It was the summer of Simone. On July 29, 2021, Biles literally vaulted into the headlines—and commanded the world’s attention—by withdrawing from the gymnastics competition in the Tokyo Olympics. Competing in an empty arena (thanks again, COVID-19), without fans or family present for support and encouragement, Biles said her mind and body were not in sync and told reporters she felt unable to compete without risking serious injury.

While athletes have historically been expected to tough things out mentally, in a matter of weeks, two well-known champions questioned that logic. First Naomi Osaka (in May), a Japanese tennis player, and soon after, American superstar Simone Biles broke with convention citing mental health as the reason they pulled out of competition.

Some fans were flabbergasted. Others, including the legions currently struggling with their mental health, felt validated.

Psycom applauds the courage of these two trailblazers. They showed the world what it looks like to respect mental health. Their example helps normalize emotional struggle and just may have ushered in a turning point…or at least the start of an important conversation. As Biles provocatively pointed out, “Physical health IS mental health.” We couldn’t agree more.

Still, there are no quick fixes. The poor state of mental health in this country has been years in the making. Despite decades of scientific discovery and expansion of some services, almost every measure of mental health—soaring rates of suicide, depression, anxiety, deaths from addiction—have gone in the wrong direction. Clearly, money and research advances haven’t solved the problem. From a corporate perspective, many companies have been slow to hitch on to the mental health bandwagon. There’s lots of talking and talking, and more talking about ‘invisible disabilities’ but few offer actual services or accommodations.

Linda Raines, CEO of the Mental Health Association of Maryland summed it up this way. “Half of the 5.7 million individuals we studied who received a behavioral health diagnosis received less than $68 per year in mental health treatment”. That’s a scary statistic—one government, business, and community leaders are finally understanding.

Noting the severity of the mental health challenges our nation faces, legislators are rallying at the local and federal levels looking for meaningful spending increases in mental health care.

But if all this sounds like more platitudes, we hear you. We’re tired of them, too.

Now felt like the right time to deploy our skills (writing, reporting, promoting…that kind of thing) and resources (top experts in the field).

Now What? A Word from The Editors

So, a few months back Psycom and Psycom PRO (our clinician brand) convened a board of experts in psychiatry, psychology, and primary care (see below). They offered insight and a brutally honest look at longstanding problems—plus, ideas for moving forward.

The result is a three-part report. Part 1 (posted in May) tells the story of one family’s struggle to get their teenager the help she needed. Although the family had health insurance there were still roadblocks. Responding to a mental health crisis shouldn’t be this hard, but right now in America, it is.

In this article (part 2 of the series) we explore follow-up questions: What if mental health care was treated on par with physical health care? How would it be implemented and what does it mean for you right now? (Part 3—a look at the disruptors—progressive approaches already being utilized that could be a step toward solving this hot mess—will post later this month.)

Before we dig in, meet our advisors:

