Make America Happy Again?
On MAHA and mental health in America
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During his confirmation hearing to become the new Secretary of Health and Human Services, Robert F. Kennedy Jr. compared antidepressants to heroin, and all around the country, mental health professionals let out a collective groan of dismay.
Not because we think that antidepressants are a perfect solution. We are well aware the problems associated with psychiatric medications.
We groaned because we know that for many patients, the decision to begin an antidepressant medication is already fraught.
I thought of the postpartum mothers struggling with depression, anxiety, or OCD who have to make the tough decision to support their mental health with medication, even while pregnant or breastfeeding.
Or the patients with severe anxiety who overcome intense fear in order to allow themselves to take the medication that they are prescribed by their doctor.
Or the patients with severe mental illness who were discouraged by their family from utilizing medication; who had to overcome significant stigma in order to get the treatment that they desperately needed.
Antidepressants save lives and they are not addictive. They are also an imperfect solution. Anyone being prescribed these medications deserves an honest assessment of both the possibilities and the risks. Misinformation about psychiatric medications will make a patient’s decision even more confusing.
Antidepressants are imperfect, but they are affordable and accessible. So it is no wonder that a suffering population is turning to these medications for relief. America’s dependence on antidepressants is a result of a mental health crisis, in fact, its an attempt at a solution. Discouraging antidepressant use is not addressing the reason that people are turning to antidepressants in the first place. If we want fewer people on medications, it would mean directing significant resources towards bolstering our mental health system in other ways.
Instead of directing more resources at scrutinizing these drugs, we could be exploring environmental contributors to mental health. We could be addressing barriers to other non-pharmaceutical interventions. What would it really take to make our families, schools, workplaces and communities healthier and more supportive environments in order to support the mental wellness of all Americans?
A Mental Health Crisis?
90% of Americans believe that their country is suffering from a mental health crisis. Approximately one fifth of adults and adolescents meet criteria for a mental health diagnosis. In 2022, one person died by suicide every 11 minutes and suicide was a leading cause of death, even among children as young as 10.
Notably, these trends vary across groups; for example, the rate of suicide among Black Americans continues to increase disproportionately. Native Americans and youth who identify as LGBTQ have historically been at higher risk of suicidal thoughts and actions.
“Make America Healthy Again”
Since his confirmation, RFK has stated that the MAHA commission will assess the prevalence and risk of antidepressant use among children. What are RFK Jr’s other plans to address mental health, in addition to examining antidepressants? On a “Make America Healthy Again” Action website, it states only that “RFK Jr. is going to address the root causes of the mental health crisis and reduce dependence on medications.”
Sounds great, right?
In fact, this gets right to the heart of my frustration with the focus on antidepressants. Essentially, if we are going to discourage use of psychiatric medications, what else will be done to support Americans and address mental health challenges?
I could not find further information about what RFK and his team mean by the “root causes” of the mental health crisis. But as a psychologist, I have a few ideas.
Treatment is difficult to access
Americans may be more likely to rely on psychiatric medication because other mental health treatment is inaccessible to much of the population. For one, much of the US suffers from a lack of qualified mental health professionals. There are simply not enough therapists and psychiatrists to meet the need. A report from the Association of American Medical Colleges Research and Action Institute states, “Less than one-third of the U.S. population (28%) lives in an area where there are enough psychiatrists and other mental health professionals available to meet the needs of the population — in fact, most states have fewer than 40% of the mental health professionals needed.”
Even in areas that are well resourced, the mental and behavioral health system is difficult to manage. It is notoriously challenging for families to navigate the system to access higher levels of care, such as rehabilitation programs for substance use disorder or residential treatment for pervasive depression.
Treatment cost is a barrier
Cost of mental health services is a major barrier to accessing care. Approximately one third of mental health professionals accept no health insurance, and many others accept only a limited number of plans. Professionals with more specialized expertise are even less likely to be on insurance panels. Health insurance companies make it difficult for therapists, psychologists, and psychiatrists to remain in-network by failing to provide adequate reimbursement that increases with inflation. Insurance companies try to dictate treatment by demanding diagnosis, limiting the number of sessions that will be covered, or only covering certain therapeutic interventions. Medicaid is the largest payer for mental health care, but it reimburses at the lowest rates, making it harder for Medicaid patients to access care. Therefore, finding a therapist that accepts your insurance, and has availability, can feel impossible.
