Policy and Mental Health among LGBTQ

I am currently a hospitalist nurse practitioner working in Hamilton, Montana (MT). I returned to school last fall to further my training in the specialty of psychiatric and mental health, to address a significant need here among hospitalized and non-hospitalized patients alike. Issues pertaining to lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) youth have taken center-stage in my community lately. Recently a rally was held in support of a church organization that withdrew their help from the Food Bank because they had distributed some flyers on LGBTQ equality. MT Senator Theresa Manzella, from Hamilton, was quoted as saying “Now, they (gay people) like to play the protected class card and they’re the minority and they’re discriminated against, and they’re scared to walk down the street hand in hand. I’ve got to tell you, I think those are normal consequences associated with the choices they made. We can’t prevent them from doing that” (Rispens, 2021, para. 21). She stated, “my right to live a righteous lifestyle based on my sincerely held beliefs does not end where their choice to live a perverse lifestyle begins” (Rispens, 2021, para. 18). While Theresa Manzella is correct that the church acted within their rights per their recently passed senate bill (S.B.) 215 (interestingly, Manzella was one of the sponsors of said bill), her words were also particularly damaging to a community already struggling with major health disparities and discrimination, especially among youth and adolescents.  

According to the MT Department of Public Health and Human Services (DPHHS, 2021), suicide is the second major cause of death in children, adolescents, and young adults ages 10-24 nationally. As of 2019, MT ranked number 3 for highest suicide rates in the U.S. Suicide occurs more often in Native Americans, followed by Caucasians, and is overwhelmingly completed via lethal means such as firearms (60%). MT adolescents ages 11-17 have more than twice the rate of suicide, when compared to the national average. Some possible contributing factors include MT’s concurrently high rate of alcohol abuse, social isolation, high poverty levels, lack of mental health care, and the frequently stigmatizing views of mental health issues held by many Montanans. LGBTQ children and young adults are 4 times more likely to attempt suicide than cis-gendered (identifies with gender assigned at birth), straight individuals. LGBTQ youth who have families who do not approve of their sexual orientation or gender identity are more than 8 times as likely to attempt suicide. For each incidence of verbal or physical abuse related to being LGBTQ, the incidence of self-harm more than doubles (DPHHS, 2021).  

The year 2021 will go down in history for its anti-LGBTQ legislation in MT, as well as around the country. MT S.B. 215 (freedom and restoration act) was signed into law April 22 and allows for remediation of situations where the government makes policies or people demand services or treatment that directly conflicts with an individual’s or entity’s ability to practice their religion or faith (S.B. 215, 2021). An example of this bill in action would be the blocking of a requirement for churches to hire LGBTQ staff, business owners to serve LGBTQ customers, and even the medical care of a patient who lives any lifestyle that directly conflicts with the “sincerely-held religious belief” of those caring for them (S.B. 215, 2021, p.2). This bill will impact an LGBTQ population in MT that already has a high rate of attempted suicide and self-harm by allowing direct discrimination towards both adults and children.

MT House Bill (H.B.) 112, also known as the Save Women’s Sports Act, was enacted into law on 05/07/21 and specifically bars youth and young adults from playing on sports teams according to anything but their gender at birth in public elementary, high school, or higher educational institutions, regardless of whether they have entered puberty or are taking testosterone blockers (H.B. 112, 2021). The original unamended bill used sexist language based on popular media sources (some outdated from the 1980s) rather than science, to point out inferiority of female athletic performance when compared to males and used this information to advance the bill as a way of addressing gender disparities (H.B. 112, 2021). Katz and Luckinbill (2017) described the current literature regarding gender and athletic performance as generally showing a higher proportion of high-performing males when compared to females, in areas of speed, endurance, and strength, but also that females with similar body weight, height, and training were capable of outperforming males.  They pointed out that rigorous scientific studies showing testosterone confers a definite and measurable performance benefit are non-existent.  They also noted historical context and treatment differences for females based on stereotypes could make it appear as if males were outperforming females. Females were classically viewed as the weaker sex.  For most of American history, sports were presumed to cause difficulties with fertility and seen as unbecoming.  Title IX was enacted in the 1970s, giving females the right to play on sports teams, but continued to advance stereotypes by not allowing females on teams engaging in full-contact sports or on men’s teams because of their perceived fragility, despite there being no data in support of this view (Katz and Luckinbill, 2017).  Research was not even required by law to include females until the 1990s, and often didn’t for fear of unpredictable effects of the menstrual cycle and the view of women as needing protection (National Institutes of Health: Office on Research on Women’s Health, n.d.). Women were not allowed to participate in all games of the Olympics until 2012 (Katz & Luckinbill, 2017). Most of the testosterone research is related to an over-representation of intersex (having differences in hormone levels or chromosomes not matching gender anatomy or ambiguous anatomy) and other conditions leading to naturally higher testosterone levels in female athletes competing in the Olympics (Handelsman et al., 2018).  I would posit we have no way of knowing if it is an overrepresentation, due to lack of testing for these things in non-athletes.  I would also point out that having medal-winners that are also intersex is not proof that testosterone levels lead to increased performance.  All these studies show is that gender is not binary and there are normal variations to testosterone levels and sensitivity (which cannot even be tested for) even among females (Tannenbaum & Bekker, 2019). Assuming there was a definite link between higher testosterone and athleticism, this point would be mute in pre-pubescent boys and transgender females taking testosterone blockers anyways (Handelsman et al., 2018).  H.B. 112 directly impacts the mental health of the LGBTQ population in MT. Participation in sports often creates mediating effects to mental health issues in youth, and the bill effectively bans transgender females from participating at a time when suicide, depression, and anxiety among transgendered individuals is at an all-time high (Schubert 2021a).

