17 minute read
The Other Pandemic
RACISM HEALTH INEQUITIES SOCIAL INJUSTICE VIOLENCE FINANCIAL INSTABILITY COVID
The Other Pandemic Mental Health
MSM’s Office of Global Health Equity and Kennedy-Satcher Center for Mental Health Equity Seek National and Global Answers to Soaring and Disparate Rates of Behavioral Health Challenges
By Peggy Pusateri
Contributer: Amanda Magdalenski
Whatever metrics one uses to examine mental health in the United States, the picture is troubling and has been worsening for years. Mental Health America’s 2022 State of Mental Health in America Report reveals worrisome data:
In 2019, almost 20 percent of U.S. adults experienced mental illness. The national rate of suicide ideation among adults has increased every year for the past decade. More than half of adults with mental illness do not receive treatment. Rates of substance abuse are increasing for both adults and youth.
“This issue of mental health is a huge area of need and has been for a really, really long time and has not had nearly the amount of visibility and prioritization in terms of funding as it needs,” notes Gigi Bastien, MA, PhD, associate director of the Office of Global Health Equity at Morehouse School of Medicine. An assistant professor in MSM’s Dept. of Psychiatry and Behavioral Sciences, Bastien researches global mental health issues, including those surrounding disaster, trauma, and migration.
Add to the long-term mental health picture the toll of a global pandemic and repeating societal shutdowns, and the snapshot is alarming. Fear, uncertainty, isolation, financial instability, illness, grief, overdose deaths: All have increased during the past two years. A 2021 survey by the National Alliance on Mental Illness (NAMI) found nearly half of participants reporting symptoms of a mood disorder within the previous two weeks; 30 percent of respondents said they were unable to get mental health support during the pandemic. In addition, more than 107,000 Americans died of drug overdose in 2021, according to the Centers for Disease Control and Prevention.
The COVID-19 pandemic took “preexisting challenges and just exacerbated all of them beyond what I think we even fully appreciate at this point,” says Dr. Bastien. “There are huge areas of need at individual levels, at family and community levels, at a national level, whether it’s the opioid crisis and substances, whether it’s issues of social isolation and depression and anxiety.”
As it does with general health, inequity plays a role in shaping the mental health landscape. The NAMI mood disorder survey revealed greater challenges for people of color, especially Hispanics and Asian Americans, who were more likely than other groups to label their mental health as poor; people in those communities faced greater stigma and were less likely to access treatment. According to the National Institute of Mental Health (NIMH), Black people face additional suicide risk factors, including experiences of racism, higher unemployment rates, financial and food insecurity, and limited access to care.
Youth in crisis The mental health of young people is of particular concern. In the fall of 2021, a coalition of pediatric health professionals declared a national emergency in child and adolescent behavioral health. Then in December, the U.S. Surgeon General issued an advisory on the youth mental health crisis. Even before COVID-19, children were in trouble: During the decade prior to the pandemic, suicidal behaviors increased among high school students, and the percentage who reported persistent feelings of sadness or helplessness rose by 40 percent. Between 2007 and 2018, suicide rates among people ages 10-24 spiked 57 percent.
Again, disparity is a factor, with Black youth facing an alarming scenario. As of 2018, suicide was the second leading cause of death
Dr. Gigi Bastien, associate director, Office of Global Health Equity, Morehouse School of Medicine
Claire Abel
faith partners
— Dr. Gigi Bastien for Black children ages 10-14 and the third leading cause of death for those ages 15-19, according to the NIMH.
The pandemic created additional obstacles for children, disrupting critical social networks and access to healthcare, food, and housing and in some cases robbing them of a parent or other caregiver. The 2022 Mental Health America (MHA) report notes 15 percent of the nation’s youth experienced a major depressive episode in the previous year. More than 2.5 million youth have severe depression, with multi-racial youth at greatest risk. Youth of color are far less likely to receive mental health treatment than are their white peers.
Diverse groups, important perspectives Equity must be at the center of efforts to improve mental healthcare, or real progress will remain out of reach for too many. Morehouse School of Medicine is immersed in national and global efforts to tackle both the mental health epidemic and inequity with a multi-faceted, interdisciplinary approach encompassing government policy, clinical care, and community relations. Since 2015, its Kennedy-Satcher Center for Mental Health Equity, part of the Satcher Health Leadership Institute at MSM, has been conducting research, producing academic material, and promoting policy — all designed to improve outcomes for traditionally vulnerable populations. Another of the center’s chief tactics is convening unique leadership groups to examine problems from new perspectives and bring the voices of unheard people to the table.
