Presidential Reflections: Mental Health Needs, Inequalities, and Health Care Reform: Calling Students to Advocacy
Tony Cellucci, Ph.D., ABPP
 

Tony CellucciI started my career as an intern when our nation’s community mental health centers were beginning their decline, and I’m now teaching a new generation of clinical health psychologists. I strive to convey to these students something about the challenges our country faces regarding unmet behavior health needs and their role in advocacy. NIMH reports that 26% of US adults suffer from a mental health disorder- and that mental health conditions are the leading cause of disability.  Moreover, it is widely recognized that only a small percentage of individuals with behavioral health needs obtain professional treatment.  SAMSA recently released its 2014 Behavioral Health Barometer. Young adults (18-25) have the highest percentage of alcohol and other drug abuse which is associated with multiple health problems yet the majority of such youth receive no interventions. Among adolescents aged 12–17 with a Major Depressive Episode (MDE), only 38% received treatment. In addition, the report also describes well-known health disparities - 63% of Latinos and 71% of African American adolescents did not receive treatment.  Perhaps not surprising, thoughts of suicide among adults (4%) are higher among those without insurance and among those with incomes less than the federal poverty level.
     There is a large literature on help-seeking and behavioral health utilization (Meyer & Takeuchi, 2014).   We know for example that seeking help for substance abuse concerns is related to problem recognition, attitudes toward treatment, family/ social support for seeking help, and perceived stigma. Race and ethnicity are significant factors in that minority groups are generally less likely to use almost every aspect of our health care system including behavioral health. Many minority individuals likely lack access and/or awareness of services, and may experience more financial and external barriers. Moreover, even when they overcome such barriers, they unfortunately may be more likely to drop out of mental health services or to have a negative treatment experience.  There are many factors at play here including cultural mistrust due to historic discrimination, language and cultural incongruence, provider bias (e.g., in diagnosis) with implicit negative attitudes and stereotypes, and our social services maintaining unresponsive and stigmatizing services.

Behavioral Health, Chronic Disease, and Health Disparities
The major causes of morbidity/ premature death in the US are now chronic health conditions such as heart disease, respiratory diseases, diabetes, cancer and stroke. Significantly, all of these health problems are known to have a large behavioral component.  Smoking, obesity and behavioral management of conditions like HTN and diabetes are said to account for at least 50% of health outcomes. Lifestyle management and medical adherence are dependent upon maintaining mental health. We know the devastating impact of depression on diabetes management.  People with serious mental health conditions have a shorter estimated life expectancy.
     Unfortunately, traditional health settings with a biomedical model are not adequately prepared to deal with behavioral health issues. Depression, alcohol misuse, anxiety disorders are under-recognized and often go untreated in medical settings. Comorbidities between general medical/ mental health are particularly important for African Americans who shoulder a disproportionate share of health problems including higher rates of diabetes, heart disease, HIV, and prostate/breast cancer as well as mental health concerns (Snowden, 2012). Research studies have indicated that African American and Latino patients with psychiatric concerns are less likely to have those needs detected in primary care, particularly if they present with chronic health conditions (Borowsky et al, 2000).
     One example of the complexity of health disparities is HIV Disease, which due to effective medications, can now be considered a chronic manageable health condition. However, it is the 3rd leading cause of death among African Americans between 35-44 and 4th among Latinos in the same age group. HIV has become a disease of disenfranchised groups, often poorer individuals who often have complex social and mental health problems (Pellowski et al, 2013). However, the causes of disparities in HIV care are not generally discussed or adequately addressed. The risk of transmission due to individual risk behavior is related to interaction patterns influenced by incarceration, substance use, and relationship dissolution, which are related to unemployment and economic factors. Individuals within communities with fewer social resources are less likely to receive HIV testing, come into health care later in the disease, and have more challenges staying in care and achieving viral suppression. Premorbid trauma, psychological distress, and unmet basic needs such as food insecurity are associated with disease progression. Internalized stigma, lack of family/social support and community discrimination all negatively affect HIV health outcomes.  The example of HIV makes clear that addressing health disparities will require more seriously considering issues of social justice.

