“Do you have a friend that’s struggling with their mental health?” reads a yellow public service billboard at a Towson University bus stop. The other day on Facebook, one of my suggested invites was to an “Opioid Overdose Awareness BBQ” hosted by a local nonprofit. I started writing this essay in September, which is Suicide Prevention Awareness Month. In a few months it will be May, also known as Mental Health Awareness Month.
I live in the state of Maryland. Next door in Pennsylvania, Governor Tom Wolf launched Reach Out, PA: Your Mental Health Matters in January of this year. The statewide multiagency initiative promises to provide “access to affordable mental health care,” to “implement more trauma-informed approaches in education, health care, the criminal justice system and other government institutions,” and to expand suicide prevention training.
“By raising awareness of the normalcy and importance of mental health care, others will be less fearful of the stigma,” Wolf’s office said.
An older and more comprehensive state mental health program exists in California. Implemented in 2004, Each Mind Matters (SanaMente, for Spanish speakers) aimed “to transform the community mental health system from a crisis-driven system to one focused on prevention and wellness and to expand services to reach previously underserved populations and all of California’s diverse communities.”
The program is funded by a 1 percent tax on income over $1 million dollars, and the state of California estimates that it has collected $15 billion in revenue since it began. This revenue funds mental health services across the state, provides a comprehensive database of mental health services by location, and issues grants to people and organizations working on projects related to mental health in the state. Like Reach Out, PA, Each Mind Matters also emphasizes the goal of raising awareness, ending stigma, and “amplify[ing] voices.”
But it’s not just government and nonprofit organizations promoting mental health awareness. Brands, too, have gotten in on the action. In May 2020, Jansport backpacks launched #LightenTheLoad, a campaign targeted at Gen Z that sponsored, among other things, Instagram Live conversations with mental health professionals. In 2018, luxury clothing retailers Saks Fifth Avenue and Lord and Taylor partnered in a campaign called “The Future Is Stigma Free,” which sold “exclusive” T-shirts bearing said slogan, sales of which benefited Bring Change to Mind, “a non-profit focused on ending the stigma and discrimination surrounding mental illness.”
And in honor of Mental Health Awareness Month in May 2019, Burger King debuted a limited-edition collection of “Real Meals” in conjunction with the nonprofit Mental Health America. Each Real Meal was named for a different emotion: the “Pissed Meal” to signify anger, the “Blue Meal” to signify sadness, and the “DGAF Meal” to signify, one presumes, indifference.
Whether they’re backed by brands, nonprofit organizations, or government entities, campaigns telling us to “reach out,” “get help,” and become “aware” of mental health issues have become ubiquitous across the United States. These initiatives are attempts to deal with a series of public health emergencies in the country. Between 1997 and 2017, the national suicide rate rose 33 percent, with the steepest increase occurring after 2006. In 2018, 39 percent of Americans told the American Psychiatric Association that they felt more anxious than they did the year before. And opioid overdose deaths have risen to epidemic levels. According to the Centers for Disease Control’s most recent data, the national opioid overdose death rate rose by 9.6 percent between 2016 and 2017.
And this was all before the Covid-19 pandemic and its attendant economic crisis. According to the results of a Kaiser Family Foundation poll in August, 53 percent of adults said that their mental health had taken a downturn because of worry and stress related to Covid-19, up from 32 percent in March. Even more dire findings were published by the Centers for Disease Control this summer, which conducted a survey finding that one-quarter of adults between the ages of 18 and 24 had considered suicide in the previous 30 days.
Responding to these crises with messaging about awareness does make some sense. In some populations—among men, for instance—there is still a stigma around seeking mental health services. And it can be therapeutic to see a billboard telling you you’re not alone. But these campaigns have always bothered me, both as a therapist and as someone who has been in therapy and on medication for decades to deal with my generalized anxiety disorder. Campaigns telling people to become “aware” and “reach out” strike me as—at best—an incorrect diagnosis of the problems at hand. At worst, they feel like gaslighting. In my experience—both professional and personal—most people are already aware of their own mental health. And what they’ve found is that it sucks.
Most people looking for care couldn’t simply “reach out,” as the billboards would have it, even if they wanted to. There are months-long wait lists for providers, and care isn’t cheap. Many providers don’t take insurance, meaning that people end up having to cough up at least $150 per session for a psychotherapist and $250 for a psychiatrist. Even if you find a clinician who accepts insurance, most insurance providers still require a co-pay, and $30 to $50 per week adds up, especially in a country where almost half of people don’t have $400 on hand for an emergency.
