For 30 years, we’ve been chasing a panacea for mental health, trying to find the right prescription or the right mix of medications as a substitute for comprehensive treatment. More and more, doctors prescribe medication alone, even though such medications should be supported by counseling.
The lack of qualified therapists is compounded by insurance companies making it even more difficult. It’s perceived that the pharmaceutical approach is less costly and more efficient. It’s easier to measure costs than quality.
We keep seeking the magic pill for behavioral and mental health — and there is no magic pill. The focus has swung too far towards stabilizing patients rather than getting them well. Getting well – having a good quality of life, being engaged in the community, maintaining strong relationships and, above all, finding meaning and purpose – requires time and effort.
Still, we keep looking for that labor-saving device. It’s not working. It’s getting worse. People are unhoused, living on the fringes, and dying of what have become known as the diseases of despair.
Here’s why we need to take a more comprehensive approach to behavioral health.
People cannot find or afford the help they need
Despite epidemic levels of psychological distress left in the wake of the pandemic, our mental health system has never been more difficult to access.
While it’s now law that health care insurance provides coverage for mental health care on par with more traditional medical health care, that’s not a reality for most people. They find their insurance plans only have a few behavioral health care providers in-network, so many people seeking care end up paying the full cost themselves or delay getting help.
Small wonder many people don’t seek counseling. Even for those willing to pay out of pocket, there are months-long waiting lists for an appointment. There are simply not enough psychiatrists, psychologists and other qualified mental healthcare workers to meet the demand.
There are huge gaps in how we educate and train health care practitioners on behavioral health
There is a disconnect among medical professionals in general, who often fail to consider behavioral health when working with patients.
Outside of those of us who work in the fields of mental health and addiction medicine, there are not enough providers who fully understand the implications of mental health, substance use disorder (SUD) or the combination of the two.
In my own work in SUD, I often see a lack of comfort among other specialties in caring for people with this disease. If the wrong drugs are used for anesthesia, for example, something as simple as a colonoscopy can risk reactivating someone in recovery. However, few anesthesiologists are trained to consider this as a factor in their preoperative evaluations.
This is a blind spot that can be easily rectified with a consult.
We emphasize stability over wellness, limiting the length of treatment
Compare this to the care we provide for an emergent disease like cancer. There’s an intensive period of evaluation and treatment for cancer, and then patients start on a treatment protocol that, in most cases, lasts several years, with surveillance for up to five years afterwards before a person is considered “cured.”
When we look at behavioral health care, instead of that comprehensive, intensive approach, we first jump to the least expensive and lowest level of care. Complete patient assessments and diagnostic testing are often limited and based solely on patient-reported symptoms without fully understanding the underlying pathology. This can lead to an incomplete or misdiagnosis, complicating further treatment. Only when someone “fails” that treatment do they graduate to more intensive care. Perhaps it’s the level of care that is failing the patients, not the patients who are failing.
There are no quick fixes.
We have siloed treatment of mental health and SUD
Substance use and mental health disorders are closely linked. Of the estimated 20 million adults in the U.S. with SUD, almost 40% also suffer from some form of co-occurring mental illness. The reverse relationship is also true, with nearly 20% of adults with a mental illness also having a co-occurring SUD.
Yet, studies show less than 10% of people with co-occurring mental and substance use disorders receive treatment for both. Just over a third receive mental health treatment only, while only 4% receive substance use treatment only. Over half received no treatment at all.
Our mental health and addiction treatment systems are not set up for any of this. There are different licensure requirements for mental health versus SUD treatment facilities, which limits the ability of treatment providers to deliver the comprehensive care needed.
Relying solely on medication is becoming a norm that dismisses what we know works
Medications for Opioid Use Disorder (MOUD) and Medications for Alcohol Use Disorder (MAUD) and medications for mental health conditions are gold standard treatment modalities. But these medications are meant to be part of a comprehensive treatment plan that includes intense counseling and recovery support.
Too often, patients get prescribed the medication without any follow-up counseling or ongoing engagement. This can be a recipe for failure because, while medications may manage symptoms of these diseases, they don’t make the diseases go away.
Our fascination with ‘magic pills’ extends to substances such as cannabis and psilocybin
Neither cannabis nor psilocybin have been adequately studied for any behavioral health use.
There’s not a single scientific study showing marijuana makes any psychiatric malady better. In fact, there is a lot of research showing that it makes them worse, but this is largely ignored, as medical care is now becoming more about marketing and influencers than facts.
The emergence of xylazine (or tranq) as a street drug underscores that there are no quick fixes
Xylazine is a non-opioid sedative approved for use in horses, cattle and other mammals. Its only reversal agent is only available for animals in a veterinary setting. It hasn’t been tested on humans and doesn’t respond to any of the existing medications. There is nothing like NARCAN, which reverses opioid overdose, available for xylazine overdoses, nor is medication alone effective in managing use disorders involving xylazine. We have to take a more comprehensive approach.
We are beyond the crisis point. We must start taking behavioral health seriously in this country instead of offering lip service. Even more, we must end the stigma associated both with having a mental illness and seeking treatment for it. People are in trouble — and many of them are dying.
As more of us understand these issues, I am encouraged by the initiative and creativity being explored.
Telehealth and AI-based tools may help improve access, but, as with medications, we should be wary of relying too heavily on labor-saving approaches. From my own experience in treating patients, both for mental health and SUD, building a trusting relationship with a patient is essential.
The most important piece of the puzzle is the therapeutic alliance built between the counselor and the patient, something that might easily be compromised by brief, “anonymous” encounters. There is no easy fix. As I tell my patients, we must do the hard work to get well.
About the author: Adam D. Scioli, D.O., DFAPA, FASAM, FAOAAM is the Medical Director and Head of Psychiatry at Caron Treatment Centers.
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