“Often, a lot of the same people get an opportunity in a platform to speak,” explains Madhuri Jha, LSCW, MPH, director of the Kennedy-Satcher Center. Her office brings together a diverse set of individuals, among
next level preparation
— Dr. Gigi Bastien them healthcare providers, policymakers, and those who live with mental illness every second of every day.
The inclusion of patients allows group discussions “to thoughtfully tackle how complicated mental health equity is, including prioritizing the experience of people with lived experience, which is really important to me,” Jha says. “From a policy-making perspective, it is the most grossly neglected piece, and yet that is the person affected by the policies we create.”
This year, the Kennedy-Satcher Center conducted a series of webinar roundtable discussions to address inequities facing currently and previously incarcerated individuals and others convicted of criminal behavior. Because crime often stems from untreated mental illness or drug addiction, treating the problem at its root reduces repeat offenses.
“I have seen first-hand how invisible and neglected this population is by our healthcare system and yet how much potential there is to reduce recidivism if approached thoughtfully,” says Jha, who also is a practicing clinician with years of experience treating patients with complicating challenges in very demanding environments.
The roundtables drew hundreds of listeners from across the globe. Panelists hailed from healthcare, patient, and law enforcement communities, which allowed care providers, policy makers, and legislators to meet with patients and people who are creating local solutions.
“The Kennedy-Satcher Center makes those introductions, connecting people from all parts of the perspective wheel,” Jha notes. “We had sheriffs of major cities come together with folks who were formerly incarcerated, with physicians who are on the frontline advocating for criminal justice and correctional health reform, leaders of mental health spaces like the CEO of Mental Health America, policy directors from organizations such as the SPLC.” Convening such diverse groups offers benefits on many levels, Jha notes.
“One, it uplifts the visibility of those who are the most marginalized,” she explains. “Two, it normalizes and destigmatizes our own conversations and addresses our own biases: Even if we are leaders in the field, we all have them. And, it creates a safe space where we can be the facilitator for that. We have a big platform at Satcher Health Leadership Institute and at Kennedy-Satcher Center. The least we can do is uplift those folks who deserve to be given a voice. There are some amazing people who don’t get the credit they deserve. That’s a huge part of the behavioral health piece. Some of the most effective work has been grassroots, local-driven, that is super culturally responsive — people just building their own coalitions to figure solutions out.”
Access to care Ensuring patients from marginalized communities have access to mental health treatment is one of the priorities of the Office of Global Health Equity, and a critical step in the process is spreading the word about available options. One successful tactic has been engaging the participation of local religious leaders who often know the individual challenges their congregants face but might not know how to help.
“A huge partner for us has been the faith community, working with churches and religious leaders to increase their understanding and mental health literacy, to familiarize them with existing supports and arm them with the resources they need to be part of a referral pathway,” Bastien explains, adding that religious leaders can be highly effective in taking essential mental healthcare messages to audiences that most need to hear them.
“We often have the right message that folks need, but we’re not necessarily the best messengers to carry that work forward,” she says of healthcare professionals. “Our faith partners have been really important champions and ambassadors for us, particularly in the global context, but we’re also using that strategy here. One of the things the Office of Global Health Equity has been working on for the past four years has been a collaboration
RACISM HEALTH INEQUITIES SOCIAL INJUSTICE VIOLENCE FINANCIAL INSTABILITY COVID
Madhuri Jha, LSCW, MPH, director, Kennedy-Satcher Center for Mental Health Equity
Claire Abel
988 dialing code
“Our current psychiatric emergency response system fails to adequately meet the needs of our most vulnerable. For Black, indigenous and people of color and other historically marginalized communities, 988 is an opportunity to ensure our system is saving and treating lives the way all humans deserve to be treated.”
— Madhuri Jha with local churches in the Atlanta area who serve large Haitian-American congregations. This is a community we know has been challenged particularly by trauma-related issues that stem from the never-ending string of disasters back home … and also trauma inherent in the migration process. That work of partnering with faith-based organizations and equipping them with the right messaging and information has also been a critical avenue for addressing issues of stigma.”