Even if we lived in a country where everyone could immediately be seen by excellent providers they could afford, there would still be problems with framing our mental health crises as a matter of awareness. Many people have legitimate reasons for feeling anxious and hopeless. A small selection: Americans work long hours while wages remain low and unemployment remains high. We are living through a pandemic that has killed more than 400,000 Americans and shows no signs of being effectively contained. Being murdered by police is a leading cause of death for young Black and Latino men, and many high-profile police killings of people of color have gone practically unpunished. We may have crossed planetary tipping points that would make climate change compounding and irreversible. By many measures, the United States is a failed state. Is it any surprise that more and more Americans are escaping these realities through drugs and even suicide?
In context, it’s hard not to find mental health awareness campaigns glib, reductive, and insulting. Too often, they pathologize normal reactions people are having to oppression and deprivation. But I wanted to hear what other people had to say. So I put out an informal request on Twitter, and within hours, dozens of people had contacted me to share their thoughts. Interviews have been edited and condensed for clarity, and some names have been withheld for privacy.
“Hate the campaigns,” said Toby, a construction worker diagnosed with major depressive disorder and anxiety. “They constantly swat at the flies while there’s a 20-foot pile of shit right behind them.”
“I find them generally well intentioned,” said Whitney, a law student who has an eating disorder. “Destigmatizing mental health needs is still incredibly necessary, especially when done in a culturally responsive way. However, I do not find them to be a replacement for actual policy solutions. Further, I find that story campaigns that don’t push at policy solutions do not effectively address the structural barriers to care.”
For others, the one-size-fits-all quality of what amounts to an ad campaign fails to speak to their experience. “I generally think mental health awareness falls into describing mental illness as either something it isn’t, such as being the same as a broken limb; or basically just describes depression and no other mental health issues,” said Alex, a writer diagnosed with bipolar disorder.
Many of the respondents told me they were already receiving mental health services—medication, therapy, and inpatient treatment. Almost all emphasized that their problems are exacerbated by their immediate financial circumstances.
“Knowing that if I have another mental breakdown like I did last year then my fiancé and I will be homeless makes me feel like the Sword of Damocles is just hovering over every choice I make,” Toby said.
“We have a fight-or-flight response to job issues and anything that may prevent our ability to work because everything depends on having a job, even health care, even if you’re too sick to work,” said Katrina, a project manager diagnosed with C-PTSD. “I’m in so much debt from school it’s a joke. I’ll never get out of debt. Combine that with paying for therapy and psychiatric meds, and paying for hospital stays and so on, there’s very little breathing room. Housing insecurity has laid additional layers of stress and trauma on me. It’s nearly impossible for me to imagine a future where all of us are experiencing less suffering.”
Rudolf Virchow—often called “the father of modern pathology”—said in the 19th century that “politics is nothing else but medicine on a large scale.” Virchow was instrumental in developing the field of public health, theorizing that a typhus epidemic in the Prussian region of Upper Silesia in 1847 and 1848 was caused by people living in unsanitary conditions due to poverty.
Virchow made a distinction between what he called “natural” and “artificial” epidemics. “Natural” epidemics occurred relatively evenly across all social classes, and included dysentery, malaria, and pneumonia. Artificial epidemics, on the other hand, occurred at much higher rates among the poor and were caused directly by the conditions under which poor people lived. Thus, artificial epidemics had an inherently political character. For Virchow, artificial epidemics included typhus, scurvy, tuberculosis, and—notably—mental illness.
More recent researchers have found similar links. In 2015 the economists Ann Case and Angus Deaton identified a phenomenon they called “deaths of despair.” They studied middle-aged whites without college degrees between 1999 and 2013, and found that the life expectancy for this group was going down because of an increase in overdoses and suicides.
Case and Deaton’s work has become a must-read among Washington policy-makers for its research into the ways that unemployment and poverty have contributed to the opioid and suicide crises in the United States. Equally alarming, but notably less publicized, is the opioid crisis in communities of color. In 2018 law student Keturah James and psychiatrist Ayana Jordan published a study showing that rates of opioid deaths over the past five years have been rising more steeply among Blacks than whites. There is also evidence suggesting that opioid use is on the rise in many immigrant communities.
