Medical Examiner

Suicide Hotlines Provide a Critical Service, but They Can’t Make Up for America’s Broken Mental Health Care System

Kate Spade sits on a white leather couch.
Designer Kate Spade at her office on Sept. 16, 2002.
David Howells/Corbis via Getty Images

Kate Spade’s apparent suicide on Tuesday is a tragic reminder that mental health problems do not discriminate—they can plague anyone, no matter how successful they seem. As people grieve today, many are also sharing critical hotlines and resources for people struggling with depression or suicidal thoughts. The New York Times included the phone number for National Suicide Prevention Lifeline in its news story announcing Spade’s death, along with a link pointing toward additional resources.

Hotlines are a critical tool in suicide prevention. I’ve volunteered for one for three years precisely because of the role they can play in saving lives. I’m relieved and heartened to see so many people sharing this type of resource. Doing so increases the likelihood that more people who need this sort of support will realize it exists and may subtly help break down the stigma against asking for help.

But a crisis hotline is just one part of the support system that ought to exist for anyone dealing with mental health issues. A suicide hotline is there in the moment, and the volunteers who are triaging the calls (with oversight from trained mental health professionals) are working their hardest to mitigate immediate harm and to direct people calling in toward longer-term solutions and plans. That second part of that triaging requires the existence of longer-term support systems to which to refer people.

These support systems are under perpetual attack in America, where we’re still somehow debating whether all insurers should have to cover such care. As June Gruber and Darby Saxbe wrote in Slate in February, “we have made remarkable progress in developing research-backed psychological interventions that work to treat chronic and serious mental illnesses, ranging from depression and anxiety to substance abuse and psychosis. The bad news is that only a small fraction of people who need these services actually receive them.”

Gruber and Saxbe went on to explain:

Why is it so hard to get effective treatments to the public? One reason is that mental health treatments remain largely unaffordable to many, especially those from lower socio-economic or disadvantaged groups. Mental health parity laws, which mandate insurer reimbursement for mental health treatment, have been in place for more than a decade—but enforcement of these laws can be stymied by, among other things, a lack of treatment providers. In 2016, Congress passed the 21st Century Cures Act, which includes a number of mental health parity provisions, but budget delays have slowed the distribution of funds, and funding for some programs—such as a community mental health block grant—have already been cut.

Recent cuts to Medicaid may worsen the problem; an estimated 40 percent of recipients of Medicaid expansion under the Affordable Care Act, for example, have mental health issues. Changes to the ACA have also allowed insurance policies free of essential health benefits to again be sold, creating concerns that the mentally ill would return to using emergency rooms for basic mental health treatment.

Not only do we not properly fund insurance coverage for this kind of care, but we don’t properly fund research into the most effective means of care. As Gruber and Saxbe also note, the National Institute of Mental Health’s funding has been flat for the past decade and a half. All of this sums up to a situation in which mental health care is difficult to access, probably for most Americans, and certainly for Americans who don’t have exceptional health insurance. (It’s also worth noting that mere access to mental health care services is not a guarantee of survival, merely a medical service that our country should provide to all citizens.)

When it comes to talking about mental health care, particularly after a public figure’s suicide, it’s understandable that the impulse is to share the most immediate and available resource. That’s probably the right thing to do. But among the glut of tweets encouraging people to do so, two stood out, one from Ivanka Trump, not just the daughter of the president but an adviser to him, and one from Nikki Haley, ambassador to the United Nations:

It is true that mental health problems do not discriminate. Unfortunately, in America, access to the tools that might help individuals cope with these problems still depends on your wealth and your access to insurance, as well as less tangible things such as your ability to cut through stigma or your willingness to access support. I hope that both of these public servants realize that part of their job is to go beyond offering short-term support, and to figure out how to offer more equitable and effective support for people living with mental illness.