Another bill, S.B. 99, was signed into law on 04/30/21 and prohibits instruction in grade and elementary schools on human sexuality, sexual orientation, gender identity, sexual anatomy, sexually transmitted infections, reproduction, and contraception without first notifying guardians and allowing them to review the curriculum beforehand, with the option to opt-out, and also forbids any provider or entity from participating in these instructive activities, that currently provides any abortion services out in the community, such as Planned Parenthood (S.B. 99, 2021). While sexual education in the schools has always been an opt-out choice for MT parents, the new bill specifically adds sexual and gender minority (SGM) information, in response to schools teaching about SGM inclusiveness. This is particularly damaging. Research by Proulx et al. (2019) showed that schools with LGBTQ-inclusive sexual education had lower rates of LGBTQ student bullying, suicidal ideation, and depression symptoms. Pearson et al. (2021) found that state-level policies supporting LGBTQ inclusiveness resulted in lower rates of suicidality among high school students. 

S.B. 280 was passed on 04/30/21 and makes it so a transgender person may only amend their birth certificate with proof that they have undergone gender reassignment surgery, and the amended status, once approved, will show up on the birth certificate as amended, unless the gender assigned at birth was a mistake and not corrected by surgery (S.B. 280, 2021). Schubert (2021b) wrote that this new requirement would out transgender individuals every time they have to supply identification, to rent a home, to apply for a job, even purchasing alcohol in a bar, would increase bullying and suicidality, and would effectively punish poor people for not having the money to undergo surgical transition. Restar et al. (2020) indicated that transgender individuals are 2-3 times more likely to forgo necessary healthcare or medical interventions due to fear of discrimination. Over 65% of those surveyed had experienced discrimination within the community. The intersectionality of transgender and other minorities such as race made it even less likely that a transgender person was able to undergo sex reassignment surgery. Restar et al. (2020) completed a study that showed lower rates of depression, anxiety, somatization (development of physical complaints related to mental health issues), and emotional distress associated with the amendment of legal identification, regardless of the ability for surgery or hormone therapies. S.B. 280 simply puts these outcomes out of reach for the majority of transgender Montanans.  

The upstream issues related to MT policies on LGBTQ people include the size of the community (mostly rural), religion (high proportion of religions who view LGBTQ as a choice and a sin), education levels, and exposure. Stifling authentic living by LGBTQ youth results in internalization of shame and hiding sexual orientation and gender identity. The more hidden this becomes, the more likely a community is to see LGBTQ as other and according to stereotypes. One of the greatest successes in the fight for LGBTQ rights has been the visibility of this group within our communities, in our families, in the media, and as friends and loved ones. This creates cognitive dissonance with the stereotypes and leads to the view of LGBTQ as regular humans with differences and similarities, much like cis-gendered straight people. Visibility in the religious community is also important.  Gay people can be Christians. Transgender people can live a life helping others. LGBTQ people can be your doctor, dentist, psychiatrist, and nurse practitioner.  

References

Handelsman, D. J., Hirschberg, A. L., & Bermon, S. (2018). Circulating testosterone as the hormonal basis of sex differences in athletic performance. Endocrine Reviews39(5), 803.

