To Improve Mental Health, Let’s Address the ‘Causes of the Causes,’ Expert Says

WASHINGTON — To improve mental health, risk factors related to “social determinants” like food insecurity or inadequate housing need to be addressed, according to some health experts. But even doing that doesn’t go far enough upstream, said one psychiatrist here on Thursday.

“It’s not enough to intervene at the level of the risk factors — [if you do], you’re actually intervening too late,” said Ruth Shim, MD, MPH, a professor of cultural and clinical psychiatry at the University of California Davis in Sacramento. “So I started looking into and trying to understand what is actually happening before the risk factor.”

Those upstream factors are sometimes known as the “causes of the causes,” Shim said at an event sponsored by the Johns Hopkins Center for Mental Health and Addiction Policy. “What’s the context that’s going to set you further upstream from the risk factor?”

The answer is that there are two “very fundamental issues,” she noted. “Social norms, or the belief in common society, about who in our society is worthy of value and who is less worthy of such value; who in our society deserves advantage, and who is less deserving of this advantage. And what are the public policies or the laws that we pass that reflect those belief systems? Because those laws that we pass then create unfair and unjust distribution of opportunity, which set into motion the social determinants of mental health, which then lead to the risk factor, which then leads to poor outcomes.”

Sally Satel, MD, a practicing psychiatrist and a senior fellow at the American Enterprise Institute here, said she recognized that all of these external forces have an effect on patients. “However, as a clinician, you’re at the internal locus of control,” she said. “It doesn’t mean you don’t recognize the constraints and challenges that patients face because [for example] they have terrible housing where no one comes to fix the lock, so when they go out, someone comes in and takes all their possessions. I mean, this is all important stuff.”

“So, again, my job — especially if you’re working with people with addiction, but really anyone who has behavioral problems, is to try to harness that internal locus of control,” she continued. “What can they do? And one of the most important things that I’ve noticed in all these years is that people have to work. Work is the best therapy there is for folks, and the longer you don’t work, the more your skills atrophy and your confidence erodes, and the more reluctant you are to get back in the system. And so that is one of the big agenda items … to just help people stand still so they can reclaim their life.”

Hannah Wesolowski, MPA, chief advocacy officer of the National Alliance on Mental Illness, expressed frustration that even when policymakers see evidence of an intervention that works, they don’t always follow through. For example, take the case of early episodes of psychosis “often hitting teenagers and 20-somethings,” she said. “We have a model that we know works. There was a groundbreaking study at NIMH [National Institute of Mental Health] … and we were able, through public policy efforts, to spread early psychosis programs across the country.”

There are now over 300 programs using the model — known as Recovery After an Initial Schizophrenia Episode (RAISE) — “but we’re still only meeting 10%, maybe 15%, of the need,” she said. “We know this works. We know it improves outcomes for the individual. We know it gets them connected to work, into school, connected with their social network and their family, and leads to better long-term outcomes and reduced hospitalizations. But we don’t provide it to everyone who needs it. We don’t fund it.”

The other thing that’s lacking, according to Brian Castrucci, DrPH, president and CEO of the de Beaumont Foundation here, is bipartisan work on solutions. He noted that in 2022, after he was discharged from the hospital following an emergency department visit and treatment for congestive heart failure, “my wife said to me, ‘You almost died. Why don’t you go talk to someone about that?’ And here I am — a relatively well-off straight white guy living in the suburbs of Maryland — and 3 years later, I have yet to find someone who can see me, [even though] I have all the insurance and I have all the privilege.”

“We’re not going to treat our way out of a mental health problem — we’re going to have to be thoughtful,” he said. “We’re going to have to work together, and hopefully we can use data that come from [RAISE] to say, ‘Look, this isn’t a red problem. It’s not a blue problem. Mental health is purple.'”

But keeping focused on only one’s own healthcare, Castrucci said, “is just a hamster wheel, whether it’s mental health care or physical health care. And you get sick because of where you live or because you’ve lost your job, and they send you to the hospital. You get better. We patch you up, and then we send you back to the thing that made you sick in the first place. We have to break the wheel — policy breaks the wheel.”

One policy intervention that has had a huge positive effect is the development of programs like Head Start, said Shim, of UC Davis. “Any type of early learning intervention, the data are overwhelmingly positive. It leads to better mental health, better employment, better income rates, less incarceration, all of these things 40 years out in the future — that’s how long it’s been studied — and it makes no sense that it is not a universal policy for everybody. [The question is] whether we can expand it and make sure that everybody gets universal pre-K or some [similar] type of intervention.”

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