Poverty is a major contributing factor to poor mental health outcomes. A study in 2019 found that in counties where automotive plants closed, opioid overdose rates rose by 85 percent after five years. And a 2020 study that looked at suicide rates and the minimum wage between 1990 and 2015 found that for every dollar the minimum wage is raised, the suicide rate decreased by 3.5 to 6 percent.
There are also specific ways that being part of an oppressed group impacts your mental health. Experiences of structural oppression—based on race, sexual orientation, gender, disability status, age, and more—are a major cause of stress. Stigma related to gender and sexual orientation contributes to higher rates of suicide and drug use among LGBTQ populations. Videos of police violence are a source of trauma, especially for people of color. There are also unique mental health problems related to the experience of immigration, and living in fear of ICE causes an incredible amount of stress.
On top of all this, the American Psychological Association published a report in 2017 on the effects of climate change on mental health. The report found that there are growing rates of “eco-anxiety,” or “a fear of environmental doom.” This makes sense given scientific realities. There is a growing number of people experiencing trauma related to natural disasters. And groups particularly affected by both eco-anxiety and disaster-related trauma include indigenous communities, poor people, communities of color, women, children, older adults, and people with disabilities or chronic illnesses.
Richard Wilkinson and Kate Pickett are two British epidemiologists who have spent their careers studying the effects of inequality on physical and mental health. In their 2018 book The Inner Level, they published their findings that societies with higher levels of inequality have worse mental health outcomes—even for the wealthy. I asked Richard Wilkinson what he thought about mental health awareness campaigns.
“I wouldn’t get very excited about mental health awareness,” he said. “I think it’s much more important to understand the causes.”
According to Wilkinson, it is not only poverty but inequality itself that is the primary cause of recent mental health crises. Central to this is the concept of the “social-evaluative threat,” a technical term for a dismayingly ordinary experience: worrying what other people think of you.
“If you’re in a situation where your self-esteem, your self-confidence, how other people judge you is in question, your cortisol levels are much more likely to go up,” he said. “Cortisol is a central stress hormone. People throughout the whole social hierarchy—not just at the bottom—react very badly to being treated as inferior. More inequality means that there are higher levels of social anxiety [and] status anxiety all the way across the population. Not just the poorest but even the richest tenth of the population show more status anxiety in more unequal societies. Inequality is upping the stakes around issues to do with dominance and subordination.”
The chaos and destruction of the present political moment also take a toll on mental health. Respondents to my informal survey who were more financially secure said that despite their material situation, the political, ecological, and philosophical quandaries of our era have affected how they feel on a day-to-day basis.
“I’ve probably been the most angry I’ve ever been in my life during this recession pandemic, and it comes out in episodes of depression and anger and annoyance much of the time,” said Kevin, a nurse diagnosed with ADHD and bipolar disorder. “I read about the political situations all over and it’s so constantly dire, but no movement toward resolution ever occurs. It’s just spiking anxiety with no relief.”
“Like many disabled people I live in a state of rage, which is not conducive to maintaining my mental health,” said Kathy, a lawyer. “That being said, I am also an incredibly privileged disabled person with the opportunity to advocate for changes to these systems. Too many of my friends and colleagues are suffering in these systems, and upholding the status quo is unacceptable.”
What awareness campaigns tend not to acknowledge is that mental health and politics are inextricable. “The campaigns are fine,” said another of my respondents, Dharna. She’s a climate journalist who struggles with anxiety and panic attacks. “Destigmatizing mental illness and raising consciousness about mental health are fine. But they don’t really do anything to change people’s material conditions.”
According to Wilkinson, people concerned with reducing the mental health crises should focus on treating the causes of inequality. He supports redistributing wealth through the creation of more progressive income tax systems and the closing of tax havens. He also suggests some kind of wage cap. He also believes in expanding democracy in the workplace through worker coops and other forms of collaborative economies and employee representation on company boards. A more equal and democratic society is a less stressful society, which is better for our mental health.
“I feel like pretty much every policy I want—Medicare for All, getting rid of at-will employment, guaranteed housing—would improve mental health conditions,” Dharna said. It’s time to move beyond awareness—not only toward more treatment, but toward actually solving the problems that create so much distress.
Anything less is just swatting at flies.