“Mental health was never considered part of ‘health,’” says Sue Abderholden. “Somehow we neglected the fact that our heads are connected to the rest of our bodies.”
Abderholden is director of NAMI (National Alliance on Mental Illness) Minnesota, has an MPH in Public Health Administration and Policy, and was given SPH’s Gaylord Anderson Leadership Award this year. With her comments, she’s addressing the historical disconnect between mental health and physical health, and the fields that treat them both.
Those disciplines came closer together as the mental health profession started following a clinical treatment model, but public health has yet to find how it can play a more effective role on the ground to increase the mental health of Americans.
Reading the signs
One area where public health has had a major contribution, says Ezra Golberstein, assistant professor in the Division of Health Policy and Management, is in documenting the basic epidemiology of mental illness — identifying its prevalence and its risk factors. Landmark studies such as the Epidemiological Catchment Area Project of the 1980s and the National Comorbidity Survey of the 1990s and early 2000s surveyed general population samples and painted a striking picture of mental illness in the United States.
These studies found that between one-third and more than 40 percent of all Americans suffer from mental illness at some point in their lives. More recent national studies have put this number at about one-half.
Golberstein’s own area of research involves studying the financing of mental health services. “We now have treatments that really work for alleviating many otherwise debilitating mental health problems,” he says. “But how we try to improve access to these services and how we as a society pay for these services continues to evolve, especially as the Affordable Care Act expands coverage for mental health and substance abuse disorders.”
But when it comes to prevention, the traditional purview of public health, things are not so straightforward. Other major public health culprits like heart disease and diabetes have more obvious cause-and-effect lines. Not so with mental illness.
“Primary prevention is still pretty tough, because we don’t have enough research when it comes to the causes of mental illness,” says Abderholden. “We can’t say, for example, ‘be a good parent,’ because we know that biology and genetics and all sorts of things are involved. We can certainly do more about secondary prevention—intervening before the first symptoms appear — because we know who’s at risk.
“But tertiary prevention — stopping a disease before it becomes chronic — is where we can really have a huge impact. When we know someone has had their first psychotic episode or beginning to experience symptoms, we want to make sure this doesn’t become a disabling condition.”
Too broad a brush
Trying to catch mental illness at its very earliest stages is the goal of many mental health professionals and conducting screenings may be the best way to do that. That methodology, however, generates some controversy.
Donna McAlpine is an associate professor in the Division of Health Policy and Management and director of the MPH program in Public Health Administration and Policy. She is coauthor of the most recent edition of Mental Health and Social Policy, the standard text for mental health policy students.
The textbook got media attention for, among other topics, the questions it raised about the best use of funds for mental health; the new categories in DSM-5, the latest manual from the American Psychiatric Association that classifies mental disorders; and the limitations of preventive psychiatry, including screening programs.
“Screenings work to identify more and more people with symptoms that may be related to mental illness, but as we are beginning to realize, we then run the risk of medicalizing emotions that are a normal part of life, like sadness,” says McAlpine.
“What can happen is that we end up classifying people as ill and bringing them into treatment. In reality, of all people identified, only a small portion will go on to develop severe mental health problems. There’s little evidence that early screening improves outcomes or identifies the right people.”
McAlpine believes that screenings and national community studies have helped reduce the stigma of mental illness by showing how common it is — 1 in 10 adults and 1 in 20 children take psychotropic drugs for a mental health condition, for instance — but that increasing comfort level with mental illness has been accompanied with a loss of focus on the people with severe and disabling problems.
“Walk down the street in any large city, like Minneapolis, when the weather begins to warm up, and you will see just how many people are struggling with untreated mental illness,” says McAlpine.
With the limited mental health resources that we have, she says, we should focus on people with the most critical symptoms who are unlikely to get better without help.
Helping people get better
When Abderholden first came to NAMI, she sat down with some people who had been through the mental health system. “I asked if anyone had ever gotten a get-well card when they were hospitalized,” she says. “Everyone said no. Just imagine what that says about how the community views you, your illness, and hope for your future.”
As an MPH student, Abderholden learned that you need to talk with the community you’re going to work with. You have to find out what people really want, what they really need.
“When I talk to people with mental illness, it’s clear what they want — a life,” she says. “Their illness might not be cured, but it might not have to be disabling either. Public health takes a broader view of health. It’s not just the absence of disease. We need to apply this thinking to mental illness.”
Both McAlpine and Abderholden see the need for a more holistic view of mental health and broader systems of care, with coordinated and accessible social services.
There may be a model for this kind of support in Minneapolis’s Hennepin Health program, where mental, clinical, and dental health services are co-located, and public health thinking plays an essential role.
In McAlpine’s opinion, public health should pay much more attention to mental health and work it into curricula.
“[As public health professionals], we have an obligation to understand how mental health correlates with social environments, poverty, trauma, and many of the other things public health turns its attention to when looking at downstream causes of disease,” says McAlpine.
“And we need to see — and teach our students to understand — how mental illness often accompanies typical public health diseases like diabetes and heart disease and can, in fact, be more disabling than any of these.”
~Illustration by Christine Roy