In a moment of candor, Ann Romney recently told a television interviewer that if her husband Mitt Romney wins the presidential election, her biggest concern would be for his "mental well-being." In a society that usually only addresses mental health through media stories of irrational acts of violence carried out by disturbed, mentally-ill individuals, these comments are refreshing and hopefully non-stigmatizing (even for a presidential candidate).
Mental health needs fly under the radar, with fewer than one-half of persons with diagnosable conditions receiving the treatment they need. While 21st century approaches to public health have increasingly focused on healthy living with diet, exercise, smoking cessation, and access to preventive health care, there is a growing evidence base to incorporate mental health into our nation's public health agenda.
In the late 1990s, a new metric for calculating the disabling aspects of more than 100 diseases in a comparative framework (the Global Burden of Disease study) documented for the first time that mental disorders were among the leading causes of diminished human productivity and impaired social functioning. In fact, mental disorders contributed as much to a lifetime of disability as do cardiovascular and respiratory diseases and surpassed all cancers and HIV. Furthermore, five of the 10 leading causes of disability worldwide were recognized as mental health-related problems, including major depression, schizophrenia, bipolar disorders, alcohol use, and obsessive-compulsive disorders.
More recent advances in the epidemiology of mental disorders have found that half of adults with diagnosable conditions had onsets by age 14 and three-fourths by age 24. But we also now know that significant delays in the detection of mental disorders from the age of onset when symptoms first manifest are commonplace. Depressive illness and anxiety disorders have delays of 8-14 years from onset to diagnosis. These findings provide strong evidence for a "window of opportunity" to carry out screening for symptoms during childhood and adolescence in order to intervene before the onset of a full-blown diagnosable mental disorder.
Access to mental health care has long been stymied by the efforts of insurers to discourage treatment utilization by imposing severe limits on benefits coverage. In contrast to insurance coverage for general medical health care, those seeking mental health treatment have faced higher deductibles, co-pays, and limits on annual and lifetime benefits, if offered at all. But the passage of the Patient Protection and Affordable Care Act ("Obamacare") in 2010 is creating a fundamental change in accessibility to mental health care. An essential benefits package will be required of insurers to cover mental health and addiction disorders at parity with all other medical conditions. Pre-existing condition will no longer be able to be applied to disqualify persons from receiving insurance coverage for their mental health symptoms. And allowing young people to stay on their parents' insurance plan until age 26 maintains benefits at those ages when mental health problems so often may emerge.
Given the early age onsets of enduring mental health problems, we will need to screen for and address the early warning signs among our youth that may signal longer term mental health challenges. To make significant gains in our nation's overall mental well-being, we will need to more widely develop service delivery models that proactively screen "at risk" families with very young children for signs of psychological distress and promote interventions that address parents and young children affected by exposure to highly stressful or even toxic environments.
Children and families who are identified, often by school authorities, as needing evaluation for psychological symptoms or behavioral problems face barriers to mental health care. Indeed, there is a low rate of follow-up with mental health professionals among those referred for care. Such services could be initiated in multiple health care settings that engage children and families, including "well baby," other pediatric, and family practice settings that offer a model of care that is family-focused, culturally-informed, de-stigmatizing, and accessible to vulnerable populations. Developing family-focused care that integrates health, mental health, and social service systems can provide opportunities for prevention and services for children and families that can help strengthen mechanisms for resiliency over time and across generations.
Mainstreaming the promotion of positive mental health and well-being into our school systems and our health and social service programs will be critical to overcoming the stigma so commonly associated with mental health care. We need more open dialogue about mental well-being as crucial to our overall health. The inclusion of mental health concerns, mental health promotion, and mental illness prevention into an integrated public health model that fully recognizes the interrelationships of physical and mental well-being will be key to making a far healthier society.
Ann Romney had it right, as did Barack Obama.
Neal L. Cohen, M.D., Interim Dean
CUNY School of Public Health at Hunter College
Former Commissioner, New York City Department of Health and Mental Hygiene
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