Last weekend, I took my son, Jason, to StreamSong to celebrate his 40th birthday. 36 years ago, I didn’t think I’d see his 5th.
At 20, I had completed college as student body president, varsity debater and athlete, and engaged to the Homecoming Queen. By 23, I had married the Homecoming Queen, finished my doctorate and was torn between job offers. And at 30, I was alone, penniless and hopeless. I lived on $700 per month, sleeping on the sofa in a borrowed office eating peanut butter to stretch pennies. Only Jason’s unconditional “I love you dad” kept me going, though my sense of hopelessness was overwhelming. I’ll never forget sitting in the Belle Meade Theatre alone on Christmas Day—my gift to me—and getting a free bag of popcorn I’d wanted but couldn’t afford.
Depression that leads to suicide is a national epidemic. Millions feel hopeless. Millions fight giving up every day. And suicide for many of these becomes a rational option. They reason it’s a suitable escape from an unhappy home life, a hostile workplace, their own destructive behaviors or financial despair. And this year, 1,200,000 will attempt and 50,000 will be successful.
Last Tuesday, the CDC released its latest report on suicide rates in the U.S. The New York Times headline read: “Sweeping Pain as Suicides Hit 30 Year High” per the National Center for Health Statistics, our suicide rate climbed 24% between 2009 and 2014, becoming the 10th leading cause of death overall in the U.S. For those between 15 and 44, it’s now the second highest cause of death. For kids between 10 and 14, it’s third.
In the midst of campaign 2016, and the announcement by UnitedHealth Group it is exiting from exchanges in at least four states, I found myself reflecting on that story. It reminded me of the struggles many face to get through their days, and the people around us who face despair that seems overwhelming. I fought the need to share my story, fearing retribution by some and the stigma that might be attached. But in the end, I had to come clean.
So here’s my take:
The brain is an organ of the body like the lungs and heart. But depression, a disorder of the brain, is treated differently than heart or lung disease. Depression, the root cause of suicide, is not consistently and appropriately diagnosed or treated by clinicians. Half those with a depressive disorder are not treated, some due to inadequate insurance coverage, some due to lack of access to mental health professionals, and some due to fear of someone might find out.
Research shows that large and growing numbers in our population lack the education, resources and opportunity to achieve a level of happiness that gives them hope. Others find themselves in work environments where bullies prevail and the work environment is not safe. Some are locked into patterns of self-destruction not easily broken, and still others conclude they don’t fit our society’s norms. Many in these groups are depressed, and suicide becomes an option.
The U.S. health system, despite the Mental Health Parity Act of 2008 and Affordable Care Act of 2010, has failed to take depression seriously as the national epidemic it is. Ours is a patchwork of public and private programs not integrated into the mainstream of our health system. The public programs funded by states and the federal government often fall into the line items of prison systems, Medicaid programs, and social services. The private programs center around self-pay centers, inpatient psych hospitals and healthcare providers who charge high out of pocket rates because insurance doesn’t pay them enough. While paying lip service to the integration of physical and behavioral health, in most communities, it’s not happening.
What can be done? At the risk of over-simplification, a few ideas—
Maybe, diagnostic testing for depression and mood disorders should be mandatory in primary care…
Maybe clinical protocols for all surgical procedures should include an independent assessment of the stress and anxiety of the patient…
Maybe the clergy should be integrated into mental health provider communities to facilitate referrals and shared knowledge…
Maybe employers should be recognized for healthy cultures that address loneliness and isolation for depressed employees…
Maybe health insurers should cover more mental health services consistently and guarantee adequate networks in their plans…
Maybe school systems should be equipped to manage student health completely…
Maybe Congress should address adequate funding for mental health services…
Maybe the mental health professional communities—psychiatrists, psychologists, counselors—should find ways to collaborate more and in-fight less…
Maybe every medical staff committee in a hospital should include a mental health professional…
Maybe those who have struggled with depression should share their stories more openly…
And maybe we should all find ways we can offer hope to co-workers, family members and others in our social networks who are hurting while hiding.
