It seems that the violence of mass killings has become a regularly occurring event that creates another media storm with various people looking for causes and solutions. In most of these instances a history of mental illness has been present. I did a diary discussing the problems faced by mental health professionals and law enforcement in detecting the potential for such violence and intervening to prevent it. People commenting in the diary very appropriately pointed out that while these tragic incidents temporarily focused public attention on mental health problems, they are not representative of the many problems that our supposed mental health "system" is unable to deal with.
Prompted by the murders in Santa Barbara, The Guardian is running a series of the US mental health services.
America's mental health care crisis: families left to fill the void of a broken system
I did a bit of Googling and found this piece from Time that was prompted by the Newtown murders.
America’s Failing Mental Health System: Families Struggle to Find Quality Care
Both articles reach one similar conclusion. There is no system. Both Adam Lanza and Elliot Rodger came from families with comfortable means who had sought treatment for their clearly troubled sons. People seeking help with mental illness who lack money or insurance are obviously at a greater disadvantage, but there are all sorts of problems about what is there and what is actually helpful.
The ACA which is just now going into effect makes a definite step in the right direction by requiring parity of coverage for mental health services along with other types of health services. However, having coverage is cold comfort if services are not available. Some of that problem would have to do with the providers included in an ACA network, but in many communities services are lacking regardless of funding issues.
From The Guardian article:
Paul Appelbaum, a Columbia University psychiatrist and an expert on legal and ethical issues in medicine and psychiatry, uses a simple phrase to sum up the biggest problem.
“Right to care does not mean access to treatment,” he says. "Tens of millions of people who did not have insurance coverage may now be prompted to seek mental health treatment. And the capacity just isn't there to treat them.”
“There really is no mental health system in the US."
Appelbaum’s blunt assessment was echoed by dozens of doctors, patients and caregivers with whom the Guardian spoke for an investigation into the US mental health care system. Inadequate access to treatment services and providers all over the country, has left families of the mentally ill picking up the burden, and the cost, of providing care.
There are of course physical illnesses for which the current state of medicine has little help to offer, but for general health care it is able to make a major difference. This is obvious in comparing average life expectancy and access to modern health care. There is a 30 year spread between nations of the developed world and the world's least developed countries.
There are some very basic questions about just what does constitute useful/helpful/appropriate mental health care. The problems start with a lot of confusion over just what is mental illness. The prevailing standard is the APA Diagnostic and Statistical Manual. The fifth edition of it just came out last year. The definition and understanding of mental illness is highly culturally based. There are behaviors that were included in past versions of the DSM that are no longer present. These include such things as variations in sexual orientation and gender identity. There is often a blurring of the social systems that deal with social control such as mental health, law enforcement and religious institutions.
The historical approach to classifying and diagnosing mental illness or psychological disorder has been an attempt to group people together in terms of similar behaviors. Since behavior can be the result of different causes this has led to a lot of confusion and a ever shifting landscape of classification. Psychoanalysis pioneered by Freud and behaviorism pioneered by Watson were the prevailing movements for much of the 20th C. Both of them are no longer considered to be particularly productive approaches.
There are still people who think that humans have both a brain and a mind. However, science has yet to locate a mind that exist apart from the brain. Human mental activity takes place in the brain. Biology has made better progress in understanding other parts of the body. Neurobiology is finally reaching a point of accelerating progress in understanding brain function. Neurology and psychology appear to be in a process of merging as scientific disciplines.
These trends raise questions about what is useful treatment for mental problems. The psychoanalytic approach was talking interaction between a patient and therapist. That basic approach was followed in most of the various schools of psychotherapy. Beginning in the mid 20th C psychoactive drugs began to become available. There has been a vast expansion of such medications. They range from mild tranquilizers and anti-depressants to very strong anti-psychotic medications. For most people with significant psychiatric symptoms medication is likely to be at least part of their treatment plan.
There is an ongoing controversy over medication vs talk therapy. The information one finds depends a lot on what sort of disorders are being addressed. For the major psychotic disorderssuch as schizophrenia or bipolar disorders there really is no substitute for medications. There is now pretty clear evidence that those are fundamentally neurological disorders that are related to such things as brain structures and neurotransmitters. A better understanding will doubtless lead to more effective medications. Very often a necessary part of the treatment plan is some form of supportive or supervised care that makes sure that medications are taken as prescribed.
There are other much more common problems that are not as pervasive and disabling as the various forms of psychosis. Depression and anxiety are probably the most prevalent. The first issue is sorting out human unhappiness from mental illness. There is not a neat, tidy and conclusive way to do that. Everybody experiences both anxiety and depression at times in their lives. They are realistic and appropriate emotions in certain situations. It is when they become frequent, persistent and not closely connected to external life events that they approach the level of illness needing some form of treatment. There is a running controversy over the preference for medication vs talking therapy for chronic anxiety and chronic depression. Here is a report of a meta analysis of a group of studies on the problem.
Meta analysis of antidepressants vs talking therapies: another example of ‘All Must Have Prizes’? - See more at: http://www.thementalelf.net/mental-health-conditions/anxiety-disorders/meta-analysis-of-antidepressants-vs-talking-therapies-another-example-of
When they combined all of the data from the different studies, they found no statistically significant difference between psychological therapy and antidepressants. -
That is of course a general statistical finding that doesn't hold true for all individuals. Medications of course come in standard doses, psychotherapy does not.
The point here is not an in depth review of the current state of medical knowledge and practice, but to raise the question of what would a passably adequate mental health system look like. Does it focus on traditional interactive therapy or biomedical approaches? There is always a tendency when people see problems that are causing suffering and hardship to want to do something about it. There is still the question as to whether what is being done is really doing anything to solve problems. I'm going to stop here with this diary as a general overview of the situation. I plan to do some more diaries looking at more specific proposals for overhauling the system.
UPDATE:
I just added a new diary to this series.
The Mentally Ill In Jail