Our Expert Panel

Alison Huffstetler, MD

Alison Huffstetler, MD

W. Clay Jackson, MD

W. Clay Jackson, MD

Jean Kim, MD

Jean Kim, MD

Julie Kolzet, PhD

Julie Kolzet, PhD

David M. McCord, PhD

David M. McCord, PhD

Michael McGee, MD

Michael McGee, MD

Andrew Penn, NP

Andrew Penn, NP

Steven Starks, MD

Steven Starks, MD

  • Alison Huffstetler, MD, Assistant Professor of Family Medicine, Virginia Commonwealth University and Georgetown University School of Medicine, Washington, DC
  • Clay Jackson, MD, Clinical Assistant Professor of Family Medicine and Psychiatry, University of Tennessee College of Medicine, Memphis, TN; family practitioner; former president, Academy of Integrated Pain Management
  • Jean Kim, MD, Psychiatrist and Clinical Assistant Professor of Psychiatry at George Washington University, Washington, DC
  • Julie Kolzet, PhD, Licensed Clinical Psychologist and Consultant, New York, NY
  • David M. McCord, PhD, Professor of Clinical Psychology at Western Carolina University, Cullowhee, NC; president, Assessment Section of Division 12 (Clinical Psychology) of the American Psychological Association
  • Michael McGee, MD, Staff Psychiatrist, California Department of State Hospitals, Atascadero, CA; President, Well Mind, Inc; Author, The Joy of Recover: A Path to Freedom from Addiction
  • Andrew Penn, NP, MS, PMHNP-BC, Psychiatric Nurse Practitioner; Associate Clinical Professor at the University of California San Francisco’s School of Nursing; Attending NP at the San Francisco Veterans Administration; Psychedelic-Assisted Therapy Researcher, San Francisco, CA
  • Steven Starks, MD, Clinical Assistant Professor, University of Houston College of Medicine, Houston, TX

A Proactive Approach

On the heels of new COVID-19 outbreaks, the Center for Disease Control and Prevention (CDC), which monitors the mental health of households, recently laid out details (race, age, gender, etc.) of our country’s mental health problems. They’re reflected in new census data and helped crystalize the issues, for better or worse.

For better:

For worse:

  • Some young people, wrestling with suicidal thoughts, felt like the only place to go was their local emergency room—not the best spot for behavioral health treatment.
  • More people died of drug overdose than ever before in our nation’s history.
  • Nearly half of Americans show signs of anxiety or depression, both adults and children, according to the World Health Organization.

Sue Abderholden, Minnesota executive director of the National Alliance on Mental Illness (NAMI), summed the issue up perfectly: “The mental health care system in this country isn’t broken. It was never built.

Indeed!

Even if societal shame was somehow magically erased, our board sees three intractable problems:

  • Lack of access to care, particularly for Black and brown communities
  • Prohibitively high costs for treatment
  • A shortage of psychiatrists and other qualified clinicians

Other barriers to care include lack of insurance or being underinsured, lack of diversity among mental health providers and culturally competent providers, language barriers, and distrust in the healthcare system. That’s a lot to manage even if you aren’t struggling with your mental health during a pandemic.

The Mind-Body Connection

Most people know that mental and physical health are connected. But fewer understand the trend toward mind-body or integrated medicine (a model that embeds a behavioral health specialist into a primary care practice)—and how it could play a huge role in remaking our current healthcare system.

Imagine while waiting to see your doctor for your annual physical exam, you fill out a screening questionnaire. If signs of mental distress—depression, anxiety, insomnia, alcohol abuse, etc.—are indicated in the pre-screen, the doctor would hand you a referral to a therapist or other qualified behavioral health specialist for treatment before you leave the practice. The end goal would be to use integrated care as the scaffolding for a new system forged in evidence-based mind-body medicine.

Mind-body-based care has the potential to dramatically lower costs, increase efficiency, and offer better mental and physical health outcomes. Of patients over 65,  80% of them have at least one chronic illness. (The top three are cancer, heart disease, and diabetes.) Ignoring the mind while treating an unhealthy body is treating half the problem.

Treated together costs decrease and efficiency increases. “Putting mental health first means putting it truly on par with physical health,” explains Michael McGee, MD, author and staff psychiatrist, California Department of State Hospitals in Atascadero, California. “The brain and the body should be treated with equal importance and insurance should cover it the same way, too.”

Our experts agree that at the very least, having a social worker or any kind of counselor on hand would be an incredible asset. Making it happen is another story. Possible? Yes. Complicated? Very.

Wanted: A Better Annual Check-Up Model

So, what if the annual old-school physical was replaced with a yearly mental health checkup, instead? You’d go for your Mental instead of your Physical?

Not so fast, say our experts. It turns out there are compelling arguments for keeping annual physicals, especially since we know physical symptoms can be an expression of mental illness (See part 1 of this report). Calling for a universal mental health check, experts said, could raise the profile of mental health, but many Americans don’t carve out the time to see a doctor unless they feel sick. Problems (mental or physical) are tough to spot when nearly half of adults under 30 years old don’t even have a Primary Care Physician (PCP).

