Societal Mental Health Challenges: Advocating for a National Policy Response

“Rarely, if ever, are any of us healed in isolation.”

—bell hooks¹

In this postpandemic world, the widespread burden of ongoing psychological distress and mental health disorders are on the minds of many, whether generated from personal experiences from the pandemic or the myriad societal conflicts that have impacted everyday lives. In 2019, 16% of US adults reported having received prescription medication, counseling or therapy for a mental health concern in the previous year.² By April 2022, approximately 27% of US adults reported having done so within the past month.³ In both cases, only 10% to 11% of US adults reported receiving any counseling or therapy as a part of their care. This medicalized approach to addressing mental health needs emphasizes providing clinical services, often pharmaceutically based, to individuals. But public mental health has a much broader mandate than this, including promotion of mental well-being at a population level, prevention of mental health morbidity, and addressing the consequences of it should it occur.⁴

THE ANTIDOTE TO PAIN

In this regard, bell hooks urges us to be disturbed by relying on a medicalized approach to “conquering” our grief, particularly good advice as we come out of this pandemic. For her, the antidote to the pain of loss lies in connecting with others and utilizing the power of our many communities to bring about healing. Danielle Carr, an anthropologist, argues elsewhere that “A crisis that affects mental health is not the same thing as a crisis of mental health.”⁵ She underscores that failure of social policies and political decisions crafted to protect mental health are more likely when mental health problems are located within individuals. To illustrate the issue, she uses the example of medicalizing “social media addiction” in children and adolescents rather than viewing technology exposures as the focus of intervention such as by requiring innovative policies and regulation targeted to reduce the potential harmful impact of our emerging technologies. As she notes, “Medicalization shifts the terms in which we try to figure out what caused a problem, and what can be done to fix it. Often, it puts the focus on the individual as a biological body, at the expense of factoring in systemic and infrastructural conditions.”⁵

CHRONIC UNDERINVESTMENT IN PUBLIC MENTAL HEALTH

While there are many reasons for the chronic underinvestment in public mental health interventions, one factor is that behavioral health conditions remain much more stigmatized than many other chronic health conditions^4,6 and the second is its siloed financing from physical health streams. Hence, it may be far easier to affix causation for mental health morbidity to the affected individual’s personality traits or morality than to center primary prevention on issues of safety, housing, economic stability, educational opportunities, and reducing war and conflict. Equally as compelling is that the mortality associated with the thousand cuts of distress⁷ associated with these conditions is distal and buried in underfunded state-governed systems of public health. These latter features are components of what has been termed social determinants of health (SDOH)—economic stability, educational opportunities, built and social environments, and health care access.⁸ SDOH is now recognized as critical in shaping both the mental and physical health of communities. Cumulative deficits in SDOH have been posited as a prominent accelerator of so-called deaths of despair—deaths from drug overdoses, suicides, and alcoholic liver disease.⁹

Explicating the differential ways in which cumulative deficits in SDOH contribute to mental health concerns, mental health related mortality, and deaths of despair¹⁰ among ethnic/racial minorities is greatly needed to serve as the basis for drafting much needed public mental health policies.^4,8 In our own work, we have shown that racialized deficits in SDOH contribute to psychological distress among ethnic/racial minorities.^11,12 In one study, we demonstrated differences in psychological distress between high-earning Black men and White men, finding that despite having high levels of income, education, and other markers of social achievement, Black men could not protect themselves from the harmful, unpredictable, and yet chronic impact of racism.¹¹ Elsewhere, emerging racialized disparities are troubling. While historically Blacks and Latines have had lower rates of suicide as compared with non-Hispanic Whites and American Indians/Alaska Natives, suicide rates among non-Hispanic Blacks and Latines, as well as American Indians/Alaska Natives individuals, are increasing.¹³ For example, among Black youths and young adults there has been a 37% increase in suicide deaths in recent years. Shockingly, this increase is being observed among Black children aged 5 to 12 years, who are now approximately two times more likely to die by suicide than their White counterparts.¹⁴

Will this crisis among Black youths be effectively addressed by individualized mental treatment alone or does it call for policy-level interventions that address the harmful effects of racism, poverty, and other SDOH deficits? The pandemic resulted in an additional 53.2 million cases of major depressive disorder and 76.2 million cases of anxiety disorder worldwide.¹⁵ We have seen the effects of the COVID-19 pandemic, but the important question is what will public mental health do now to both address the current state of mental health needs and the growing role that compounded grief and bereavement will play in our next crisis?

SOCIAL POLICIES TO PROMOTE MENTAL HEALTH

Enacting social policies that improve public mental health is possible, especially in response to the issues that the COVID-19 pandemic unmasked. In some countries, such as New Zealand, France, and Japan, new labor policies have been put in place that are protective of public mental health such as leave for funerals, bereavement, and grief. In the United States, California passed the Mental Health Services Act 20 years ago authorizing a 1% tax on personal income of high earners to be used to fund mental health and substance use services for those in need. This year, a state proposition is seeking to amend the original act to expand the program to address the crisis of homelessness as well. In 2022, the US Surgeon General released recommendations for the new workplace in response to pandemic-wrought changes that emphasize normalizing and supporting employee mental health. President Joe Biden, in his Build Back Better Act, proposed a national paid family and medical leave program, although this has yet to be passed. In September 2023, President Biden created the first White House Office of Gun Violence Prevention. Recently, Oregon, Illinois, and Maryland enacted mandatory policies that can help employees to take unpaid bereavement leave.

Each of these efforts reflects a growing awareness that addressing public mental health is much broader than merely treating those with mental health concerns. It reflects the strategy of using social and legislative policy to create equity in opportunity for the mental health and well-being of all. If the United States is to remain economically competitive, innovative, and a world leader, attending to societal needs through enacting innovative and effective social policies can help to ensure that all have the opportunity to experience mental health well-being.