May 29, 2019

The Changing Face of Mental Health

Q&A with John Oldham, M.D., M.S.

In conjunction with Mental Health Awareness Month, we talked to Dr. John Oldham to get his insight on the prevalence of mental health issues today, the progress we are making in addressing the need for access, and the outlook for making mental health a priority alongside our physical health.

How prevalent are mental health issues today?

In the media and in our culture, we’re seeing an increasing awareness of the prevalence of mental health issues.  But what many will find surprising is that this isn’t a new concept – it’s one that’s starting to catch on. In the early 1990s, Ronald Kessler of Harvard University was the principal investigator of the National Comorbidity Survey, the first nationally representative survey of the prevalence and correlates of psychiatric disorders in the U.S. He found that the lifetime prevalence of major categories of psychiatric disorders was 46%. Around that same time, the U.S. Surgeon General’s Office produced its first report on mental health, finding that 20% of the population experienced a mental disorder in any given year – and half the people with mental illness decline to seek treatment.  A replication of the National Comorbidity Study was published in 2005, showing that the lifetime prevalence of these combined disorders was still 46%.

It may seem surprising that almost half of the general population will have a mental illness at some time in their lives.  But compare that to the fact that more than 99% of us will have a physical illness in our lifetime.  And brain disorders can be just as disabling as chronic physical conditions, or more so.

Clearly, mental-health challenges are persistent and pervasive.

The studies and data have been there for decades, and while I believe we are making progress in getting people help, I also believe we still remain unaware of just how many people currently are, or have the potential to be, affected in their lifetime with behavioral health issues.

How does this prevalence of mental health compare with other major diseases?

In 2010 the National Quality Forum analyzed “high-impact conditions,” ranking the top 20 conditions that account for 95% of Medicare costs. Depression was the No. 1 condition – higher than heart disease, diabetes, breast cancer, or other major medical categories. And the World Economic Forum found that mental health was more costly than any other major medical condition. The brain has the distinction of being the most complex organ in the body, but it doesn’t have the history of being treated with prominence like other organs and diseases.

These numbers seem remarkably high. Why do you think that is?

Experts believe there are several underlying reasons. First, patients haven’t historically sought treatment or acknowledged they have a mental health issue due to both lack of awareness and stigma. One study found that two out of three patients subsequently diagnosed with major depression initially presented with physical symptoms to their PCP – such as fatigue, pains, or other symptoms that are common early signs of major depression – and so depression initially went undiagnosed.

Second, setting aside hereditary/physiological factors, it’s clear that the world is changing. The pace is faster, the media is more diverse, and it’s more challenging for people to create and sustain an environment for mental health. Our culture is in part driving prevalence, while at the same time it is also bringing awareness.

Is stigma still a barrier to effective care?

It is. For example, according to the World Health Organization (WHO), 350 million people suffer from depression, but it’s widely undiagnosed because of stigma, which is a stubborn problem.

But there are other factors, too.  Ineffective protocols and a lack of access to trained clinicians are also important obstacles to be addressed.

When we think of illnesses affecting other organs in the body – the heart, the lungs, the pancreas – we don’t view them as signs of weakness. But it’s a pervasive and pernicious notion that an illness in the brain – the most complex organ we have – is somehow a deficiency in the individual. That has to stop – and we’re making progress.

What about access?

This is a huge issue. People simply can’t get appointments with psychiatrists to get treatment. Almost half of the world’s population lives in a country with only two – two psychiatrists per 100,000 people.

With virtual care, we have a proven way to address both stigma and access. Telemedicine for mental health is discreet, providing care for patients on their terms – when and where they are able to have appointments. And it’s available.

What “grade” would you give the healthcare profession when it comes to mental health awareness?

That’s hard to judge. We’re certainly not pulling down As just yet, but we’re making real strides. Depression and other mental illness are coming out of the closet – and awareness is increasing.

In my opinion, the key is to shift from a paradigm of “mental illness” to one of “mental wellness.” This aligns with a person-centered modality of care and lets us focus on prevention and wellness before issues can develop.

How does this affect employers and how can they address the challenges?

Undiagnosed mental illness – anxiety, depression, substance abuse, or other conditions – creates problems that are often hidden or indirectly visible on the job. So-called “presenteeism” can bring down productivity while employees struggle to cope with unfamiliar burdens.

Employers can proactively offer education opportunities for mental wellness in the form of workshops, paid time off to attend seminars, and other sessions that employees invariably find useful. That’s as important as providing access to care and knowing the signs of mental suffering to help employees identify that they need help.

In my career, I’ve been particularly interested in personality styles and personality disorders.  We have a website ( designed to get people interested in their personalities.  Just learning, for example, what personality profile fits best with what type of job (e.g., manager vs. team player) can lead to better job satisfaction and, potentially, head off anxiety or depression

In the healthcare profession, how would you like to see mental health treatments improve?

I think behavioral health needs to continue to integrate with primary care – perhaps by having mental-health clinicians literally in the same suite as primary-care physicians. That reduces stigma and improves access.

We have to increase our workforce – not just psychiatrists but also nurse practitioners, psychologists, social workers, and other therapists.

And virtual care can play a vital role in all of this. It’s a completely different experience to simply turn on a computer or your smart phone and begin an encounter than to get in a car, drive to a hospital, ask where the psych clinic is, and be identified. Virtual care can create a more comfortable patient experience and can motivate people to seek care sooner, with the ability to lead to better outcomes.

Dr. John Oldham is the distinguished emeritus professor of psychiatry in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine, and he is chief of staff at the Menninger Clinic. He is a past president of the American Psychiatric Association and past chair of the Council on Quality Care that reviews needs for access and assesses evidence-based treatments.a