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Mental Health, Substances, and Access

I have been thinking about Aaron Carter's death since I first heard about it 48 hours ago. I wouldn't call myself a fan; I am not sure I could even name more than a few of his songs. So, Aaron's death is not something that hit me hard like the deaths of other celebrities have in the past. But, as I

have been researching mental health these last few months, it is becoming more apparent how substance use/abuse and mental illness go hand in hand.

Not every individual with a mental illness will abuse alcohol or other drugs, and not every individual with a substance use disorder (SUD) has a mental illness (MI). However, there is a significant overlap between the two. For example, a study suggests that in 2020 the United States had approximately 17 million individuals with both MI and SUD, which works out to not quite 5% of the population and about 30% of people with MI. There are several reasons that SUD and MI have such a high co-morbidity, but there is one in particular that I want to spend some time on. That is access to care.

Before we dig into access to care, let's briefly talk about why I think individuals with MI misuse drugs or alcohol at a higher rate than the general population. I am approaching this from my perspective and experiences as an individual with bipolar and ADHD.

My bipolar has been diagnosed with the specifier of "anxious distress." A diagnosis of anxious distress means an individual experiences at least two of the following symptoms more days than not.

· Feeling keyed up or tense

· Feeling unusually restless

· Difficulty concentrating due to worry

· Fear that something awful may happen

· Feeling loss of control of themself

I constantly felt on edge, I had difficulty concentrating, always thinking about the worst-case scenario, and there were times when my heart would race, and I couldn't sit still. Sometimes it would feel like I was living in an almost panic attack for days or weeks at a time. It was miserable, and I would do anything to make it stop, even if for just a few minutes.

I experience ADHD as an inability to concentrate, my mind constantly going, and it is virtually impossible to quiet; I often fidget or feel restless, I may act on impulse, and I can lose my temper at the drop of a hat. In short, it can feel like I am incapable of turning my body off much of the time, making relaxing, concentrating, or sleeping difficult.

The core of the symptoms I experience without treatment revolves around my inability to quiet my mind and body. I was constantly worried, agitated, and on high alert. This made concentrating on anything complicated. I would struggle to function in social settings. It often felt impossible to fall asleep and stay asleep. I couldn't live the life I wanted; I was miserable. As I have talked about before, I had tried to find answers and relief, yet none came.

When I tried marijuana for the first time, I loved how I felt. I was able to relax and enjoy the people around me. I was detached from the world around me, and it felt like I didn't need to worry about things. My brain no longer felt like a million things were going on inside it. It was the opposite of how I usually felt and a welcome relief. After that first experience, I wanted that feeling all the time, so I began to smoke more and more regularly.

The first time I got drunk, there was a feeling of happiness and dissociation that felt good. It felt like things slowed down, and be more present in the moment. I loved how it felt when I was intoxicated, but I hated how I felt the following day, and yet it was worth the hangover to have that brief respite.

Over the years, I used marijuana and alcohol to escape how I felt. There were times that my use of alcohol and marijuana negatively impacted my life, but I was lucky that I never had any legal or health troubles as a result. I was so desperate for relief that it was worth whatever potential risks were associated. I was using marijuana and alcohol to self-medicate because no prescribed medications did what I needed. Once I received treatment, my perceived need for marijuana decreased, so my usage decreased over time.

While I had access to doctors, therapists, and medication, without the correct diagnosis, my care was ineffective. It was as if I wasn't receiving care in many ways. With no real relief from my symptoms despite searching for treatment, self-medication felt like my only option. Unfortunately, it wasn't the best option, which likely made my daily life more difficult. Mental health treatment is expensive, and treatment for substance abuse is even more costly for our society. I'll eventually get into how substance use impacts all of us, but let's talk about access to care to help us understand why many people with MI try to "treat" themselves with substances not intended for mental health care.

