Healing A Broken Mental Health System: Dr. Daniel Castellanos Of Creighton University School Of Medicine On 5 Things That Can Be Done To Fix Our Broken Mental Health System

An Interview With Stephanie Greer

Decreasing social stigma. Overcoming the stigma of mental illness and getting mental health care remains a big issue. All types of stigmas — public, self, perceived, health practitioner and structural — remain barriers to mental health care. Stigma appears to be particularly more of an issue for certain groups, such as Hispanics. Media coverage such as this, helps move the dial towards addressing this issue.

The current state of the mental health system is a conversation that echoes in the halls of policy-making, the corners of social advocacy, and within the private struggles of individuals and families. As we continue to witness an unprecedented need for robust mental health support, the shortcomings of the existing system become more glaring. It is within this backdrop that we seek the insight of those who are at the forefront of behavioral health. In this interview series, we are talking to behavioral health leaders, policymakers, mental health practitioners, advocates, and reformers to share their perspectives on healing our broken mental health system. As a part of this interview series, we had the pleasure of interviewing Dr. Daniel Castellanos.

Dr. Daniel Castellanos is a distinguished psychiatrist specializing in Child and Adolescent Psychiatry, currently serving as the Founding Associate Dean for Graduate Medical Education and Professor of Psychiatry at Creighton University School of Medicine in Phoenix, AZ. With a deep commitment to the field of mental health, Dr. Castellanos brings extensive expertise and a compassionate approach to his practice and academic endeavors. Dr. Castellanos completed his residency at Jackson Memorial Hospital/University of Miami School of Medicine in Florida, where he honed his skills in general psychiatry. Subsequently, he pursued a fellowship in Child and Adolescent Psychiatry at the New York State Psychiatric Institute/Columbia-Presbyterian Medical Center in New York City, further specializing in the complex needs of young patients. Throughout his career, Dr. Castellanos has demonstrated proficiency in diagnosing and treating a wide range of mental health conditions, with a particular focus on anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorders, and depression. Fluent in both English and Spanish, Dr. Castellanos ensures effective communication and understanding with diverse patient populations. His commitment to education and mentorship is evident in his role as Associate Dean, where he plays a pivotal role in shaping the next generation of healthcare professionals.

Thank you so much for joining us in this interview series. Before we start, our readers would love to “get to know you” a bit better. Can you tell us a bit about your background and your childhood backstory?

Dr. Daniel Castellanos has spent his career dedicated to the education and training of students, residents and professionals. He is the recipient of the prestigious 2020 American Psychiatric Association’s Simon Bolivar Award, the 2021 Florida Psychiatric Society Partitioner of the Year award and the 2024 American Society of Hispanic Psychiatry Lifetime Achievement Award for Academic Psychiatry.

Born in Havana, Cuba to a family of physicians, the field of medicine has always been in his life. He is the grandson of a pediatric cardiologist, nominated twice for the Nobel prize for his pioneering work in cardiac catheterization; the son of a cardiologist, an internationally renowned electrophysiologist, grandnephew of a forensic physician, brother of a neurologist and father of a pediatric cardiologist. As an adult, his wife and children have provided continued inspiration by the fact that all of them have dedicated their careers to helping youth, particularly in minority and underserved communities.

Today, Dr Castellanos is the Founding Associate Dean for Graduate Medical Education, the Designated Institutional Official and Professor of Psychiatry at Creighton University School of Medicine-Phoenix. In this capacity, he has the responsibility for the oversight and administration of all 12 accredited residency and fellowship training programs encompassing over 330 physicians in training.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

“Physician know thyself.” A variation of “Physician, heal thyself” (Medice, cura te ipsum), suggests that self-reflection is foundational for professional and personal growth. Throughout life being able to honestly self-reflect has served as a catalyst to become a better person, child and adolescent psychiatrist and leader.

Let’s now shift to the main part of our discussion. It is often said that “the mental health system in America is broken”. What does that statement mean to you? From your perspective what is “broken” today?

