Wednesday, December 13, 2006

How the Failure to Address Mental Illness as a Public Health Issue Disproportionately Impacts Low SES Populations - Mary Sharon Kaminski

Although public health has now nominally recognized that mental illness is a serious concern in the United States, there remains a widespread lack of resources devoted to the prevention and treatment of psychiatric disability. According to the National Institute of Mental Health, about one in four adults suffer from a diagnosable disorder in a given year (NIMH). Despite this high prevalence of mental illness, only 7 percent of total healthcare expenditures in 1996 were for mental health. The situation has since worsened: over the last decade, spending for mental health has declined as a percentage of overall health spending (Surgeon General).

Depletion of financial resources due to across-the-board social cutbacks and the consistent reduction of benefits by insurance companies lay the burden of responsibility on an overextended and under-funded public health system (Fink & Tasman, 1992). These factors all result in a dearth of resources available to those requiring mental health services, and most people in need of mental health care do not receive it (Thornicroft, 2006). Compounding and perhaps contributing to these financial concerns, widespread stigma acts as another obstacle to mental health care access. In general, public perception of mental illness is generated by “a mixture of little and wrong information…alongside wary and cautious attitudes about mentally ill people” (Thornicroft, 2006). The healthcare profession itself perpetuates bias and prejudice against those afflicted (Fink & Tasman, 1992). Internalization of this stigmatization leads to reluctance to pursue appropriate healthcare, even when such services are available (Thornicroft, 2006). Most psychiatric treatment is prohibitively expensive, and, paradoxically, those who can least afford it need it the most. People in lower socioeconomic populations experience greater incidence of mental illness (Eaton, 1980), and are, therefore, disproportionately affected by lack of services. This disparity is compounded by high levels of comorbidity with other illnesses (Felker, 1996), so people of lower socioeconomic status are doubly impacted. This iniquity is directly at odds with the stated goal of Healthy People 2010 to reduce health disparities. Its lack of attention to the societal factors of mental disorders and potential preventative interventions greatly hinders its attempts to make sure that “good health, as well as long life, is enjoyed by all” (Healthy People 2010).

Access to mental health care is stymied by prejudice from many different sectors. The health care profession has been found to be one of the greatest offenders in this regard, and “often perpetuate the biases of laypersons” (Fink and Tasman, 1992). Due to several factors including inadequate training and stigma, “mental health care systems create barriers to optimal treatment” (Thornicroft, 2006). Health professionals often “demonstrate a lack of will to help those with mental illnesses.” The perceived needs of those with mental health issues are judged to be less than those with physical illness. General medical wards tend to be quicker in discharging patients with mental illness, and treat patients taking overdoses with contempt. (Thambirajah, 2004) Federal policies are also working against people with mental illness, through budget cutbacks in social spending, which “mentally disabled people are the least likely to protest” (Smith & Giggs, 1988). Policy-makers are unconcerned about providing adequate funding for mental healthcare services, as they “hold a low opinion of the chronically mentally ill, seeing them as a welfare burden and largely undeserving group” (Smith & Giggs, 1988). The insurance industry is also a culprit, placing severe limitations on coverage, with inadequate reimbursements for both inpatient and outpatient care. Massachusetts Blue Shield has been quoted as describing its constituents as “aberrant” in their use of mental health care, and in the eighties the state insurance commissioner overruled Blue Shield’s attempt to withhold benefits for certain diagnostic categories (Smith & Giggs, 1988). Although the public health system has assumed most of responsibility for mental healthcare, it suffers from lack of funding and complex rules and regulations, providing “ a maze of impediments to treatment” (Fink and Tasman, 1992). These financial barriers conspire to ensure that “most people with mental disorders in the United States remain either untreated or poorly treated” (Thornicroft, 2006). It is clear that public health in the United States does not consider mental health as a priority, as there is no concerted effort to battle the rampant injustices inflicted by health care providers. Stigmatization of persons with mental disorders is pervasive and persistent, and the only real effort to combat stigma is made by advocacy groups and not by the public health system.

