Continuing on the theme of issues in American health, this time I want to talk about two things that haven’t gotten much attention so far: mental health and addiction.
The good news is that mental health in the United States isn’t as stigmatized as it used to be. Overall, we speak about it more openly, and are more willing to seek treatment than in the past. The stigma is eroding, albeit slowly.
Even so, significant problems remain in this area. Spending is not the issue; we spend about as much as other countries, per capita. While we used to institutionalize people with severe mental illness in facilities that were often poorly-run if not downright abusive, our transition away from long-term inpatient treatment has instead shifted the burden onto homeless shelters and the prison system. Likewise, whenever there is a mass shooting in the US, the discussion immediately turns to mental illness as the main cause, rather than easy availability of guns. Perhaps unintentionally, this helps reinforce the same stigma that needs to be eliminated, suggesting that people with mental illness are more likely to perpetrate violence, when in fact the reverse is true. As often as the issue comes up, however, significant strides to address mental illness more generally in the US are not made. Existing laws establish parity between insurance coverages for mental health and physical health, and the Affordable Care Act has indeed expanded coverage, but poor Americans still remain more likely to suffer from untreated mental illness. Being poor is itself extremely stressful–a lack of material security takes both immediate and long-term tolls on one’s physical and mental health.
Given limited access, inadequate benefits, and logistical difficulties with obtaining mental health care, it is not uncommon for people in such dire straits to turn to other substances, both legal and not. Use of illegal drugs is often portrayed or characterized as a primarily recreational activity–a source of fun. It is then criticized on the basis of its potential for serious consequences to one’s physical and mental health. Such consequences–along with the fact that producers and suppliers significantly profit from their sales–are used to justify various law enforcement actions and criminal penalties. Our drug laws have long been draconian, resulting in mass incarceration and untold ruined lives and futures. Producers and distributors are sometimes caught, but more often small-time dealers and individual drug users are swept up and punished. My intention here is not to write a screed against the Drug War; it is self-damning in its scope and impact. Rather, my point is to illustrate that we have taken a problem spawned primarily by poverty and, rather than address the underlying poverty conditions, sought to suppress its symptoms.
Harm reduction methods have seen both recent success and increasing interest lately, which I consider a very good thing. But some drug dependence could likely be eliminated altogether–or at least more easily prevented in the future–by understanding and rectifying what drives people to drugs in the first place. The National Institutes of Mental Health have performed various studies into the use of intoxicants and illegal drugs as means of self-medicating mental illness. The findings of one such study:
Use of illicit drugs other than marijuana increased with unmet need for mental health care (4.4 versus 3.2 percent, p=.046) but was not reduced with mental health-care use. Heavy alcohol use was not associated with increased unmet need for mental health care, but was higher among individuals with no mental health care use (4.4 percent versus 2.7 percent, p<.001). By contrast, marijuana use did not appear associated with either unmet need or mental health care use.
Substance use varies with past year unmet need for mental health care and mental health care use in ways consistent with the self-medication hypothesis. Results suggest that timely screening and treatment of mental health problems may prevent the development of substance-use disorders among those with mental disorders. Further research should identify subgroups of individuals for whom timely and appropriate mental health treatment would prevent the development of substance-use disorders.
And from another study focused on post-traumatic stress disorder:
Approximately 20% of individuals with PTSD used substances in an attempt to relieve their symptoms. Men were significantly more likely than women to engage in self-medication behavior. In adjusted models, using illicit drugs or misusing prescription medications to control PTSD symptoms was associated with a substantially higher likelihood of dysthymia and borderline personality disorder. After controlling for mental disorder comorbidity, self-medication was independently associated with higher odds of suicide attempts (adjusted odds ratio=2.46; 95% confidence interval 1.53-3.97) and lower mental health-related quality of life.
Many questions could be raised as to why people suffering mental illnesses turn to alcohol and other substances to alleviate their symptoms. Lack of access to better mental health treatment is an obvious explanation, though it doesn’t offer the full story. To the extent people in need of mental health treatment can obtain appropriate medications, they may either be too expensive to afford reliably, or have highly unpleasant side effects which reduce adherence. Psychiatric drugs also tend to be more effective when complemented by a regimen of regular talk therapy, which is much less practical if you are poor, and possibly entirely unavailable. Alcohol and illegal drugs can often be obtained easily and offer relief more quickly and readily than prescription medications, perhaps without the lingering side effects of prescription drugs.
The results of the first study are cause for concern also because they demonstrate that, once one has come to rely on illicit drugs, access to better mental health care does not result in less use. I would suspect that this is because addiction has taken hold by that point, and drug addictions are notoriously difficult to dislodge. It should go without saying but this is also not a matter of willpower–it is a problem of physical and psychological dependence. Once present, it is very hard to shake, and presents its own lingering issues.
This is obviously a complex issue–even a vast series of complex issues–and there is no simple answer as to what would address it, because it encompasses so many interlinked, interdependent problems. The root cause, as has been typical in this series, is poverty. Poverty is stressful. By itself, it impairs both your physical and mental health. The means available to alleviate one’s own poverty are limited; options for treating the damage it inflicts upon you range from dangerous to inadequate to nonexistent. The problems of poverty compound upon the individual, as well. Certainly, imprisoning people for what are essentially the consequences of being poor (and, just as often, non-white) is worse than useless–it’s cruel and inhumane.
Better access to mental health treatment might help–and it should be provided–but grinding poverty is the real killer here. More broadly, mental illness must be destigmatized, and not used as a rhetorical football every time someone shoots up a school. On top of that, we must stop demonizing and persecuting people addicted to drugs–or even those who use them recreationally. I am less concerned about the latter and don’t see any reason to inflict legal consequences on people for drug possession or use whatsoever, but for people suffering with addiction, we must be willing to provide sufficient and non-judgmental help while understanding that many mental illnesses and addictions cannot be cured, only managed and treated.
For too long, we have ignored the real consequences of poverty, and have shuffled around the responsibility for addressing mental illness to all the wrong channels. These are serious public health issues and should be treated as such. You don’t fix health problems through stigma and criminalization. You treat them. You spend money and resources on them. You help the people affected.
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