H.B. 112, 67th legislature, 2021 Reg. Sess.  (MT. 2021).  Retrieved Nov. 30, 2021, from https://legiscan.com/MT/text/HB112/2021

Katz, R. S., & Luckinbill, R. W. (2017). Changing sex/gender roles and sport. Stanford Law & Policy Review28(2), 215–244.

Meadows, E. (2018). Sexual health equity in schools: Inclusive sexuality and relationship education for gender and sexual minority students. American Journal of Sexuality Education13(3), 297–309. https://doi.org/10.1080/15546128.2018.1431988

Montana Department of Public Health and Human Services.  (2021, Jan).  Suicide in Montana: Facts, figures, and formulas for prevention.  Retrieved Nov 28, 2021, from https://dphhs.mt.gov/assets/suicideprevention/SuicideinMontana.pdf

National Institutes of Health: Office on Research on Women’s Health.  (n.d.).  History of women’s participation in clinical research.  Retrieved Dec. 1, 2021, from https://orwh.od.nih.gov/toolkit/recruitment/history

Pearson, J., Wilkinson, L., & Wooley-Snider, J.L.  (2021).  State-level policy, school victimization, and suicide risk among sexual minority youth.  Sexual and Gender Minority Health, 21, 65-101. https://doi.org/10.1108/S1057-629020210000021009

Proulx, C. N., Coulter, R. W. S., Egan, J. E., Matthews, D. D., & Mair, C. (2019). Associations of lesbian, gay, bisexual, transgender, and questioning: Inclusive sex education with mental health outcomes and school-based victimization in U.S. high school students. Journal of Adolescent Health64(5), 608–614. https://doi.org/10.1016/j.jadohealth.2018.11.012

Restar, A., Jin, H., Breslow, A., Reisner, S. L., Mimiaga, M., Cahill, S., & Hughto, J. M. W. (2020). Legal gender marker and name change is associated with lower negative emotional response to gender-based mistreatment and improve mental health outcomes among trans populations. SSM – Population Health, 11. https://doi.org/10.1016/j.ssmph.2020.100595

Rispens, S.  (2021, Nov. 18).  ‘God, Country, Family’ tour stops in Clinton to support pastor accused of hate speech.  Retrieved Nov. 29, 2021, from https://www.montanarightnow.com/news/state/god-country-family-tour-stops-in-clinton-to-support-pastor-accused-of-hate-speech/article_af9fbb65-3824-50d4-b8a7-43d97a1703da.html

S.B. 99, 67th legislature, 2021 Reg. Sess.  (MT 2021).  Retrieved Nov. 30, 2021, from https://legiscan.com/MT/text/SB99/2021

S.B. 215, 67th legislature, 2021 Reg. Sess. (MT. 2021).  Retrieved Nov. 29, 2021, from https://trackbill.com/bill/montana-senate-bill-215-establish-the-religious-freedom-restoration-act/2026371/

S.B. 280, 67th legislature, 2021 Reg. Sess.  (MT 2021).  Retrieved Nov 30, 2021, from https://legiscan.com/MT/text/SB280/2021

Schubert, K. (2021a, May 7).  Transgender sports bill signed into law: Opponents warn of bill’s economic and social impacts.  Daily Montanan.  Retrieved Nov. 30, 2021, from https://dailymontanan.com/2021/05/07/transgender-sports-bill-signed-into-law/

Schubert, K.  (2021b, June 17).  Opponents: This is a life or death matter.  Daily Montanan.  Retrieved Nov 30, 2021, from https://dailymontanan.com/2021/06/17/opponents-this-is-a-life-or-death-matter/

Tannenbaum, C. & Bekker, S.  Sex, gender, and sports.  BMJ, 364, l1120.  https://doi.org/10.1136/bmj.l1120

Cervical Cancer and Henrietta Lacks

Disparities, or differences, in the incidence and outcomes of cervical cancer exist.  Our current understanding of cervical cancer and human papillomavirus were born of a situation that parallels some of the same issues that exist today, while highlighting the reasons behind changes to rules about informed consent.  One cannot write about cervical cancer without discussing Henrietta Lacks.  Henrietta Lacks was an African American woman who was treated for her cervical cancer in 1951 at Johns Hopkins Hospital in Baltimore, one of the few institutions that would provide care for low-income people of color at the time (Johns Hopkins medicine [JHM], n.d.).  The tumor was biopsied and then Lacks underwent surgery and radiation.  However, she ended up dying from the cancer months after diagnosis, in a segregated ward (Kaylin, 2006).  On autopsy, it was discovered that the aggressive cancer had metastasized throughout her body (Sands, 2010).  According to JHM (n.d.), during that same timeframe researchers were trying desperately to grow human cell lines from samples taken from patients, albeit unsuccessfully.  Informed consent was not something that was routinely obtained or required.  When Lack’s doctor biopsied her tumor, the cells were sent to a researcher, Dr. Gey, who tried to grow them out, just as he had done to countless other tumor samples.  Until these cells, attempts at culturing would end with cell death within 36 hours.  In the case of Ms. Lacks, her cells rapidly multiplied, and in fact, continue to do so today.  They have been named HeLa cells for the first two initials of Henrietta Lacks first and last name (JHM, n.d.).  HeLa cells have been used for medical research on HIV, cancer, in vitro fertilization, and to create vaccines such as HPV, polio, and COVID-19 (Cramer, 2021). 

