The old adage of not discussing politics and religion with strangers is good advice.

We are wired as social creatures to protect ourselves and to recognize how hot topics can lead to strife with others. The divisive political climate has taught many of us to avoid talking even with our own family members about our political choices and who we might have voted for. This chasm has contributed to Thanksgiving celebrations being boycotted by some because of concerns over heated debates. So much has been written about these conflicts creating barriers.

Many of us remember the battle between George W. Bush and Al Gore. After the election there was a discussion of “pregnant chads” and determining who voters intended to vote for. It was disquieting that the presidential election took several weeks to declare who had actually won. However, even in the midst of this battle, the volume of disagreement didn’t rise to what we have observed over the last few years. The country is deeply divided and scholars at home and abroad have speculated about there being an inevitable civil war.

In order to survive in the world, we all need a support group that we can consistently rely upon. When children are growing up, this base refers primarily to one’s parents. There is a term called rapprochement, that describes how children can explore their world with confidence because their parents are standing nearby. Developing minds can eventually move forward, and individuate as separate individuals as long as parenting has been consistent. One of the reasons that divorce is so traumatic is that the most important relationship of our adult lifetime suddenly disappears. The bedrock of support turns into an earthquake fault line. This explains how depression and anxiety and even suicide can tragically occur during or after divorce.

About 25 years ago, a patient hospitalized for depression explained to the treatment team that he would kill himself if his wife chose to divorce him. At the time, he wasn’t suicidal and was hopeful that he would be able to make his marriage work. When he was emotionally stabilized and no longer met the criteria for hospitalization, he was discharged. He was provided with appointments for therapy and we were all hopeful that his life would become stabilized. Tragically, his wife later did file for divorce, and about a month after his discharge, we learned that he did in fact die by suicide.

How could we have prevented this? The unfortunate reality of health care is that patients are admitted and discharged sometimes within days, primarily because insurance companies find any excuse they can to avoid paying for treatment.

In the 1980s, some psychiatric hospitals were able to keep patients for months. The Institute of Living Hospital in Hartford, Connecticut, where I completed a fellowship in 1987, maintained a swimming pool and tennis courts to provide physical activities for emotionally recovering patients. Years prior, the hospital even had a fleet of luxury cars to take patients on relaxing rides in the community.

In 2023, the mental health support system has moved from a humanitarian and nurturing environment into impossibly high barriers, preventing some patients from meeting criteria for treatment and hospitalization. Empathy and compassion are increasingly viewed as clinician weaknesses, leading to administrative criticism of health care providers who wish to spend more time with patients beyond the 15 minute med check.

Psychiatrists are actually penalized for providing great patient care when the only requirement is to keep them as cogs in the wheel of the business of healthcare. Psychiatric hospitalization has turned into big business where the only focus is on revenue return and expeditious discharge. When our country was focused more on helping others, instead of exploiting others, human decency was the primary tool to help troubled individuals. The U.S. has moved from sensitivity around healthcare needs to an almost hyper rational and insensitive environment. Patients are forced to lie about suicidal thoughts to get admitted at all. If someone is on the brink of suicide, but has yet to make a physical attempt, insurance companies might deny their admission. If these patients are fortunate and able to get admitted, the medication that the psychiatrist prescribes for these patients might be vetoed by managed care review because they are deemed to be too expensive. Frequently, patients are required to “fail” treatment with other less expensive medications before the psychiatrist’s order will be followed. Some have said that this process is tantamount to the insurance companies practicing medicine without a license.

Throughout this gut-wrenching process, doctors are effectively being ignored and life and death decisions are often based upon insurance coverage. If insurance doesn’t support the treatment plan, the medical community is forced to alter their treatment recommendations and become subservient to whatever managed care demands.

Mental health is, theoretically, a bedrock of functionality where each individual believes that they have a voice and will be heard. Sadly, this has become mostly mythic, and physicians who have been in school for 15 years to become expert clinicians, are often treated with disdain. No wonder that one physician per day dies by their own hands.

There is a concept known as parallel process, where disparate fields are impacted, in a given time period, to mirror one another. For example, turmoil in the medical field parallels the turmoil in another domain, such as politics. This in turn impacts family unity and family health and participation in the political process. Political instability can lead those with mental health issues to become more marginalized. This cohort will then be unable to understand and relate to the political environment and where it is leading our country.

In addition, there are several forces in place today that both increase the perception of partisanship that also seem to define it. Mental health issues create a clear divide between the ability or interest to vote, versus the barriers that prevent those afflicted to reach the polling booths and to better understand their rights.

Given the heated culture that has overcome our country, it is of great relevance to evaluate the impact of mental stress on the electorate and voting behaviors. It is also of keen relevance to evaluate the role of politics, party choice and the political Zeitgeist on the mental health of voting citizens.

The pandemic has given scientists the opportunity to study the impact of a very divided nation on health indices within individuals. A key differentiator for the impact of politics on mental health is the degree to which citizens view the polarization in our country.

If a given individual views the polarization in the present as much greater than polarization in the past, they are more likely to report severe mental health issues than prior to the 2020 election. The reason for this is that perception, which can turn into subjective reality, leads an individual who is struggling with emotional lability to feel that there isn’t even a slim foundation of support underneath. Furthermore, the anxiety, sadness, financial instability and pandemic-related mortality rates all contribute to marginalize the emotionally unstable subset of the population to discount political involvement. Like Maslow’s Hierarchy of Needs, those who suffer from emotional distress must heal before they can be elevated to higher levels of independence and participation in important lifetime activities such as voting and engaging their rights as citizens.

Mental health can impact the voting process in much the same way that the voting process can create silos between those who support their party vision.

Although each individual may believe they are being objective in their political observations, the reality is that social psychology, and the impact of the group upon the individual, is more potent in influencing individual perceptions and behavior than the free will of the individual. The same dynamic can occur among focus groups where each individual who speaks attempts to, consciously or unconsciously, avoid disagreeing with the group. We have seen this process among politicians who claim autonomy of their beliefs, but who end up publicly voting for the group platform, fearful of being ostracized.

Although voters with mental health issues tend to exert greater preference for a liberal or left wing self expression, overall the voting patterns among this cohort do not differ much from the voting statistics of the general voting community. However, there has long been recognition that mental illness can lead to social exclusion and decreased access to mental health care. The lack of treatment for this population increases the stress and emotional trigger responses and in turn that further isolates and marginalizes this population. It is a triple catalytic reaction that combines the stigmata of mental illness, decreased access to mental health care for the disempowered, and a vicious cycle of increased morbidity and functional impairment.

Feeling overwhelmed and unsettled, however, is not limited to those with a history of emotional illness. Those who have never experienced mental illness in the past may now be facing overwhelming pandemic related depression and anxiety, marginalizing them from their peers, and decreasing their motivation to participate in the process of democracy.

It becomes difficult to treat those without insurance or with only limited coverage. I don’t wish to sugarcoat this. We are in a very difficult and uncertain time in our Republic, and I believe the majority of the electorate is fearful and uncertain of where we are headed. Some believe the U.S. is already on life support and others are fearful of the future. I have friends who have moved from our country to another nation that seems more supportive and hospitable.

As a psychiatrist in practice for more than 30 years, I, too, am uncertain of the future. No nation on earth has ever achieved immortality. The more estranged the mentally unstable, the less that they can participate in the American Experiment. However Warren Buffet, in a television interview, stated that the U.S. experiment is working and the country is behaving as it should. I hope that he is right.