Our “mental health system is broken” is a term used to describe the numerous, long-standing deficiencies in our mental health system of care. As a society, we are not meeting the needs of many Americans living with mental health issues and mental illness. The number of vulnerable populations with mental health and substance use disorders is a major societal problem. Individuals living with homelessness experience a much higher rate of mental illness compared with the general population. It has been documented extensively that our jails and prisons have become the largest mental health providers in the country. Individuals who are uninsured or underinsured have lower access to care than people who are insured. Stigma and bias toward mental illness remain a major barrier to people accessing needed care. The rate of unmet mental health needs is higher for many minority groups who are less likely to receive mental health care services compared to their white counterparts. These and many other factors are why we are failing to meet the mental health needs of persons living in the US today.

What about any bright spots? Do you think there are any elements that we get right in today’s world that we wouldn’t want to reverse unintentionally?

We have come to understand and accept the importance of social determinants of health (SDOH) in relation to mental health. The US Office of Disease Prevention and Health Promotion defines Social Determinants of Health (SDOH) as “conditions in one’s environment — where people are born, live, work, learn, play, and worship — that have a huge impact on how healthy certain individuals and communities are or are not.” In recent years health professionals, insurance companies and other funding agencies have recognized how the SDOH influences mental health outcomes. An estimated 20 percent of health outcomes are linked to medical care; the remaining 80 percent stem from socioeconomic, environmental and behavioral factors. These factors, such as food insecurity, housing insecurity, transportation insecurity, interpersonal safety, and financial challenges, are linked to poorer health and disproportionately impact minority communities. On a positive note, healthcare experts are increasingly acknowledging that achieving equity and improving all health outcomes necessitates addressing these underlying factors influencing all aspects of health. We hope that individuals responsible for funding of care continue to recognize that health outcomes and experience of care are driven by the conditions in the environment and therefore can be better addressed through a myriad of changes.

In your opinion, what are the 5 most impactful things that could help heal the broken mental health system? These could be on any level including training, workforce, policy, culture, equity etc.

1 . Increasing awareness. While more individuals in the US have sought treatment, there also is a large portion of the population who have wanted to get care but did not. Minorities and underrepresented groups are probably a bigger portion of those who did not. In addition, many individuals are not sure where to find legitimate resources to get the care they need. So, awareness and education are basic foundational pillars necessary to build the mental health system of care.

2 . Decreasing social stigma. Overcoming the stigma of mental illness and getting mental health care remains a big issue. All types of stigmas — public, self, perceived, health practitioner and structural — remain barriers to mental health care. Stigma appears to be particularly more of an issue for certain groups, such as Hispanics. Media coverage such as this, helps move the dial towards addressing this issue.

3 . Access to treatment is a good start but more is needed. Much has been documented about the need to improve access to appropriate, affordable, timely mental health. To truly effect change, more is needed. Many rely on data that highlights utilization — number of mental health appointments, who goes to appointments, etc. Going for care (attendance) is an important yet insufficient step. Attendance is a proxy for participation in treatment. Participation in care is a proxy for engagement. Ultimately, we want to have persons engage in their care. Engagement in effective, high-quality treatments provided by competent clinicians is needed. Getting certain populations to engage is an even more complex issue. We seek ways to train clinicians and have health delivery organizations look at how to better engage individuals to improve outcomes.

4 . Improving the quality of care offered. Merely increasing training or expanding which professionals can provide certain types of services doesn’t guarantee improved quality of care. Just because individuals are in treatment doesn’t directly predict they will receive quality care or have improved outcomes. For example, extensive evidence supports the use of cognitive-behavioral therapy (CBT) for a variety of disorders, such as depression. Almost all clinical practice guidelines recommend CBT for major depression. The reality across the country is that few clinicians are adequately trained or adequately utilize CBT. A disconnect exists between what we know science says works with what happens in the real world. Healthcare insurers, funding agencies, healthcare organizations, training programs and ultimately the individual clinician, all play a part in seeking to improve quality mental health care for all.

