Shootings in places like Isla Vista, Calif., and Newtown, Conn., have turned a spotlight on the mental health system, and particularly how it handles young, troubled males with an aggressive streak. About one in 100 teenagers fits this category, according to E. Jane Costello, a psychiatric epidemiologist at Duke University School of Medicine, and they often have multiple diagnoses and are resistant to treatment.
Most of these young men will never commit a violent crime, much less an atrocity. But the questions of how best to help them and how to pay for it are among the most intractable problems hanging over the system.
Thousands of families know this experience too well: No single diagnosis fits, no drug brings real relief, and if the teenager rejects the very idea of psychotherapy, there is little chance of lasting improvement.
Congress has taken steps to bring about so-called parity for mental health, requiring insurers to cover treatments for mental illnesses as they do those for diseases like cancer and diabetes. But parents like the Serpicos have found that, even with good insurance, they often cannot get the expensive, long-term residential treatment they believe their child needs.
And it is not clear how effective intensive residential treatment is for teenagers. Some improve, experts say, but they are usually discharged to the same environment in which they got into trouble, and precious few studies follow them for longer than several months.
“The problem is that, while some kids may benefit from these extremely costly services, we don’t know which ones they are, and we don’t have a good model for distributing those services, no matter who’s paying,” said Sherry A. Glied, dean of the Wagner Graduate School of Public Service at New York University.
Lena and Robert Serpico knew something was not right before their son was in kindergarten. They had taken him and his younger brother in as foster children from a mother who used drugs, and they later adopted both.
As the teenager became increasingly indifferent to school and defiant, the family got him into a highly recommended day therapy program. He was thrown out for bringing a razor blade to a session. The family tried again, at another day program, and this time the program kicked him out for refusing to participate.
“It’s useless, all this stuff,” he said in a brief interview. “It’s a waste of my time.”
He entered an alternative school last fall, and his parents, who both work outside the house, decided they had only one option left, recommended by their son’s doctor and therapist: long-term residential care. Costs ranged from $10,000 to $60,000 a month.
“No way we could afford that,” Ms. Serpico said.
Out of options, the Serpicos did what many affluent families do: They hired a lawyer. In January, they petitioned the school district to pay for their son’s education at a therapeutic school. A consulting psychologist hired by the district concluded that their son needed “a 24-hour-a-day therapeutic milieu over an extended period of time, i.e., longer than two months, in order to keep him safe and gain the skills necessary to function post-high-school.”
Last month, they learned that the suit had been successful. The Geneva School District will pay for the young man to attend a therapeutic school in Montana for one academic year. There will be horses, physical labor, and group and one-on-one talk therapy. Ms. Serpico and her husband broke the news to their son this month.
When asked about going to the new school, he shrugged and looked away.
“I don’t know,” he said. “Probably useless, too.”
Economics traditionally treats people as rational actors seeking to maximize their “utility”. While this idea is contentious even in “normal cases”, when considering those suffering from mental illnesses, the rational maximizer model becomes almost completely irrelevant. Despite the obvious benefits for those who need mental healthcare, potential patients (particularly young men) often reject the idea of therapy because of the stigma of “weakness” or embarrassment associated with it–I know this because I was once one of these young men.
Health care reform–so called insurance “parity” for mental healthcare–has gone a long way in making treatment affordable to those who need it. This was a fix to the “supply side” of the equation. However, it is very clear that there are “demand side” issues related to mental healthcare that are leading to under-treatment.
Demand traditionally focuses on the willingness of a person to pay for a particular good or service. However, young people are almost never expected to pay the cost of their own mental healthcare–those who need treatment the most often reject it even if it is being paid for by their parents or the state (or some combination of the two). To get these people the help they need, we must address the non-monetary concerns–the stigma–associated with mental healthcare.
This is a difficult task, but it can be aided by cultural and technological progress. Culturally, those in the public spotlight (movie stars, musicians, athletes, etc.) who are comfortable with their mental health issues should open up about them. It is amazing how someone who is perceived as “cool” can get through to people and change public perceptions. To this end I would like to commend All-Pro Wide Receiver Brandon Marshall, who has become a poster-boy for mental health awareness, to the benefit of both the general public and, according to him, himself; we need more role models like Mr. Marshall. Of course, these public figures can always utilize social media to amplify the effect of their message.
Another cultural shift which makes sense would be changing how we educate kids about mental healthcare. My first semester in college, we had something called “University 101”, where students where prepped and talked about the challenges and opportunities present during college life. It seems to me like there should be a similar class required during ones first semester in high school–a common time for mental health issues to arise–with a greater focus on mental health awareness. I also took a a health class in high school, but it focused much more on drug use and safe sex, and not nearly enough about mental health issues.
Often times young people are not comfortable talking to their problems with peers, for fear that news of their issues will become public knowledge before they are ready to be open about them, or used against them by bullies. In such an instance, virtually connecting with groups dedicated to peer-to-peer dialogue via social media (Facebook, Skype, etc.) could offer a way for children to start opening up about their issues to people they can relate too (other kids), without having to worry about those issues coming out in their immediate social circles.
As someone who went from rejecting the very idea of therapy to realizing its incredible benefits, this issue is deeply personal to me. I can say one thing–seeking mental healthcare is by no means a sign of weakness, or something one should be embarrassed about. The open, self-reflecting, honest approach needed for therapy to be effective requires incredible strength of character. This is the lesson we should be teaching our kids–pursuing mental healthcare is a sign of strength, not weakness.
For those who think Mental health issues are only a “rich country problem”, think again. According to a recently release United Nations report, depression is the number one cause of illness and disability globally among adolescents (10-19 yrs old).
In an increasingly complex and global world, it is only natural for new sources of anxiety to affect current and future generations of children. These new sources of anxiety will be reinforced by old social and cultural stigmas related to mental illness / healthcare. In the coming decades youth populations are expected to grow in developing countries, where youth unemployment tends to be highest and (relatedly) conditions are very conducive to mental health problems. The problem will only become more pronounced, unless we use all the tools we have to address adolescent mental health issues in a holistic and inclusive manner.
In a political / media landscape dominated by debates over fiscal responsibility and climate change, the potential of looming global mental health epidemic is not discussed. You want to talk about a “Great Depression”? Aggregate all the lost output that will systematically come out of the global economy if the proper resources are not dedicated to youth employment, mental healthcare and awareness programs. And then there are the linkages to poverty, insecurity, human suffering…