Lest the government’s suicide report last week be dismissed as just another set of healthcare stats, pause if you receive this missive to think about those around you hurting and those that need encouragement. The increasing rate of suicide in this country should get and keep our attention.
P.S. Next week, “The Biggest Misconceptions about the Affordable Care Act”
Fact File: Suicide in the U.S.
Prevalence: In 2014, there were 42,773 deaths by suicide in the United States—105 per day. Suicide is the 10th leading cause of death in the US for all ages but #2 for those aged 15-34, and #3 for adolescents 10-14. Suicide among males is 4x’s higher than among females. Male deaths represent 79% of all US suicides. Worldwide, suicide is the 3rd leading cause of death for those 15-44 accounting for more than 800,000 deaths. CDC
Diagnosis & Treatment: Depression is the root cause for suicide impacting one in four adult but fewer than half get treatment. "This is part of the larger emerging pattern of evidence of the links between poverty, hopelessness and health." (Robert Putnam, Harvard). Only half of all Americans experiencing an episode of major depression receive treatment. 80% -90% of adolescents that seek treatment for depression are treated successfully using therapy and/or medication. TADS, NAMI
Trend: From 1999 through 2014, the age-adjusted suicide rate in the United States increased 24%, from 10.5 to 13.0 per 100,000 population, with the pace of increase greater after 2006. Rates increased from 1999 through 2014 for both males and females and for all ages 10–74 and was greatest for females aged 10–14, and for males, those aged 45–64. There is one suicide for every estimated 25 suicide attempts and one suicide for every estimated 4 suicide attempts in the elderly. Females experience depression at 2 times the rate of males and are more likely than males to have had suicidal thoughts. CDC
Methods: The most frequent suicide method in 2014 for males involved the use of firearms (55.4%), while poisoning was the most frequent method for females (34.1%). Percentages of suicides attributable to suffocation increased for both sexes between 1999 and 2014. CDC
Access: Although the Affordable Care Act (ACA) requires insurers to provide mental health services in addition to medical care, access to psychiatrists has been dwindling at a sharp pace as a growing number of psychiatrists refuse to accept Medicare and Medicaid and commercial/private insurance due to their low reimbursement rates. In the five years between 2005 and 2010, investigators found that the percentage of psychiatrists who accepted private insurance dropped by 17% to 55%, and those that accepted Medicare declined by almost 20% to about 55%. Acceptance of Medicaid is 43%, the lowest among all medical specialties. NCHS
Regulatory framework: the Mental Health Parity law (2008) requires coverage for mental health consistent with physical health coverage i.e. if coverage for a condition like diabetes specified unlimited doctor visit, the same would be applicable to treatments for depression, schizophrenia and other mental health conditions. The Affordable Care Act builds on the parity law by requiring “coverage of mental health and substance use disorder benefits in individual and small group markets for people who currently lack coverage and expands requirements to apply to those (Americans) whose coverage did not previously comply with those requirements.” KFF/KHN
Funding: $4 billion cut from state mental health budgets during the recession. (That’s money that goes to support community clinics that are supposed to be the safety net). NIMH
Workforce: There are 552,000 mental health professionals in the U.S. including 34,000 psychiatrists (5% of physicians). The number of psychiatrists dropped 14% from 2000 to 2008 and fewer medical students are choosing to go into psychiatry. NIMH
Income of psychiatrists: Median compensation range is $203,000-$266,000—below most specialties i.e. non-invasive cardiologists ($291,000-$476,376), general surgeons ($313,809-$414,266) and other specialties but proxemic to primary care i.e. family medicine ($189,152-$250,255) and general internal medicine ($207,000-$266,200) Modern Healthcare Physician Compensation 2014.
Independent Healthcare Research & Policy Analysis