Envisioning the New Health Care System
The US Health Care system is generally seen as badly in need of reform; we are known to have the mostly costly system (16-17 % GDP) yet poorer health outcomes than most industrialized nations. Health care reform centers on increased access, lowering cost, and improving quality. Central to this vision is a shift to a bio-psych-social model of treating the whole person with particular emphasis on integrated primary care.  The new health care system will be built around interprofessional teams, hopefully including health psychologists to address behavioral factors. This model has the potential to improve health disparities in that many ethnic minorities with behavioral health needs are more likely to see a medical professional than seek specialty care. Yet much work needs to be done. There is a lack of mental health professionals specifically trained to work within integrated primary care settings and funding mechanisms do not yet exist to support behavioral health professionals in settings like Federally Qualified Health Centers (Johnson, 2013).
     It is sobering to realize that despite the extensive burden of mental health problems, mental health accounts for perhaps 6% of total health spending and much of that is on prescription drugs rather than effective psychosocial treatments. This is true even though survey research indicates that many populations such as the elderly actually prefer psychological treatment over medication. Behavioral consultation is not a replacement for having a mental health system (Freeman, 2012). It is not integrated care vs specialty mental health. We need both for a viable system. Working with substance dependent women, I learned how many of them had not had a basic physical/ OBGYN exam. From another perspective integrating care means placing a nurse practitioner and other primary care providers in that system. I’m very supportive of the new paradigm but I have this fantasy of writing a paper just before I retire where I rediscover the need for specialty mental health care in our communities and become famous.    

The Peculiar American Struggle and the Need for Advocacy
 Although primarily aimed at proving insurance coverage to 30 million Americans, the Patient Protection and Affordable Care Act (2010) is consistent with the shift to patient-centered care including behavioral health. However, the struggle to provide universal coverage and especially quality mental health care is ongoing. The Wellstone-Domenici Mental Health Parity Act (2008) recognized that treatment of neurobehavioral disorders should not be limited any more than other illnesses, but many Americans do not have health insurance that covers behavioral health. In Paul Star’s book, Remedy and Reaction, he describes “the peculiar American struggle over health care”-  where many groups including those with tax advantaged employer programs, seniors with Medicare, etc. along with special interests such as health systems for profit and big pharmacy pose obstacles to true reform -not seeing themselves as having common health needs with the working poor who they perceive as looking for a government handout. 
     Last weekend, a few of my students and I participated in a NAMI fundraising walk for mental health awareness. We walked around the old Dorthea Dix Hospital in NC.  It was certainly a small step but it made me feel proud. Psychologists and psychologists-in training need to see themselves as part of a larger struggle to afford all people human rights and dignity. I hope my students become passionate about health care as a basic human right, able to speak to the burden of untreated mental health problems in our society, and committed to working to end health inequalities.   

Selected References
Borowsky, S. J. et al. (2000).Who is at risk for non-detection of mental health problems in primary care? Journal of General Internal Medicine, 15, 381-388.
Cooper, L., Hill, M.N., & Powe, N. (2002). Designing and evaluating interventions to eliminate racial and ethnic disparities in health care. Journal of General Internal Medicine, 17, 477-486.
Freeman, J. S. (2015). Providing whole person care: Integrating behavioral health into primary care, North Carolina Medical Journal, 76, 24-28. NC Medical Journal Mental Health Issue online http://www.ncmedicaljournal.com/archives/?mental-health
Johnson, S. B. (2013). Increasing psychology’s role in health research and health care.  American Psychologist, 68, 311-321. 
Meyer, O.L.  & Takeuchi, D.T.  (2014). Help-seeking and service utilization. In F. Leong (Ed.), Handbook of Multicultural Psychology. DC: APA.
Pellowski, J., Kalichman, S., Mathews, K., and Adler, N. (2013). A pandemic of the poor: Social disadvantage and the US HIV epidemic. American Psychologist, 68, 197-209.
Snowden, l. R. (2012). Health and mental health policies’ role in better understanding and closing African American –White American disparities in treatment access and quality of care.  American Psychologist, 67, 524-531.
Starr, P. (2011). Remedy and reaction: The peculiar American struggle over health care reform.  Yale University Press
Substance Abuse and Mental Health Services Administration (2015). Behavioral Health Barometer: United States, 2014. HHS Publication No. SMA–15–4895. Rockville, MD: Substance Abuse and Mental Health Services Administration.