I experienced this nightmare firsthand when my husband needed detox and residential rehabilitation for alcohol use disorder. Once he had finally agreed to go to treatment, we had to find an appropriate placement that accepted our health insurance and had an open bed. As a licensed psychologist, I thought I would have a leg up on the process. But I quickly found myself overwhelmed and confused.
The hospital social worker found us a bed at a facility that she promised was a perfect fit. She stated that it was family-oriented and equipped to treat not only substance use, but also underlying mental health concerns that may be contributing to addiction. The facility was less than an hour from home and welcomed family participation in treatment. It sounded too good to be true.
Well, that’s because it was. Despite its proximity, the facility was out of state and our insurance did not cover out of state behavioral health care. So instead, my husband was picked up by a stranger in a van and taken to a facility four hours away from our home.
This was just the beginning of a long and expensive journey through various facilities across two states. When we were desperate for life saving intervention, we said yes to treatment that we could not afford. In the lowest moments of his addiction, my husband had to find new employment in order to access more comprehensive health insurance that would cover a better-quality facility. Thankfully, he had the privilege of an education and work experience that permitted him to do this. Many families are not so fortunate.
With new insurance, we found the treatment that ended up saving his life. But we only made it there through years of persistence, research, phone calls, and wasted time. My position as a professional in the field gave me a critical understanding of the different levels of care and types of interventions that my husband needed. But I still felt woefully ill-equipped to navigate the broken system on a shoe-string budget.
Treatment looks at individuals, not systems
Americans may be more apt to use antidepressants, rather than other mental health interventions, because of our hyper-individualistic orientation towards both mental illness and mental health treatment. Think about it; in a society that values personal autonomy, self-reliance, and individual achievement, mental illness is seen as a personal failing, rather than a result of environmental stressors, systemic oppression, and lack of societal support and safety nets.
The same attitude that tells you to “pull yourself up by the bootstraps” is the one that stigmatizes the need for mental health medication as “weak” or “taking the easy way out.” And that same hyper-individualistic orientation leaves individuals alone with their pain. It underestimates the ways that our unhealthy culture contributes to individual mental health problems like depression, anxiety, and posttraumatic stress disorder. As a result, the many ways that society contributes to poor mental health are not addressed. Individuals are blamed for their suffering and then chastised for turning to antidepressants for relief. We are damned if we do, damned if we don’t.
Social Determinants of Mental Health
These societal and environmental contributors to mental wellness are referred to as “social determinants of mental health.” Social determinants are defined as “the set of structural conditions to which people are exposed across the life course, from conception to death, which affect individual mental health outcomes, and contribute to mental health disparities within and between populations.” In contrast to individual risk factors, such as genetics, these environmental contributors include socioeconomic status, access to healthcare, education, food and housing security, exposure to childhood trauma, and racial and sexual discrimination.
To put it simply, the risk of developing mental illness is greater for those struggling with poverty, experiencing higher levels of family and neighborhood violence and dysfunction, and those experiencing chronic oppression and discrimination.
But it is not as simple as stating that ‘poverty causes depression’ or ‘racism causes anxiety’. We need more research to better understand how social determinants are related to mental health problems. This understanding will help inform possible interventions at the family, school, and community levels.
Examples of such interventions that already exist include programs designed to promote positive parenting behaviors in at-risk parents of young children and school-based programs for suicide prevention.
This is also not to say that mental illness is only caused by social conditions. Mental health disorders vary on how much they seem to be caused by nature (our genes) and nurture (our environments that activate these genes).
The uncomfortable truth is that there is a lot we still do not know about how mental health conditions develop. But everywhere I turn, I see the science about what we do know being misrepresented in ways that harm the individuals and families that are working hard to understand and manage their mental health. This is why we should avoid oversimplification and use critical thinking when discussing mental health solutions.
