What Could Finally End the U.S. Mental Health Crisis

Key points

• The U.S. mental health care crisis continues to worsen.

• Medicine is not likely to voluntarily correct its focus on physical disease, nor its profit motives.

• Only an angry public can overcome the chronic inertia.

Americans have lived with a mental health crisis for as long as most of us can remember. And for just as long, medicine has been warned of two urgent fixes.

First, the system must produce more psychiatrists. Second, medical education must prepare primary care physicians who provide 75 percent of all mental health care to recognize and manage psychiatric illness. Neither has happened. And almost no one pressed for what, in my opinion, is a key third fix: weaving psychology and other mental health professionals into the very fabric of medicine.

The consequences of these failures are staggering. Primary care and other medical doctors, untrained in mental health, wrote most of the opioid prescriptions that fueled more than 200,000 overdose deaths in the opioid epidemic. Of 48,000 suicides per year, 40-45 percent of the patients see their medical doctor in the 2-4 weeks beforehand—potentially preventable suicides if doctors were universally and appropriately trained.

Unfortunately, many medical doctors also overlook or administer the wrong treatments for depression, anxiety, and substance abuse in hundreds of millions of patients leading to avoidable divorces, job failures, school dropouts, addictions, homelessness, and incarceration. But don’t blame them, we're often told; they’re not trained.

Why Hasn’t Medicine Changed?

Two forces stand in the way of real, systemic change in the field.

The first barrier is intellectual. Modern medicine grew out of the 16th- and 17th-century Scientific Revolution, which drew a sharp line between body and mind, today called the “mind-body split.” This model focused exclusively on physical disease and left the care of mental and social problems to the church or community.

It worked with unrivaled benefits. Life expectancy doubled in the last century. But as people lived longer, mental disorders became the most common health problems, surpassing heart disease and cancer combined.

Yet medical education still reflects the split. Students and residents spend more than seven years immersed in learning about physical illness. Less than 2 percent of training time addresses mental health and other psychosocial features such as empathy, lifestyle, and social medicine. The result is generation after generation of physicians trained primarily in physical disease.

Compounding scarce exposure to mind issues, physicians and other clinicians are not trained to think “out of the box.” Medical education typically focuses on rote learning of facts (usually about physical disease), thus interfering with recognition of nonphysical disease problems to say nothing of the knowledge to diagnose and treat them.

And it is not just practitioners who exhibit this. Physician leaders in medical education, research, and clinical care receive the same training. Many leaders have not grasped the need to better train and provide care for medicine’s most common health problem. We don’t teach any more mental health care than we did over 100 years ago. In clinical care, we have a worsening crisis.

The second barrier is economic. By the mid-20th century, medicine’s successes gave rise to a powerful medical industrial complex (MIC), with hospitals, insurance companies, pharmaceutical firms, and medical equipment manufacturers among the key players. At first, these institutions advanced medicine’s altruistic goal: better care for all.

But profit soon eclipsed purpose. Because regulations were weak and the financial incentives enormous, the MIC flourished by doubling down on medicine’s physical-disease orientation. Today, it prevails over doctors in control of the $5 trillion spent annually on health care, nearly one-half in hospitals alone. And with profits tied to maintaining the status quo, there is little appetite for change.

I argue that these twin forces intellectual inertia and economic self-interest explain why medicine has not acted despite decades of warnings. Medicine is too entrenched in its outdated model to lead reform. The MIC, meanwhile, is thriving financially and has no incentive to jeopardize that success. Both institutions have been allowed to operate with minimal oversight.

The political philosopher Hannah Arendt cautioned that sciences like medicine must be subject to public control, or they risk veering dangerously off course. Mental health care is a textbook example of what happens without such oversight.

History also shows that resistant institutions rarely reform voluntarily. Civil rights, women’s rights, the end of the Vietnam War none came from the goodwill of entrenched powers. They came because ordinary citizens became outraged enough to demand change. Consumer activism has similarly toppled industries that put profit ahead of safety, from Ralph Nader's Unsafe at Any Speed to Rachel Carson’s Silent Spring.

Health care, by contrast, has escaped such reckoning. Americans, likely grateful for the real advances in physical disease medicine, have largely trusted that the system also serves their best interests in mental health.

I fear their trust is misplaced. Behind the curtain lies widespread neglect, staggering human loss, and trillions of wasted dollars each year.

The truth is stark. America’s health crisis will not, in my opinion, be cured from within medicine. It will only change when the public demands it when citizens insist on accountability, when they refuse to accept preventable deaths and broken lives as the status quo.

The stakes are painfully clear. Until outrage becomes action, America’s mental health crisis will grind on. But if history teaches us anything, an enraged public can do what medicine will not: force the change our mental health system so desperately needs.

Note: This article originally appeared on Psychology Today.