Author: hanstewart

Repealing the ACA will be catastrophic for America’s mental health

by hanstewart, posted in Policy and Advocacy

On December 18, 2019, a big piece of healthcare news went relatively unnoticed amidst the impeachment vote in the United States House of Representatives. A federal court based in New Orleans ruled that the “individual mandate” within the Patient Protection and Affordable Care Act (ACA), the provision that imposes a tax penalty on those in the US who do not have health insurance, was not constitutional. The court failed to make decisions on the rest of the law, asking a lower court to decide if the ACA could hold up with the individual mandate removed. Democrats in favor of the healthcare bill have vowed to fight for its longevity, and it’s expected that it will eventually be heard before the US Supreme Court. 

Still, the future of the ACA is once again in question, and the countless Americans who have accessed healthcare in the last decade with the help of Medicaid expansion and marketplace subsidies now face uncertainty. So far, the bill is estimated to have saved the country about $2 trillion in health costs. But with the repeal of the individual mandate, 13 million Americans are expected to choose to go without coverage by 2027, leading to an expected 10% increase in annual premiums on average for plans in the individual marketplace. For many, this translates to even higher costs in a country that is already spending disproportionately more on healthcare. Those of us that live with a mental health concern have particular cause for concern. 

How the ACA Changed Mental Health Care in the US

  • The ACA required that a number of preventive care services, including certain screenings, be available to patients at no cost. One of these screenings was the inclusion of a yearly screener for depression, alcohol misuse, and cognitive impairment. 
  • Insurance companies could no longer deny plans to individuals based on their pre-existing conditions. This was a big win for the mental health advocacy community, as serious mental health concerns (major depression, anxiety, etc.) were the second most common reason cited for health coverage denials. Even mental health counseling for situational or acute concerns (grief, trauma, etc.) could count as a “pre-existing condition” prior to the ACA.
  • The legislation also expanded the existing mental health parity laws in the US (Mental Health Parity and Addiction Equity Act of 2008). The former parity laws required that mental health services had to be covered in a way that was equal to physical health services but only IF mental health services were offered by the plan. Many plans got around these laws by simply not offering coverage for mental health and substance use services. The ACA closed this loophole by listing mental health services as one of the ten “essential health benefits” for individual and employer-provided health plans (different parity laws apply to plans offered by Medicaid and Medicare). 
  • The Community Health Center Fund, established by the ACA, generated over $11 billion in grants for community health centers, the primary care clinics seeing a huge portion of the country’s under- and uninsured population, to expand services in their communities. Behavioral health services were one of my qualifying service targets eligible for funds. 

As a result of these provisions, million uninsured Americans were able to obtain coverage. The number of patients with mental health concerns that were uninsured or could not afford treatment dropped post-ACA implementation. The ACA has allowed providers and health networks to find innovative ways to integrate physical and behavioral health. As a result, patient satisfaction with providers and treatment has, not surprisingly, increased. Nearly one-third of Medicaid dollars are now spent on mental health or substance use disorders. Those living at 138% of the Federal Poverty Line, those who may have previously had to delay seeking care for mental health concerns, are now able to receive earlier intervention and more consistent care. 

Image Source: https://twitter.com/ObamaWhiteHouse/status/819607805552394241/photo/1

Having a mental illness isn’t cheap, and healthcare reforms have been instrumental in improving access to care for countless Americans. A 12-month prescription for antidepressants costs approximately $800. An in-patient hospital stay costs more than  ten times that. Individuals with depression have more than twice the number of outpatient visits per year than those without and more than three times as many prescriptions. Repealing the Affordable Care Act or dismantling its’ individual provisions could mean that the United States returns to a not-so-distant past where nearly 20% of individual plans offered no coverage for mental health services. With Medicaid expansion removed, 3 million low-income Americans with with serious mental health concerns could find themselves with nowhere to turn for care. Repealing the essential health benefits would allow insurers to go back to side-stepping parity laws. And should states be allowed to reduce Medicaid eligibility again, individuals living with a mental health concern will be disproportionately impacted. 

There’s still time for major portions, if not all, of the ACA to be saved. Due to the lengthy court proceedings, the case would not make it in front of the Supreme Court until after the 2020 elections, lending hope that a new wave of elected officials might hinder attempts to dismantle the legislation. But whatever the next year of divisive American politics brings, those living with mental health concerns should not be punished. At a time when illness attributed to mental health or substance use are on the rise in the United States, and at a time when more economic productivity is lost to mental health concerns than any other non-communicable disease, weakening the current mental health delivery system is more than irresponsible: it’s dangerous. 

