Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.
A young woman who voluntarily comes to the emergency department for help dealing with suicidal thoughts ends up in handcuffs in a police car. Her crime? She lacks health insurance, so she must be transported to a state hospital. A man with severe anxiety stays in a crowded, windowless emergency department for more than a week. The reason? The hospital has no open psychiatric beds, and other hospitals nearby refuse to accept someone with drug-related issues. And following a suicide attempt, a teenager must travel 200 miles from her parents’ home to reach the closest available psychiatric facility.
These examples come from my two-plus decades in medicine, spanning my years as a student through today as a professor of psychiatry at Duke University School of Medicine. They underscore the painful reality that many patients and their family members experience as they seek vital mental health care. A 2024 West Health/Gallup survey put a number to it: 75% of U.S. adults reported feeling that mental health issues are identified and treated worse than physical health issues.
Although we live in a time when everyone from politicians to professional athletes to the woman at the grocery checkout seems willing to share their emotional struggles, we as a society often ignore the alarming obstacles that people seeking help for their mental distress face. This problem grows from a powerful root: a health care system built on the assumption that the mind and the body basically exist on different planets.
And while there are many fingerprints at this crime scene, the medical profession must accept its responsibility and start seeing patients’ physical and emotional selves as truly interconnected. Given escalating concerns that the United States is in the midst of a mental health crisis, the status quo marginalization of mental health care hurts us all.
The problem begins early in medical training. The overriding focus on learning to identify and treat disease places far greater significance on diagnostic tools such as lab tests and X-rays than on the skills of interviewing and observing patients. Over time, medical students and young doctors too often become conditioned to think of “body” medicine as objective and essential, while “mind” medicine is much squishier and ultimately less valuable.
Back in medical school, before I began to appreciate the value of psychiatry, several of us spent one morning during a break between lectures complaining that the time we were spending on our psychiatry rotation was “wasteful” and would have been better utilized doing shifts in the emergency department or working in other medical and surgical subspecialty hospital settings. The consensus was that students who wanted to treat psychiatric patients should attend a different type of graduate or professional school where that was their sole focus.
That division between physical health and mental health we sought would have made sense if body and mind were indeed separate from each other. Instead, a recent national analysis found that more than 15% of primary care visits focused on mental health concerns such as depression and anxiety. Additional data suggests that this figure exceeds half of primary care encounters when health concerns known to have a large emotional and behavioral component, such as tobacco use and weight-related problems, are included. And these same issues are important not just to primary care doctors, but to medical providers across a range of disciplines. That’s because when mental health issues are not addressed, medical outcomes — for heart disease, stroke, cancer, obesity, and many other diseases — suffer.
Unfortunately, the type of psychiatry we learn in medical school often fails doctors who encounter patients in need of mental health care. Most students rotate through inpatient facilities, where they see patients in severe emotional distress receiving complex and aggressive medication treatments. The vast majority of these learners receive minimal or no exposure to outpatient care, the setting where more than 80% of patients receive mental health treatment.
So instead of meeting people who are being treated for depression, anxiety, or post-traumatic stress disorder who are navigating life in the outside world, the formal psychiatric exposure that most future doctors receive is almost exclusively crisis-mode mental health care.
Seeing a young man restrained and forcibly injected with medicine, for example, has little relevance to counseling a person on how to stop smoking or cope with the emotional strain of living with diabetes. A major culprit that doctors cite as a contributing factor in burnout is the mismatch between what they’ve been taught in medical training and the skills required in actual practice. The marginalization of mental health training doesn’t just fail patients: It fails doctors too.
On the flip side, psychiatrists treating those with severe mental illness too often do so in isolation from other physicians. Most psychiatric patients die prematurely from heart disease, cancer, stroke, and lung diseases. Put more simply, having a mental health problem is bad for your physical health. And in the end, people on both sides of the physical versus mental divide are harmed: Patients with physical health problems need better mental health treatment, and those with severe mental illness need better general medical care.
These long-standing problems beg for solutions.
One of the best-known options is the collaborative care model, which works to integrate mental health services into primary care and other medical disciplines. Studies done in various settings and locations show that collaborative care increases the likelihood that patients will receive mental health treatment, improves patient and provider satisfaction, and reduces the burden of depression, which complicates various medical conditions such as heart disease.
For more than a decade, I have worked in various outpatient clinics where I have experienced this approach up close.
A team of psychiatrists, psychologists, nurse practitioners, clinical social workers, and mental health nurses all interact directly with primary care providers (PCPs) as they see their patients. In some cases, the primary care doctor wants a psychiatrist’s input on which medication to prescribe or to have a mental health nurse follow up with a patient sooner than the PCP can. At other times, a patient might benefit from brief psychotherapy. And then there are those whose struggles are more intense: Our team is available to see them in a “warm handoff” to provide care quickly and smoothly. The reality that a patient can see their primary doctor for a routine visit and then, if needed, immediately see a mental health professional a few doors away can help reduce stigma around help-seeking and disabuse people of the notion that emotional challenges are somehow distinct and less significant concerns.
It can also be lifesaving. Some years ago, I was able to see a patient with depression immediately after his primary care visit because I was right down the hall. It was only after he felt better several months later that he confided how depressed he’d really been at first: He had created an elaborate plan to kill himself before he saw me. He’s since told me many times that my presence there that day saved his life.
This integrated arrangement has improved my relationship with the primary care doctors with whom I collaborate, as we have a better appreciation for the unique challenges our specialties face as well as for our shared mission to help our patients.
And while the collaborative care model is most widely implemented and studied in primary care, the truth is that mental health impacts patients and treatment outcomes in all medical disciplines. Patients seem to increasingly understand that reality, as a recent survey revealed that 70% of Americans expressed a preference that health care providers ask about both their physical and mental health concerns during medical appointments. As one wise leader in the integrated health care model told me, “There needs to be a layer of mental health care around every medical service.”
At the same time that we must reform medical practice, we must also modify how we train the next generation of doctors.
Most medical students will not become psychiatrists, but virtually all will provide medical care for those whose mental illness may complicate or interfere with treatment. How we expose them to the array of people who suffer psychiatric distress will impact their future practice.
It is in that spirit that for nearly a decade, I have been teaching a course for medical students that goes beyond the traditional inpatient clerkship. Among the varied sessions is a visit to a local clubhouse designed to support the recovery of people with severe mental illness. There, these individuals receive assistance with education, job training, healthier eating, and establishing a supportive social network.
Some years ago, a student in this class saw a young woman he’d encountered months earlier while rotating on the inpatient psychiatric unit. When he’d first met her, she was actively psychotic and unable to participate in her treatment. Nearly a year later, she was calm, coherent, and actively planning for a hopeful future. The student was perplexed: His exposure to mental illness during his psychiatric clerkship had already conditioned him to think that people with schizophrenia never really got much better. He wrote an insightful essay thanking me for this opportunity to see mental illness more broadly, while promising to take that experience with him into his future medical residency and fellowship in cardiology or oncology.
Ultimately, we need to break down the stubborn barriers that isolate the mind from the body in our systems of education and practice. People with physical problems are prone to emotional suffering, and those whose issues we deem psychological inhabit bodies in need of care. The more we can embrace that approach as we build hospitals, devise health systems, and teach the future generation of health care providers who will care for us in our time of need, the better off we will all be.
