusses solutions, with an eye toward the role of social policy.

Past Successes

Development of effective mental health treatments, prevention interventions, and recovery support services has been a major success of the past 75 years. Since the introduction of antipsychotic and antidepressant medications in the 1950s, the United States has made major mental health treatment advances, with a wide range of evidence‐based pharmacologic and behavioral—and, increasingly, digital—treatments available for the spectrum of mental health conditions. ¹⁸ Mapping of the human genome has led to increased understanding of the role of genetics in mental illness and holds promise for development of gene therapies, though such advances are likely still many years in the future. ¹⁹ , ²⁰ In addition, we now have a robust evidence base supporting the full spectrum of preventive mental health interventions, ranging from mental health promotion interventions, like school‐based programs to foster positive coping skills among youth, to tertiary prevention programs, like cognitive remediation interventions among people with schizophrenia; the evidence for preventive interventions is especially strong for interventions targeting youth. ²¹ Recovery support services like psychiatric rehabilitation, supportive housing, and supportive employment can be effective at fostering long‐term recovery, ²⁰ , ²¹ , ²² , ²³ , ²⁴ a person‐centered process in which people with mental illness improve their health and wellness, live a self‐directed life, and work to reach their full potential. ²⁵

Related to these treatment advances—particularly medications to manage the symptoms of serious mental illnesses like schizophrenia, bipolar disorder, and major depressive disorder—the past century has seen a major transition from institutional care to community care for mental illness. In the 1960s, the Kennedy administration led a deinstitutionalization effort to dismantle the predominant system of long‐term institutional psychiatric care—“care” is a grossly overgenerous germ, as the horrific conditions of many psychiatric institutions, or “asylums,” were a key driver of the deinstitutionalization movement. ¹⁸ Although this effort shuttered most inpatient psychiatric institutions, it failed to realize the Kennedy administration's vision of replacing institutions with comprehensive community‐based care, and a lack of adequate community services has contributed to high rates of homelessness and criminal legal system involvement among people with mental illness. ¹⁸ , ²⁶ , ²⁷ In recent years, the certified community behavioral clinic model, supported through a federal Department of Health and Human Services demonstration program, has supported growth of community‐based mental health crisis response services, a long‐standing gap in the United States post‐deinstitutionalization mental health system. ²⁸ , ²⁹ In July 2022, the United States introduced a three‐digit dialing code (988) that everyone in the United States can call, text, or chat to reach the National Suicide Prevention lifeline, which will connect people to a network of over 180 crisis centers across the United States. ³⁰

Expansions to insurance coverage for mental illness have been a major success of the first two decades of the 2000s. The 2008 Paul Wellstone and Pete Domenici Health and Addiction Equity Act prohibited commercial group health plans that provided mental health benefits from imposing greater benefit limitations (e.g., covering fewer visits or requiring higher copays) for mental health services relative to medical and surgical services. Since the passage of the law, which went into effect in 2010, it has been expanded to apply to individual health insurance plans purchased through a state health insurance marketplace, Medicaid, and the Children's Health Insurance Program. ³¹ In addition, the Patient Protection and Affordable Care Act of 2010 included mental illness as an essential health service, requiring most health insurance plans to cover physician visits, inpatient care, and prescription drugs for mental illness. ³² Prior to these policies, many health insurance plans provided less generous benefits for mental health services relative to general medical and surgical services, and some plans did not cover mental health treatment at all. ³³

Two middling successes, with some aspects discussed below in the section on continuing challenges, are the integration of mental health care into the general medical system and stigma reduction. Over the past two decades, there have been major improvements in the treatment of common mental illnesses, particularly mild anxiety and depression, in primary care settings; primary care providers now prescribe the majority of antidepressant medications in the United States. ³⁴ Stigma toward depression has declined among the overall US adult population; from 1996 to 2018, there were statistically significant decreases in desire for social distance, a standard measure of public stigma, from people with depression in work, socializing, friendship, and marriage. ³⁵ For example, the proportion of US adults who reported that they were unwilling to work closely with a person with depression declined from 46% in 1996 and 47% in 2006 to 29% in 2018. ³⁵

Continuing Problems

Most people with mental illness do not receive evidence‐based based treatment; in the United States in 2020, only 46% of US adults with mental illness received any specialty mental health treatment. ⁴ Similarly, the multiple effective prevention interventions and recovery support services discussed above are not widely scaled at the population level. ²¹ Inadequate community‐based mental health services are often credited with the “reinstitutionalization” of people with mental illness in the criminal legal system; the Los Angeles Twin Towers Correctional facility is infamously known as the national's largest mental health facility. ³⁶ Vulnerable groups experiencing criminal legal system involvement, poverty, housing instability, and unemployment experience disproportionately high rates of mental illness and low rates of treatment. ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ Racial and ethnic inequities in mental health treatment also exist; White people with mental illness are more likely to receive treatment than people identifying as Black, Asian, or Hispanic. ⁴⁰

