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Issue 69
May 3, 2020
___ _ ___ / __\___ ___ __| | / __\___ _ __ / _\ / _ \ / _ \ / _` | / _\ / _ \ | '__| / / | (_) || (_) || (_| | / / | (_) || | \/ \___/ \___/ \__,_| \/ \___/ |_| _ _ _____ _ _ _ /_\ _ __ __ __(_) ___ _ _ ___ /__ \| |__ ___ _ _ __ _ | |__ | |_ //_\\ | '_ \ \ \/ /| | / _ \ | | | |/ __| / /\/| '_ \ / _ \ | | | | / _` || '_ \ | __| / _ \| | | | > < | || (_) || |_| |\__ \ / / | | | || (_) || |_| || (_| || | | || |_ \_/ \_/|_| |_|/_/\_\|_| \___/ \__,_||___/ \/ |_| |_| \___/ \__,_| \__, ||_| |_| \__| |___/

There is no shortage of data that underpins what is painfully obvious, even to the untrained eye: as a result of COVID-19, this quarter will probably mark the worst contraction of America’s economy since the Great Depression in 1929.

Another corollary courtesy of the coronavirus is opaquer yet damaging nonetheless: its effect on Americans suffering from mental illness and the impact of those who are newly battling this silent epidemic.Quarantine, as prescribed by lawmakers for the sake of the greater good plays a prominent role. Uncertainty about the future, adjusting to the “new normal” and worries about economic security are also factors that contribute to the newly afflicted.

We know what some of you are already thinking -- Americans are over-diagnosed with mental ailments and over-prescribed medication. These are not empty arguments. But using conservative estimates to control for over-diagnoses, ~17% of Americans experience a mental illness at least once and ~4% of Americans live with a serious disease of the mind. Since COVID-19 reared its ugly head, rates of anxiety, depression, suicide (and domestic violence) have markedly increased.

Be “Mindful”

Anxiety disorders are the most common mental illness in the United States. They develop from a "complex set of risk factors, including genetics, brain chemistry, personality, and life events" and often co-exist with depression, a separate illness that carries its own (sometimes overlapping) set of symptoms and risk factors.

Prior to the coronavirus permeating America’s borders and forcing governors across the nation to institute shelter in place orders, according to the Anxiety and Depression Association of America (ADAA), the numbers of Americans suffering from the following mental illnesses were as follows:

• Generalized Anxiety Disorder (GAD) (~7 million)

• Panic Disorder (PD) PD (~6 million)

• Social Anxiety Disorder affected (~15 million)

• Obsessive-Compulsive Disorder (OCD) (~2.2 million)

• Post-traumatic Stress Disorder (PTSD) (~8.5-9 million)

• Major Depressive Disorder (MDD), the leading cause of disability for ages people aged 15 to 44, impacted more than 16 million people.

• Persistent depressive disorder (PDD), a form of depression lasting least two years or longer (~3 million)

• Bipolar disorder, which is not on the same spectrum as traditional depression or anxiety disorders, affected just over 2 million American adults.

*In depth explanations of each genre of anxiety and depression are nuanced and extremely complicated subjects to tackle. Their granularity goes well beyond the depth of this post. They can, and should be, topics of a separate TQC article, penned by an expert in the field.

Through a combination of talk therapy and (sometimes) medication, anxiety disorders and depression are usually treatable. Unfortunately, only ~33% of those suffering from an anxiety disorder and 60% of those suffering from depression receive professional care. Indeed, while the surge in mental illness due to the coronavirus pandemic is a new phenomenon, the lack of resources to treat mental illness, is not.

There are three primary reasons for this:

1) Despite general progress understanding and appreciating mental illness, there is still a stigma associated with it. Those who suffer are loath to inform employers let alone loved ones and family members. They often suffer in silence.