World Suicide Prevention Day 2019

by hanstewart, posted in APHA IH Section

Author’s Note: This article discusses suicide and may be triggering for individuals with lived experience. While resources will be presented later on, this website has a list of country specific resources for those who need them. If you or someone you know is struggling with passive or active suicidal ideation, please reach out for help. 

The National Suicide Prevention Hotline in the USA is 1-800-273-8255.

Every 40 seconds someone, somewhere in the world, takes their own life. That amounts to over 800,000 deaths per year. On September 10th each year, World Suicide Prevention Day, the world comes together to reflect on the lives lost and bring suicide prevention to the forefront of the conversation. 

What Suicide Looks Like Around the World

Like most things in global health, there’s no single causal factor and no “one-size-fits-all” solution. Preventing suicide globally will require an understanding of the way individual, interpersonal, societal, and cultural factors interact to affect suicidality. High income countries, on average, have higher rates of suicide than low- and middle- income countries (LMICs), with the exception of LMICs in South-East Asia where the regional suicide rate is the highest in the world (17.7 deaths per 100,000 people). While rates may be higher elsewhere, suicide isn’t just a problem for high-income countries. The majority of suicides actually occur in LMIC settings, highlighting these countries as important stakeholders in the global conversation around suicide. 

Image Credit: World Health Organization (WHO)

Like the rates themselves, at-risk sociodemographic groups vary from region to region. Suicide is the second leading cause of death, globally, for young adults (18-29 years of age). Middle aged men in high-income countries generally have a higher risk, while adolescents and aging adults in LMICs are more likely to take their lives. 

Globally, males are 2-3 times more likely to complete suicide than women. This has long been blamed on differences in care seeking behaviors and socially acceptable coping mechanisms deemed acceptable for different genders. But it’s important to keep in mind that women are generally more likely to experience suicidal ideation and more likely to attempt suicide. Men, however, have historically used more lethal methods of suicide and more likely to take measures to prevent intervention. 

The means of suicide attempts vary drastically and adapt to environments. Pesticide poisoning accounts for about one-third of global suicides. Almost all of these deaths occur in rural subsistence farming communities. Self-inflicted firearm injuries account for a large proportion of suicides in the Americas. Urban contexts with much stricter firearm regulations, such as Hong Kong and Singapore, experience a higher number of deaths related to jumping from buildings and bridges. 

What We Can Do

Suicide may look differently depending on where we sit on a map, but the truth remains that the pain and suffering that causes and is caused by suicide cuts across every sociodemographic variable and exists in every corner of the world. Despite its inclusion in both the WHO’s Mental Health Action Plan and the United Nation’s Sustainable Development Goals (Target 3.4), suicide remains a low-priority agenda item for policy-makers worldwide. Only about 40 countries currently have national strategies or action plans in place to respond to suicide, and even fewer of these are in LMIC settings where the majority of suicides occur. 

While national strategies with government engagement will be crucial to eliminating suicide, suicide prevention requires multisectoral and multilevel approaches that treat suicide as the complex public health problem that is. It is the community and the individuals close to a victim of suicide that will suffer the most in the aftermath and have the most power in targeted prevention efforts delivered to the individual. 

Primary care professionals, especially those serving communities that are underserved by specialists, can and should be more familiar with using depression screeners like the Patient Health Questionnaire or Beck Depression Inventory to assess suicidality in the exam room. Educators can advocate for school-based intervention and encourage (not punish) help-seeking behaviors. And while we can’t all be psychiatrists, suicide crisis line volunteers, or counselors, we can all be kind people to those around us. Use today to raise awareness for the issue. Educate yourself (and others) about suicide prevention resources available in your community. As friends and family members, we can all do a better job of dismantling the stigma around mental health and identifying when those close to us are experiencing acute stress or grief that may serve to trigger or exacerbate existing suicidality. 

Where we live might affect what suicide looks like, who is at risk, and how often it happens. Our professional roles may dictate at what level we help break the cycle. But today is a reminder that we are all responsible, as stewards of humanity, for reducing the number of suicides in our world. In the time it took you to read this article, five people will have taken their own life. Every suicide death is one too many, so now is the perfect time to consider: what will YOU do to make sure it doesn’t happen again?

Looking for a starting point? I’ve compiled a wealth of resources that may be helpful, in addition to the links embedded in the text throughout the article. 

