A recent study led by Prof Ian Goodyer and co-authored by Prof Barbara Sahakian of the University of Cambridge has sparked great interest and debate from all schools of thought concerning screening youth for mental health. The study, originally published in the journal Plos One, Nov 2012, is among one of the first studies to identify a testable factor that could successfully indicate youth at risk for developing mental health problems later on. They tested adolescents aged 15-18 yrs for the presence of a particular serotonin transporter gene and for any early childhood traumas or situational stressors. The experts found that the presence of both of these factors led to an inability of the adolescents to process information and emotions normally. Their findings support that adolescents who have the inability to process information and emotions are at greater risk of developing mental health problems, such as anxiety and depression. With this early marker identified could we see an increase in preventative measures for mental illness and a decrease in the illness rate?
Continual Rise in Mental Health Illness Rate
Results from the mental health findings of the 2011 National Survey on Drug Use and Health, found that ‘in 2011 there were an estimated 45.6 million adults aged 18 or older in the United States with any mental illness.’ This represents 19.6% of all adults. The same 2011 survey also showed that of the 45.6 million recorded as having any mental illness only 17.4 million (38.2%) received mental health services in the past year. The same is true for children. NAMI (National Alliance on Mental Illness) cited ‘…only 20% of children with mental disorders are identified and receive mental health services.’ This number was taken from a report on the Surgeon General’s conference on Children’s Mental Health, US Public Health Service.
So why the Deficit?
Stigma and lack of information are big contributors to the reason there is such a big gap in numbers of those being identified and those being treated for mental illnesses. However the majority of research tends to focus on the stigma and lack of knowledge held by the sufferer or their family and friends. A fear of being ‘labelled’, not wanting to seek help for something that they’ve been told is their fault, uneducated in mental health, have all been found as reasons individuals avoid seeking help for their mental health problems. But, there is a stigma and unwillingness to explore possible mental health diagnoses with patients that rides on the shoulders of some health professionals as well. The first professional contact a person has with mental health, be it for their own problems or those of someone close to them, is often the most impressionable one and will determine whether they continue to seek help for their problems or not.
A recent report released in March 2013 by the Department of Managed Health Care in California found that lack of information for the patients was definitely detrimental in the decision making process to seek further assistance. The report was looking into the behavioral health services of the Kaiser Foundation Health Plan, Inc, which covers about 40% of the health care in California. ‘The Plan’s failure to provide consistent and effective health education services, as shown in the inaccurate materials distributed to enrollees, may have discouraged some enrollees from seeking and accessing medically necessary behavioral health services.’ How we access mental health services and more importantly who we access them with has a big role to play in whether individuals continue to seek help or admit to having mental health problems at all.
The First Contact
AAFP, Mental Health Care Services by Family Physicians (position paper) concluded that the ‘majority of patients with mental health problems will continue to access the healthcare system through their PCP.’ It stands to reason that for most of us, if we’re not quite sure where to turn to, we generally start with our primary care physician who we are the most familiar with. As well as familiarity the other factor that has many turning to their PCP first is the financial one. If an individual has little or no insurance and doesn’t quite qualify for state medical assistance, they often cannot afford the services of a psychiatrist or other mental health care provider, instead opting for the only health intervention that they can afford. However, to receive any treatment or support from your physician relies heavily on the opinion of your PCP or your child’s pediatrician. Of course that is set up so that patients can be screened, which is necessary, but if your doctor has a subjective view or maybe even negative opinions about mental health, then how do you get access to the services you need?
The Ones who Suffer
I am a long time sufferer of Major Depression and I have unfortunately come across many doctors, including mental health professionals as well as primary care providers, who dismissed my symptoms or quickly diagnosed them as something else. After my daughter was born and I had a relapse of my depressive disorder that I had already been officially diagnosed with 10 years previously, I faced having to go to my primary care physician to not only get the medication that I needed but also for them to fill out mental health assessments from my disability insurance I had through my employer at the time. I was in a position where not only could I not afford a psychiatrist but was too ill to even turn my mind in the direction of looking for a psychiatrist. All of my energies were going towards looking after my infant daughter, there simply was nothing left over. As a result my disability and medication depended on the opinion of my primary care physician.