According to the Kaiser Family Foundation, approximately 150 million Americans are living in areas with shortages of Mental Healthcare Providers. The federal government defines this shortage as having a population-psychiatrist ratio greater than 30,000-1 and/or a population-core mental health provider (think therapist) ratio greater than 9,000-1. Considering that 20% of the population experiences MI, the ratio used means each psychiatrist is, on average, caring for 6,000 people and therapists 1,800. I really like numbers so let's break this down a little more. So, each provider saw every person with MI annually; a psychiatrist would need to see 24 patients a day and a therapist seven. This means each individual only receives two mental health care visits per year.

My first year of treatment included 6 or 7 visits to the psychiatrist and close to 75 therapy visits. In this last year, I have been to my psychiatrist seven times which is more frequent than the previous year due to the addition of ADHD medication to my treatment plan. Typically, I would see my psychiatrist three times per year, and while I am currently not in therapy, 26 visits per year would be "normal" for someone like me. To make things easy, let's say 30 mental health care visits annually for an individual with a severe mental illness (SMI). The number of visits needed would likely be less for people with less severe concerns and/or those who do not require medication as part of their treatment plan.

Since I love numbers and statistics, I'm going to do a little math to show what I think that population-to-provider ratio should be. If we say the average person with MI needs 15 visits with a care provider per year, and the average provider sees 40 patients per week, then each provider can care for about 150 patients per year. Remembering that 20% of the population is experiencing MI, in theory, we would need a population-provider ratio of 750-1. I am oversimplifying this, but with this basic math, the number of providers actually required is 15-40 times higher than what the government states the bare minimum should be. Of course, not every person will choose to receive treatment, and not every person will need as many visits as I used in my calculations, but it is clear that currently, there are not enough providers.

Beyond the availability of providers, there is a genuine financial barrier. Just over 40% (20 million) of people with MI report they cannot receive the care they need due to the cost, and close to 30% of individuals with SMI don't receive necessary treatment due to cost. As of 2020, 80% of therapists and 45% of psychiatrists do not take insurance, meaning even with insurance, many mental health visits are paid out of pocket. Without insurance, the average therapy session cost is $90, and a psychiatrist visit is around $200. You may be wondering why many care providers don't accept insurance, the short answer is they get reimbursed at a lower rate through insurance, and the paperwork, including the need for "proof" of a mental illness, push many providers away from taking insurance. And, with such a lack of care providers, they don't need to accept insurance to make a living and will likely have a higher income without acceptance of insurance. As a result, these individuals are not receiving adequate care, not because they don't want help but because they cannot afford it.

Okay, here are more numbers. Suppose someone needs three psychiatrist visits per year and only ten therapy visits; that totals roughly $1500 without considering any medications required. That $1500 may not sound like a lot to some, but it works out to about $30 per week or 4 hours of work at federal minimum wage. Many individuals earn more than minimum wage research suggests that the average income is lower for individuals with mental illness than those without. We can infer from this that people with the highest need have less money to care for their mental wellness.

I threw a whole lot of numbers at you. And there are many links to additional research, studies, and articles, which I would encourage you to take a peek at. Based on what I have read, experienced personally, and heard from others, something needs to be done about access to affordable and comprehensive mental health care. I'll be 100% honest; I don't know how we fix a broken system broken to its core. I have some ideas that all cost money and will likely take a decade or longer to implement. This includes incentives for those providers willing to work in underserved areas. A change in how mental health care is reimbursed by insurance—a considerable increase in the number of public health clinics and more providers in schools.

So, what can we, as people living in this society, do with this knowledge? Honestly, not much alone, but I believe we can make a change together. This begins with opening conversations about the need for access to mental health care. Find agencies in your local community providing care to those with a financial barrier and volunteer, help raise money and awareness, or donate. The reality is that the best thing we can do is to reach out to our local, state, and federal elected officials and talk about how more affordable care is needed. Ask what they are doing to ensure there are more care providers. Tell them you want to see mental health made a priority. Make sure they hear all of us loudly, clearly, and passionately. If you aren't sure who represents you, check here and get loud, make the conversations uncomfortable, and don't stop talking.

*Research suggests marijuana can help relieve some symptoms of mental illness. As medical and recreational marijuana legalization in the US grows, I hope this research continues. I believe there is potential for the use of cannabis to assist in treating many diseases, but there is not enough data yet.


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