Helping Individuals At-Risk:

List of International Suicide Crisis Lines
Learn the Signs Factsheet (Take 5 to Save Lives)

Helping Someone in Crisis (Take 5 to Save Lives)

Find a Mental Health First Aid Course (USA)

Suicide Prevention: A Resource for General Physicians (Available in Multiple Languages)

Get Involved in World Suicide Prevention Day:

Download and post a WSPD banner in your native language

“Light a Candle” for victims and survivors of suicide

Post on social media using the hashtags: #wspd, #suicideprevention

Data:
Look up your country’s suicide rates. 

Suicide Factsheet (WHO)

Suicide Prevention: A Global Imperative (WHO)

World Suicide Prevention Day Fact Sheet (IASP)

National Prevention Strategies:
Does your country have a national action plan for suicide prevention? 

National suicide prevention strategies: progress, examples and indicators (WHO)

Evidence based strategies for safer access to pesticides (WHO)

“Tejas means friend” and other lies we tell ourselves.

by hanstewart, posted in APHA IH Section, mental health

If you hear me speak more than a few sentences, you’ll hear the unmistakable accent. And as soon as I can find a natural way to fit it into the conversation, I’ll tell you flat out: I’m from Texas.

As a Texan, I was required to take one year of Texas history in the seventh grade, a statewide tradition since 1946. In Texas history, you’ll undoubtedly learn a few facts that every one of us 29-million Texans has engraved in our hearts.

1.     You don’t pick bluebonnets. They’re a sacred part of our state’s landscape.

2.     Texas was a sovereign nation once: the Republic of Texas. 

3.     California may have more people, but we’re bigger in size.

4.     “Tejas means friend”.

I’ve always found the root of the state’s name to be fascinating, because it has evolved with the land itself and represents the story of Texas. The word traces back to the Caddo word for “friend”, taysha. That word would be misspelled and mispronounced to be Tejas and eventually, Texas. For those of us whose hearts are deeply intertwined with the “Lone Star State”, the root of the word feels right. It embodies our roots, who we were, and the Southern hospitality on which we grew up. The origin of Texas’ name does NOT embody who we are today.

Texas has become the frontline of continued inhumane policy experimentation by the Trump administration. To deter undocumented entry to the United States and tamp down the number of asylum claims made at ports of entry, Trump and his nominated officials began separating children from their caregivers. 2,654 children were taken from their parents, guardians, and chaperones during the peak of this policy’s enforcement, and most of those children were detained in Texas.

The science around this matter is still developing, but one thing is certainly clear: this is bad news for the cognitive development and mental health outcomes of these children. In fact, the picture is becoming clearer that family separation policies produce rates of toxic stress and trauma that are as detrimental to the child psyche at the violence as the violence and insecurity they are fleeing. Researchers, and even the United Nations, cite evidence that separating children from their caregivers creates the type of emotional disturbance and dysregulation seen in survivors of torture.

We aren’t talking about acute emotional disturbance that will recede after reunification. The child’s brain has evolved to be incredibly respondent to its environment. Continued exposures to “fight, flight, or freeze” (especially in the absence of a trusted attachment figure) train the brain to bypass emotional inhibition and complex, rational thought to depend on more primitive survival mechanisms. This means permanent alteration of the brain, shrinking the prefrontal cortex and hippocampus (the parts of the brain that largely control decision making, working memory, and personality expression).  Their brains, and often their relationships with the parents, may never recover. 

“Here we have taken away what science has said is the most potent protector of children in the face of any adversity—the stability of the parent-child relationship”

– Jack Shonkoff

It’s not just theoretical damage happening in research studies void of a human face. Children inside these Texas detention centers have reported high rates of insomnia, decreased ability to concentrate, diminished literacy (even in their native languages), severe mood swings, and feeling constant states of panic and fear. And when they leave, their medical records (including any psychiatric care they’ve needed or received) are often incomplete. Many of these children will receive asylum in the United States, and we will have to face the mental health epidemic we created with a mental health system that is underfunded and culturally inadequate.

Sweeping separation of families and detainment of children was theoretically stopped, but the Human Rights Watch has found that nearly 200 children have been subject to the continuation of this policy since last year. There is no law on the books in the US that requires the separation of families at the border. This was a policy decision that can be rescinded as quickly as it was haphazardly implemented.

These children have often experienced trauma before they ever arrive at our border. They have left the familiarity and comfort of home. They are often physically vulnerable at the end of their migration journey. And they are welcomed with something that, for most of them, is even more traumatic: facing the hostility of a foreign country all alone.

