At this point in time, the U.S. is not exactly a beacon of hope for mental illness. The state of our current mental health system is seriously challenged in the areas of access, equity, and quality of care. While many would try to fix the current mental health system with small changes, others believe that it requires a complete overhaul from top to bottom.

Access to mental health services is dwindling, especially in rural areas of the U.S.

Some disturbing statistics about this dearth of care in remote areas include:

  • Almost 60% of those in rural areas of the U.S. live in areas where there is a shortage of mental health professionals
  • The suicide rate in rural areas is higher, especially among adult males and children
  • Women in rural areas are more likely to suffer abuse as a result of this shortage of care

In urban areas, access is also limited, especially for children. An estimated 20% of children have mental health issues, yet between 60 and 90% of them fail to receive treatment. Poverty and lack of insurance is a barrier to treatment in urban areas, but lack of trained mental health counselors working in schools where students spend most of their time is also to blame.

This lack of access in all areas of the country has led to a three-fold increase of psychiatric consults in emergency room visits. Arica Nesper, MD, MAS of the University of California Davis school of medicine in Sacramento, led the study that found not only an increase in psychiatric consults but also in length of psychiatric hospital stays by 55%. She noted:

“As is often the case, the emergency department catches everyone who falls through the cracks in the health care system. People with mental illness did not stop needing care simply because the resources dried up. Potentially serious complaints increased after reductions in mental health services, likely representing not only worse care of patients’ psychiatric issues but also the medical issues of patients with psychiatric problems.”

Even when access to care is there, the quality of that care as it relates to typically disadvantaged or underserved populations is generally poor.

A survey from the University of Michigan National Voices Project found that while access to mental health services for teens across the U.S. is improving, the quality and availability of care depends highly on racial, ethnic, and income disparities. In communities with less disparity of race and income, 54% of adults perceived good availability of care, as compared to 35% among adults in neighborhoods with more diversity.

Further, a study from Israel found that therapists were not immune to racial bias, misdiagnosing their disadvantaged patients at a rate twice that of an advantaged group.

Ora Nakash, study lead and a clinical psychologist at the Interdisciplinary Center in Herzliya, Israel explained the potential assumptions therapists could make based solely on race or perception of disadvantage, noting:

“…a White therapist can interpret affect disregulation symptoms of a client who is also White as rooted in financial pressures and diagnose him/her as having transient adjustment disorder. Conversely, if the client is African American, the same symptoms might be seen as proof of the client’s persistent borderline personality disorder.”

While typically disadvantaged populations may not experience mental health issues at higher rates than advantaged populations, the lack of care and misdiagnosis when care is received may cause these issues to become more severe as time passes. This is similar to what occurs among veterans returning from service overseas suffering from post-traumatic stress disorder, anxiety, and depression.

What results is a mental health system that is broken and does little to protect and serve its most vulnerable populations.

An essay in U.S. News and World Report calls for “disruptive change” in all areas of healthcare. This type of change doesn’t mess around with small tweaks to a broken mental health system. Rather, the whole system is overhauled, starting with improving diagnosis in primary care and instituting treatment reforms in a comprehensive manner.

Because half of mental disorders are apparent by age 16 and ¾ of them before age 25, it makes sense to look to primary care for screening and treatment options. Unfortunately, primary care physicians lack the training or the motivation to screen for mental illness, even though mental disorders are more common than other conditions that physicians routinely screen for (e.g. diabetes and cardiovascular disease).

New York State is leading the way in changing the way mental health is screened for and treated.

They have implemented a federally-funded program that integrates standard medical care with behavioral treatment programs for adults with depression. This program focuses on collaborative care in which mental health is treated with evidence-based methods that are incorporated into treatment for other health conditions. For example, depression is often comorbid with diabetes. A collaborative treatment plan might include nutritional counseling to incorporate not only healthy food choices but increase levels of vitamins and minerals that might benefit a person with depression.

Key tenets of collaborative care include early screening, tracking of treatments, coordination of care among specialists and other doctors, and evidence-based, holistic treatments that look at root causes instead of just treating symptoms.

Because many mental health initiatives are in response to a crisis, their approaches may be limited as far as early detection and treatment of mental illness. The Substance Abuse and Mental Health Services Administration (SAMHSA) of the federal government is trying to change that by helping states develop and implement early intervention in mental health issues and prevention of suicide. Each program would be different based on each community’s identified needs, but SAMHSA offers a framework to open a discussion about identifying and treating those with mental health issues.

The mental health system in the U.S. has a long way to go in terms of improving access, equity, and quality of care. What do you feel is the most important part to focus on first?


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