America’s Turn to Learn About Mental Health Care

The US may be one of the planet’s most well-resourced countries, but it’s clearly doing a much worse job of providing health care—particularly mental health care—than many countries.

“If the last 15 months has taught us anything on public health in the United States it is humility,” said Thomas J. Bollyky, a senior fellow and director of the Council on Foreign Relations Global Health Program, framing a discussion Wednesday co-hosted by the Johns Hopkins Bloomberg School of Public Health exploring lessons from other countries for the US health system.

Setting up a session focused on mental health and substance use challenges, moderator Susan Dentzer, a senior policy fellow at Duke University’s Robert J. Margolis Center for Health Policy, noted that the WHO ranks the US as the third most depressed country in the world, just after China and India.

And yet, the US spends more than any other country on the planet on mental health, has more mental health professionals, and spends more mental health dollars, said panelist Vikram Patel, principal research fellow with the Wellcome Trust and a Harvard professor of global health. “In every single metric on the supply side of mental health care, the US outranks every other country in the world by a long mile,” he added, noting that the state of California alone has more psychiatrists than the entire African continent.

Where is all the money going? Largely, Patel says, on mental health professionals—with skilled providers accounting for ~80% of mental health care spending in the US.

The investments haven’t been enough. Even pre-COVID-19, every single mental health indicator has worsened over the last 4 decades, according to Patel—from the burden of disease as measured by DALYs, to suicide mortality rates. “The US’s mental health indicators are the worst of any OECD country in the world,” he said.

It shows in America’s disproportionate diseases and deaths from suicide, accidental overdoses and alcoholic liver disease: a crisis panelist that Angus Deaton dubbed “deaths of despair” in a book by the same name he wrote with Anne Case.

Other countries aren’t experiencing anything like America’s struggle with opioids, for example, said Deaton, a senior scholar and professor emeritus at Princeton University.

These deaths and diseases of despair, according to Deaton, are essentially afflicting less educated Americans. “The educated elite and the owners of Apple have been doing pretty well over the last 50 years, whereas people without a 4-year degree have been falling off the end of the world,” he said.

Deaton traces the causes to crumbling social structures—marriages falling apart, social lives disintegrating, the loss of churches and other institutions. But he also blames American pharmaceutical companies that are pumping out opioids: “In Britain, for example, you’ll get opioids, but they don’t send you home with hundreds of pills … Other countries just don’t permit that, and it’s a terrible failure, and it’s falling on the mental and physical health of less educated Americans.”

Patel also blames the “narrow binary biomedical framing of mental health that drives every aspect of the industry in this country”—starting with the need to have a diagnostic code, which then triggers a whole range of interventions, primarily for reimbursement purposes. “Mental health has to be viewed through a broader prism than medical care,” he said.

Joshua Sharfstein, vice dean for Public Health Practice and Community Engagement at the Bloomberg School, also questioned US spending priorities. The US health care system is based on a business model that is pricing itself beyond the reach of much of the population, he noted, pointing to psychiatrists and other well-paid health professionals who will no longer accept insurance—"essentially making mental health care at that level the purview of the privileged.” 

Community-level resources that could help address much of the need, meanwhile, are not funded through the health care system. Sharfstein hopes that the recent American Rescue Plan, with funding for hopefully 100,000 community health workers, presents an opportunity for the US to advance more community-led care.

The Indian NGO Sangath, which Patel co-founded, offers a potential model for the US. Working across Africa, Latin America, and Asia, Sangath has applied the community health care model to mental health, with a focus on providing care that taps existing resources within communities. Patel is now rolling out a new program, The Empire Initiative, to bring mental health interventions delivered by community health workers to the US; it will be rolled out in Texas this fall.

Sema K. Sgaier, co-founder and CEO of Surgo Venture, shared another community health care model, which is addressed heroin use in northeast India and achieved zero overdose deaths during the course of the program.

Sgaier, who is also an adjunct assistant professor at the Harvard T.H. Chan School of Public Health, credits the empowerment of the communities surrounding people struggling with heroin use—their peers, their families, even the drug dealers—to have a simple antidote like naloxone available anytime, anywhere.

The program offers big global health lessons for the US, she says, in leveraging social networks and connections our peers to “de-medicalize the solutions.” She noted that in almost all low- and middle-income country programs, community health workers rather than professional doctors or nurses form “the backbone of the response.”

Deaton emphasized the need to address core inequities, including soaring costs that put health care out of reach for many, as well. “We’re creating a lot of this crisis. It costs pretty much the same to look after everybody, but it’s crippling the people who have the least—this is what is causing despair.”

“The problem is not how to cure despair but how to stop creating it,” Deaton concluded.

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