What does a public health approach to mental health and illness look like?

Childhood adversity is a prominent risk factor for mental illness. A recent report in Washington Post It found that in Chicago alone, more than 2,400 children saw their parents killed by gun violence between 2016 and 2020.

A 2020 report by the National Academies of Sciences, Engineering, and Medicine found that social isolation was associated with about 50% greater risk of dementia and that loneliness was associated with higher rates of depression, anxiety, and suicide.

In 2015, Princeton University economists Anne Case and Angus Deaton popularized the term “deaths of despair” — deaths from suicide, overdose, and alcohol-related illnesses that have contributed to Americans’ declining life expectancy. They linked the crisis to the excesses of capitalism, the growing power of corporations, and the weakening of labor unions.

Photo: Gary Belkin, MD, Ph.D.  , MPH

Psychiatry should vigorously advocate for payment systems that reward psychiatrists for spreading their expertise to allied health professionals and everyday people in the community, says Gary Belkin, MD, PhD, MPH.

In all of these ways and many others, economic and social conditions—sometimes creating public policies that may be years or decades old—can be a breeding ground for mental illness.

Today, some psychiatrists, including members of the APA Presidential Task Force on the Social Determinants of Mental Health, appointed by former APA President Vivian Binder, would like to see psychiatry deal vigorously with the broad social, economic, and structural conditions that create mental illness.

“It is clear that the experience of discrimination, the lack of housing, the absence of social networks to navigate adversity — all of these are surrounded by social and economic barriers that lead to mental illness risk and path to illness and recovery far away,” said Gary Belkin, MD, PhD, MPH, member of the task force. “More than genetically endowed biology. “Many of the drivers of mental illness are social – we haven’t been able to understand that professionally.”

Belkin and others who have spoken with Psychiatry News Seriously addressing the social determinants of mental health, he said, required a new paradigm for psychiatry practice—”public health psychiatry” that focused on mental health promotion, primary prevention of mental illness, policy change, and community engagement.

Photo: Ken Thompson, MD

“Tackling the social determinants of mental health is inherently political. We cannot avoid the issue of politics and power in this conversation,” says Ken Thompson, MD.

“There is clear evidence that the clinical model [of seeing one patient at a time] As a way to address the country’s mental health challenges, it cannot be successful at any cost we can imagine paying, said Ken Thompson, MD, chair of the Public Health Task Force’s Task Force on Public Health. “We have to learn how to prevent mental illness and promote mental health because we will not have enough psychiatrists to take care of all psychological challenges under any imaginable future. If we don’t build this kind of approach, we are basically ensuring that some people won’t get the resources they need, and they will get sick when they don’t have to.”

“The real failure is a failure in public policy”

So, what does public health psychiatry look like? For Thompson and colleagues, it is a work in progress, but there is precedent in the history of American psychiatry. Psychiatrist Leonard Dohl, who died in 2020, was the founder of the healthy cities movement in the 1970s. He championed the concept that creating livable cities—with fair housing, clean air, potable water, and strong communities—produces healthy people and healthy communities. Duhl’s Healthy Cities Movement has been adopted as a project by the World Health Organization and municipalities around the world.

In the UK this year, the Royal College of Psychiatrists launched the Public Mental Health Implementation Center to promote the mental health of the population locally, nationally and internationally.

“In our conception of ‘public health psychiatry,’ psychiatrists use the tools of epidemiology and policy change,” said Michael Compton, MD, MPH, also a staff member. “The goal is to promote mental health and prevent mental illness. As such, it relates to It’s about primary prevention. We know from other areas of medicine that prevention works. In psychiatry, we haven’t been entirely convinced that prevention works — I think it does.”

Compton said he preferred the phrase “political and social determinants of mental health”. In a session during the 2022 APA annual meeting in New Orleans, just a day after a mass shooting killed 19 students and teachers at a Texas elementary school, Compton said social determinants such as social isolation or unemployment may have contributed to the shootings. fire. .

But referring to easy access to guns, Compton added, “The real failure is the failure of public policy.”

Urgent need

Public health psychiatry also requires a new paradigm of practice, moving from offices that treat one patient at a time to working in the community and creating partnerships and alliances that can expand access to psychiatric care.

In an article published in October 2019 in Psychiatry services Belkin, titled Psychiatry’s Path to Thrive, described the need for “task-sharing” by psychiatrists and the training of allied health workers and – in some cases – lay people to expand the range of psychological expertise in society. He wrote that there is “a growing evidence base about task shifting, or task sharing, drawn largely from low-resource countries but increasingly emerging in research from the United States, [that] It shows how a large number of tasks of effective treatment, prevention, and early intervention can be easily and effectively managed by non-physicians, such as educators, clergy, parents, community health workers, and other health practitioners.”

As Deputy Health Commissioner for New York City from 2014 to 2019, Belkin initiated ThriveNYC, an effort by the New York City government to expand mental health care, prevention, and promotion efforts in places where traditional services have had difficulty reaching. It has also placed doctors near areas such as primary care offices, senior centers and homeless shelters. A component of ThriveNYC, the Early Childhood Mental Health Network, teaches trauma-informed coping and social-emotional skills to public daycare providers and parents who need it most. As of June 2019, this team has provided on-site training to 4,631 early care staff and parents, according to Psychiatry services Article.

“When we spoke to the psychiatrists and other mental health professionals who were involved in this, they had tears in their eyes,” Belkin said. Psychiatry News. They said, “This is the most satisfying thing I’ve ever done.” I’m reaching out to people who really need this and would never come to formal care.”

Belkin said psychiatry should strongly advocate for the creation of payment systems that invite and reward psychiatrists and mental health professionals for publishing their expertise in similar ways. “In a time of unimaginable mental health crisis, shame on us for not fighting tooth and nail for ways to explode our traditional notions of access and movement upstream,” he said. “All structural hurdles are fixable – the main hurdle is that our profession is in the dark ages and must be awakened or it will become irrelevant to what promotes mental health.”

So how does a psychiatrist trained in the clinical model of caring for individual patients begin to take a public health approach to treating mental illness? “I would like to ask that psychiatrist, where are the places you are interested in?” Belkin said. “Is it your local YMCA? your place of worship? Find the local place you’re interested in and start asking where the need is and how you can expand your expertise to meet the need.”

The APA Board of Trustees recently agreed to create a caucus on the social determinants of mental health, and Thompson said members interested in building public health psychiatry should consider joining by writing to [email protected]

Urgent need. “With what appears to be the end of the COVID-19 pandemic and a return to meeting in person, it is easy to think we are back to normal,” Thompson said. “The truth is that if you look around there is no objective evidence whatsoever that we are in normal times. There is no evidence that the political, social and international instability and climatic challenges are abating. They are, in fact, gathering strength. We cannot be complacent.”

He added: “Tackling the social determinants of mental health is inherently political. We cannot avoid the topic of politics and power in this conversation.” ■

Leave a Reply