Rahn Kennedy Bailey, M.D., D.F.A.P.A. 113th President National Medical Association

Chairman & Professor Dept. of Psychiatry and Behavioral Sciences

Elam Mental Health Center Meharry Medical College

Nashville TN1/38

Barriers to Mental Health Treatment

November 7th, 2014

2014 Gulf Coast of Texas African American Family Support

Conference

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Disclosures

Private Grants

Eli Lilly

Janssen

Sunovian

Ortho McNeil

Federal Grant Treatment Access Project II

5th Annual Lloyd C. ELAM Symposium NIH Grant

NIMHD Translational Health Disparities Training August 2013

Programs at Elam Mental Health Center

Adolescent Day Treatment

Rainbow Unit

SISTER’S Story (Supported Intensive System of Treatment, Empowerment, & Recovery)

Tennessee Psychiatric Association Innovative Grant

Project COPE (Community Outreach Prevention Education)

REACH (Recovery is for Everyone Accepting a Change in Health)

Adult Continuum

Detoxification

Residential Rehabilitation

Intensive Outpatient

Outpatient

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Disclaimer

The Health Policy Writing Collaborative is sponsored in part by the Robert Wood Johnson Foundation for Health Policy at Meharry, and the Department of Health and Human Services’ Health Resources and Services Administration (HRSA), D76HP20862 grant award.

The content is solely the responsibility of the author(s) and does not necessarily represent the official view of the Robert Wood Johnson Foundation or the Department of Health and Human Services.

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Learning Objectives

At the conclusion of this presentation the attendees will be able to:

Explain top five barriers to seeking Mental Health Care

Stigma and its impact on help-seeking for mental disorders

Explain the need of Mental Health Treatment Barriers

Implications for Public Policy to address the Mental Health Issues

The impact of Affordable Care Act in improving mental health treatment 5/38

The burden and prevalence of mental disorders

Depression and anxiety are highly prevalent mental disorders with estimates indicating they affect up to almost one fifth of the population in high income countries worldwide.

Prevalence of mental disorders is greatest among younger people aged 16-24 years than at any other stage of the lifespan.

Common in childhood and adolescence with 14% of those aged between 4 and 17 years affected.

High susceptibility in adolescents and young adults to developing a mental disorder is coupled with a strong reluctance to seek professional help.Rickwood D, Deane F, Wilson C: When and how do young people

seek professional help for mental health problems? Med J Aust 2007, 187(7 Suppl):S35-39.

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Barriers To Mental Health

System-level barriers:

Access issues :

Inaccessibility location, Transportation problems Lack of health insurance

Availability of services:

Few opportunities for group counseling In-home services

Social issues: lack of child care

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Ward et al. (2009) Quality Health Res. 2009 November ; 19(11): 1589–1601.

System-level barriers:

Poor quality of care:

Limited access to culturally competent clinicians and case management

Cultural matching: few opportunities to work with racial and ethnic minority clinicians

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Ward et al. (2009) Quality Health Res. 2009 November ; 19(11): 1589–1601.

Individual-level barriers:

Internalized stigma of mental illness

Shame and embarrassment about mental illness

Lack of knowledge of mental illness

Cultural norms

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Ward et al. (2009) Quality Health Res. 2009 November ; 19(11): 1589–1601.

Attitude

Attitudinal barriers commonly caused Americans to not seek mental health care.

These barriers include believing that the mental illness will resolve on its own and not believing that psychiatric care is beneficial.

Evidence that suggests that athletes may have even less positive attitudes towards seeking help from a counsellor than non-athletes.

In particular, male and younger athletes have been reported to have less positive attitudes towards seeing a sport psychologist than female and older athletes

Sareen et al. Perceived barriers to mental health service utilization in the United States, Ontario, and the Netherlands. Psychiatr Serv. 2007

Mar;58(3):357-64.Watson J: College student-athletes' attitudes toward help-seeking

behavior and expectations of counseling services. J Coll Stud Dev 2005, 46(4):442–449.

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Limited Availability of Medication and Health Professionals

Unavailability of essential medicines is particularly prevalent in developing countries, and severely restricts access to treatment for psychological disorders.

