31.2 The Mental Health Crisis

The Origins of the U.S. Mental Health Crisis

According to a White House briefing, “our country faces an unprecedented mental health crisis among people of all ages.” Specifically, “two out of five adults report symptoms of anxiety or depression. And, Black and Brown communities are disproportionately undertreated—even as their burden of mental illness has continued to rise” (The White House, 2022). Even before the COVID-19 pandemic, rates of depression and anxiety were rising. Loneliness and social isolation during the pandemic exacerbated these trends, with increasing numbers of children reporting thoughts of suicide and self-harm.

Mental health services in the United States are insufficient to address this crisis. A majority of Americans (76 percent) report that they consider mental health as important as physical health, and more than half of Americans (56 percent) seek mental health services (National Council for Mental Wellbeing, n.d.). Americans seeking these services tend to be younger, with lower incomes, and often from military backgrounds. Among Americans seeking treatment, 96 million (38 percent) have had to wait over a week for mental health treatments. A National Council for Mental Wellbeing study found that a large percentage of Americans want to seek treatment for mental health issues for themselves or loved ones but have not done so in part because they do not know where to go. What’s more, 53 million American adults (21 percent) have wanted to see a mental health professional but were unable to for reasons outside of their control including lack of insurance, an available provider, transportation (private or public), and child care, as well as geographical isolation, conflicting work or school schedules, or domestic violence issues. Gen Z (born between 1997 and 2012) and millennial (born between 1981 and 1996) Americans are less sure about available resources for mental health services compared to older generations. The National Council for Mental Wellbeing study suggests that these younger generations are also more likely to find it difficult to distinguish legitimate mental health resources online, turning instead to unreliable social media resources, including Facebook, YouTube, and Twitter, for information (National Council for Mental Wellbeing, n.d.).

The Ongoing Global Expansion of a Mental Health Crisis

Behavioral health disorders are on track to become the number-one cause of disability worldwide, surpassing all other illnesses. For example, one in four people globally experience mental disorders, more than those with cancer, diabetes, or heart disease (Clubhouse International, 2023). Half of those with mental disorders begin to show signs of the disease by age 14 but often take more than 10 years to get treatment (National Alliance on Mental Illness [NAMI], 2023). Worldwide, suicide has become a global epidemic with 90 self-directed deaths every hour, which calculates to nearly 2,200 people/day, 800,000/year. Ninety percent of these suicides are directly related to mental health disorders (World Health Organization [WHO], 2019, 2022a).

Globally, mental illness (MI) now accounts for 30 percent of the overall burden of the health care industry, yet only 3 percent of the world’s health care budget goes toward providing mental health care services (WHO, 2016). This imbalance highlights the need for nurses to be savvy in mental health assessment and treatment strategies.

The Effects of Stigma, Prejudice, and Discrimination on Mental Health

The social stigma associated with mental health continues to be a barrier to seeking help (American Psychiatric Association, 2023). In this context, stigma refers to negative attitudes that disparage a person with a mental health condition. This stigma causes many individuals to delay seeking treatment. According to a National Council for Mental Wellbeing study (n.d.), nearly one-third of Americans, or 31 percent, have worried about others judging them when they told them they have sought mental health services, and over a fifth of the population, or 21 percent, have lied to avoid telling people they were seeking mental health services. Stigma is an especially acute problem among younger Americans. Among respondents in a National Council for Mental Wellbeing study, 49 percent of Gen Z respondents (born between 1997 and 2012), 40 percent of millennial respondents (born between 1981 and 1996), 30 percent of Gen X respondents (born between 1965 and 1980), and 20 percent of baby boomer respondents (born between 1946 and 1964) indicated that they have worried about others judging them when they say that they have sought mental health services.

Stigma often comes from lack of understanding or fear. Inaccurate or misleading representations of mental illness contribute to both of those factors. A review of studies on stigma shows that while the public may accept the medical or genetic nature of a mental health disorder and the need for treatment, many people still have a negative view of those with mental illness.