The mental health services gap is driven by an interrelated set of issues, including provider shortages, system fragmentation, and persistent stigma around serious mental illness, particularly psychotic disorders like schizophrenia. Serious and persistent shortages in mental health providers exist in the United States. In 2021, the US psychiatry workforce met only 28% of population treatment needs, with an estimate 6,600 additional psychiatrists required to fill the gap. ⁴¹ Workforce shortages are not limited to psychiatrists; psychologists, counselors, and peer support specialists are also in short supply. ⁴² , ⁴³ Efforts to address mental health workforce gaps, like loan repayment programs, have failed to make major gains in overcoming the provider shortage. To significantly expand the workforce, we likely need to increase insurance payment for mental health services to levels that incentivize providers to choose careers in mental health; ⁴⁴ an estimated 45% of psychiatrists do not take insurance at all, as they can have a more lucrative career by charging out of pocket. ⁴⁵

Although some progress has been made on integrating mental health care into the general medical system, particularly with regard to psychotropic medication prescribing for mild to moderate mental illnesses as noted previously, the US specialty mental health system remains largely separate from the general medical system, and there are multiple barriers to integrating care across systems. ⁴⁴ , ⁴⁵ The Collaborative Care Model for integrating mental health care into primary care settings (related models have more recently also been applied to the integration of physical health care into specialty mental health systems) has been shown to improve mental health treatment and outcomes, particularly for depression, in multiple randomized clinical trials but has not been widely scaled because of financing, infrastructure, and workforce barriers. ⁴⁶ , ⁴⁷ , ⁴⁸

Historically, a key barrier to the implementation of integrated mental–physical health care models like Collaborative Care has been a lack of insurance reimbursement mechanisms for the care coordination and management services central to these models. That is beginning to change, most prominently through the recent introduction of the Centers for Medicare and Medicaid Services behavioral health integration billing codes, but uptake of these codes is very low; in 2017 and 2018, the first 2 years these codes were rolled out, only 0.1% of Medicare beneficiaries with mental illness or substance use disorder received services through these codes. ⁴⁹ Qualitative research suggests that practices often do not have the infrastructure that is required to be in place to bill for care integration services, such as a psychiatric consultant on staff and an electronic patient registry. ⁵⁰ Further, the primary care workforce receives minimal training in mental health, the mental health workforce receives minimal training in primary care, and neither group receives robust training in the type of team‐based care required to coordinate mental and physical health care for people with mental illness. ⁵¹ , ⁵²

Although public stigma toward depression has decreased over the past 15 years, stigma toward schizophrenia has remained unchanged or, by some measures, has increased. Specifically, the proportion of US adults who believed that a person with schizophrenia will likely be violent toward others increased from 54% in 1996 to 60% in 2006 and to 67% in 2018. ³⁵ This trend is likely driven in part by the past 25 years’ prominent national dialogue around the role of mental illness in mass shootings in the United States. ⁵³ , ⁵⁴ Although the news media, policymakers, and some gun rights and mental health advocacy groups often spotlight the role of mental illness in mass shootings, at the population level, people with serious mental illnesses like schizophrenia are more likely to be victims than perpetrators of violence, and only about 4% of all interpersonal violence in the United States is attributable to mental illness. ⁵⁵

Racism and oppression based on other attributes—including but not limited to gender, religion, disability, income, and class, all pervasive in US society—are critical but often neglected drivers of mental illness and suboptimal mental health. Growing research demonstrates clear links between oppression—which is defined as prolonged cruel and unjust treatment and comes in interrelated forms, including but not limited to interpersonal, systemic, and structural—and mental illness. ⁵⁶ , ⁵⁷ , ⁵⁸ Chronic stress caused by oppression leads to neurobiological changes that increase the risk of mental illness. ⁵⁹ Interpersonal oppression involves interactions among people in which individuals use oppressive behavior, including violence and more subtle but harmful behaviors like microaggressions. There is a large literature documenting the connection between trauma and mental illness; for example, a recent review concluded that childhood traumas including bullying, emotional abuse, physical neglect, and parental loss are associated with adult mental illness, ⁶⁰ and recent studies show that exposure to police violence is associated with psychological distress and other indicators of poor mental health. ⁵⁸ , ⁶¹ , ⁶² Growing literature supports the negative mental health consequences of microaggressions, or ongoing brief, low‐intensity events conveying negative messages toward a member(s) of a racialized group. ⁶³ , ⁶⁴ Systemic oppression is the role societal systems (e.g., the health care system, the child welfare system, the criminal legal system) play in producing, condoning, and perpetuating pervasively unfair treatment of people with a certain attribute, and structural oppression is the laws, policies, and institutional norms on which the systems are built. ⁵⁶ , ⁶⁵ Systemic and structural oppression shape people's education and employment opportunities, material circumstances, social cohesion, and social capital, all well‐established risk factors for poor mental health and clinical mental illness. ⁶⁶ , ⁶⁷ , ⁶⁸ , ⁶⁹ , ⁷⁰ In addition to contributing to the incidence of illness, oppression, and the “‐isms” (e.g., racism, ableism, sexism), it stems from impeded access to treatment; public policies and health systems are often designed to benefit the most privileged in society, ⁷¹ and interpersonal oppression by health care providers is well documented. ⁷² , ⁷³