So why did HeLa cells survive and replicate when no other human cell lines had?  The first thing was that they were infected with the virus human papillomavirus (HPV).  HPV acts by inserting its DNA into the host cell nucleus where the chromosome (cell DNA) is located, thereby creating mutations that might bypass the body’s defenses or make infected cell lines more resistant to them (Kaylin, 2006).  In the case of Henrietta Lacks, the virus caused mutations that interrupted the normal cell p53 function responsible for repairing mutations in normal body cells and stopping tumor growth, which resulted in unchecked division and growth (Kaylin, 2006).   All DNA viruses (RNA viruses work a little different) cause mutations this way, and the discoveries obtained from working with HeLa cells eventually led to knowledge about the link between a number of different viral infections and cancers, such as hepatitis B and C to hepatocellular carcinoma, Epstein Barr virus (EBV) to Burkitt lymphoma and nasopharyngeal carcinoma, and human T lymphotropic virus type I to adult T cell leukemia/lymphoma (Kaylin, 2006).   Second, Henrietta Lacks was also infected with syphilis, postulated to be a gift from an unfaithful husband, and this caused changes in her cervix and immune function that predisposed her to HPV infection and subsequent aggressive tumor growth (Sands, 2010).  Third, HeLa cells have overactive telomerase, which is an enzyme that adds repeating sequences on the end of chromosomes, thus making them immortal (Ivanković et al., 2007).  Normal chromosomes have telomeres at the end, which have protective functions, and become shorter each time a cell divides and replicates (the definition of aging interestingly).  Once the chromosome becomes short enough, this serves as a shut-off for cell replication, and prevents out-of-control growth, such as what occurs with tumors (Ivanković et al., 2007; Sands, 2010).    

This all relates back to health disparities because of what happened to Henrietta Lacks immortal cell line.  Let me start by saying that the initial researcher that grew out HeLa cells never profited from them (Sands, 2010).  He freely shared the cells around the world.  Again, obtaining informed consent was not standard in that time (JHM, n.d.).  Lacks presented to an institution willing to provide care for African Americans (unfortunately rare then), and she received full treatment for her cervical cancer (JHM, n.d.).  The cervical cancer’s particularly aggressive nature is probably what led to its immortality, and because the cancer tolerated pretty much any growth condition, growing conditions could be experimented with and this led to knowledge about culturing less hardy human cells later (Sands, 2010).  According to Stump (2014), eventually over 11,000 medical patents would exist on HeLa cells, and they would be mass produced and sold by for-profit institutions.  Her entire genetic code was mapped out and posted on the internet, potentially violating the privacy of living relatives.  The family was not informed of the cell line until a news article outed this information.  Researchers also obtained blood samples from family members without explaining the reason, and family were allowed to believe they were being tested for some condition, rather than as subjects of study.  Biotech companies commercialized and then profited off the cell line, all the while the Lacks family were never compensated (Stump, 2014).  

Today, health disparities continue for racial minorities and low-income women, both of which are embodied by the life of Henrietta Lacks.  According to Olusola et al. (2019), African American women are more than 60% more likely than Caucasians to get cervical cancer and they are more likely to be diagnosed at later stages.  Hispanic women have even higher rates of cervical cancer and poorer outcomes, and this difference cannot be accounted for entirely by differences in screening rates.  Low-income women are less likely to undergo routine screening per recommendations due to inability to pay, and so are more likely to be diagnosed at later stages of disease.  The same can be said of women who live in rural or remote areas.  They forgo routine screening due to geographical location, and as a result, present with later stages of cervical cancer (Olusola et al., 2019).  Bryant (2021) described various factors which may contribute to these health disparities, including cultural norms such as who can do a pelvic exam and whether or not this causes shame, implicit bias such as the provider assuming that a lesbian would not need screening for HPV because she does not engage in vaginal-penile sex, healthcare system issues such as access to affordable care, and sociocultural issues such as poor health literacy or lack of transportation to healthcare visits.  

