In its simplest form, mental health is defined as:

“one’s emotional, psychological and social well-being. It affects how we think, feel and act as we cope with life. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence
through adulthood.”¹

Mental health is becoming increasingly integrated into the realm of public health; as there is a growing recognition that: (1) more people are succumbing to behavioral health issues; and, (2) greater attention is needed for these people.² There are a myriad of factors that can cause mental disorders, which can be classified as biological, psychological, or environmental, among others. Some factors that may cause mental disorders include:

1. A genetic predisposition to these types
   of disorders;
2. Infections linked to brain damage;
3. Prenatal damage to brain;
4. Substance abuse;
5. Severe psychological trauma, i.e., emotional, physical or sexual abuse; and,
6. Certain stressors that can trigger an illness in a person who is susceptible to mental illness.³

Mental illness in America is more common than cancer, diabetes, and heart disease.⁴ In fact, one in four adults (an estimated 61.5 million Americans) experience mental illness in any given year, and approximately one in 17 adults (an estimated 13.6 million Americans) live with a severe mental disorder.⁵ The cost of serious mental illness in the U.S. is approximately $193.2 billion.⁶ Individuals living with serious mental conditions also have an increased risk of having chronic medical conditions.⁷ A good portion of the world’s older adult population is expected to double; the anticipated growth rate is 231%.⁸ As the “Baby Boomers” generation enters retirement age, the need to understand mental and behavioral health grows as well as the need for resources to manage these conditions.⁹ “Over 20% of adults aged 60 and over suffer from a mental or neurological disorder and 6.6% of all disability among over 60s is attributed to neurological and mental disorders.”¹⁰ The Federal and State governments, as well as mental health advocates have implemented easily accessible resources to educate and assist in mental health treatment, such as:

1. MentalHealth.gov, which provides mental health information and assessments;
2. Substance Abuse and Mental Health Services Administration (SAMHSA), which leads public health efforts to advance the mental and behavioral health of the U.S. population;
3. The National Institute of Mental Health, which drives to both cure and prevent mental illnesses through basic and clinical research; and,
4. The National Alliance on Mental Illness, NAMI, which is the nation’s largest grassroots mental health organization and advocates for access to services, treatment, research, and awareness.¹¹

The enactment of the Affordable Care Act (ACA) marks one of the largest expansions of mental health coverage, by requiring both employer-sponsored and individual health insurance plans to cover mental health services for their insurers.¹²  Additionally, on January 31, 2014, $50 million was made available, to assist Community Health Centers (CHC) across the nation in expanding or establishing their mental health services for people living with mental illness in their area.¹³ These mental health services include “rehabilitative and habilitative services” that can be used to support patients with behavioral health issues.¹⁴ These ACA provisions further develop the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), which requires:

“group health plans and health insurance issuers to ensure that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder (MH/SUD) benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits.”¹⁵

Another provision of the ACA is the individual mandate, which requires individuals to have a health insurance plan or potentially pay a penalty for noncompliance.¹⁶ Both Medicare and commercial health insurance plans cover mental health services. Patients insured through Medicare Part A are covered for mental health care services in the hospital, if that patient is admitted.¹⁷ Part A insurance provides for treatment of mental health disorders at general hospitals, if the hospital provides such services, or at psychiatric hospitals. For health insurance plans in the Marketplace, there are a variety of conditions. Mental and behavioral health services are classified as “essential health benefits,”¹⁸ which are benefits that must be covered by health plans, as mandated by the ACA.¹⁹ These mental and behavioral health benefits must include items and services within the “mental health and substance use disorder services, including behavioral and health treatment.”²⁰ In addition to the required coverage of mental health services, Marketplace plans: (1) must provide certain “parity” protection between mental health benefits on one hand, and medical and surgical benefits on the other; (2) cannot deny a recipient coverage or charge an excess price due to pre-existing mental conditions, and, (3) cannot impose yearly or lifetime dollar limits coverage of essential
health benefits.²¹

The implementation of the ACA has not been the only form by which the government has decided to increase availability and access to mental health services. In January 2013, President Obama signed “an omnibus appropriations bill” which secured $115 million for new mental health initiatives as part of a comprehensive plan to reduce gun violence.²² However, even with these increased funding measures, there are still many barriers and disparities which affect access to mental health services.

