Co-written with Michael B. Friedman, LMSW
One in four Americans suffer from a mental or substance use disorder each year; 50% during the course of their lifetimes. In other words, these conditions are more common than diabetes, heart disease and cancer. Yet only 40% get any treatment for these common, painful and potentially disabling conditions. Worse still, quality is typically abysmal with a highly noted national study showing that only one in eight people with mental health problems in primary care settings (the major site where people go for care) get "minimally adequate care". We should be ashamed. We don't understand how this level of primary care performance is tolerated, especially since the effectiveness of proper treatment for common mental disorders like depression and anxiety conditions is in the range of 75%, as good or better than the other ongoing illnesses served in these settings. It's not the doctors, its how we go about health care, especially mental health care.
Have you heard a word about mental health in the deluge of information and policy discussions that populate health reform communications on TV, radio and newsprint? Have you seen any mention in Federal legislative offerings? Oops, we forgot to include highly treatable and deeply burdensome conditions that spare hardly a family, community, school or business as we try to re-engineer health in this country. We don't get it. Untreated depression complicates the treatment of diabetes, heart and lung disease, asthma and cancer, increasing the likelihood of disability and premature death, and driving up the costs of medical treatment. The productivity of American workers and the educational success of students hinges on recognizing and effectively treating mental disorders. Being older really hurts: 75% of seniors who killed themselves were in a primary care doctor's office in the 30 days anteceding their death -- 40% in the week before. Is anybody paying attention?
Good mental health, in primary care or specialty mental health care, is possible -- but not easy. But it is not possible if no one says it must be so. Here is where we should start:
- Implement simple screening tests for depression and problem drinking in all primary care settings for adolescents, adults and seniors
- Provide care paths for the treatment of these conditions in primary care, with referral to specialty care for the limited number of people who want to be seen by psychiatrists and mental health professionals or who do not improve in primary care
- Support the creation of medical homes and mental health homes (1) where accountable, patient focused (as opposed to for the convenience of providers) prevention and intervention are financially supported
- Identify populations at high risk for mental illness, morbidity and mortality such as Veterans, seniors, people with chronic medical problems, pre and post-partum women and monitor their access to effective care and treatment - since we know that most medical services (and thus its costs) are used by a minority of high need individuals
- Provide public information and messaging that says "there is no health without mental health"
- Find and engage champions in government, media and the world of celebrity to support inclusion of mental health in evolving health care policy
It's not too late. There is time to attend to mental health as we shape the course of health care to come. If we don't, we will (continue to) pay the price in the suffering of individuals and families and from the vast economic costs of ignoring among the most important and greatest barriers to recovery from physical and mental disorders.
(1) Smith, T, Sederer, LI: A New Kind of "Homelessness" for People with Serious Mental Illnesses? The Need for a "Mental Health Home." Journal of Psychiatric Services. 2009; 60:528-533
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