References

Bryant, A.  (2021, Sept 13).  Racial and ethnic disparities in obstetric and gynecologic care and role of implicit biases.  UpToDate.  Retrieved Nov. 16, 2021, from https://www.uptodate.com/contents/racial-and-ethnic-disparities-in-obstetric-and-gynecologic-care-and-role-of-implicit-biases?search=health%20disparities%20cervical%20cancer&source=search_result&selectedTitle=6~150&usage_type=default&display_rank=6

Cramer, M.  (2021, Oct 13).  Henrietta Lacks, whose cells were taken without her consent, is honored by W.H.O.  The New York Times.  Retrieved Nov. 16, 2021, from https://www.nytimes.com/2021/10/13/science/henrietta-lacks-cells-who.html

Ivanković, M., Cukusić, A., Gotić, I., Skrobot, N., Matijasić, M., Polancec, D., & Rubelj, I. (2007). Telomerase activity in HeLa cervical carcinoma cell line proliferation. Biogerontology, 8(2), 163–172. https://doi.org/10.1007/s10522-006-9043-9

Johns Hopkins Medicine.  (n.d.).  Honoring Henrietta: The legacy of Henrietta Lacks.  Retrieved Nov 16, 2021, from https://www.hopkinsmedicine.org/henriettalacks/

Kaylin, J.  (2006).  The virus behind the cancer.  Yale Medicine magazine.  Retrieved Nov 16, 2021, from https://medicine.yale.edu/news/yale-medicine-magazine/the-virus-behind-the-cancer/

Olusola, P., Banerjee, H.N., Philley, J.V., & Dasgupta, S. (2019). Human papilloma virus-associated cervical cancer and health disparities. Cells, 8(6), 622. https://doi.org/10.3390/cells8060622

Sands, J. M. (2010). The Immortal Life of Henrietta Lacks. Jurimetrics, 51(2), 131–140.

Stump, J. L. (2014). Henrietta Lacks and the HeLa cell: Rights of patients and responsibilities of medical researchers. History Teacher, 48(1), 127–180.

Herd Immunity

Herd immunity is a method of preventing the spread of an infectious disease through achieving a high rate of natural or vaccine-acquired immunity within a population (Biscontini, 2020). Herd Immunity reduces or eliminates the spread among the unprotected and protected alike.  Herd immunity is not so much a function of getting a disease or not, but rather preventing transmission of the disease-causing organism, with immunity falling upon a spectrum depending on immune function, health, environment, and individual, causative organism, and society factors (Robertson, 2021).  Robertson supported this idea of a spectrum by providing examples of many factors that lead to herd immunity.  He discussed brucellosis in cattle, the so-called contagious abortion, and how isolating the mother cow and allowing her to recover left both her and her offspring usually immune to further disease.  He pointed out that free range animals are far less likely to contract disease than those kept in enclosed spaces, such as dairy cows.  He wrote about infecting parasites and mechanism of spread (e.g., how easy it was to spread and exposure to risk factors for spread such as eating undercooked infected meat).  He also discussed diphtheria and the partial immunity among poorer schoolchildren that had repeated low-dose exposures within their crowded communities and were thereby less susceptible to severe infection.  He described antigenic shift (small changes to an organism over time that changes how it infects, how infective it is) in influenza virus, and how that affects resistance to new variants of influenza related to being previously infected with others.  Robertson wrote that eventually the term herd immunity came to be known as a function of how many individuals were immune (a binary event), which has led to the misunderstanding of the term amongst the public.  Note that all previous examples indicated chance rather than complete protection.  People who are vaccinated can often still get and transmit the disease-causing organism, and likewise those previously infected with the organism can be infected again.  Herd immunity is rather a balance achieved between a host, an infecting organism, and the herd, or population of interest, resulting in reduced or eliminated disease transmission (Robertson, 2021).  

Lets consider for a moment that a mother brings in her baby for immunizations, but states that she wants to skip the ones due this month, because she figures that herd immunity will protect her baby. Again, based on the definition above, herd immunity refers to resistance to spread, rather than individual infection (Robertson, 2021). Herd immunity is an important topic to discuss when trying to control disease transmission that is, or previously was, rampant and resulted in poor outcomes in terms of mortality and morbidity (death and disability respectively).  It is not so important when discussing individual protection for a baby.  This mother is likely seeing herd immunity as a binary, and as an individual protective strategy, which it is not.  For example, in the current coronavirus 2019 (COVID-19) pandemic, people choose to get vaccinated because they are either worried about getting infected for the first time or again (individual immunity), or they are worried about infecting their elderly or immunocompromised loved ones (herd immunity), or both.  Relying on herd immunity does not protect the baby from infection, rather it protects the population from transmission.  

