In the past several weeks, two impressive reports have been released that can help guide policy and practice around mental health systems and youth suicide prevention activities for the coming years. The first, is the result of a partnership among leading mental health organization in the USA and titled, A Unified Vision for Transforming Mental Health and Substance Use Care. As its name implies, it sets out a broad approach to transforming the tattered patchwork that is our current mental health system. It includes content around implementing prevention efforts, handling emergency response and crisis (with suicide and overdose rates at alarming highs, these are absolutely urgent concerns), addressing equity and supporting traditionally marginalized groups, integrating mental health and physical health efforts, parity in insurance coverage, working toward excellent standards of care, and supporting the development of an adequately sized and well-trained mental health work force. It is a commendable effort and an excellent report.
The second report just released by SAMHSA is titled, Treatment for Suicidal Ideation, Self-Harm, and Suicide Attempts Among Youth. This clear and thorough review of youth suicide demographics, risk and protective factors focuses on several interventions that have been shown to lower risk for suicidal behaviors in youth and presents several other promising approaches. The featured treatment approaches aim to build psychological resiliency and adaptability in youth-bolstering basic skills that may be relatively deficient in youth who are more likely to manifest suicidal behaviors (Dialectical Behavior Therapy) and improve interpersonal and family connections (Attachment Based Family Therapy). The guide further discusses implementation strategies.
Both of these brief reports are highly recommended along with the excellent report from the CDC on suicide prevention policies, programs and strategies from several years ago for anyone seeking a good, comprehensive overview of what we need to be considering in improving mental health and suicide prevention efforts in the USA.
What’s the problem?
As I reviewed these recent reports, I found myself with a nagging sense of uneasiness. I realized that there is a tremendous body of information out there about what contributes to under-managed mental health and substance use problems and about what increases and decreases risk for suicide. The problem is not knowing what we need to do. The problems appear to be in doing the things.
While this is of course wildly oversimplified, I’d like to mention and briefly discuss two impediments to progress in policy and practice. The first problem is that the medical system tends to be inherently conservative-i.e., we tend to prefer to do what we have previously done and what is familiar. While there is something to be said for avoiding recklessly adopting new technologies, treatments or policy approaches, we often are very slow and hesitant to adapt and adjust to new knowledge and to evolving circumstances-but currently this is the smaller problem.
As I read the reports, I was increasingly aware that the kinds of problems needing to be addressed and the activities and approaches that need to be adopted largely are in the realms of social, community or public health. Unfortunately, our primarily fee for service/free market driven health and mental health system is completely antithetical to public health, integrated care and prevention focused approaches. Some of the problems we need to address need to be handled as part of a public social safety net. Insurers have no incentive to support education and training of future mental health clinicians. Politicians have little incentive to find ways to attract clinicians to their states. And people with mental illness and substance use problems are not a large enough or vocal enough coalition to represent a voting block with impact.
So, we need to acknowledge as a society that mental illness, substance misuse and suicide have a profound impact on our social fabric and are impacted by the nature of our society as well. We also need to recognize that while many may not speak openly about it, problems like depression are incredibly widespread and economically impactful and that as a whole, proper services for mental health and substance use is economically sensible and prudent for society writ large. The efforts by groups like the Well Being Trust and the Kennedy Forum are a good starting point but it feels like we will need a real revolution in how we think about and fund health care and social services in this country to make significant headway. This will ultimately need to happen at multiple levels of our political landscape: national, state, and local. We cannot wait for this to happen before we try to make things better, but we will not make things better enough until we have meaningful, universal political commitment to change and progress.