Providing care is an ongoing challenge

Mental health care doesn’t carry the stigma it once did and more is understood about mental health disorders than ever before. Yet millions of those meeting the criteria for a psychological disorder still don’t receive care, presenting an ongoing challenge in how to improve access and make sure effective treatments are delivered.

Around 26 percent of U.S. adults meet the criteria for a disorder within a given year, while the lifetime prevalence is around 46 percent. These were the conclusions of the National Comorbidity Survey (NCS), a National Institutes of Mental Health-funded study of more than 9,000 adults first done in the early 1990s and repeated 10 years later.

The latter survey found that the number of people seeking treatment for a psychiatric disorder had risen by around 50 percent compared with the first study, in part because of greater public awareness and more extensive screening and outreach programs. Still, fewer than half of people with a diagnosable disorder in the second study – around 41 percent – had used mental health services in the previous year. Even when treatment was sought, it was often found to be inadequate, in terms of drug regimens or frequency of visits to a primary care doctor or mental health professional.

John O’Brien, Ph.D., a clinical psychologist in Portland, Maine, points out that the overall prevalence figures in the studies include both people with severe disorders – estimated to be about six percent of the population in a given year – and those with much milder ones, such as adjustment disorder after a divorce or some other major life change.

“At the same time, if you realize that a lot of conditions go undiagnosed, the numbers may be an underestimate,” he says – a possibility that was noted by the study’s authors.

A number of initiatives nationwide are aiming to increase people’s access to mental health care and integrate it with other services. Some of the work funded by the NIMH, for instance, focuses on at-risk populations, including people with diagnosable mental health issues who are leaving prison and youth transitioning out of state systems.

Mental health screening is also being incorporated into medical screening and in doctors’ visits – in OB/GYN offices, for example (to help stem post-partum depression) and in pediatrician visits.

“One of the things we know about mental health is that, compared with physical health, services are delivered across so many different sectors,” says David Chambers, D.Phil., Branch Chief of Services Research and Clinical Epidemiology Branch at the NIMH. “We’re trying to improve access by picking up people [who may benefit from psychological treatment] in other venues.”

Meanwhile, growing numbers of mental health professionals are being trained to work in primary care offices. One such program in Primary Care Behavioral Health is offered at the University of Massachusetts Medical School in Worcester.

Part of the reason for an integrated approach is that most patients come to the doctor describing physical symptoms with no clear biological cause. If a doctor refers these patients to a mental health provider, the patients may feel insulted or that they’ve wasted the doctor’s time, notes Alexander Blount, Ed.D., director of the UMass Medical School program in the book “Integrated Primary Care: The Future of Medical and Mental Health Collaboration.” A team approach would allow both physical and psychological components to be addressed.

Another reason for integrating care is that research has shown patients are more likely to go for mental health treatment when they’re offered a collaborative approach in the primary care setting rather than when they’re referred to a provider in another location. Studies have also shown better outcomes for people with major depression when they’re treated in an integrated plan.

Working in a primary care setting requires a change in perspective for mental health professionals, Blount says.

“Most of us are trained in specialty mindset,” he says. “We’re trained to see people for an hour. The ideal mental health treatment is six to15 visits, then a person doesn’t have to come back anymore.”

Primary care mental health is much more brief and episodic, he continues, and relies on information being shared with primary care doctors to “get people back to functioning.”

Where integrated care has been tried, providers and patients have been highly satisfied, Blount says. One challenge to widespread implementation, he acknowledges, is figuring out a suitable payment system.

Yet he firmly believes integrated care is the future.

“It’s mandated in federally funded centers and by the armed services,” he says. “That doesn’t mean it’s happening yet, but it’s clearly coming.”