This visit with the mother and infant should be used as an opportunity to discuss this mother’s fears and concerns.  There are several common fears that lead to vaccine hesitancy, including the belief that immunizations such as MMR can cause autism (based on a fraudulent Wakefield study published in 1998 and subsequently retracted), vaccines will cause the disease or make a child very ill, and parental beliefs that children are no longer at risk for the diseases vaccines protect against (Pluviano et al., 2019).  Some parents are also distrustful of pharmaceutical companies and believe they are just out to profit off children and adults, and others believe that receiving multiple vaccinations at once overwhelms the immune system, leading to significant problems later in life (Geoghegan et al., 2020).  The article by Geoghegan et al. (2020) lists common vaccine myths and then goes over the evidence against each systematically and could be used as an excellent source for educating parents.  

References

America’s Health Rankings.  (2020).  Annual report: Childhood immunizations.  Retrieved Nov. 7, 2021, from https://www.americashealthrankings.org/explore/annual/measure/Immunize_b/state/MT

Biscontini, T. (2020). Herd Immunity. Salem Press Encyclopedia of Health.

Centers for Disease Control and Prevention (CDC).  (2021).  Immunization schedules.  Retrieved Nov 7, 2021, from https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html#note-mening

Geoghegan, S., O’Callaghan, K. P., & Offit, P. A. (2020). Vaccine Safety: Myths and Misinformation. Frontiers in Microbiology, 1–7.

Pluviano, S., Watt, C., Ragazzini, G., & Della Sala, S. (2019). Parents’ beliefs in misinformation about vaccines are strengthened by pro-vaccine campaigns. Cognitive Processing, 20(3), 325–331. https://doi.org/10.1007/s10339-019-00919-w

Robertson, D. (2021). Of Mice and Schoolchildren: A Conceptual History of Herd Immunity. American Journal of Public Health, 111(8), 1473–1480. https://doi.org/10.2105/AJPH.2021.306264

Saslow, R.  (2015, Feb 19).   Where are all the anti-vaxxers?  The Washington Post.  Retrieved Nov. 7, 2021, from https://www.washingtonpost.com/news/parenting/wp/2015/02/19/where-are-all-the-anti-vaxxers/

The Problem with Addressing Mental Health and Burnout

Medicine has historically addressed health as a function of treatment of disease. Due to soaring costs and increased focus on evidence-based medicine, there has been a movement towards preventing disease and promoting health, and this holds true for mental health as well. The burden of mental health is high, with 46% of adults having experienced at least one mental illness during their life (Misra et al., 2021). According to the Substance Abuse and Mental Health Services Administration (SAMHSA) and Center for Mental Health Services (CMHS, 2007), benefits of prevention programs include money savings, such as that realized by lower resource utilization with acute care services, special education and disability programs, and foster care among others, and reduction in expenses associated with incarceration or inpatient psychiatric treatment. Treating mental illness early results in an interruption of the processes that lead to disproportionate chronic conditions in its sufferers with inordinate use of healthcare services. The “human capital” benefits to disease prevention and health promotion include individual contributions to society such as gainful employment, community service, and safety. An example of safety as a human capital benefit is illustrated when programs reduce incidence of drunk driving and result in lower harms and costs associated with accidents caused thereof. Finally, one cannot put a price on the benefit of quality of life achieved from health promotion and disease prevention (SAMHSA & CMHS, 2007). 

 
        Unfortunately, the United States (U.S.) faces some major hurdles for implementation and maintenance of health promotion and disease prevention processes in mental health. Stigma is “negative beliefs and actions including prejudice (stereotypes) and discrimination (behavioral manifestations of prejudice)” and encompasses stigma from society, organizations and laws, other individuals, or self (Misra et al., 2021, para. 4). Misra et al. found that stigma resulted in “financial, healthcare, and legal barriers to mental health services” (para. 21) such as the high cost of psychiatric medications, application process for social programs, and availability of quality programs for undocumented immigrants and incarcerated patients. They also pointed to communication-based stigma as problematic, in that mental health information often was not available in the right language or at the reading level of patients needing service. Stigma as related to feelings about mental illness from family, friends, and self could lead to concealment of symptoms or diagnosis, feelings of burdening loved ones, low self-efficacy, and self-isolation. They indicated that stigma arose from a lack of knowledge about mental illness, including beliefs about this as a moral failing, something that interferes with the value of an individual, contagious, a failure of family to appropriately raise or parent, and stereotypes about what a person with mental illness is capable of (Misra et al., 2021).  


