The Time has come to Apply Ethical Principles to Mental Health, Doing the Right Thing is Good for our Health

Introduction

At a recent meeting I described a colleague’s attempt to make an appointment with a mental health professional for her adolescent child who was experiencing some anxiety in the beginning of the current Covid19 Pandemic. While it is clear this child wasn’t alone, the response was “we can see you in three months, or four months”. My comment at the meeting was “how many would stand by if someone with noticeable hypertension was told “we’ll see you in four months”? The reaction was a predictable expression of disgust and frustration.

What is behind this not uncommon behavior? We will attempt to describe some of the key background points, key opportunities for change for the better, why we can retain some hope, and why this is the ethical – right thing to do.

We live in a society where for generations mental health symptoms are ascribed only to those with a diagnosable mental illness. In those cases, for much of our recent history these were discussed in whispers – and sometimes still are – leading us to deny or diminish any symptoms that lead to a need for mental health care or support [1]. We now know this is backwards, many of use experience symptoms like anxiety, depression, sleep disturbances, and others that interfere Commentary with our health, our relationships, and our wellbeing in every sense of the word. This is not in any way to diminish the need for early identification and treatment of diagnosed mental illness, rather it calls for us to acknowledge just how normal it is to experience some of these symptoms at points in our lives or chronically. It is in this normalizing that we can have open dialogue and support one another at addressing these challenges to be a healthier people in general [2].

This leads to our first change – we need to be able to talk openly about our mental health without fear of social isolation, discrimination in many facets of life, or facing futility when we know there are positive steps we can all take. Our educational system at all levels can help us with this, from childhood education to college to preparation for professionals, we can make a difference if we focus and make this a common goal. If you are tempted to think “there is no way we’ll get this done”, I challenge you to recall that this country was founded by a group of people who believed deeply that only white male landowners deserved the vote, women had no rights, and slave holding was normal. If we can change this much to where we are today, we are convinced we can go further.

Each of us is bombarded with electronic communication often multiple times daily; some divisive, some incorrect; all that create pressure and stress. The result of that stress is those symptoms we referenced above. We may not change the world or how it works, but we can change how we react. Normalizing talking about our anxiety, depression, and frustrations can help each of us and all of us reduce the impact of these same factors. It can also lead to address the systemic issues that are currently obstacles. Let me explain.

The mental health workforce in the US is currently a fraction of what is likely needed. To complicate matters the WHO recently reported that during the Covid19 Pandemic we have seen a 25% increase in anxiety and depression [3]. (The factors to consider here are: How is it paid for? Are those payments enough to be impactful? What are the professions needed? How can we grow them in meaningful ways?) Some of the answers are clear – insurance coverage for mental health services is spotty and inadequate; access to professionals is challenging at best; the array of professions vary from state to state and sometimes within states (and most report inadequate supply) [4]; growing these professions requires a system of payment that supports the field, a system of education that fills the need both in numbers and quality; and oversight systems that monitor the professions to assure quality of outcomes. Note that correcting these issues would both enhance services for the general population who may have a mild presentation or episodic symptoms and those with diagnosed mental illnesses.

So, to reiterate, we need to normalize and accept the reality of mental health needs in our communities and families. This needs to happen strategically at many levels simultaneously with the support of educational and social systems, professions, and higher education. We need to revisit our approach to payment for mental health to assure access for all and adequate access to support and grow the field to address real needs present today.

Lastly, we need to acknowledge that our mental health is inextricably entwined with our physical health. When we look at someone experiencing some mild mental health symptoms, we see immediately they are more likely than their neighbor to not eat a healthy diet, not engage in regular physical activity, and not manage other conditions they may already have (cardiovascular disease, diabetes, cancer, arthritis, etc.). This discussion [3] shows us clearly there are factors in our lives that are causing us to engage in behaviors that increase our risks for many chronic conditions. Fixing problems after they exist is much less effective than prevention. Conversely, we recognize that access to mental health care to address symptoms like depression and anxiety can support healthy weight and regular activity. This then enhances both physical and mental health and supports us living more normal lives.

We make these points as you see because science supports the change, but also because it is the right thing to do from and ethical perspective. When we think of the Principle of Autonomy, we recognize that one of the drawbacks to exercise autonomy for the individual is being “fully informed”. This isn’t possible without open dialogue and access to informed experts; lifelong learning about wellness (both physical and mental); and assurance we are educated to what works to keep us healthy. The added challenge of misinformation and disinformation adds to this area and complicates every effort made to address autonomy [5]. These twin attempts to confuse/indoctrinate/and sway opinion and action ultimately violate all principles of ethics and cause harm to the people impacted and all who they contact. The Principle of Beneficence calls on each of us and those referenced below to approach every issue or question with the intent to do good, for all. All health-related professionals pledge to “do no harm”, this requires that we focus in problems and issues and correct inequity and gaps as we note them [6]. Finally, we have the Principle of Justice – calling on each of us to have systems based on fairness for all. This is truly a social justice issue in every sense. This underlies the truth that when we are all better off individually, we are all better off collectively.

So let this serve as a challenge to public officials at every level, leaders in professions and higher education, community leaders and those in education and healthcare systems, leaders in private health insurance and Medicaid and Medicare Systems. Let us recognize the reality of this Commentary and the opportunities we must address the issues raised and ameliorate the conditions that exist now for a better future for all.

I would be remiss not to acknowledge this dialogue has begun with groups like the National Association of Chronic Disease Directors with convening a Thought Leader Round Table on Mental Health and Chronic Disease in July 2022, Robert Wood Johnson Foundation raising this issue in several venues, American Psychological Association, Mercy Justice Team, and others along with governmental bodies including the National Center for Chronic Disease Prevention at CDC, NIH, NIMH, SAMHSA, Youth.gov. and others. To these I say thank you for beginning the recognition of this significant public health, healthcare, and social justice issue.