Mental Health as a Human Right

Scott Breitinger, a psychiatrist in the Mayo Clinic Division of Integrated Behavioral Health, unpacks how social and economic inequality impact mental well-being. 

Scott Breitinger is a board-certified psychiatrist at the Mayo Clinic, and has dedicated his career to improving mental healthcare effectiveness and efficiency. His diverse fields of study include sociology, economics, mental healthcare, and digital strategy, which give him a unique perspective into the complex issues surrounding mental healthcare in America. 

Committed to the belief that every American deserves equitable access to effective care, Dr. Breitinger has spent his career researching and facilitating the development of innovative tools to revolutionize healthcare systems design. I recently sat down with Dr. Breitinger to discuss the complex variables surrounding mental health in America.

Tell us about yourself.

I grew up in Bucks County, Pennsylvania, outside of Philadelphia. After being in New York City throughout my education and medical training, I’m now based in Rochester, Minnesota, where my wife and I work at the Mayo Clinic and live with our two young sons. We moved here after my wife matched for a cardiology fellowship and I was very fortunate to get a staff position in Integrated Behavioral Health at Mayo. It's a perfect fit for me. The work that I do is taking care of patients’ psychiatric needs in the primary care setting, and that allows me to focus on the things that are most important to me in mental health care:

• Improving access to care so that it's more equitably distributed, and
• Leveraging our medical expertise to make mental healthcare more broadly available.

Mayo Clinic has been a place where I can both work as a clinician with direct patient care but also think about how we can leverage psychiatric expertise and also embed it more deeply in the healthcare environment. I never anticipated that I would be living west of Broadway, but here I am, and I couldn’t be more grateful for the opportunities I’ve had.

What attracted you to mental healthcare?

In undergrad, I read a lot of books by people like Paul Farmer and Jeffrey Sachs. It was their work in the public health domain, and in areas of extreme poverty, that had an impact on me. I've always felt that there is a human rights element in access to adequate healthcare. Public health and wellness is a foundational need for economic development of any community, without which you don't have the basic human infrastructure for sustainable social and economic progress. 

On the wall of one of the main hospital buildings at Mayo, there is a plaque with a quote from Dr. Charlie Mayo: "The most important asset of a nation is the health of its people." He wrote that in 1919 and I think the point still stands today. Health—and mental health as a part of that—is as essential to societal stability and progress as it gets.

Furthering access to high-quality healthcare as a facilitator of broader social and economic opportunity has always been my north star. Once you go into medicine, you're inside this ecosystem, and the question is: where is that problem of quality healthcare most pressing? In my mind, mental health is the biggest leverage point. We know that mental health and mental illness impact overall cost of care and wellness as much if not more than any other area. If you're looking to reduce cost of care and make healthcare more accessible to a population, it's one of the first places that you'd look. 

One of the problems with how psychiatry is predominantly practiced is that it is so heavily reliant on a one-to-one model, where your attention as a clinician is consumed with the person in the room with you. However, that leaves a vast unmet demand for care. Thinking about how we can improve the overall level of wellness of a community just fundamentally requires a different model. 

Mental health is one of the most challenging domains, because there are so many barriers to accessing mental healthcare. There's a stigma element, but then there's the fundamental economic structure of the cost of care. The patients that we work with in this field have a broad range of wellness levels and cognitive abilities. The nature of mental illness, especially severe mental illnesses, is that it affects cognition. For a lot of people, that can make it more difficult to access, engage, or figure out how to get the right form of care. These are all really complicated and complex problems, and ones that are worthy of investing my career in to try and solve—the idea of equitable access to effective care. 

Then, on a personal level, I think the questions in psychiatry are much more engaging and sustainable over a 30 or 40-year career. There's so much that we're still learning about the field and so much about both normal and pathological cognition that impact our understanding of other fields of knowledge. 

Given the complexity of these issues, how do you deliver care?

Being an integrated behavioral health specialist, I am responsible to a number of people. I'm responsible to the patient, but I am also consulted by the primary care provider to provide my expertise. In addition, effectively interfacing with my colleagues in social work, psychology and other medical specialties (e.g. sleep medicine, neurology, internal medicine, endocrinology, gastroenterology, etc.) is essential for providing team-based care. In many ways, I'm a translator; I simplify and distill information about a mental health concern so that it's accessible to both patients and providers.

Often in mental health, there's a false dichotomy between thinking about concerns being either biologically based or being psychologically based. It permeates how some providers and patients think about care. There can be either a singular focus on medication management and identifying a particular disease label that fits with the DSM criteria, or other individuals who eschew medication and the biological aspects altogether and frame things purely in psychological terms. Neither approach really provides a full picture without the other.