        Fragmentation of care can be especially dangerous in terms of mental health treatment and health. Patients with psychiatric diagnoses are more likely to have substance abuse issues, engage in risky or dangerous activities, attribute lower importance to diet and exercise, more likely to be of lower socioeconomic status, and may be in unsafe environments (Ward & Druss, 2019). Increased complexity of care, cost, and specialization has led to providers providing in-depth care in their respective specialties, but major aspects get missed when patients do not have access to all specialties needed either due to lack of specific providers, cost, patients feeling overwhelmed with the care they already require, and time constraints for both the patient and providers (Timmins et al., 2021). When specialties are unavailable, patients struggle to get any care, even from the providers they do have available to them. Primary care will not manage psychiatric medications they have been on for years. Psychiatric providers feel uncomfortable counseling on diet and exercise. Screenings get missed. According to Koven (2013) over a third of mental health care is provided in the U.S. by primary care providers, mostly due to a lack of mental health providers. This ties into the next problem in the U.S.  


       Availability of affordable mental health services is problematic. According to Walter et al. (2017), 43.1% of patients surveyed went without mental health care because they could not afford it. They wrote that the Affordable Care Act (ACA) of 2010 reclassified mental health care as an essential medical service and required insurance companies who cover it to reimburse similarly to that covered for medical or surgical care. The preexisting condition clause of ACA made it illegal to deny care based of previously diagnosed conditions, and this extended to mental illness. The ACA also started requiring mental health screenings /preventative care to be reimbursed at 100% (Walter et al., 2017). Unfortunately, this does not address the lack of mental health providers, or the patients not covered by insurance. The U.S has 268.6 mental health providers from all specialties for every 100,000 population (Health and Human Services [HHS] & Centers for Medicare and Medicaid Services [CMMS], 2020). This includes specialties such as psychiatrist, phycologist, counselor, and psychiatric and mental health nurse practitioner (PMHNP). HHS & CMMS wrote that “one in 5 Americans experienced some form of mental illness (not including substance abuse disorders) in 2019, but only 44.8% of adults with any mental illness and 65.5% with a serious mental illness reported receiving treatment in the last year” (para. 5). Most counties within the U.S. are currently experiencing a mental health professional shortage, and this is only expected to get worse with the current coronavirus 2019 (COVID-19) pandemic.  


        These major challenges are highlighted in my community by the current struggle with healthcare worker burnout during the COVID-19 pandemic. According to Kelly et al. (2021), professional burnout is “the occupational exhaustion, disconnect, and lack of personal accomplishment associated with one’s work” (para. 9). Previously viewed as an individual health concern, the World Health organization (WHO) changed the definition to designate burnout as an “occupational phenomenon” just prior to the pandemic (Kelly et al., 2021). There are three distinct components of burnout that can occur in concert or as a progression: emotional exhaustion, cynicism, and reduced feelings of making a difference or self-efficacy (Howell, 2021). According to Howell (2020), exhaustion happens when nurses and other healthcare personal are asked to work overtime, take more complex patients in areas of medicine they haven’t traditionally been trained for, reduced resources such as ventilators and trained nurses, lack of self-care and recovery, new and changing protocols, upsets in routine, insomnia, lack of communication, and strained communication within the interdisciplinary care team. This eventually leads to moral distress “when a person acts in a way that goes against an established ethical and moral response to a situation… Institutional and structural limitations have placed nurses in positions where they must make a series of decisions, shift after shift, minute by minute, which run counter to their training, responsibilities, and often, their personal beliefs” (Hossain & Clatty, 2021, p. 27). According to Howell (2021), cynicism is the depersonalization of patients to allow emotional distance between them and the healthcare worker, as a defense mechanism. Lack of self-efficacy leads to shame and reduced productivity. All of this results in increased rates of depression, anxiety, post-traumatic stress disorder, substance abuse, insomnia, poor self-care, and suicide (Howell, 2021). 