Finally, the United States lacks a true public mental health system. The fragmented mental health system discussed thus far is predominantly a treatment system. The “public mental health system” refers not to publicly funded mental health treatment, though increased public funding could certainly expand access to services, but to a system designed to address mental health from a public health perspective. The World Health Organization (WHO) defines optimal mental health as not simply an absence of illness but as a state of well‐being in which an individual can realize their own abilities, cope with typical life stressors, work fruitfully, and contribute to their community. ⁷⁴ Public mental health, therefore, entails a population approach to mental health, encompassing widespread promotion of mental well‐being across all segments of society, prevention of mental illness and prevention of the adverse impacts of mental illness when such illness occurs, treatment, and recovery support. Following the framework put forth by Jonathan Purtle and colleagues, a public mental health system can be conceptualized as a system delivering interventions in three interrelated domains ⁷⁵ : first, health care system interventions, including both clinical services and nonclinical interventions implemented in the health system setting; second, public health practice interventions implemented outside the health care system, for example by public health agencies or within schools; and third, social, economic, and environmental policy interventions that shape the upstream determinants of mental health.

Potential Solutions

Digital health, population‐based global budgets, embedded stigma reduction, and social safety net policy are four broad types of solutions that crosscut the challenges discussed above. Digital mental health includes mental health services delivered via telehealth technology: health information technology applied to mental health care, such as fully integrated electronic health records, which have been shown to support mental–physical health care coordination ⁷⁶ ; mobile health (mHealth) technologies, such as cognitive behavioral therapy–based smartphone applications; and wearable devices, like smartwatch sensors that track sleep patterns. ⁷⁷ Digital mental health was growing quickly prior to the COVID‐19 pandemic, which prompted even more rapid growth. Although research on the effectiveness of the increasingly wide range of digital health approaches for mental health is nascent, growing evidence suggests that digital mental health services—which can range from treatment via telehealth technology to universal prevention via mindfulness smartphone applications—can be effective. ⁵⁸ , ⁵⁹ , ⁶⁰ , ⁷⁸ , ⁷⁹ , ⁸⁰

Digital mental health treatment approaches, like counseling delivered via telehealth technology or adjunctive cognitive behavioral therapy “homework” through an mHealth application, have the potential to mitigate, though not eradicate, mental health provider shortages and improve clinical outcomes by making it easier for patients to engage with treatment. In addition, digital mental health approaches can remove the barrier of stigma; for example, when you participate in mental health treatment via videoconference from your living room, you do not have to worry about a neighbor seeing your car in the mental health clinic parking lot. Digital mental health is also a key vehicle for moving beyond treatment and incorporating prevention approaches, like the increasingly widespread use of mindfulness applications, into daily life.

Although digital mental health holds promise, key challenges remain, including inequitable access to technology and the internet among many of the groups experiencing disparities in mental health treatment, such as people with low income, those in rural areas, and people who identify as Black or Hispanic. ⁸¹ Study of the effectiveness of rapidly evolving digital mental health services is a priority for future work, as to date, relatively little is understood about which types of services work for whom. Regulation of digital mental health is rapidly evolving, with many open questions regarding how to best ensure high quality, support privacy and security, and prevent fraud and abuse as well as market consolidation and antitrust concerns; digital health is at the intersection of health care and technology, two fields already at the forefront of these issues. ⁸² , ⁸³