Equity in 988 In addition to stigma and problems accessing treatment, individuals in need of mental healthcare face inadequate or inappropriate response by emergency professionals, which increases trauma for patients in crisis. All too often, historically marginalized communities are the ones who suffer.
“Over the years, I have seen people of color dismissed and not get the care they need or deserve,” says Dr. David Satcher, former 16th U.S. Surgeon General and founder of the Satcher Health Leadership Institute. “Our crisis and emergency response system simply does not know how to respond to diverse needs or is just negligent at times.”
Jha also has seen firsthand the results of inappropriate intervention.
“I have been witness to a 911 call going badly for someone in crisis,” she says. “It is the type of mental image that stays with you forever in this line of work.”
This summer, the national 988 dialing code went live. Devoted to psychiatric response and preparedness, it connects callers to the National Suicide Prevention Line and offers professional assistance with mental illness and substance abuse, especially for people in crisis. Equity in response is a critical part of creating an effective 988 system.
“Our current psychiatric emergency response system fails to adequately meet the needs of our most vulnerable,” Jha notes. “For Black, indigenous and people of color and other historically marginalized communities, 988 is an opportunity to ensure our system is continued on page 34
Rep. Mary Margaret Oliver (D), House District 82, Georgia
HB1013
Georgia’s New Mental Health Parity Act
Takes Big Strides Toward Improving Treatment
Primarily Caring sat down for a conversation with state Rep. Mary Margaret Oliver (D), of House District 82. A veteran lawmaker with 35 years in the Georgia General Assembly, Oliver was one of two co-sponsors of the critical legislation.
What is the current picture of mental health in Georgia? The state currently ranks 48th in the nation in access to mental health. Our mental health system is weak. We spend less money on mental health than almost any other state, per capita, so our statistics are bad. More importantly than that, the speaker [David Ralston, Georgia House Speaker (R)] talked about this and I experienced it, individual family members who are constituents coming to me. David Ralston told one story about a lady who came to him and said her son had committed suicide, and they didn’t know how to cope and they didn’t know where it was coming from. Then six months later she came to [Ralston] and said her husband had committed suicide because he couldn’t deal [with the grief]. Those are the kind of stories every member of the General Assembly is listening to.
All of a sudden, the legislation hit pushback in the hearings, but getting it across the finish line, what did that feel like?
It’s an amazing amount of work. I don’t think people outside the political world know how hard you have to work.
And the session is so compressed. It’s just 40 days.
And the players are so diverse — big and little. An 80-page bill that really goes after big-business insurance interests, has significant moving of public money around, and has some controversy issues, is going to be followed by lots of people. We had 10 hearings. The House process was very substantive. We accepted over 50 amendments. Organizing the incoming 50 to 100 suggestions was a huge amount of work. Then we got to the Senate and there was this explosion of fringe groups [protesting]. The things they said were so preposterous, yet the Senate was scared about this incredibly visible activity. But it was countered by activity of people who wanted [the legislation]. The show of support that was organized from the advocates in the medical community, the psychiatrists and the hospitals, CHOA (Children’s Healthcare of Atlanta), it was just unbelievable support. The fact, though, that it passed with unanimous votes in both chambers was a real shock to me, a happy shock.
What is this going to mean for people experiencing mental health challenges? Also, we are training the next generation of healthcare professionals. How does this change the calculus and the situation?
We have short-term and long-term goals to implement. Parity has been part of the federal law since 2008. It has not been enforced. Our bill was using that federal bill to implement measures and logistics and operations so that we could enforce parity. That’s huge. The insurance industry has fought that tooth-and-nail since 2008.
The other thing that is long-term is $10 million of loan forgiveness for those going into mental health services. We are a dramatically underserved state. We have counties with 2,000 people and we have counties with a million people, and we have a mental health system that is not consistent across those. The long-term loan forgiveness, which enhances opportunities for people to practice in underserved areas, is huge.
Organically, police agencies across Georgia have been implementing co-responder programs, making mental health workers a part of the 911 screening system and part of police teams. Picking someone up in the middle of a psychotic crisis and taking them to jail helps nobody and costs money.
Co-responder programs have been very successful in other parts of the country.
That’s what the data is showing us, so we set up a whole system of co-responder funding and structure and data collection.