Early Intervention: The Missing Link

One way to prevent mental health struggles from spiraling out of control is to nip them in the bud. The truth is the field is flooded with quality screening tools but there aren’t enough doctors offering them—nor are there enough mental health practitioners to treat them post-diagnosis. So, the problem isn’t the screening tools, it’s the inability to act on the results.

“Our healthcare system disincentivizes primary care folks from doing these screens both in their own practices due to risk/time factors as well as lack of mental health referral sources,” adds Jean Kim, MD, clinical assistant professor of psychiatry at George Washington University, Washington, DC.

Testing Yes, Treatment No

Our experts tell us the best diagnostic tools are remarkably simple and include about a dozen short-ish (5 to 20 minute) screenings that can be done on paper or on a computer.

“The gold standard of screens used by most clinicians is the Patient Health Questionnaire-9, or PHQ-9. It’s a nine-question screener with decades of research supporting its reliability and validity in detecting patients with major depressive disorder,” explains Dr. McGee. (Keep in mind that depression is one of the top three leading causes of disability in the US.) “If skillfully used in an integrated care setting, it can significantly enhance care and treatment outcomes.”

If there’s no one on the spot to create a treatment plan and offer practical advice, no screening can be of help. There’s also the likelihood that a person struggling with a mental health issue who is not treated promptly will wall falls through the cracks.

But creating a solid referral system for treatment that is satisfactorily covered by insurance could be years in the making, our expert board agreed.

Right now, the referral system seems more like a road to nowhere for the average American. “Getting people to the right professional who can strategize and follow through on an evidence-based treatment plan is a huge missing link. There are not enough of us,” says Julie Kolzet, PhD, a licensed clinical psychologist in New York City.

Andrew Penn, NP, associate clinical professor, Department of Community Health Services, School of Nursing, University of California San Francisco agrees, adding: “When a primary care doctor finds someone with depression, they’re often faced with referring that patient to a system that may be woefully inadequate and often have long waiting lists and do not take insurance.

The C-Word: Cost

You can’t talk about mental health care without talking (okay, screaming) about the prohibitive costs (the C-word) for access.

Even before you begin treatment say for depression, you may go through an “intake” process involving multiple assessments that could run you around $750. Then there’s therapy. You may be looking at a $175 therapy appointment every week, paid out-of-pocket because the therapist is out-of-network if you can even manage the cost in this economy.

If you’re in a specialized program, such as dialectical behavioral therapy (DBT) program (perhaps the most effective form of evidence-based treatment according to some experts) you may have an individual session and a group skills class that meets weekly.

If you stick with the program, it’s likely you’ll meet your deductible and finally, your insurance will start reimbursing you for half of your fees. And that’s not even getting into medication costs. And while your mind is ruminating on how to pay for it all, your body is likely slouched on the couch after a long day at work. So much for mind-body integration.

Does Mental Health Care Actually Cost More than Physical Health Care?

To be fair to hard-working specialists, we should note that psychologists and psychiatrists don’t necessarily charge more for their services than other doctors do; they seem more expensive because they rarely take insurance. And the reason is that insurance companies pay them so little.

By some estimates, care providers will receive anywhere from $60-90 per 45-minute session from insurance companies, compared to what they can charge patients directly. On top of the lower fees, taking insurance involves a lot of paperwork and more regulation. It can mean spending hours on the phone with insurance companies, demanding and justifying certain medications for your patients.

It’s egregious enough that Dr. McGee describes working with insurance companies as “traumatic.” In fact, doctors, nurses, and caregivers dealing with the disjointed health system, particularly in the pandemic, could say the same.

Is Hybrid Care Next?

Let’s pull out the crystal ball for a minute. Since the pandemic, all kinds of therapy have moved online using video and many say this will be the new normal. That may have seemed ridiculous a decade ago.

Dr. McGee, an early adopter of telehealth says. “Even five years ago, when I first started using teletherapy, someone reported me to the medical board. They thought it was reckless or inappropriate. It turned out to be ahead of the curve,” Dr. McGee says. For him, it was also a necessity. When he moved his office to a different location, which for some was an hour away, he faced either losing long-time patients or using teletherapy.