According to the American Psychiatric Association (2023), researchers identify different types of stigma:

• Public stigma involves the negative or discriminatory attitudes that others have about mental illness.
• Self-stigma refers to the negative attitudes, including internalized shame, that people with mental illness have about their own condition.
• Institutional stigma, which is more systemic, involves government and private organizations’ policies that intentionally or unintentionally limit opportunities for people with mental illness. Examples include lower funding for mental illness research or fewer mental health services than other health care services.

General prejudice, a preconceived negative opinion not based in facts, toward people with MI may predispose people to dislike and/or disrespect others with a specific diagnosis, such as schizophrenia or depression (American Psychiatric Association, 2023). Prejudiced attitudes toward people with MI range from discomfort with having them as a neighbor to avoiding someone because of their diagnosis. Researchers studying prejudice and MI identified four dimensions underlying prejudice: fear/avoidance (fear of people with MI and the desire for social distance from them), unpredictability (belief that the behavior of people with MI is unpredictable), authoritarianism (belief in the need to control people with MI), and malevolence (lack of benevolent attitudes and belief in inferiority of people with MI) (Kenny et al., 2018).

Discrimination, unfair treatment based on irrelevant characteristics, is an ongoing challenge for those diagnosed with MI. Americans are familiar with the idea that refusing employment to a person based on their gender, race, or sexuality is unfair and amounts to sexism, racism, or homophobia. Although discrimination based on MI can be more subtle, it negatively affects the individual’s quality of life and career. According to the Americans with Disabilities Act National Network (2023), discrimination based on mental illness includes:

• Terminating an employee based on the discovery of their MI
• Assigning an employee bad or inconvenient shifts or assignments
• Making insulting jokes about the MI
• Failing to make reasonable accommodations for the employee with MI
• Offering only poor working conditions
• Not allowing the employee to miss work for medical appointments
• Not allowing the individual enough time to complete tasks

Stigma, prejudice, and discrimination directly affect individuals with MI and the loved ones who support them. In some communities, MI stigma is a barrier to obtaining mental health services. For example, in some Asian cultures, seeking professional help for MI may be counter to values of strong family, emotional restraint, and avoiding shame (NAMI, 2019). Distrust of the mental health care system prevents individuals from certain racial and ethnic groups from seeking care; this is often seen in Black communities (African American Wellness Project, 2023).

The Nurse’s Role in Addressing the Mental Health Crisis

Nurses are in a unique position to recognize mental health concerns, as they are often the first to connect with a client and can swiftly establish rapport with them, starting all interactions using the steps of the TIC Approach. As trusted advocates, nurses can provide the compassion that clients may need at a difficult time and can help them access treatment. Nurses must be aware of the potential impact of stressors on their clients and how these may manifest in a crisis. Population health nursing focuses on the common good of the population in addition to individual client health. The public health/community health nurse may work with individuals, families, and groups to implement changes to mental health services that affect an entire community or population.

Nurses use a systematic process to assess health status, identify resources, and develop programs to improve mental health in communities. The first step is to create a therapeutic nurse-community (as client) relationship. The nurse establishes an understanding of who the community as client is, what is occurring in their lives, and what resources are available by assessing demeanor, beliefs, and support systems to determine if a specific health issue or environmental situation is progressing to a crisis state. Crisis intervention is an important role for the nurse and health care team, as they can work swiftly to develop effective resolutions. During the crisis intervention process, the client develops new skills and coping strategies, resulting in change. A crisis state is time-limited, usually lasting several days but no longer than 4 to 6 weeks. Using the nursing process in crisis resolution planning, nurses implement therapeutic interventions based on the stage of the crisis to assist the individual.

The foundational goals of crisis intervention include (Caplan, 1964):

• Identification, assessment, and intervention
• Swift return to a prior level of functioning
• Lessening negative impact on future mental health

Various factors can influence an individual’s ability to resolve a crisis and return to equilibrium, such as realistic perception of an event, adequate situational support, and adequate coping strategies to respond to a problem.