Some of the primary barriers and disparities affecting the mental health community, according to the World Health Organization (WHO), are:

1. Disasters and extreme violence, which have a large impact on mental health;
2. stigma and discrimination which prevent people from seeking proper mental health care;
3. human rights violation of the mentally ill;
4. huge shortages of skilled human resources for mental health due to the shortage of mental healthcare professionals²³; and,
5. The lack of integration of mental health services into primary care systems.²⁴

In regards to the shortage of mental health professionals, the Kaiser Family Foundation (KFF) published data displaying the Mental Health Care Health Professional Shortage Areas (HPSAs) within the U.S. KFF defines HPSAs as:

“Federal regulations stipulate that, in order to be considered as having a shortage of providers, an area must have a population-to provider ratio of a certain threshold. For mental health, the population to provider ratio must be at least 30,000 to 1 (20,000 to 1 if there are unusually high needs in the community).”²⁵

As of April 2014, there were a total of 3,968 HPSA nationwide, with a need for an additional 2,707 practitioners required to meet the demand for mental health services.²⁶

Mental health also has a significant level of disparities that derive from racial, cultural, and geographic barriers.²⁷ A 2001 report of the Surgeon General stated that minority populations are less likely to have access to available mental health services due to their socioeconomic status, and further, that minority populations traditionally receive poorer quality of care.²⁸ Another challenge involves the vast majority of Americans living in rural, remote, and underserved areas of the nation. Due to their location, rural residents generally begin care later in the course of illness, with more serious and persistent symptoms, which can result in more expensive and intensive measures
of treatment.²⁹

Also of concern in the mental health community is the fear of stigma associated with mental illness. Stigma can be classified into public stigma and self-stigma.³⁰ Public stigma refers to the way the mentally ill are feared, excluded, and believed to be “unsafe in society.”³¹ They are deemed irresponsible, considered “childlike,” and need to be cared for.³² Mental health issues are predominately portrayed in a negative light, particularly in media productions. Specifically American media:

“usually only addresses mental health through media stories of irrational acts of violence carried out by disturbed, mentally-ill individuals.”³³

Self-stigma refers to an individual’s self-esteem and confidence, and the heightened level of anger generally displayed by these individuals arising from the prejudice they have experienced from society.³⁴ The Saginaw County Community Mental Health Authority (SCCMHA), a mental health agency, has suggested avenues by which both classes of stigma can be ameliorated, such as increasing heightening advocacy and support for patients, avoiding the use of derogatory terms, and increasing opportunities to learn about different mental illnesses.³⁵

The progression of mental health treatment started back in the 1400’s with the first establishment designed specifically for people with mental illness.³⁶ In 1949, Australian psychiatrist J.F.J. Cade introduces lithium to treat psychosis, which was later used in the 1960’s to treat manic depression.³⁷ Moving forward to the 1990’s, a new generation of anti-psychotic drugs was introduced; they were proven effective and resulted in fewer side effects.³⁸ Today, there are a number of psychoactive drugs used by psychiatrists and other medical doctors that are highly effective. A variety of therapies are also used, such as electroconvulsive therapy and psychotherapy (known as talk therapy).³⁹ “With electroconvulsive therapy, electrodes are attached to the head, and while the person is sedated, a series of electrical shocks are delivered to the brain to induce a brief seizure. This therapy has consistently been shown to be the most effective treatment for severe depression.”⁴⁰ Although, there are risks and side effect associated with this treatment method. Some concerns following ECT are (1) confusion, (2) memory loss, (3) nausea, (4) vomiting, (5) headache, and (6) minor medical complications due to the use of anesthesia.⁴¹ 

One major discovery is the identification of a gene which is linked to schizophrenia. With this new discovery and the assistance of computerized brain imaging techniques, physicians can further study and show chemical abnormalities in the brain in individuals who are diagnosed with schizophrenia and other mental disorders.⁴² Similarly, the Genome-Wide Association Studies (GWAS) has allowed researchers to use data from the Human Genome Project of 2003 to find genetic markers strongly correlated with diseases.⁴³ Instead of scientists having to examine over 3 million Single Nucleotide Polymorphisms (SNPs) across a large sample size of individuals, they now only have to examine 500,000.⁴⁴ With this innovative technology, findings have suggested a genetic marker linked to Obsessive-Compulsive Disorder (OCD).⁴⁵

Socioeconomic barriers and other disparities still persist in the mental health community, and affect 42.5 million individuals nationwide.⁴⁶ With so many individuals impaired, it is important to keep abreast of developments in the mental health community as the field continues to progress. In the next installment of this series, special sub-populations within the mental health community will be discussed, specifically prisoners within the justice system and the homeless subpopulation. This article will discuss the lack of mental healthcare within prison systems, barriers among the homeless, types of therapy used, and mental care within re-entry programs.