 
        Stigma, availability of care, and fragmentation of care are at the root of the problem with burnout. Let us say that one hospital is addressing this by bringing in speakers for an hour to speak about burnout, followed by a 15-minute appointment with a counselor if you are willing to wait around after the lecture. This is during time off. There have been no requests for staff input into what will help prevent or mitigate burnout. There is no push for nursing empowerment. This hospital used to offer influenza vaccination on nightshift, so these workers wouldn’t have to come back to the hospital to get them, on their day off or during sleeping hours. This year is the first year that they are requiring all staff to come to a vaccine clinic during normal business hours. Hospital staff have started to have communication issues and anger between departments. Management’s response has been that we need to accommodate those angry reactions because everyone’s stress level is high right now. People are called in to work extra shifts at all times of the day and night. People are working extra shifts and guilted if they do not sign up for any. Maybe vacation time has been canceled and put on hold. Nurses are taking more patients than what was previously established as safe staffing ratios. There are too few intensive care unit nurses, so they are being paired with a medical-surgical nurse “helper” so they can take more patients. People are feeling bad about the care they are providing, and no one is recognizing their hard work. The kitchen has been closed to staff for some time now, as to discourage congregation during the pandemic.   Perhaps the hospital did create a program to address burnout, involving coming in early for mandatory meetings for staff to discuss how they are feeling and how they are going to address the current crisis. But they probably did not ask frontline staff for input before implementing and putting further demands on their very precious personal time.     

There is shame in seeking mental health help. Healthcare workers notoriously have had a culture of stoicism and focus on patients’ needs before their own. All of this is in the setting of a much greater shortage of mental health professionals than what is average in this country. Insurance often covers a select group of mental health professionals, some of whom may not be accepting new clients right now. Maybe my personal mental health professional is not covered. No one has time for preventative care, and most are worried about increased contact with the public, given the massive numbers of COVID-19 patients we are seeing every night. Three weeks ago, Montana had the highest COVID-19 cases in the country (Schabacker, 2021). 

References

Health and Human Services, Centers for Medicare & Medicaid Services. (2020, Sept). National Plan and Provider Enumeration System, United Health Foundation.  America’s Health Rankings analysis of U.S. Retrieved Oct 24, 2021, from AmericasHealthRankings.org
Hossain, F., & Clatty, A. (2021). Self-care strategies in response to nurses’ moral injury during COVID-19 pandemic. Nursing Ethics, 28(1), 23–32.         https://doi.org/10.1177/0969733020961825
Howell, B.A.M. (2021). Battling burnout at the frontlines of healthcare amid COVID-19.  AACN Adv Crit Care, 32(2): 195-203. https://doi.org/10.4037/aacnacc2021454
Kelly, L. A., Weston, M. J., & Gee, P. M. (2021). A Nurse Leader’s Guide to Reducing Burnout: Strategies to Improve Well-Being. Nurse Leader, 19(5), 467.            https://doi.org/10.1016/j.mnl.2021.03.012
Koven, S. (2013, Oct 21). Should mental health be a primary-care doctor’s job?  The New Yorker. Retrieved Oct 24, 2021, from https://www.newyorker.com/tech/annals-of-technology/should-mental-health-be-a-primary-care-doctors-job
Misra, S., Jackson, V. W., Chong, J., Choe, K., Tay, C., Wong, J., & Yang, L. H. (2021). 
Systematic review of cultural aspects of stigma and mental illness among racial and ethnic minority groups in the United States: Implications for interventions. American Journal of Community Psychology.https://doi.org/10.1002/ajcp.12516
Schabacker, E. (2021, Oct 19). Montana leads country in COVID cases per 100K.  Billings Gazette. Retrieved Oct 24, 2021, from https://billingsgazette.com/news/local/montana-leads-country-in-covid-cases-per-100k/article_b33f0833-20ef-5cce-a4c6-520aeee485c6.html
Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.  (2007). Promotion and prevention in mental health: Strengthening parenting and enhancing child resilience.  DHHS Publication No. CMHS-SVP-0175. Rockville, MD.  
Timmins, L., Kern, L., Ghosh, A., Urato, C., & Rich, E. (2021). Predicting fragmented care: Beneficiary, primary care physician, and practice characteristics. Health Services Research, 56, 60–61. https://doi.org/10.1111/1475-6773.13782
Walter, A.W., Martinez, L.S., and Lopez, L.M. (2017). Mental health care in the Affordable Care Act Era: Harnessing the power of communities. In S.J Rosenberg and J. Rosenberg (Eds.), Community mental health: Challenges for the 21st century (3rd ed., pp. 314-322). Routledge.  
Ward, M. C., & Druss, B. G. (2019). Treatment considerations in severe mental illness: Caring for the whole patient. JAMA Psychiatry, 76(7), 759–760.         https://doi.org/10.1001/jamapsychiatry.2019.0903