This isn’t exclusively a Texan issue. ICE detention centers now exist in all 50 states. And it isn’t uniquely American, as 100 other countries have policies that allow children to be detained as part of standing immigration policy. But Texas has become ground zero for what the inhumane treatment of children looks like. Texas is no longer a land of Southern hospitality. It certainly isn’t embodying the state motto of “friendship”. And no one should be angrier about what’s happening in our home state than Texans ourselves. 

This article was written in memory of the children who needlessly died in Texas as a result of inhumane immigration policy. These faces represent the failure of all of us.

From top left to bottom right:

Mariee Juarez, aged 2, died after leaving a detention center in Dilley, TX

Carlos Hernandez Va’squez, age 16, died in US custody in Brownsville, TX

Jakelin Caal Maquin, age 7, died in US custody in El Paso, TX

Juan de Leo’n Gutie’rrez, age 16, died in US custody in Brownsville, TX

The Rise of Global Mental Health

by hanstewart, posted in APHA IH Section

The constitution of the World Health Organization (WHO) opens with a definition of health that underscores the importance of “mental…well-being.” Even still, mental health has struggled to achieve parity in global health. For much of its history, the field of mental health developed parallel to public health. Mental health, and the lack of it, was nebulous and eluded the gold standards of clinical measurement like bioassays and microscopy. As a result, psychology and psychiatry (components of the larger field of mental health) were shunned by other disciplines for a perceived lack of scientific basis and over-emphasis of sociological factors. Those with mental disorders, cognitive and developmental impairments were thusly cared for largely by religious institutions and, eventually, asylums rampant with inhumane treatment and neglect. 

Psychiatric patients in Bucharest sleep two to bed with feet bound;
Image Credit: Bernard Bisson

By the 1970’s the United States was moving toward deinstitutionalization and curiosity about how to effectively study and treat mental illness in the context of culture. Mental health research worldwide began engaging with patients as active participants with “lived experience.” The sharing of epidemiological data around mental health indicators became more fluid. The push for data-driven and evidence based decision making in global mental health produced big payoffs. The 1990’s saw both the WHO’s first World Mental Health Report and the first iteration of The Global Burden of Disease study. 

These publications highlighted the sheer burden of poor mental health. Of the ten leading causes of disability, five were mental illnesses, including the leading cause of disability in the world: unipolar major depression. Self-inflicted injury was among the top ten leading causes of premature death in developed countries. While the psychiatric epidemiological data continued to underscore the need for new interventions and novel funding mechanisms for global mental health, not much has changed. Last year, the Lancet Commision on global mental health and sustainable development released a 45-page report outlining a global health crisis that is severely underfunded relative to its burden on society. Even in developed countries, only 20% of individuals living with depression will receive adequate treatment. In developing countries, the number is a dismal 4%. But only 1% of global health development funds are allocated to mental health programs. That comes out to just $0.85 per year of healthy life lost to mental illness, compared to $144 for HIV/AIDS programming and $48 for malaria and tuberculosis. 

Even if the funding existed, global health education has yet to produce a reliable pipeline of mental health professionals with the skills necessary to address the crisis. Educators at schools of public health in the United States have identified that mental health is still not adequately integrated into public health curriculum. Johns Hopkins remains the only school of public health in the country with a dedicated mental health department. While the majority of other public health programs offer coursework that have mental health as a component of its curriculum, few programs offer tracks or courses that have mental health as its primary focus, leaving students interested in the field to piecemeal their education together through independent study and practicum/thesis work. 

(Read the study on mental health in schools of public health here)

The evidence is clear that global mental health should be recognized as a global health and global development priority. Despite the lack of full acceptance by the global health donor community and larger public health community, the field of global mental health has continued to grow. Organizations like the Movement for Global Mental Health serve as collaboration spaces for mental health researchers and advocates. The Lancet Commission on Global Mental Health continues to produce calls for action that elicit drastic, even if short-lived, spikes in mental health earmarked development assistance. And just this year, the field’s superstar, the Peter Piot or Paul Farmer of global mental health, Dr. Vikram Patel was awarded the prestigious John Dirks Canada Gairdner Global Health Award. 

“...All countries can be thought of as developing countries in the context of mental health“

Patel et al.

