"That is 28 percent of the adults right here in our community," said Drew Wilder, emcee for the 2022 Shape of the Region Conference and a reporter with NBC4 Northern Virginia. There were 300 attendees at the March 15 conference put on by The Community Foundation of Northern Virginia with 17 regional partners.

Complex barriers hinder access to basic mental health care such as early intervention, counseling and medication, Wilder said. The conference's two presenters and panels of state and national experts expanded on the issues.

Keynote speaker Regina S. James, M.D., deputy medical director and chief, Division of Diversity and Health Equity for the American Psychiatric Association, said what worries her the most is that some of the over 500,000 individuals in Northern Virginia who are now suffering from depression and anxiety do not have access to the treatment they need. Mental illness and substance use disorders should be identified sooner than later. Early detection, diagnosis, and treatment, according to James, can improve productivity and attention at work and school. "It gives you the motivation to get up and do things… It allows you to overcome that," James said.

"Bottom line, we are all suffering."

— Regina S. James, M.D., American Psychiatric Association

The most important considerations in obtaining mental health care are cost and insurance coverage, James said. Shortage of practitioners who can recognize, diagnose, and treat the disease also results in lengthy waits for appointments. Difficulties navigating the system, lack of transportation, and stigma, are also issues.  

Some people also do not recognize they need help. "It is not easy to identify markers to say that there is something wrong, so people find it difficult to grasp the concept that there is actually something wrong," James said. Mental illness and substance use disorders are costly to society and individuals who do not get assistance. Mental and physical health are inextricably linked.

"For every dollar invested in scaled-up treatment for depression and anxiety, there's a $4 return and better health and productivity," James said. Personal repercussions of untreated mental illness include interference with daily activities, loss of productivity, and the capacity to build relationships and perform at work or school. Overdose and suicide are also risks.

When it comes to unmet mental health needs, certain communities or groups face a disproportionate share of the burden. "Those who are marginalized and disenfranchised," James said. These groups include racial and ethnic minorities, LGBTQ+ people, people experiencing homelessness, people who are incarcerated, immigrants, and people with serious mental illnesses and drug addictions. Treatment for mental health and substance abuse issues varies widely among young people, especially those of color, in terms of availability and quality.

James went on to warn that the COVID-19 pandemic is impacting mental health and that the effects would last for years. Since the pandemic began, students have been four months behind in reading and five months behind in math. Among teenage girls, ER visits for attempted suicide rose 51 percent.

According to James, college-age people and those early in their careers have the highest unmet mental healthcare needs, with women having a substantially higher rate. The trend continues among individuals through mid-career and those beyond age 65.

"Bottom line, we are all suffering," James said. However, navigating mental health services and receiving treatment may be challenging since it is difficult to know where to begin and how to seek out someone with whom the individual can relate.

James discussed methods and government policies for addressing unmet health needs. The collaborative care paradigm is the most cost-effective. It is holistic, encompassing both physical and mental components. "Once you tell your primary physician that you are having these mental health issues, there is a warm hand-off, so to speak, so that the psychiatrist can then take on the issues," she said.

President Joe Biden's Fiscal Year 23 budget proposes doubling funding for primary and behavioral health integration programs and authorizing Medicaid reimbursement of inter-professional consultations so that primary care providers can consult with a specialist. The Fiscal Year 23 Budget recommends improving rate parity. All health plans must require behavioral health treatments with a sufficient provider network and three behavioral health appointments each year at no cost to the individual receiving them. 

Regarding the treatment of substance abuse disorders, James notes that the latest 2022 Mental Health Parity and Addiction Equity Act Report to Congress indicates that companies continue to violate some of the act's provisions for mental health and addiction. "The good news is that agencies are continuing to try and place more rigorous enforcement of this act," James said. Treatments should be covered like other medical illnesses.

James said that addressing social needs like food insecurity, transportation, and housing can improve mental health. The Accountable Health Communities Innovation model aims to address a critical gap between clinical care and the health-related social needs of Medicare and Medicaid beneficiaries.

Finally, James explained that as of July 1, 2022, new federal legislation mandates all states have a call number for individuals to seek quick and appropriate treatment for mental health or drug use emergencies. Similarly, to dial 911 for a local emergency, 988 will be a dedicated call-in line for dispatching trained personnel. They will respond to mental health and substance use emergencies, now handled chiefly by law enforcement.

Elizabeth Hughes, senior director, Insight Region for Community Foundation for Northern Virginia, presented a companion report to the day's event. Before the pandemic, around 8 percent, 150,000 of the adult population in Northern Virginia experienced active symptoms of a mental health disorder. The rate rose to 39 percent, or approximately 600,000 adults, a year into the pandemic before leveling off at 545,000.

