Mental health disparities in the US are so staggering that I can’t refer to healthcare as a “system” because that suggests “unified” and let’s be honest, it is anything but. This blog is meant to be a resource and what often helps me when I am feeling so in the weeds about something is to zoom out and look at the greater picture. Context can bring clarity.
As you may have noticed from last week’s post, I’m lukewarm on Mental Health Awareness Month because more often than not, it’s performative, not substantive. This year, though, I’ve decided to dig into when it started, why, and where we’ve gone since then.
Stick with me because the most important part comes partway in.
Mental Health Awareness Month began in May 1949, launched by Mental Health America founded in 1909 by Clifford Beers, a former psychiatric patient turned reformer. The goals were to educate the public, promote prevention and early treatment, and reduce shame associated with mental illness.
World War II played a major role in shaping public attention toward mental health. Returning veterans suffered from what was then called “shell shock” or “battle fatigue,” now recognized as PTSD and other trauma-related disorders. The war also exposed the inadequacies in the US mental health system to handle widespread psychological trauma.
Through the ‘50s and ‘60s, the greater focus was on humanizing mental illness and promoting community-based care over institutionalization. This was in part due to the Community Mental Health Act of 1963 signed by President Kennedy.
The Act aimed to deinstitutionalize mental health care and shift treatment from asylums to community-based centers (female hysteria, anyone?). Kennedy was partly motivated by his sister having undergone a lobotomy and seeing firsthand that compassionate care was lacking. The Act was considered a landmark moment in US mental health policy.
Now, keep in mind that during the centuries leading up to the early 20th century, most mental health “care” consisted of locking people up and treating them like animals (not that animals should be treated this way either). Did people always have a mental illness? No, of course not, and confident women were often sent away for living in a man’s world, as ridiculous as that sounds.
The goal of the Act was to build 1,500+ community mental health centers across the country and provide comprehensive care, including inpatient care, outpatient care, emergency services, partial hospitalization, and consultation and education.
Great idea, crap execution.
Centers were underfunded or never built, with only about half the proposed number ever opening. Federal funds covered construction of centers but not long-term operations, which was left to underprepared states. Many psychiatric hospitals closed very quickly without a robust community system in place, which led to the revolving door we see today of homelessness and incarceration among people living with serious mental illness.
In October 2022, I sat down at a full café in Dumbo to study. It was my last semester of grad school and it was noon on a weekend. A woman sat down at the table next to me and started talking to me, mumbling something followed by “in God amen.” She was clearly homeless and potentially mentally unstable given her behavior, so I told her calmly that I was sorry but couldn’t chat because I had to keep studying (i.e avoid engagement and diffuse the situation).
A couple minutes later, she got up and hovered in the corner behind me. Then I felt her weight on my back and her punches, which turned out to be stab wounds from a 2” switchblade (according to the police). I now have 3 stab wounds on my back and was lucky she didn’t go for my throat.
When the federal DA asked me what result I wanted (after having testified in front of a grand jury), I told her I didn’t want this woman just thrown in a cell for a year and have that be it. My take was that she should get the mental inpatient care she needed to prevent her from hurting anyone else now and in the future. I never heard back from the DA.
When I asked her what would happen to the woman during trial and she said the police would monitor her and check in (putting others in danger). This woman was just one of many who got police after the fact instead of a medical professional to prevent the crime in the first place.
Yes, I’m simplifying things here to illustrate a point.
One of the biggest – if not THE biggest – mental health disparities in the US is insurance status and financial ability, with 1 in 8 Americans (30+ million) uninsured. Even those with insurance face high deductibles, meaning you pay hundreds or thousands before insurance kicks in, narrow provider networks, as many therapists don’t take insurance, and limited session caps (e.g., 6-12 per year).
Many therapists don’t accept Medicaid or Medicare due to low pay and administrative burdens, which mostly impacts low-income people, people with disabilities, the elderly, and BIPOC communities. On top of that, Medicaid is state-managed and often restricts types of care, especially for adults without dependents.
Then there’s the all-too-often situation where psychiatrists who accept Medicaid or Medicare are more or less legal drug dealers.
I was unemployed and on Medicaid in my early 20s and needed psychiatric help, i.e. a medication to manage my suicidal thoughts and insomnia. I went to a clinic in FiDi that I had learned accepted Medicaid. Once I sat down with the psychiatrist and began telling my story, what symptoms I had, and what I needed help with, she cut me off.
She wrote a prescription for a random (as she hadn’t heard what I might respond to) antidepressant and basically told me to leave. She was there to dish out prescriptions, it didn’t really matter what they were for.
Over 50% of therapists in the US are out-of-network, mostly because insurance reimbursement rates are low, paperwork and billing take a lot of work, and some plans deny or delay claims. This means that even if we have a decent-paying job with insurance, we often still have to pay $100-$250 PER SESSION out of pocket. Weekly sessions? I hope you don’t have kids, a wedding to plan, or a gym membership you actually use.
The amount of money I have spent on therapy, psychiatry, prescriptions, and bloodwork is disgusting.
I didn’t know this was a thing, but mental health care should, by law, be covered equally to physical care. However, insurers routinely violate this by requiring more documentation, pre-authorization, or denying coverage. States also lack resources or willpower to enforce the law.
And here we get to the federal-state disconnect that leaves millions of us without accessible, quality mental health care.
Mental health disparities in the US are in large part due to a federal-state-local disconnect. They have overlapping authority but diffused responsibility, creating serious gaps.
The result? Many of us fall through the cracks, not getting the care we need, which then affects our ability to work and sustain ourselves without government assistance.
I wish this weren’t true, but it’s largely cultural. The deep-rooted belief still persists that mental illness is a moral failing, personal weakness, or lack of willpower – especially when compared to physical illness.
What this means in terms of policy and access to care is:
So the next time you wonder why it’s so difficult to find a therapist, why which professional you see is determined by your insurer, or why there’s no country-wide standard for mental health care, this would be why. The US is wonderful in so many ways and community-based care is a great concept, but some things should be standard for all patients across the country without getting political about it.
A girl can dream!
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