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Addressing Behavioral Health’s Role in US Excess Mortality is an Urgent Matter
Even as the US climbs out of the COVID-19 pandemic and related death rates fall to a low level (now about 80 deaths per day), concerns persist about excess mortality in our population. A recent study by the Boston University School of Public Health found that, in 2021, about 1.1 million deaths would have been averted if the US had mortality rates similar to those of other wealthy nations. The study lead, Jacob Bor, ScD, calls these unfortunate people the “Missing Americans.”
The study examined US mortality rates between 1933 and 2021, and compared US age-adjusted death rates with those of 21 other wealthy nations. In World War II, the US had lower mortality rates than other wealthy nations; in the 1960s and 1970s, similar rates. After 1980, US rates became higher than other nations, finally spiking in 2020 and 2021. Compared to other countries, “the US is experiencing a crisis of early death that is unique among wealthy nations,” according to Dr Bor.
The 1.1 million excess deaths in 2021 accounted for 26.4 million years of life lost, an average of about 24 years per person. The study authors connect the large excess mortality burden to the failure of US policy to adequately address major public health issues, including the opioid epidemic, gun violence, environmental pollution, economic inequality, food insecurity, and workplace safety.
Not addressed by the study authors, but also clearly factors in early mortality are mental illness and its correlates, such as homelessness, poor diet, and lack of needed behavioral health and primary care services. A clue to this linkage is the fact that US excess mortality rates became higher than those of other countries in the early 1980s. This was a period of major state hospital deinstitutionalization, when many persons with serious mental illness became homeless after they left the hospital.
Another clue to the linkage with mental illness is my own work on mortality of persons served in public mental health systems. Results from 8 states showed that mental health clients die, on average, about 25 years prematurely. This number is almost identical to that found for average years of life lost in the Boston University study.
If we assume that behavioral health conditions are represented among those who die prematurely in about the same ratio as in the adult US population overall (about 25%), then about 275,000 premature deaths per year and about 6.6 million years of life lost actually occur among those with mental health or substance use conditions. We know that opioid overdose deaths account for about 100,000 of these deaths each year.
Particular steps will be essential for us to make progress on this urgent problem. First, we must come to terms with and address our current workforce crisis. Right now, we can serve only about one-quarter of those with behavioral health conditions. Second, we must amend our training and field practices to incorporate social care. Social determinants of life are a major factor in premature mortality. Third, we must integrate behavioral, primary, and social care for those most in need. Only through this action will we be able to begin moving from treatment to prevention.
For us, US excess mortality is a “canary in the mine” that reflects how well we are doing in providing mental health and substance use care, essential primary care, and social care to those with serious behavioral health conditions. To restore years of potential life lost, we must address each of these areas of care in a systematic manner.
Ron Manderscheid, PhD, is the former president and CEO of NACBHDD and NARMH, as well as an adjunct professor at the Johns Hopkins Bloomberg School of Public Health and the USC School of Social Work.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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