World Health Organization reports that nearly 20% of countries do not have at least one common antidepressant, one antipsychotic, and one antiepileptic medication available in primary care settings.

Lack of mental health care professionals in low- and middle-income countries

Low-income countries have a median of 0.05 psychiatrists and 0.16 psychiatric nurses per 100,000 people.

Saxena, S., Thornicroft, G., Knapp, M., Whiteford, H. (2007). Resources for mental health: scarcity, inequity, and inefficiency. Lancet, 370: 878-89. 11

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Limited Affordability

In many low- and middle-income countries, the high cost of psychiatric treatment, often due to high medication prices, poses significant financial barriers to patient care.

Psychological disorders are not covered by insurance policies in many countries, making mental health care unaffordable for many people.

WHO reports that 25% of all countries do not provide disability benefits to patients with mental disorders.

One-third of the world’s population lives in countries that allocate less than 1% of their health budget to mental health.

31% of countries do not have a specific public budget for mental health.

World Health Organization. “Investing in mental health”. Retrieved 29 June 2012.

Saxena, S., Thornicroft, G., Knapp, M., Whiteford, H. (2007). Resources for mental health: scarcity, inequity, and inefficiency. Lancet, 370: 878-89.12

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Policy Limitations

Global lack of comprehensive mental health policies, which are crucial for implementing and coordinating mental health care services, a key barrier to public access to mental health care.

Nearly one-third of all countries, and almost half of all African nations, have no comprehensive mental health care policy or plan

22% of countries do not have laws that offer legal protection of the human and civil rights of people with mental illnesses.

In many low- and middle-income countries, the localization of mental health care resources in large cities has also been cited as a key barrier to providing mental health care to the entire population.

Saraceno, B., van Ommeren, M, Batniji, R., Cohen, A., Gureje, O., Mahoney, J., Sridhar, D., Underhill, C. (2007). Barriers to improvement of

mental health services in low-income and middle-income countries. Lancet, 370: 1164-74. 13

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Lack of Education

Limited knowledge about mental illness can prevent individuals from recognizing mental illness and seeking treatment.

Poor understanding of mental illness also impairs families’ abilities to provide adequate care for mentally ill relatives.

The majority of individuals with an untreated severe mental illness did not seek care because they believed they did not have a condition that required treatment.

Of responders with a severe mental illness who did not receive care but recognized that they needed treatment,

52% reported situational barriers to care

46% cited financial barriers

45% dropped out of care because they felt that treatment had not been effective.

72% of respondents who did not seek treatment chose to do so because they wanted to “solve the problem on their own”

Kessler et al (2001). The prevalence and correlates of untreated serious mental illness. HSR: Health Services Research, 36(6):

987-1007.

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Stigma

Stigma associated with mental illness often prevents patients from seeking and adhering to treatment, as patients may “attempt to distance themselves from the labels that mark them for social exclusion”.

Stigmatisation of those with mental illness has been conceptualised as a process ultimately resulting in status loss and discrimination.

Three levels of discrimination: Individual Structural Discrimination qua self-stigmatisation.

Wahl, O.F. (2012). Stigma as a barrier to recovery from mental illness.

Trends in Cognitive Sciences, 16(1): 9-10.15

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Stigma

Self-stigmatisation occurs when members of a minority group internalise the stigmatising ideas of their social environment and start to believe that they are of less value and will be rejected by most people.

The stigma attached to mental illness often leads to underestimation, underdiagnosis and undertreatment of mental disorders.

A lack of knowledge of causes, symptoms and treatment options of mental disorders and a lack of personal contact with persons suffering from these disorders, can lead to prejudices and negative attitudes towards them – and subsequently to stigmatization, social exclusion and discrimination.

Riecher-Rossler et al., 2006; Sartorius & Schulze, 2005; 16

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Stigma

Stigma is a risk factor leading to negative mental health outcomes.

Stigma is responsible for treatment seeking delays and reduces the likelihood that a mentally ill patient will receive adequate care.

It is evident that delay due to stigma can have devastating consequences.

Intervention studies show that destigmatisation may lead to increased readiness to seek professional help, but other aspects like knowledge about mental diseases seem to be at least as important.

