De-Prioritizing Treatment for Mental Illness May be Due to Flaws in Reasoning

By Kelsey Berry

In a recent article in Science Translational Medicine, former NIMH Director Steve Hyman explores possible reasons for the policy failure to prioritize treatment of mental disorders worldwide, even when evidence and cost-effective interventions are available and validated.

Hyman notes a number of potential factors, loosely falling into four categories.

  1. Stigmatization challenges;
    • Fear of the severely mentally ill
    • Superstitions about the causes of mental illness
    • Attribution of imagined moral flaws or weaknesses to sufferers or their families
    • Belief that mental health professionals are in the profession because they are similarly troubled
  2. Scientific challenges;
    • Relatively slow scientific progress and translation of discoveries into clinically useful diagnostics and therapeutics
  3. Advocacy challenges;
    • Diminished ability of the mentally ill to advocate effectively for themselves
    • Low commercial advocacy due to difficultly in discovering marketable treatments
  4. Flaws in reasoning;
    • A tendency to focus on saving lives versus improving them – a problem that puts most non-lethal disabilities at a disadvantage in priority setting
    • A tendency to distinguish mental disorders from other “biologically based” disorders that we do not control, due to the subjective experience of one’s own (healthy) mind

Though none of the categories above are without normative dimensions, the last category raises two clear points worth mentioning just now. 

Mortality versus Morbidity

First, identifying as irrational a human tendency to favor life-saving over life-improving relies on a normative conception of health and the proper role of the health system. Though few would disagree with a broad definition of health as encompassing both quality and quantity of life dimensions (see, for instance, WHO, Daniels, Nussbaum, Sen, and others), it is not obvious how these two dimensions should be balanced in priority setting. Giving greater weight to mortality versus morbidity concerns, or vice versa, is not necessarily a flaw in reasoning.

Perhaps, as Hyman seems to suggest, the flaw in reasoning occurs when policy makers acknowledge the significance of both dimensions, but nevertheless ignore data on the relative contribution of each dimension to ill-health. Still, it is not clear from this that policy makers are acting incoherently when they set priorities that deviate from the data: if policy makers disagree with the compilation of the data, and how composite measures establish the relative weights of non-lethal and lethal disabilities, then their priority-setting may be justifiably inconsistent with the data.

Of course, policy makers are also beholden to their constituencies. A tendency to prioritize life-saving interventions versus life-improving interventions may not reflect a hero complex, or disagreement with how composite measures of population health are constructed, but a desire to produce results both communicable and valuable to the public. This brings us back to some of the advocacy challenges mentioned above.

Interestingly, the prioritization of improvements in mortality (whether due to a cognitive flaw, a justifiable weighing of the dimensions of health, or a reflection of public interest) may become part of the UN’s Sustainable Development Goals for 2030. A well-developed proposal by a diverse research team suggests setting as the SDG health target the avoidance of 40% of premature deaths in each country over 2010-2030, and improvement in health care at all ages. The former part of the proposal could be criticized for placing excessive focus on mortality related goals, at the expense of morbidity related goals. However, the researchers advocate effectively for setting a concrete goal that is justifiable and intuitive for policy makers; while also relying on data that shows morbidity tracks mortality quite closely at the national level.

Control versus No Control

In any case, mental illness remains at an uncertain position relative to other disabilities that contribute the majority of their burden in loss of quality of life — in part due to the second potential cognitive flaw raised by Hyman. Hyman notes that people may fail to recognize mental disorders as biologically based disorders, outside the control of individuals. He postulates that this may be because (mentally healthy) individuals are familiar with their own minds, observing some continuity between their thoughts, reasons, and actions. In other words, we assume we are autonomous. Extending this view on our autonomy may lead individuals to postulate that mental disorders should be controllable by the patient.

This flaw, if it leads to misplaced beliefs about personal responsibility for mental disorders and the success of treatment, seems a viable candidate underlying the deprioritization of mental disorders in policy making. Barring a longer discussion here, we might simply ask ourselves: how do our current systems for dealing with the mentally ill – such as the justice system – reinforce these misplaced beliefs about personal responsibility?

kelseyberry

kelseyberry

At the conclusion of her fellowship year, Kelsey Berry was a PhD candidate in health policy and ethics at Harvard University. She holds a BA in political philosophy and neuroscience from Princeton University. Kelsey's research interests include theories of justice in global health, partiality and fairness in resource allocation, and ethical issues in the health of vulnerable populations. Kelsey was a 2014-2015 Student Fellow at the Petrie-Flom Center, during which she worked on a research project entitled "Rights and Duties Against Conditional Funding Agreements in Global Aid." The paper presents a normative argument for holding global health development assistance channeled through non-governmental organizations to standards of egalitarian justice, and assesses PEPFAR's "anti-prostitution pledge," which was challenged in a landmark 2013 Supreme Court case, relative to these standards. Kelsey's other work includes empirical research on issues in mental health policy, like assessing progress in achieving equitable insurance coverage for mental health disorders subsequent to the 2008 federal mental health parity law and the Affordable Care Act. She planned to continue such work with the Department of Health Care Policy at Harvard Medical School, and on a 2015-2016 training grant with the National Institute of Mental Health.

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