Around 1 million persons in Northern Virginia, or more than half of the local adult population, reported feeling tension in the recent two weeks, with 14 percent feeling that way daily. Worry is slightly less, 870,000 adults, which is 45 percent of our population, felt worried, and 11 percent felt this way daily. All told, those symptoms together, 24 percent are experiencing clinical anxiety levels, Hughes reported. 

Loss of interest or pleasure, coupled with sadness and feeling down, represents a positive screen for depression. "In Northern Virginia, 770,000 adults reported feeling one or both of these feelings, and around 18 percent met the clinical threshold for depression, Hughes said. "Together, anxiety plus depression is what we are talking about when we say a mental health disorder."

According to Hughes, one in every two NOVA residents between the ages of 18 and 30 shows clinical levels of anxiety and depression. The same goes for LGBTQ+ people. About one in two is experiencing clinical levels of anxiety and depression. By race and ethnicity, the rates are closer to one-third of Hispanics.

There is a positive visual relationship between income and mental health. Those with resources that are not having trouble paying their monthly bills are still not fine, but they are better off than the population experiencing acute financial need.

Hughes said, "Among those who reported it was very difficult to pay their monthly expenses, two-thirds are experiencing a mental health disorder. It is very, very high."

Hughes qualified that not everyone with anxiety or depression needs or wants to seek mental healthcare. However, in NOVA, 40 percent of the people who want mental healthcare cannot get it. "My analysis revealed that half of the therapists do not accept any kind of insurance in Northern Virginia, with a going rate for self-pay at around $215 for a 45-minute session," Hughes said.

Panelists' Discussion Highlights (Text lightly edited.)

Q: If you could change something about the current system to make it more responsive to our needs, what would it be?

A: We would increase the number of licensed behavioral health professionals. The good news is that, as terrible as the situation is now, there are ways that we can dramatically improve it. Some of those are underway as we speak. We need more psychiatric residencies in Virginia. The General Assembly is considering that now. Senator Favola is here. Yea, the Senate included funding for that in their budget. We are hoping the house will eventually see the light. - Deborah Oswalt, executive director, Virginia Health Care Foundation

Q: Why is collaborative care so important?

A: Seventy percent of antidepressant prescriptions are written in primary care. Primary care is a low-stigma setting, and people are there. - Darcy E. Gruttadaro, J.D., director, Center for Workplace Mental Health, American Psychiatric Association Foundation

Q: Shouldn't teachers and school counselors be better trained for serving and referring actions? They are the ones on the front edge of this.

A: As a pediatrician, we need to think about how to help children where they are. They may be in the pediatrician's office for 15 minutes an hour, but they are in school eight to 10 hours a day. - Sandy L. Chung, M.D., FAAP, FACHE, AAP President 2022, CEO, Trusted Doctors 

A: I can tell you that for certain of our patients that we have had admitted to the Institute, having some partnership with their priest, pastor, or community leader has been effective in certain cases. We will have them come to the hospital, meet with the treatment team, meet with the family. It can decrease stigma, like taking medications or receiving mental health care in a socially acceptable or spiritually acceptable context to the patient and their family. - Navid Raschid, M.D., FAPA, medical director, Northern Virginia Mental Health Institute

Q: What do we mean by mental health equity, and why is engaging in a discussion around mental health equity important?

A: When we think about equitable access to care and mental health equity at The AAKOMA Project, one of the things that we say is that every child, inclusive of all aspects of identity, race, culture, immigration status, if they are LGBTQ, if they have a disability, deserves the opportunity to live authentically and unapologetically as the best version of themselves. Equitable health care and equity in mental health are about understanding all those nuances, all the intersectionality, and ensuring that the care we provide allows for all that intersectionality, authenticity, and realness to show up in care. -Dr. Alfiee M. Breland-Noble, founder, AAKOMA

Q: If we increase the raw number of licensed mental health professionals, do you think it will address this issue of cultural fit meaningfully?

A: Let us think about whom to train. We will not solve the mental health crisis in the country with M.D.s, Ph.Ds, or even, quite frankly, more masters. It is not scalable... You do not have to train for six, seven years… People who do some entry-level stuff with folks who are also trained to identify when people need more. Then they kick them up to a slightly higher level of care... maybe your master's level trained person. - Keith D. Renshaw, Ph.D. Department Chair and Professor of Psychology, College of Humanities and Social Studies, George Mason University