In the beginning the doctor was sympathetic and open to treating me because she continued to stand with the position of my diagnosis being post natal depression that would be short lived. This was regardless of my history with depression already documented. It was very clear to me that this was not just a bout of post natal depression but an acute depressive episode the likes of which I had already experienced at least twice through my history with the illness. I knew I was bedding in for the long arduous road to recovery. This was not going to just pass and I kept expressing these concerns to my doctor. Each time I would go back to the office, my doctor seemed to be getting more agitated with my lack of response to the minimal pharmaceutical treatment she was prescribing me, increasingly implying that my recovery was in my hands. Finally one of the last times I saw this particular doctor, I was told ‘ok, come on, when are you going to admit that this is a lifestyle choice not an illness?’ In this physician’s opinion I was applying for a continuance of disability pay because I wanted to be a stay at home mom, not because I was suffering from depression. For me the effect was devastating. This was the one link to health services that I had, which is the same for many patients in similar economic positions, and for that professional to not only be blind to the fact that I was genuinely going down hill fast, but to suggest I didn’t have a medical problem at all only managed to push me into a deeper place of helplessness and hopelessness.
By the time a patient or a parent goes to the doctor with real concerns, and it has already been documented that mental health illnesses tend to be diagnosed later because of the reluctance or inability of patients to recognize their problems as being mental health related, they are generally by that stage having real difficulties. Meaning as a sufferer it was probably all you could do to even make the appointment. The previously mentioned 2013 report on Kaiser Foundation Health Plan, inc, stated also that individuals ‘..with medical or mental health conditions must be seen by an appropriate health care provider within appropriate intervals (e.g. clinical, regulatory, etc.) in order to effectively treat the condition and/or prevent further deterioration…’ If you are already deteriorating on a daily basis, not being able to access mental health services in a timely manner or being discouraged to consider the possibility of a mental health diagnosis by a professional, just speeds up the rate of your deterioration. You can’t fight the professionals and the system when you are already using every mental faculty and bit of energy you possess to fight your illness.
Challenge to Keep up with Mental Health Demands
With the increasing rate of people presenting with mental health problems PCP’s and pediatricians are under increasing pressure to be the first point of contact for a myriad of illnesses, both physical and mental, which means requesting screening for any mental health illnesses requires extra time and money that the doctors don’t have. Being overwhelmed by the sheer number of patients, while at the same time being understaffed is a viable reason why mental health patients are not being identified sooner or at all. However the numbers don’t account for the lack of attention and ability. The American Academy of Family Physicians points out a lack of training and funding for family physicians in their position paper, ‘improving mental health treatment requires enhancing the ability of the PCP to treat….’
The number of adults and children needing mental health is only going to continue to rise and accessing services through primary care providers will continue to be the route the majority of people take. With this in mind it becomes more important than ever to ensure every resource available to help prevent and treat mental health is being applied. The publication of ‘Mental Health Services in Primary Care’ by Lesley Russell a visiting fellow to the at the Center for American Progress in 2010 stated that ‘there is a lack of application of evidence based screening, early intervention and treatment guidelines to ensure higher levels of treatment to remission and more effective recognition and care of comorbidities that accompany mental health disorders.’ Now with the recent findings of Prof Barbara Sahakian and Prof Ian Goodyer having produced an accessible screening tool, there might still be a ‘lack of application’ but there is not a lack of availability.
Note to Parents: For information about diagnosing and treating children with mental illness please see the National Institute of Mental Health’s fact sheet, Treatment of Children with Mental Illness
Results from the 2011 National Survey on Drug Use and Health: Mental Health Findings, Substance Abuse and Mental Health Services Administration
Mental Health Care Services in Primary Care, Lesley Russell, Center for American Progress, Oct 2010
American Academy of Family Physicians, position paper – Mental Health Care Services by Family Physicians
5-HTTLPR and Early Childhood Adversities Moderate Cognitive and Emotional Processing in Adolescence, Plos One, Nov 2012 Matthew Owens, Ian M. Goodyer, Paul Wilkinson, Anupam Bhardwaj, Rosemary Abbott, Tim Croudace, Valerie Dunn, Peter B. Jones, Nicholas D. Walsh, Maria Ban, Barbara J. Sahakian
Department of Managed Health Care, Help Center, Routine Medical Survey of Kaiser Foundation Health Plan, Inc, Behavioral Health Services, March 2013
National Alliance on Mental Illness, Facts on Children’s Mental Health in America