It has become a cliche to say the U.S. mental health care system is in crisis. But it’s true. Treatment options are limited, drugs are often ineffective, and there are too few providers to meet the ballooning demand for services.
As a psychiatric resident physician who regularly diagnoses and treats depression and anxiety, I believe one critical step to addressing these woes will be to reframe our very definition and goal of mental health care.
The nation’s mental health care system is currently focused almost exclusively on preventing and treating mental illness — conditions like depression, anxiety, and personality disorder that adversely affect a person’s mood and behavior. Although these are critical factors in mental health, so too are the components of life that are associated with feeling good, finding happiness and meaning, connecting with others, and feeling engaged — qualities that can be collectively described as positive mental health, or mental wellness. In its myopic effort to prevent and treat illness, the mental health care profession has often treated wellness as an afterthought. And that shortsighted approach has weakened an already struggling health care system.
Although the exact definition of mental wellness may differ depending on whom you talk to, what’s clear is that it is not merely the opposite or absence of mental illness. It encompasses emotional well-being (positive emotions, happiness, life satisfaction), social well-being (feeling connected to others, contributing to others), and psychological well-being (self-acceptance, autonomy). Research suggests that rather than thinking of mental wellness and mental illness as lying at two ends of a single continuum, it is more accurate to think of them as two distinct, but related constructs.
In a 2005 study, for instance, Emory University sociologist Corey Keyes assessed a sample of 3,032 individuals and found that around 10 percent of them were “languishing” — that is, they lacked characteristics of mental wellness — despite having no diagnosis of mental illness. Meanwhile, about 16 percent had been diagnosed with mental illness but nevertheless showed healthy levels of mental wellness. A later study by researchers at the University of California, San Diego, found that even among individuals with schizophrenia, 38 percent described themselves as happy. It is possible to live well with illness.
Yet, mental wellness is often overlooked as a factor in mental health. Of the four main goals outlined by the National Institute of Mental Health — the world’s largest mental health research funder — in its latest five-year strategic plan, none were directly related to mental wellness or well-being. A recent review reported that, whereas 94 percent of studies on youth depression measured symptoms of illness, fewer than one in 10 measured wellness outcomes like personal growth, relationships, or quality of life.
When mental health is framed primarily in terms of illness, care providers tend to characterize their patients in a pathology-focused language. In our current system, for instance, doctors are taught to ask patients about a checklist of symptoms, and to prioritize those symptoms in their diagnoses and treatment plans. But studies show that when people with mental illness are asked how they define recovery, they tend to set goals not just for remission of symptoms but for mental wellness. I have found in my own work that it is helpful to ask patients not only about symptoms but about what makes them feel happy, healthy, and whole; it provides me an opportunity to align my treatment goals with theirs.
Although it takes additional effort, prioritizing mental wellness may ultimately save time and resources. Studies have shown that people with high levels of mental wellness are less likely to develop future mental illness. In one study that tracked adults over a period of 10 years, people whose wellness declined from high levels over that period were more than eight times as likely as those who retained high levels of wellness to be diagnosed with a new mental illness. These and other findings underlie what’s known as the promotion and protection hypothesis: the idea that bolstering a person’s mental wellness early on may act as a preventative strategy to lessen the incidence and severity of mental illness later.
To promote mental wellness on a system level will require new terminology, structure, and tools. What would that look like?
Perhaps psychiatrists, instead of only asking patients if their symptoms of mental illness have eased, would be trained to ask about how medications have affected a patient’s happiness and ability to experience positive emotions. Therapists, rather than merely asking a person about what’s wrong, could spend more time reflecting on the feelings of joy and the wins since the previous session. Insurance companies could consider reimbursing policy holders for services that promote mental wellness, such as life coaches, self-help resources, and other services that have traditionally been outside of mainstream medicine. And it should become standard for all mental health research to track outcomes associated not only with distress and illness but with mental wellness.
In other words, the entire mental health care system — clinicians, insurers, researchers, policymakers — must take ownership of mental wellness. In the short run, this could mean integrating additional work into an already overburdened system. But in the long run, it may be a necessary step to build a more robust and resilient mental health care system — and to foster a happier and healthier society.
Jeffrey Lam is a resident psychiatry physician and researcher at Cambridge Health Alliance in Cambridge, Massachusetts.