5 . Addressing the workforce shortage. As discussed in #4, a need exists to increase the number of adequately trained clinicians. The issues are not simply addressed by training or allowing more individuals to provide care. That is — -“More is not always better.” We need to increase funding for more education and training programs, specifically in evidence-based practices that result in better outcomes. We should also address the maldistribution of mental health providers. The tendency for many clinicians to work in private and/or self-pay settings clearly impacts the care for individuals who are underinsured, uninsured and those who have fewer resources. Ensuring adequate compensation, especially for those who work with underprivileged populations is another essential component. Efforts should focus on incentivizing clinicians to provide care for vulnerable populations or accept reimbursement from public payers such as Medicare and Medicaid.

If all of the items on your list were magically implemented tomorrow what change might we see in the world? What are the signs (big and small) that would show us that the system is being healed?

We all seek to have a healthier population. It may be too idealistic to believe we will eliminate all mental illness, but I hope that individuals experience fewer mental health issues. I would want those who may still live with mental illness to feel less distress and be able to live their lives productively. A big reduction in emergency department visits for suicide attempts as well as suicide deaths might also signal that our system of care has improved. Our jails and prisons would be less crowded if individuals were to receive and engage in appropriate care for their mental illness.

What is a project you or others are working on today that gives you hope? How can our readers learn more about this work?

We are currently examining data that addresses the integration of behavioral health into pediatric primary care. This SAMHSA-funded project managed by the Florida Department of Health, looks at increasing access to mental health care in youth through pediatric primary care practices. The aim is to increase the identification of mental health issues, increase pediatrician comfort and skills in diagnosing and/or treating mental health disorders and help link them to care when they cannot do so. For more information see: https://www.floridahealth.gov/programs-and-services/childrens-health/cms-specialty-programs/title-5-program/Behavioral-Health-Services/index.html

How do you see technology shaping the future of mental health care and its accessibility?

Advances in technology have opened a range of opportunities in mental health care. For example, mental health apps, telehealth and other technologies bring a lot of potential for individuals seeking mental health care. They help increase access to care, can be more affordable and align with the desires of many individuals. On the other hand, questions remain as to whether the use of technology is supported by scientific evidence, the lack of consensus on how to evaluate quality and possible overselling or overpromise of how effective it can be.

Advances in virtual reality, artificial intelligence (AI), wearable devices and digital medicine are promising and continue to be developed. The use of specific technologies may have different benefits and risks for different populations. Efforts are underway to better understand how these resources can be better utilized.

In your view, how do social factors like poverty, education, and culture affect mental health care and its effectiveness?

Please see the “Bright Spots” section above.

In light of the growing mental health crisis among young people, what innovative approaches or interventions have proven most successful for children and adolescents?

The solutions to these challenges are multiple and varied. We need to continue to innovate and learn from different fields, different models, and different countries, and we must continue to improve our scientific and clinical knowledge. Although not necessarily innovative, the systematic screening for mental health issues in primary care needs to be expanded. Furthermore, systematic screening for SDOH isn’t standard clinical practice yet. Efforts to increase access to mental health services by building collaborative partnerships within pediatric primary care as well as addressing the SDOHs, need to be examined more and/or expanded.

A word of caution, emerging and innovative interventions need to be assessed for their merit and impact. Advancements in evidence-based psychotherapies, digital technologies, and other strategies for youth mental health services have yet to yield significant improvement in public health outcomes. History provides many examples of costly overpromise; the use of secretin for autism spectrum disorder is one such example. So we need to move forward seeking innovative ways to help our youth, we should balance this with judicious assessment of evidence of efficacy and impact.

How can our readers further follow your work online?

Website: https://www.creighton.edu/healthsciences

Instagram URL: https://www.instagram.com/creightonphx/

Facebook URL: https://www.facebook.com/creightonuniversity

Twitter URL: https://twitter.com/creighton

Youtube URL: https://www.youtube.com/user/Creighton1878

Linkedin URL: https://www.linkedin.com/company/creightonphoenix/

Thank you for your time and thoughtful answers. I know many people will gain so much from hearing this.