The pandemic has shone a bright light on a stark reality. Mental health concerns are pervasive, and access to quality care — or any care at all — is incredibly unequal.
In Washington, more than one in five adults has a diagnosable mental illness. And all signs suggest mental health issues became more prevalent — and more extreme — over the past 18 months. In the spring, Gov. Jay Inslee declared a youth mental health crisis. National data shows 40% of adults have experienced a mental or behavioral health condition during the pandemic.
But mental health concerns have always been common, and the way treatment is researched, funded and provided has long been plagued by racial and economic inequities — and slowed by bureaucracy. Failure to get help can bring dire consequences: People with severe mental illness die, on average, 10 to 25 years earlier than those without a mental health condition.
“These are life-stunting conditions,” said Dr. Larry Wissow, director of child and adolescent psychiatry and behavioral medicine at Seattle Children’s.
There’s much we can do to help.
The Seattle Times is launching a new reporting team dedicated to enhancing the public’s understanding of mental illness, holding agencies accountable and finding solutions that can help people get the care they need. As we begin, we turned to local clinicians such as Wissow, researchers and policy experts to answer some pressing questions about the state of mental health in Washington.
What do we mean by mental health, behavioral health and mental illness?
The words people use to describe mental health vary and can depend on a person’s cultural, family or religious background. In general, “mental health” includes a broad spectrum of social, psychological, emotional and behavioral traits. It’s part of how we think, feel and act on a daily basis, and includes how we respond to stress or other life events. And like physical health, it can vary from day to day, and from one stage of life to the next.
“Behavioral health” is closely related to mental health. There’s no single definition of behavioral health, and its definition has changed over time. Some in the mental health community use the term to broadly describe the relationship between behaviors and overall health and well-being, and the treatment and support of those with mental and substance-use conditions. Some use it interchangeably with “mental health.” Others believe the term is misleading or stigmatizing, and implies a person’s problems are mostly voluntary, or within the bounds of their control.
“Mental illness” is distinct from both of these terms. Having a mental illness signals that a person’s pattern of thinking, their mood or their behavior has changed in a way that negatively affects their well-being or typical functioning. Mental illness is also distinct from developmental conditions such as autism and intellectual disability, which arise early in a child’s development and last the course of their lifetime. Mental illness and neurodevelopmental conditions can co-occur, however.
Depression and anxiety are among the most common mental health conditions. Eating disorders and schizophrenia are other examples of mental illness. Substance use disorders are closely tied to mental illness. They can lead to, or be exacerbated by, mental illness. As with mental health, the severity of these disorders and the traits that accompany them occur on a spectrum.
How common are mental health conditions among Washington children and adults?
Unfortunately, Washington ranks poorly on several national markers of mental health.
About 22% of adults here are experiencing a mental illness, according to data from the national nonprofit Mental Health America’s 2021 report, compared to 19% nationally. Only five other states — Oregon, Indiana, West Virginia, Idaho and Utah — have a higher prevalence of mental illness than Washington. Among children, Washington ranks among the 10 states with the highest prevalence of severe depressive episodes and substance use disorders.
This likely underestimates the extent of mental health concerns. The 2021 report includes data through 2018, before the COVID-19 pandemic and national uprisings over racial injustice. Early data from the Centers for Disease Control and Prevention suggests mental health issues skyrocketed after the pandemic hit.
What common signs of mental illness should people look out for?
Symptoms of mental distress can come in many forms, experts say. In general, though, people should start to have concerns about themselves or their loved ones when their everyday functioning becomes impaired.
Common signs of mental health issues include persistent trouble focusing on work, taking care of physical hygiene or fulfilling a role as a caregiver, said Jane Simoni, a professor and director of clinical training in the University of Washington’s psychology department. Symptoms in children might be more subtle, or look different: Children might complain about headaches or refuse to go to school instead of saying in words that they feel anxious or stressed out.
What causes mental or behavioral health problems?
A person’s mental well-being is influenced by many things, including their experiences, genetics and family history of mental illness. Some people are born with difficulties managing their emotions that could make them prone to developing mental health issues early on. Others grow up without serious concerns until adolescence or adulthood.