What about people who are uninsured? Will the new law help them?
Uninsured people are being taken to jail now. Uninsured people receive mental health services in the form of the police right now. Co-responder programs and other crisis mental health programs recognize that a person has to be taken to a crisis mental health system, and nobody’s asking if they have insurance on the ground. Once the crisis is over, then the question of who is going to pay becomes relevant.
HB1013
Requires private insurers to provide the same level of benefits for treating mental illness and substance abuse as they do for other medical conditions.
Prevents insurers from collecting higher deductibles or copays for behavioral health treatment. Encourages growth in the ranks of Georgia’s mental health professionals with $10 million in loan forgiveness for people studying to enter the mental healthcare field.
Creates co-response teams of law enforcement officers and behavioral health professionals to answer emergency calls involving people experiencing a psychiatric crisis. Adds mental health crisis beds across the state. Passed unanimously in both houses of the Georgia General Assembly.
saving and treating lives the way all humans deserve to be treated.”
Toward that end, the Kennedy-Satcher Center partnered with Beacon Health Options, a leading behavioral health services company, to present a policy brief with concrete recommendations for equitable and effective administration of the 988 system. In June, they released Embedding Equity into 988: Imagining a New Normal for Crisis Response.
Among the recommendations is that law enforcement be deployed in psychiatric emergency situations only when necessary. With 75 percent of the nation’s counties lacking mental healthcare services, police officers without mental health training become first responders in psychiatric emergencies. Too often, a crisis becomes escalated, leading to avoidable arrests, unnecessary use of force, and casualties, particularly for communities of color and other marginalized groups.
The policy brief’s other 988 equity recommendations include:
• Uplift groups that historically have been excluded or inadequately reached by psychiatric emergency services. This includes BIPOC and LGBTQIA+ individuals as well as immigrants, non-English speakers, the disabled and people who are neurodiverse, homeless or formerly incarcerated.
• Psychiatric crisis response teams should include licensed mental health professionals such as psychiatrists and nurses. The policy paper suggests medical translators be part of effective response teams in areas with large populations of non-English speakers. Additionally, it recommends the inclusion of peer recovery specialists whose lived experiences build trust with those in crisis. • Mobile response units should be placed at local medical and mental health clinics. The brief notes that existing local clinics as well as LGBTQIA+ organizations and homeless housing agencies are appropriate and effective host sites for response teams.
• Because culture plays a critical role in ensuring appropriate and equitable response, key crisis response personnel should undergo comprehensive training to prioritize skills that contribute to more equitable outcomes.
• Allow callers to opt in or opt out of a geolocation feature that identifies their location. Providing an option offers anonymity protection, something that makes many callers feel safer accessing services.
Jha has high hopes for the 988 system, especially for youth, who make up the largest population of people already using the national suicide prevention line. “I won’t be surprised,” she says, “if a lot of our investments (in the 988 system) are most effective for kids.”
An expanding challenge Adequately staffing the needs of mental health patients is an ongoing struggle, and recent forces — some positive, some negative — are driving additional demand. Heightened consciousness of the importance of mental health is leading more people to seek care. At the same time, pandemic aftermath and societal influences create a greater need for that care. Behavioral health professionals, already in short supply, become overwhelmed and step back from the profession, exacerbating the provider shortage.
“I am often amazed at how many (mental health professionals) have had to take a timeout over the past couple of years, just in terms of being overwhelmed with the magnitude of need in the midst of a pandemic and all that we’ve been grappling with in terms of racial issues in the country,“ Bastien says.
Filling the provider gap takes a creative approach. Just as the Office of Global Health Equity works with local faith leaders who serve as referral pathways, it has found success implementing a similar tactic with healthcare professionals outside the mental health field. The strategy of task shifting, Bastien says, is gaining traction globally.
“How do you take the professionals in the health workforce and provide them at least a base level of understanding and training around mental health and mental illness to be able to address an initial line of need before folks are elevated to the next level?” she asks. “That involves training primary care providers, training nurses and midwives to be able to look for these things. Folks will not necessarily call a psychologist or psychiatrist. They often will share some challenges with their family physician, with their nurse. The strategy of ensuring those folks have at least a certain level of preparation to address those needs is one that has been a focus of our work, both locally and outside of the U.S.” M