2) There is an acute shortage of psychiatrists (and psychologists) in America. Though it varies by location, the general physician/patient ratio in the United States is ~275 doctors per ~100,000 citizens. However, there are only ~11 psychiatrists for every 100,000 citizens. “More than 60 percent of all counties in the United States-including 80 percent of all rural counties-do not have a single psychiatrist. In rural counties just 590 psychiatrists serve more than 27 million Americans.” Given that ~25% of psychiatrists are over 65 years old and < 5% of new residents choose psychiatry, this serious situation is bound to get progressively worse.

3) A disproportionate number of mental health professionals do not accept insurance. According to The Journal of the American Medical Association (JAMA), ~90% of all health care professionals accept insurance but only ~55% of psychiatrists do. The rationale is straightforward -- when it comes to remunerating doctors for psychiatric services, most insurance providers “don’t pay.” As a result, even in the few locations where there are enough psychiatrists to meet demand (typically in large metropolitan areas) outpatient treatment is only available to Americans fortunate to have the financial resources to pay “out of pocket,” or for people lucky enough to have the very best insurance plans.

Food for Anxious Thought

Medical insurance companies and their respective polices are penny wise and dollar dumb. Indeed, their backwards economic incentives for physicians in (and out) of their network(s) create massive inefficiencies in delivering care and unwittingly force doctors to practice overly defensive medicine. These factors also contribute to the shortage of psychiatrists (and psychologists), and most importantly, why patients are worse off today.

Insurance companies typically pay handsome sums per procedure, per test, per operation, etc. However, they do not pay much, if at all, for time. Hence, family doctors/internists are economically incentivized to order as many tests and/or perform as many procedures as possible, on as many patients as possible, in as little time as possible. Of course, some of these tests are necessary (especially when it means protection from an overzealous trial lawyer). But some are probably not. It does not matter, doctors are compensated per procedure, regardless if it takes 30 seconds or 30 minutes to complete.

There are financial disincentives for talking with a patient for 30 minutes and discussing options on how to live a healthier lifestyle. Doctors are not compensated accordingly for engaging in this type of sensible medicine. This is perverse. A 30-minute conversation can result in a patient leading a healthier life, which reduces the probability of that person having to undergo a litany of tests and/or a medical procedure in the first place. Insurance companies would also benefit from a healthier society. They would pay out less in claims and their profits would increase.

Psychiatry

When a person is mentally ill, a psychiatrist will often incorporate a combination of psychotropic medication and talk therapy into that patients’ treatment regimen. Sometimes a patient will only be prescribed drugs, other times talk therapy will be used exclusively. A “medication only” patient is typically in a psychiatrist’s office for at least 15 minutes, no procedures or tests ordered – just medical management. A talk therapy patient’s session is between 45-60 minutes. Treating mental illness takes time; but as we previously explained, insurance companies do not pay much for time. This distorts the market for psychological services.

As a result, a very small number of hard-working psychiatrists situated in a few cosmopolitan locations can earn upwards of $500,000 per year catering to a predominately wealthy client base (to be fair, many of these psychiatrists take pro-bono cases and /or cut fees for the less fortunate) – both doctor and patient unencumbered by the constraints of the insurance industry. Other psychiatrists work on staff in hospitals, dealing with psychiatric emergencies or the uninsured with no other options. The balance work in private practice and accept insurance. Most are overworked and grossly underpaid for treating some of the most vulnerable people in society.

Career Choices

A consistent exercise regimen, positive thinking, eating a nutritious diet, and various natural supplements are imperative to maintaining mental health. Unfortunately, these conscious lifestyle choices do not always suffice; for some people suffering from mental illness, professional help is necessary.

There are many reasons why medical students choose a specific specialty. Some incentives are altruistic – many doctors are. Nonetheless, money is also a driver of the process, especially for a 26-year-old saddled with hundreds of thousands of dollars in medical school debt. The current healthcare system disincentivizes medical students from pursuing a career in psychiatry. It must change or the acute shortage of psychiatrists in America will persist and too many people afflicted with mental illness will go untreated. This is indeed, a “time” sensitive matter that if not rectified will be costly to all members of our society.