I think a more adept way of practicing psychiatry and mental health care integrates the two. There's not a dichotomy between them—just because something has a psychological aspect to it doesn't make it less biologically rooted. I often tell my patients that medications are a foundation to help them engage as fully as possible with psychotherapy. Not all patients need medication, but awareness of the appropriate role of medication offers a more comprehensible approach for most patients. 

And then there are the social aspects of the equation. We're all very intensely social beings—our brains are structured that way—and thinking about how somebody is functioning in terms of their interpersonal relationships, their career, their sense of meaning and purpose in their communities, etc. are all really important aspects of helping somebody become actualized as the person that they want to be.

Given these varying approaches to care, what do you think is the biggest misconception about the mental healthcare space?

A couple of thoughts come to the top of my mind. The first is that some people worry that building a working relationship with a therapist will make them dependent on a therapist and that they won't have the ability to solve problems themselves. But the real goal of therapy is to help a person build a greater awareness of potential patterns of thinking and behavior that may be less helpful than other potential alternatives.

Another way to look at it is, what brings anybody into a doctor's office? A pain point, right? You don't go there unless you have something that you're suffering from. But at the same time, the human condition is such that we all have blind spots and limits on our insight. Sometimes, what we think is the reason we are suffering and coming to a therapist or doctor’s office, isn’t necessarily the root issue—and it takes work with a trained clinician to bring greater clarity and awareness.

The psychotherapy process can be a profound investment in oneself. Working with a trained psychotherapy provider can help people be in touch with all the natural assets, capabilities, talents and hard-earned wisdom that we each have through adverse experiences in our lives. There is certainly the health aspect of counseling people when they're in crisis, and that is a central core component of the work that we do, but there's also the opportunity to live a fuller life. I think that aspect of psychotherapy is not appreciated as much as it could be.

Given the ability of therapy to improve people’s daily lives, how do you hope the mental healthcare space evolves? 

I think fundamentally the two aspects of therapy – the healthcare component and what we in the field might call ‘self-actualization’ (which is basically helping somebody to reach their fullest potential) require two different models for providing care. 

On the healthcare side, there are never going to be enough mental health care practitioners to treat every American in need on a one-to-one basis. We need a different architecture for the population at large so that everyone can receive access to care in the manner that all Americans deserve.

The question is, how can we use the expertise of mental health care providers to make clinical work more precisely tailored to individuals, but at the same time more automated so that there's a lower need for direct clinical interaction? Can we build a system where psychotherapy is perhaps supported by other collaborators in the care environment, who might not have advanced healthcare expertise, but have the empathy, capacity, and human intelligence to interact with a patient in need of support?

The answer is yes, but to do that, we’ll need to give those health coaches the tools to provide the patient with the right form of care at the right time while capacitating patients with the necessary psychotherapeutic and educational resources through digital interventions and access to automated digital care solutions. This would allow us to transform the model that we operate with today as one-to-one direct clinical interaction to a model where one provider can reach many more patients, although it may be in a lighter touch sort of way. The key is to do that in a way that feels human and feels supported to the patient, which is a challenge, but one that can certainly be addressed if we have the right tools.

Do you think Nirvana could help facilitate that transition?

Absolutely! Nirvana frees up clinician time to focus on the patient in front of them. Presence is important on both sides of the therapeutic interaction and I think Nirvana goes a long way towards making that possible for the patient and the provider. Having to deal with the business aspects of providing care takes away hours on the clock, which is time for seeing patients. It also creates a cognitive burden of having to think about those aspects of care with every single patient that you're interacting with. 

Nirvana takes that off the table and unburdens the provider so that they can be present with their patients. With a provider’s career, I think it is an essential element to maintaining the stamina to do this cognitively strenuous work without burning out.

On the patient side, the cost of care is a burden for almost everybody except the wealthy. There's tremendous attrition from a patient Googling a care provider to actually showing up for the first visit. There's a lot of opacity and a lack of clarity about the actual costs of mental healthcare. When a patient has that information up front, it does a tremendous amount of work to lower the barriers to care. The more we can do to reduce those barriers, the more effectively people will be able to engage in the care that they deserve. 

 In my mind, these are the two central organizing principles of Nirvana:

• Help clinicians be fully present with their patients in session by unburdening their administrative load, and 
• Help patients access care that they deserve and ensure that the cost of care is not an undue burden.

So, I'm very optimistic—and I look forward to seeing what Nirvana does in the coming years.

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This interview has been edited for length and clarity.

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