Population‐based global budgeting approaches like Accountable Care Organizations (ACOs) and total cost of care (TCC) models have the potential to improve population mental health by incentivizing health systems to control costs while simultaneously improving outcomes for the populations they serve. ⁶⁴ , ⁶⁵ , ⁶⁶ , ⁶⁷ , ⁸⁴ , ⁸⁵ , ⁸⁶ , ⁸⁷ In effect, these types of models hold providers accountable for health outcomes through financial risk/reward arrangements in which providers receive bonus payments if they improve health outcomes and control costs and face financial penalties if they do not. ACOs, which have not yet achieved improvement in mental health care or outcomes, may be able to do so by increased inclusion of specialty mental health providers in ACO networks and by aligning ACO payment with mental health performance measures. ⁶⁸ , ⁶⁹ , ⁷⁰ , ⁸⁸ , ⁸⁹ The accountable health communities model extends the ACO idea beyond the health system to build partnerships with other community organizations with the goal of improving whole‐community health. ⁹⁰ Though this new model has not yet been rigorously evaluated, the idea holds promise as a strategy for integrating health system and community‐based mental health interventions and supporting the development of a public mental health system.

An innovative global budgeting model is Maryland's TCC model, which sets a per capita limit on the total Medicare cost of care in Maryland. ⁹¹ This incentivizes health care providers to provide value‐based care and reduce unnecessary services; in addition, the TCC includes financial incentives for the state to improve population health, with an initial focus on reducing the incidence of diabetes mellitus in Maryland. In the future, these types of models could target mental health; doing so has the potential to incentivize both the delivery of high‐quality mental health care and integration of preventive interventions and recovery support services to prevent high‐cost care.

Stigma reduction needs to be interwoven into all aspects of mental health service delivery, from prevention to treatment. Evidence‐based stigma reduction approaches exist, for example, educational interventions and interventions facilitating contact between people with mental illness and members of the public, ⁹² communication campaigns emphasizing structural barriers to treatment, ⁹³ and dissemination of narratives that humanize people with mental illness and depict recovery. ⁹⁴ Although these interventions can be effective when delivered on their own, they may be even more effective when coupled with other approaches. For example, embedding stigma reduction interventions into the implementation of ACOs may support providers in improving delivery of mental health services.

A critical failing in our current system has been the exclusion of people with mental illness in its design and implementation. ⁹⁵ Policy change is needed to facilitate this shift. There is growing evidence showing that people with lived experience of mental illness are uniquely well suited to helping their peers navigate treatment and other support services. States are increasingly offering “peer support specialist” certifications, and more insurers are covering services delivered by peers, but reimbursement varies considerably across payers and, within Medicaid, across state Medicaid programs. In addition, health systems need to embed sustained structures and strategies for engaging people with lived experience in the design of mental health services. One model for doing this is coproduction, in which people with mental illness are involved as equal partners in the design, rollout, and evaluation of services. Critically, equal partnership requires compensation for time and effort. The British National Health Service is increasingly integrating coproduction approaches into its health system—including but not limited to the mental health system—and could serve as a model. ⁹⁶ , ⁹⁷ , ⁹⁸ , ⁹⁹ , ¹⁰⁰

Finally, social policy changes are critical to improving population mental health moving forward. ⁷⁵ Specifically, the relationship between oppression and poor mental health points to the imperative to dismantle public policies that perpetuate oppression, such as mandatory minimum sentencing policies and funding of public education via property taxes. ⁵⁶ , ¹⁰¹ , ¹⁰² In addition, it is critical to strengthen social safety policy, including policies that protect against poverty, homelessness, unemployment, disability, and other social determinants of mental illness ¹⁰³ Social determinants of adverse mental health outcomes among individuals are the result of structural inequalities in US institutional systems, and policy change is needed to mitigate these social determinants; ⁷⁰ racial equity impact assessment tools should be used to design equity‐producing policies. ¹⁰⁴ Federal policy proposals to advance universal childcare, to expand Medicaid coverage of home‐ and community‐based care for seniors and people with disabilities, and for universal preschool are the types of policies needed but have not yet advanced into law. ¹⁰⁵ President Biden has recently pledged funding increases for high‐need schools serving many students experiencing socioeconomic risks for mental illness and for delivery of mental health services within schools, ¹⁰⁶ a potentially promising step toward improving public mental health among youth. In addition to societal safety net policies benefiting, by definition, all of society, policies targeting people with mental illness specifically, such as federal or state laws allocating resources to evidence‐based supportive housing and employment programs, or creation of insurance reimbursement mechanisms to pay for these services, are needed.

Conclusion

To realize the vision of a public mental health system supporting delivery of a full range of evidence‐based prevention, treatment, and recovery support services supported by robust social safety net policy, we must build a cadre of public mental health leaders. In 2022, only one US school of public health has a department focused on public mental health; ¹⁰⁷ additional education and training initiatives are urgently needed, and people with lived experience of mental illness must have leadership roles in efforts to build the public mental health system of the future.

Conflict of Interest Disclosure: No disclosures were reported.