Schomerus G, Angermeyer MC. Stigma and its impact on help-seeking for mental disorders: what do we know?

Epidemiol Psichiatr Soc. 2008 Jan-Mar;17(1):31-7.17

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Stigma of Mental Illness:

Shrivastava A, Johnston M, Bureau Y. Mens Sana Monographs, Vol. 10, No. 1, January-December, 2012,

pp. 85-97

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Stigma of Mental Illness: Non-compliance and Intervention

Shrivastava A, Johnston M, Bureau Y. Mens Sana Monographs, Vol. 10, No. 1, January-December, 2012,

pp. 85-97

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Stigma of Mental Illness: Non-compliance and Intervention

Shrivastava A, Johnston M, Bureau Y. Mens Sana Monographs, Vol. 10, No. 1, January-December, 2012,

pp. 85-97

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Barriers to help-seeking for mental health problems reported by elite athletes.

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Gulliver et al. BMC Psychiatry 2012, 12:157

Barriers to Mental Health Treatment

Globally, more than 70% of people with mental illness receive no treatment from health care staff.

Evidence suggests that factors increasing the likelihood of treatment avoidance or delay before presenting for care include

Lack of knowledge to identify features of mental illnesses

Ignorance about how to access treatment

Prejudice against people who have mental illness

Expectation of discrimination against people diagnosed with mental illness.

Thornicroft G. Most people with mental illness are not treated. Lancet. 2007;370(9590):807-808. 22/3

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Reasons for Not Receiving Mental Health Treatment in the Past Year among Adults aged 18 or Older

Results from the 2006 National Survey on Drug Use and Health. DHHS/SAMSHA Office of Applied Statistics 23/3

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Mental health and development: targeting people with mental health conditions as a vulnerable group / Michelle Funk … [et al].

World Health Organization 2010

The relationship between vulnerability, mental health conditions and adverse

development outcomes

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Mental Health Treatment by Race/Ethnicity

SAMHSA, National Survey on Drug Use and Health, 2008

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Adherence to Psychiatric Treatments

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Disparities in Treating Depression

Traditional masculinity norms contribute to Men’s under-utilization of health care services.

Seeking mental health treatment is perceived by many men to be in conflict with traditional gender norms.

Even though medical services are provided free of charge, most men would still not seek treatment.

Mackenzie CS, et al. Age, gender, and the underutilization of mental health services: The influence of help-seeking attitudes. Aging & Mental Health. 2006;10(6):574-582.

Griffith DM, Gunter K, Watkins DC. Measuring Masculinity in Research on Men of Color: Findings and Future Directions. American journal of public health. 2012;102(S2):S187-S194.

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Disparities in Treating Depression

only 14% of African American men received mental health care from professional services , while 29% did not seek any help.

Underutilization of mental health services lead to disproportionate burden of morbidity and mortality compared to other racial/ethnic groups.

African American Men have highest rates of chronic medical disorders in the U.S. and die approximately 6years younger than White Americans.

Woodward AT, Taylor RJ, Chatters LM. Use of Professional and Informal Support by Black Men with Mental Disorders. Res Soc Work Pract. Jul 2011;21(3):328-336.

Satcher D, et al. What if we were equal? A comparison of the black-white mortality gap in 1960 and 2000. Health affairs. Mar-Apr 2005;24(2):459-464.

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Disparities in Treating Depression

African American Men are twice as likely to be unemployed compared to White Americans.

Factors preventing African American Men from getting Mental Health Care

Socioeconomic inequities Stigma of Mental Illness Lack of Access to Care High Incarceration Rates Low levels of education

Holden KB, et al. Journal of men's health. Jun 1 2012;9(2):63-69.Ayalon L, Alvidrez J. Issues in mental health nursing. 2007;28(12):1323-1340.

