Population Mental Health in the 21st Century: Aspirations and Experiences

This special issue of AJPH is a reflection of the growing need to conceptualize the assessment of diagnosis, trends, treatment, and stigma of psychiatric disorders as central foci of public health. We solicited an open call for manuscripts related to issues of population mental health, and the high number of quality scientific studies received bespeaks the prolific output of research within this field. Presented in this issue are a variety of articles selected for rigor, diversity of perspectives and topics, and heterogeneity in research on prevention and intervention. We also solicited commentaries and opinions from thought leaders in the field to advance our discussion through provocative and innovative thinking regarding mental health challenges around the globe.

These reports, and the invited commentaries and editorials, focus on a wide range of evidence from a multilevel and life course perspective, including policy (e.g., Dedania and Gonzales, p. S221; Keyes et al., p. S236), service delivery (e.g., Belkin and McCray, p. S156; Arevian et al., p. S205), prevention (e.g., Compton et al., p. S185), and technological innovation (e.g., Merikangas and Merikangas, p. S171: Insel, p. S168). Taken together, they provide an overview of the state of the science and the exciting promise of future efforts.

A fundamental principle highlighted in this issue is that we cannot achieve population mental health successes by focusing only on treating those with psychiatric disorders once they emerge. Prevention and early intervention are critical to improving population mental health, but they do not come without challenges. A stark example of the promise and challenge is provided in the commentary by Malla and McGorry (p. S181), which focuses on early intervention services to improve long-term clinical and functional outcomes for first-episode psychosis. Despite a range of successful randomized trials of early intervention services, much work remains to accurately identify, effectively treat, and comprehensively follow those who would most benefit from services. But more broadly than early intervention for psychosis, a thread throughout many of the articles is that psychiatric symptoms have planted their roots long before full criteria are met for a disorder or an individual is evaluated clinically. Early detection using mobile technology is one potential promise, as discussed by Insel, but it brings concerns of privacy and the potential to increase social inequities if the technologies are not equally distributed in society.

Public health approaches to population mental health that acknowledge the need for safe and nurturing education, family dynamics, housing, and health care, from very early in life through to adulthood, are articulated across the articles. As noted by Compton et al., “The risks associated with substance use begin long before an individual smokes the first cigarette, has a first drink of alcohol, or tries an illicit substance” (p. S187). The same concept is apparent for many of the disabling psychiatric disorders that we are committed to reducing. Focusing on the concept of wellness, both among the mentally ill to provide competent and comprehensive care (Arevian et al., p. S205) and among the population at large, will advance our public health agenda in ways far beyond any particular policy or set of interventions. Furthermore, such a focus may also advance etiologic research, as argued by Merikangas and Merikangas. Efforts to understand the genetic underpinnings of psychiatric disorders have rapidly advanced, but they have been hampered by the lack of focus on detailed measurement of the social and lived experiences of individuals in the community.

In addition to amelioration of risk and promotion of wellness early in life, efforts to expand and sustain programs to address treatment gaps and improve treatment effectiveness are highlighted in this issue, given that psychiatric disorders continue to be highly stigmatized health conditions. We also highlight several models of population mental health interventions as road maps for how cities and municipalities may address mental health concerns. ThriveNYC (Belkin and McCray) is an unprecedented endeavor by one of the largest US cities to funnel resources and action plans for improving mental health service use. This program uses a concentrated multipronged effort to reduce stigma, improve access to care, and engage a range of community stakeholders in the process. Engaging the community across multiple sectors is echoed in the trials reported by Arevian et al., which demonstrate that continuity of care, sustained engagement in social and community programs, and addressing not just symptoms but the sources of life stress and challenge are essential to creating interventions that work. The signal that emerges is that psychiatric disorders arise because of a wide range of challenges that individuals face, including housing and food insecurity, early life trauma, and other social determinants of health. These factors must be addressed along with symptoms—not only to cure or control disease but also to promote wellness. We also note that to make advances in the treatment gap, stigma must be reduced. Collins et al. (p. S228) demonstrate that a statewide campaign in California to reduce the stigma of mental illness resulted in more self-recognition of symptoms and service utilization.

Among the most pronounced changes in access to health care in the United States in recent decades is legislation that has promoted parity in access between physical health and mental health or addiction care.¹ This is based on long-overdue recognition that mental and physical health are equally important for promoting wellness. One example is 2008 legislation that largely overhauled the government’s response to the breadth of health care coverage and changed private insurance denial of mental health and addiction care to be on a par with insurance coverage for medical–surgical care. Mulvaney-Day et al. (p. S190), using an interrupted time-series design, conclude that this change in legislation led to substantial increases in utilization of mental health and addiction care because of increased access. At the same time, Dedania and Gonzales, analyzing data from the National Health Interview Survey collected after the Affordable Care Act (which was intended to reduce barriers to access as well as increase parity for mental health service use), found that individuals with moderate-to-severe mental illness still report affordability as a major driver of unmet need and care access patterns, regardless of other risk factors for service underutilization.

In addition to championing a series of systems designed to improve population wellness, it is as important to expose misconceptions as it is to figure out what works. Indeed, a consistent thread in the discussions of the current state of psychiatric disorders has been the role of firearms. Guns are the third-leading cause of injury death, behind motor vehicles and opioids, and firearms continue to be a central cause of morbidity and mortality in the United States, especially among young adults. The role of psychiatric disorders has received substantial attention in the wake of high-profile mass shootings, as the role of mental health among shooters takes front-page news. In the wake of these shootings, a common refrain among media pundits and those elected to political office has been to restrict the civil rights and liberties of those with psychiatric disorders, in two ways: limiting gun access and expanding long-term inpatient institutions. Two articles in this issue provide nuanced assessments of why both strategies are misguided. Keyes et al. use agent-based modeling to show that restricting access to guns among those with psychiatric disorders, though reducing suicide among high-risk groups, is unlikely to achieve population benefits unless restriction criteria are so broad that they are arguably unconstitutional, disenfranchising millions of Americans and potentially increasing stigma. And Perera and Sisti (p. S176) argue that the declining number of psychiatric hospitals has been observed in many countries worldwide, but only the United States has demonstrated an epidemic of gun deaths and mass shootings. Instead, many have argued for a public health approach to reducing firearm morbidity and mortality, focused on balancing gun restrictions among those identified at high risk of violence and self-harm, as well as a broad range of population-focused policies to reduce gun availability. Such public health approaches, even with divisive issues such as gun rights, will continue to take center stage in population mental health in the coming decades.