Adam Lanza, the mentally ill adult who precipitated the 2012 catastrophe at Sandy Hook Elementary School, was not alone. The action of mass shooting followed by suicide has become a far too common one, and one that must be eliminated at all costs. Lanza’s actions demonstrate a broader problem with far-reaching implications on our notions of security and stability. In light of the precedent established by events such as Columbine, Sandy Hook, Virginia Tech, Oak Creek, and Isla Vista, we must ask ourselves: Are we willing to suffer such loss at the hands of an amenable issue of our public health system?
A cyclical and systemic pattern of violence has been, much like an infectious disease, breeding unabated. Rather than applying a Band-Aid solution, the mental health crisis necessitates a long-term patching of the wound through comprehensive and reformative integration policy. Gun control is one aspect of the solution, but mental health is the long-term patchwork and can no longer exist in a vacuum. Without integration into mainstream primary care, these mental health diseases will only continue to grow and result in a greater loss of life.
Mental illness doesn’t subscribe itself to a certain sect of any country’s population: it is found in all countries, in women and men, in rich and poor settings, and in all stages of life. From a medical care perspective, the problem has been organizing mental issues into a separate dimension of healthcare treatments, such as establishing psychiatric care facilities but not facilitating integrated primary care treatments for those with mental disorders. Reports from the World Health Organization show that up to 60% of people who attend primary care clinics have a diagnosable mental disorder. Unless primary care providers are trained to identify these disorders and appropriately respond to them, these diseases will only continue to worsen.
The majority of mental healthcare services illustrate two underlying problems that create the natural schism with primary care. The first problem is stigma. Individuals with mental disorders are often discriminated against, especially in poorer communities where healthcare resources are sparse. For example, when I visited a village named San Marcos in Honduras last year, I met a woman demonstrating symptoms of PTSD following a traumatizing experience of sexual abuse. Rather than help her, the community and the doctors dislodged her from the makeshift healthcare system, telling her the condition would not be treatable given the resources. Moreover, she received no help from her friends. With no one to help her, she had to consult the village priest, the only individual whom she felt confident putting her faith in. This example is far too similar to other global problems. Although this incident occurred in Honduras, the inherent issue exists in every country across the globe, developed or developing.
The second seemingly minute problem has enormous repercussions: unnecessary referral to specialist services. All medical care starts with primary care. Regardless of what condition I have, for example, I must consult a primary care physician first for a preliminary diagnosis. When primary care physicians are untrained in a certain area, they are more susceptible to refer patients to specialist services that may not always be desirable. The translational inefficiencies are massive, stemming from increased costs associated with specialist services, having to put individuals through the burden of further travel (if they come from remote locations), and separating individuals from their families through more severe treatments in facilities further away from home.
Take the case of Juan from Chile. Juan suffered from schizophrenia for a long time, and before his hospital integrated mental care with primary care services, Juan was repeatedly shuffled in and out of a psychiatric hospital, where he suffered human rights abuses. He was separated from his family for an issue that could have been greatly mitigated by his primary care doctors. Upon incorporating mental care provisions with his primary care months later, the World Health Organization reports: “Juan’s condition became well managed and he was able to be reintegrated with his family. He hasn’t been back to the psychiatric hospital for four years now.”
An important concern when considering this hypothetical integration is the associated cost. Past successes indicate that primary care for mental health is very affordable. In fact, many low- and middle-income countries have made the successful transition to integrated primary care for mental health. That being said, it is equally important to realize that varied models tailored to the needs of individual states best fulfill mental health integration. There is no “one-size-fits-all” approach.
Countries that wish to proceed with integration can look to several past examples as models for their own customized programs:
In the Macul District of Santiago, Chile, general physicians have been trained to diagnose mental disorders and prescribe medications where required. Other family health team members and psychologists provide support services and group therapy. Instead of solely concentrating on individual improvements, family health teams provide advice and support to communities of those affected by mental disorders. Data from Chile shows that over time, more people with mental disorders have been identified and treated.
Likewise, in the Ehlanzani District of Mpumalanga Province, South Africa, clinics that accommodated local needs when crafting their integration models saw massive increases in mental healthcare service delivery. Between 1994 and 2007, there was an over 80 percent increase in the number of primary healthcare facilities delivering mental health services.
So, successful examples demonstrate the efficacy of proposals to integrate mental care with primary care. Mental health policy must be supported by legislation and a deeper commitment from governments and healthcare providers to shape directives for medical care reform. The physical harms and related burdens that mental health issues elicit can be mitigated, as can the prevalence of psychiatric care services, where human rights violations are generally greater.
Next time, there can be a preventive solution to Adam Lanza’s disorder—one that can deter predatory aggression that would otherwise culminate in the loss of innocent life.
Bjelopera, Jerome P. et. al. “Public Mass Shootings in the United States: Selected Implications for Federal Public Health and Safety Policy.” Congressional Research Service. March 18, 2013. http://fas.org/sgp/crs/misc/R43004.pdf
Chris Collins. “Evolving Models of Behavioral Health Integration in Primary Care.” 2010. http://www.milbank.org/uploads/documents/10430EvolvingCare/EvolvingCare.pdf
World Health Organization (WHO) and Wonca. “Integrating mental health into primary care: A global perspective.” 2008. http://www.who.int/mental_health/resources/mentalhealth_PHC_2008.pdf