Although a few mental health conditions are highly heritable, researchers and clinicians also point to environmental influences — a person’s income, how they were raised, work or school stressors, their connectedness to community — on individuals’ mental health outcomes. Personal and intergenerational trauma also have clear links to mental well-being.
“There’s always a biological and social component,” said Jonathan Kanter, who directs UW’s Center for the Science of Social Connection. “We’re getting better at recognizing that many mental health problems are a function of what’s going wrong in people’s context, in people’s community, in people’s social world.”
How are mental health conditions diagnosed?
Unlike many physical conditions, mental illness isn’t diagnosed using biological tests. Although genetic research and brain scanning studies continue to pick up differences between those with and without mental illness, in general, scientists haven’t found biological markers that can be reliably be used to predict or diagnose mental health conditions.
Instead, mental health professionals use behavioral diagnostic tools and clinical observation. They look for conditions as defined by the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases, standardized manuals that aim to make diagnosing mental disorders consistent.
In recent years, the federal National Institute of Mental Health has made a push to drop the diagnostic labels we’ve used for decades, and instead, has prioritized studies that focus on individuals’ traits or symptoms. This new framework for studying mental health conditions recognizes that many traits and their underlying biology map across various DSM-defined diagnoses. The reality is, many people have characteristics of several diagnoses — and even receive several diagnoses over their lifetime — because symptoms overlap between conditions and can evolve over time. This is one example of the many ways that diagnosing and treating mental illness is complex.
What types of treatment exist?
Mental health treatment falls into two big buckets: behavioral interventions or talk therapy — and pharmaceutical drugs.
Both forms of treatment continue to advance through medical research. But each faces significant challenges. Talk therapy is effective but, practically, it’s difficult and expensive to scale up. And the pharmaceutical industry, for all its years and research investment, hasn’t discovered “silver bullet” drugs for most people with mental disorders.
What systemic barriers exist to receiving care?
The list is long. But here are several examples:
- Ability to pay: Many people are uninsured or underinsured — and some therapists don’t accept insurance from those who have it because enough people are willing to pay out of pocket.
- Pipeline issues: Not enough professionals graduate each year to meet demand.
- Racial disparities: Like the rest of the health care system, mental health care lacks Black and brown providers. Culturally competent care can be hard to come by.
- Rural vs. urban living: Finding a therapist is nearly impossible in many rural communities — and still very difficult in urban areas.
- Stigma: Some communities consider mental illness a weakness; others don’t talk about mental health at all.
- Lack of coordination between primary and mental health care. For instance, a person in mental distress seeking help at an emergency room might find the physician on duty isn’t trained to screen for — or treat — mental health conditions.
Most of these barriers are interrelated. For example, because of a lack of availability or coordination of care, schools and child welfare agencies have become the de facto system of care for many children and adolescents. Prisons and jails have played the same role for some adults with serious mental illness.
One persistent tension in the effort to break barriers is the competing need to fund long-term, high-intensity inpatient and community-based care for those with severe mental illness — an expensive endeavor — and the need to scale up and pay for treatment for the many more people living with significant, but less debilitating conditions.
In an ideal world, we’d adequately fund both, said Dr. Jürgen Unützer, chair of UW’s Psychiatry and Behavioral Sciences Department.
What prevents mental health concerns from emerging or escalating?
The universality of the pandemic has opened doors for people to talk about their mental health.
Talking about mental health, teaching about mindfulness and helping people recognize signs of problems as they arise are all starting points to prevent mental illness from emerging or worsening, Simoni said; these efforts can happen in classrooms, workplaces, families and churches. “We’ll never have enough mental health therapists for those who need them, so we need to do more to focus on prevention,” she said.
Experts also point to the role of society, and inequities baked into our systems. People of color, in particular, face systemic discrimination that has clear ties to a negative impact on their mental health, said Pamela Collins, professor of psychiatry and behavioral sciences and global health at the University of Washington. Another example: A weak social safety net might force someone with severe mental illness into homelessness.
Alternatively, being involved in community activism can be an important form of mental health coping, Kanter said. Likewise, having a place to sleep, food to eat and support from family or friends might be the difference between someone’s ascent or descent through a mental health condition.