The pandemic taught this country and our legislators a lot about prioritizing health care of all kinds and for all people. Congress is of late, paying close attention to Americans’ long-standing concerns about the cost of care and accessing it.

Maybe that’s because politicians pay attention to numbers.

Approximately $225 billion was spent on mental health in 2019 according to market analysis by Open Minds, a national firm that analyzes data to help medical experts within a community system to provide great service—and make a decent income. Spending has grown by 52% over the past decade, from 2009.

We’ve been loaded up with worries.

Penn has a workaround that isn’t easy to hear. “One of the uncomfortable elephants in the room about healthcare in general, and mental health for sure, is that if we really want more evenly distributed care, we’re either going to have to significantly increase our taxes, or more healthcare providers are going to have to make significantly less money.”

Another possible solution: Primary care doctors and medical students would receive yearly mental health training. Changing the compensation model is also being discussed. Paying physicians a salary as opposed to a fee for each service could change things up (possibly in a good way), too.

In the meantime, plenty of great minds, in business and health, are thinking about your future. Below, some of the trends we are honestly excited about—and so is our board of experts. (For more innovations, watch out for Part 3 of this report in the coming weeks.)

Trendspotting: Where Will Mental Health Be 10 Years from Now?

  • Virtual care is here to stay. As an article in JAMA Psychiatry reported recently, psychiatry needs to capture data to understand lessons learned from this telehealth revolution. Meanwhile, real estate companies have been experimenting, too, by partnering with healthcare providers to offer virtual healthcare to residents.
  • Peers with lived experience will fill gaps in care. Alcoholics Anonymous’s 12-step program is a well-known example of how people with lived experience can effectively mentor others struggling with substance abuse. What if some mental health interventions came from people like you or others in your laypeople? Teen peer support programs like Mental Health America’s Center for Teen Peer Support and the Michigan Peer-to-Peer Depression Awareness Program. NAMI local chapters/support groups have initiatives like End the Silence.  Schools could be utilized in this way as well.
  • Community Crisis Response Teams, Churches, and Alternate Treatment Facilities. All around the country, local governments are creating care options that bypass emergency room visits and enlisting mental health responders to intervene in a crisis, rather than deploy law enforcement. Places of worship and community centers are hosting mental health awareness days to connect people who are struggling with support. Hackensack Meridian Health in New Jersey is the nation’s first urgent care clinic devoted to behavioral health. In Eugene, Oregon, a mobile crisis intervention team called CAHOOTS cares for locals and is receiving a ton of attention. Other areas including Georgia, Arizona, and a parish in Louisiana have built replicable networks and links to support communities battling the effects of the substance abuse crisis, rising rates of suicide, and the anxiety, stress, and disability services before, during, and now, very much after the pandemic’s second Delta wave.
  • Other local resources and technology will be utilized. Crisis Now has been creating roadmaps for communities to address mental health and substance abuse crises, including crisis call/text centers, 24/7 mobile units, crisis stabilization programs, and a collection of best practices. NAMI’s Terri Brister, PhD, LPC, National Director of Research and Quality Assurance says, “It really does take a comprehensive effort, and it takes champions on the ground to make it happen.”
  • A new hotline for mental health emergencies—988. In October 2020, a new federal law was signed creating a 988 hotline for suicide prevention and other emotional crises. This new three-digit helpline will be operational in July 2022. Funding the new line has been a battle—states lack the money to boost capacity at local crisis centers and are often left on their own to figure out how to deploy the service, says Brister adding that fees can be collected from mobile service providers.

Up Next

In part 3 of the series, we’ll look at viable solutions—small-scale models that could be applied on a larger scale, progressive programs, and innovative workplaces that are leading the charge. Bookmark this page for updates. To learn more about what the docs think, read Should There Be An Annual Mental Health Assessment?  on the PRO side.

Last Updated: Sep 8, 2021