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Alegria, M. et al. (2008) Disparity in Depression Treatment Among Racial and Ethnic Minority Populations ion the United States. Psychiatric Services, 59(11), 1264-72

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ACA and Mental Health Prior To Affordable Care Act:

one-third of those who are currently covered in the individual market have no coverage for substance use disorder services

Nearly 20 percent have no coverage for mental health services, including outpatient therapy visits and inpatient crisis intervention and stabilization

47.5 million Americans lack health insurance coverage

25 percent of uninsured adults have a mental health condition or substance use disorder or both

ASPE Issue Brief, "Essential Health Benefits: Individual Market Coverage," ed. U.S. Department of Health & Human Services (2011). 31/3

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ACA and Mental Health ACA will expand coverage of mental health in three distinct

ways:

1. By including mental health and substance use disorder benefits in the Essential Health Benefits :

About 3.9 million people currently covered in the individual market will gain either mental health or substance use disorder coverage or both

An estimated 1.2 million individuals currently in small group plans will receive mental health and substance use disorder benefits under the Affordable Care Act

2. By applying federal parity protections to mental health and substance use disorder benefits in the individual and small group markets :

Under this approach, 7.1 million Americans currently covered in the individual market who currently have some mental health and substance use disorder benefits will have access to coverage of Essential Health Benefits

ASPE Issue Brief, "Essential Health Benefits: Individual Market Coverage," ed.

U.S. Department of Health & Human Services (2011). 32\3

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ACA and Mental Health ACA will expand coverage of mental health in three

distinct ways:

3. By providing more Americans with Access to Quality Health Care that includes coverage for mental health :

Affordable Care Act will expand insurance coverage to a projected 27 million previously uninsured Americans

Access to private health insurance in the individual and small group markets, the Marketplaces, and Medicaid.

In total, 32.1 million Americans will gain access to coverage that includes mental health and/or substance use disorder benefits

An additional 30.4 million Americans who currently have some mental health and substance abuse benefits will benefit from the federal parity protections.

By building Mental Health Parity and Addiction Equity Act, the Affordable Care Act will extend federal parity protections to 62 million Americans.

ASPE Issue Brief, "Essential Health Benefits: Individual Market Coverage," ed. U.S. Department of Health & Human Services (2011). 33/3

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Parity Protection for Behavioral Health

Parity law — the Mental Health Parity and Addiction Equity Act (MHPAEA);

Rules to fully carry out the law were issued in Nov. 2013. Effective July 1, 2014; for some plans, effective Jan 2015.

In the past, when health plans offered mental health coverage, it was often at less generous levels than benefits for medical care. These discriminatory practices kept people from getting mental health care, and they are no longer allowed under the parity law.

When health insurance plans provide coverage for mental ailments, it must be comparable to coverage for physical ailments.

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Parity Protection for Behavioral Health

Plans cannot set higher deductibles or charge higher co-payments for mental health visits than for medical visits, and cannot set more restrictive limits on the number of visits allowed;

Plans cannot limit mental health care to a specific geographic region, if they do not do so for physical illnesses;

Plans cannot make getting prior-approval for inpatient mental health treatment more difficult than that for admission to an acute care hospital;

The law also applies to “intermediate” treatment options for mental health and addiction disorders, like residential treatment or intensive outpatient therapy.

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Conclusion

Mental healthcare is limited by factors such as

lack of knowledge to identify mental illness

how to access treatment prejudice against mental illness individual negative attitudes and beliefs perceptions of stigma anticipated discrimination.

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Conclusion (contd..) Sophisticated approaches are needed to

realistically eliminate these and other barriers. Public policy should focus on criteria for need

for care and encourage interventions that facilitate treatment when it can be helpful.

Appropriate insurance coverage is indispensable, and achieving mental health parity will require careful management of care.

Policymakers must help to create a trustworthy management structure that is inclusive, that develops and disseminates models of best practice.

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Conclusion A major promise of the Affordable Care Act is to improve care and

financial protection for vulnerable populations such as the many lower-income Americans with mental disorders.

The key features of the Affordable Care Act are :

The expansions of insurance coverage through federally subsidized health insurance exchanges

Medicaid eligibility for all individuals up to 138% of the federal poverty line, coupled with tax penalties for forgoing insurance.

These insurance expansions are expected to increase coverage for lower-income populations, which have a higher prevalence of mental disorders.

Individuals with mental illness will see significant gains in insurance coverage and access to care. 38/3

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Thank you!

Questions and Answers