What MAHA Could Do
Government actions and policy decisions directly impact an individual’s exposure to societal risks or protective factors by impacting “the distribution of money, power and resources at global, national and local levels.”
To address social determinants of health, we must address the impacts of extreme economic disparity, and other inequities in our communities. Unfortunately, the new administration seems intent to do the opposite. President Trump’s list of “banned words” is already having a demonstrable impact on future research. It is being reported that researchers have been instructed to review and revise grant proposals with any flagged words; namely, words associated with diversity, equity, and inclusion. Researchers are faced with losing or being denied future federal funding if they choose to pursue research in these areas.
These directives have even begun to impact the training requirements for mental health providers, as professional licensing boards begin to re-evaluate the need for therapists to complete cultural competency and diversity training.
So what would it really take to “make America healthy again?” in regard to mental health? Here are some suggestions for the politicians with the power to influence policy and allocate funds and resources:
If they want fewer students on antidepressants, they might try addressing the major shortage of school psychologists and guidance counselors and the threat of gun violence in American schools. Given that LGBTQ youth experience significantly higher rates of depression, anxiety, and suicidality, schools should be taking particular care to offer services and programs geared to this population.
If they want fewer mothers on antidepressants, then I sure hope they are planning on supporting mothers with expanded paid maternity leave, affordable childcare, and investment in research and programs that address perinatal and postpartum mental health.
If they want fewer Americans on antidepressants, then they must address the lack of access to mental health treatment, make health insurance more affordable, defend mental health parity, and invest in research on innovative interventions.
Obviously these suggestions are just a few of the many, many ways we could begin healing as a nation.
I have no doubt that mental health professionals and patients will welcome genuine and meaningful attempts at making “America Healthy Again.” But attacking antidepressants is not it. It’s a distraction from addressing our broken mental health system and the ways in which social inequity makes people sick. If the goal is to have fewer people on medication, then listen to experts and direct that funding towards creating programs and policies that support healthier families, schools, and neighborhoods.
As always, I invite you to meet me in the comments to share your thoughts!
What do you think is most needed to address mental health in the US?
What are your experiences with finding and accessing mental health treatment?
If this was helpful, please let me know with a like, comment, or a share. Sharing helps get my work in front of more readers and it is so appreciated.
Further reading:
For more information on the risks and benefits of antidepressants, check out “Mental Health Doctor Reacts to RFK and Antidepressants” by Jake Goodman, MD, MBA
To read about how to safely get off an antidepressant (with the assistance of your doctors!) read “What to know before tapering off anti-depressant/anxiety medication” by Tanmeet Sethi, MD
A few of my substack mutuals have also written about MAHA this week:
“RFK Jr's Vision of a Healthy Lifestyle is a War on Moms” by Naomi Gottlieb-Miller
“Purity Based Wellness Culture” by Vanessa Scaringi, PhD
I don’t always write about politics, I promise! If you are in the mood for something different, check out these posts you might have missed:
Disclaimer: This article is a reflection of my personal and professional experiences as a licensed clinical psychologist. It reflects my current and best understanding of these issues. It is intended to be educational and informative, but is not medical, clinical, or therapeutic advice. Any questions about your personal mental health treatment should be directed to your personal medical professional. You can find a therapist at Psychology Today.
Dr. Amber_Writes is a newsletter designed to be informational, entertaining, and engaging. It is not therapy. Following this newsletter does not establish a therapeutic relationship with me. Dr. Amber_Writes, and other written communication by Amber Groomes on Substack, is not a substitute for treatment, diagnosis, or consultation with a licensed mental health professional. I assume no liability for any action taken in reliance on my writing here at Dr. Amber_Writes.
Thank you for this nuanced take on mental health care, Amber!
The stigmatization of medication creates a cruel double-bind. We’re told we're weak for needing help, then criticized for using the most accessible option available.
As someone who's benefited from both therapy and medication, I appreciate you highlighting that addressing mental health requires systemic solutions beyond just scrutinizing antidepressants.
The barriers you describe are painfully familiar.
Well said Amber. A clear and thoughtful piece.