We are living in the age of a changing climate, protracted humanitarian crises, and a global population that is increasingly forcibly displaced from their homes. The burden of mental health problems will continue to pose a threat to health that will require the unique skill set of the field of global mental health. Leaders like Dr. Patel continue to advance the global mental health agenda in an effort to realize the complete definition of health that lies at the core of global health. For those of us for whom global mental health is our calling and passion, we must continue to push for our place at the table when the global health agenda is being set. 

Note: One of the photographs used in this blog appears elsewhere on the internet in an unredacted form. However, to protect the privacy and dignity of those who appear in the photograph, I’ve elected to hide their faces.

Global Mental Health: How Are We Doing? (WHO)

31,285 Human Rights Violations and Counting: Hypocrisy in America’s Liberal Bastion

by hanstewart, posted in Health Equity, Human Rights

On February 8, 2019, city councilors in Los Angeles met to approve a resolution declaring LA a “city of sanctuary.” It was hailed as a victory amid growing political tension and derision, a “symbolic welcome sign,” according to Councilman Gil Cedillo, that was supposed to “set the tone for the way we want our residents to be treated.” However, for the 31,285 Angelenos who are experiencing homelessness, Los Angeles is anything but a sanctuary.

You know you’ve stumbled into LA’s Skid Row the moment you arrive. Trash clings to the streets in heaps, stacked haphazardly against rows of tents so densely packed it’s difficult to find the sidewalk. It’s a stark contrast to the dazzling city skyline that frames the neighborhood. This isn’t a part of Los Angeles you can see from the sterile aerial shots that punctuate film and television, but it’s the reality of a county with over 10,000,000 residents and wage growth that can’t keep up with the rising cost of living.

Everyone in Los Angeles, from City Hall to residential streets, agrees that more must be done. Inevitably, however, most attempts to build temporary or permanent supportive housing in Los Angeles is met with public resistance. NIMBY, the acronym for “Not in My Back Yard,” refers to the opposition of development in one’s own neighborhood, even if they would otherwise support such a project somewhere else. NIMBYism is rampant in LA’s complex and powerful network of neighborhood associations and councils. When city officials met with residents of Sherman Oaks, a wealthy neighborhood on the west side of the city, to show proposals for homeless housing projects, residents turned out in force to oppose the plans. One resident went so far as to propose his own solution to the need for emergency shelters in Los Angeles:

“You want me to have compassion for people who don’t care about themselves?…I’m proposing maybe you build a reservation for these homeless somewhere out in the desert…when we interned the Japanese during the Second World War, we didn’t intern them in the city”.    

Much of this resentment and stigmatization comes from the deeply held American belief in the “prosperity gospel.” In other words, those who work hard and are free from vices are protected against material scarcity. Homelessness, then, is a personal failing and not a societal one. It’s time we reframe homelessness.

Public officials, public health professionals, and advocates across Los Angeles need to change the way we talk about homelessness to end the rampant NIMBYism in the city. It’s time to adopt a rights-based approach that focuses on the systemic failures that are determinants of homelessness. We need to abandon the “treatment first” approach to combating homelessness, where we attempt to fix the precipitating effects of inadequate housing (substance abuse, mental illness, poor health) before providing stable housing. Instead, programmatic and policy efforts should focus on “housing first” approaches that satisfy basic human needs before attempting to solve complex behavioral and lifestyle issues. The model is evidence-based and, unlike many interventions designed to combat homelessness, it’s effective. Investments in housing first approaches reduced homelessness by 91% in Utah, and research efforts in Seattle show that the savings generated by reducing the need for crisis intervention services more than makes up for the cost of housing first projects.  

Image Credit: The Spotlight

Los Angeles has the opportunity to lead by example in a world that is growing increasingly less empathetic to the plight of the vulnerable. However, we cannot be the city that birthed the “Me Too” movement and turn away from the fact that half of all women who are homeless report that they are domestic violence survivors. We cannot say that we are a city that believes that black lives matter when we know that while only 8% of LA County identifies as black or African American, they make up over one-third of the unsheltered population. It is unconscionable that our city turns out in force for Pride but fights efforts to house homeless youth, nearly half of whom cite whom they love as the reason they are homeless.

In December, Los Angeles hosted the UN’s celebration of the 70th anniversary of the Universal Declaration of Human Rights, a document that states in no uncertain terms that housing is a right of every person everywhere. If we are to be taken seriously in our defiance of increasingly discriminatory national rhetoric, we must do better here at home.

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.“
-UDHR, Article 25.1

Read more about evidence based messaging campaigns around homelessness.