Self-stigmatization is an unfortunate byproduct of commonly held misconceptions about people with mental illness. Because people with mental illness are generally “members of the general population and share the same pool of information about psychiatric disorders” (Thornicroft, 2006), they internalize the same common negative views about mental illness that many healthcare providers hold. Often they are slow to observe or admit symptoms, and there is generally a long delay before they seek out appropriate professional care. (Fink and Tasman, 1992) People with mental illness “expect to be discriminated against…[and] these expectations can themselves be profoundly disabling.” (Thornicroft, 2006) The shame of having such conditions perpetuates a self-fulfilling prophecy: when met with prejudice, people who expect such prejudice are unlikely to challenge it, and are likely to avoid treatment in order to avoid being labeled as mentally ill. They anticipate, correctly, many adverse consequences to such a label. Not only does stigmatization discourage mentally ill people from pursuing treatment, it also works to amplify and worsen their conditions. Link et al, 1997). When they do seek the treatment they need, they are often met with inadequate care: “Contact with mental health services, whatever the intentions of staff, can be experienced by users as disrespectful.” Many patients choose to sever contact with mental health services, because of their dissatisfaction with the care they receive (Thornicroft, 2006). Whether because of consumers’ actual experiences or because of their anticipation of prejudice, they exhibit great reluctance to seek out and receive treatment for mental disorders.

It is commonly recognized that “lower social classes have higher rates of mental disorders” (Fink and Tasman, 1992). Lower SES groups tend to lack the level of social networks and supports enjoyed by higher SES groups, due to such factors as economic instability due to employment, and the lack of social resources experienced by economically disadvantaged communities (Williams, 1990). The support provided by these bonds raise “self-esteem, self-confidence, and feelings of self-worth, which, in turn, maintain and promote psychological adjustment.” (Greenblatt, 1982) The absence of such bonds is therefore closely related to the development of a mental illness. A host of other stressors barrages people of low SES status, including high crime rates in urban centers. Inadequate education available to poorer children and lack of socialization help to “disable them in dealing with complex stressful situations” (Eaton, 1992) inherent in modern society, and occurring more frequently to those in lower socioeconomic brackets. Low self-esteem is an attendant problem of a poor financial situation, and is “thought to be the core deficit in mental disorders by some psychiatrists” (Eaton, 1992). The logical conclusion to most studies regarding the connection between class and mental illness is that “the increment in stresses connected to health in the lower classes leads to an increment in risk for mental disorder” (Fink and Tasman, 1992). Mental illness in lower economic brackets is also perpetuated from generation to generation, as it is a commonly held belief that children of those with mental illness are highly likely to develop mental illnesses themselves. Parents of lower socioeconomic status report high levels of stress due to financial factors, and data indicates that children whose parents worry excessively have an increased mental health risk (Langner & Michael, 1963).

Because mental illness is disproportionately more present in lower SES populations, economically disadvantaged people feel the aforementioned inadequacy of mental health services most acutely. According to a survey of 10,000 American adults, “unmet needs were greater for the poor”. (Thornicroft, 2006) These unmet needs are responsible for increased health disparities, both mental and medical. Mental health and physical health are inextricably linked, (Surgeon General) and “numerous studies… have consistently shown that psychiatric patients have higher mortality rates than the general population” (Felker, 1996). The physical component to mental disorder contributes to other medical conditions; for example, anxiety symptoms are significantly linked to elevated risks of fatal coronary heart disease (Felker, 1996). Additionally, poor self-care and judgment about health needs contribute to increased risk of medical illness, including obesity and excessive smoking (Holmberg, 1999). High-risk behavior that is often concomitant with severe mental illness often leads to HIV and other infectious diseases (Meade, 2005) and diabetes (Felker, 1996). Substance abuse is also a common consequence of mental illness: as many as half of people with serious mental illness develop a drug or alcohol addiction (Surgeon General). These high levels of comorbidity disproportionately affect lower SES populations, who experience higher levels of mental illness.

In light of the stated goal of Healthy People 2010 to reduce health disparities, surprisingly little attention is given to reducing barriers to mental health care. Mental illness is listed as a “focus area” in which the program aims to reduce disparities. However, there are many shortcomings in the publication regarding mental health (Healthy People 2010, Vol 2) . Age, gender, race, and physical disability are listed as major contributing factors towards mental health disparities; however, the list does not account for socioeconomic status. General stigmatization is recognized as a barrier to adequate mental health care, but the pervasive prejudice practiced by health care professionals is not. The publication acknowledges strong comorbidity of substance abuse disorders and other mental disorders, but does not make any connection between mental health and physical health. Because there is no discussion of the positive association between socioeconomic status and mental illness, there is no discussion of the societal factors that contribute to such disorders. Most importantly, there is no discussion of possible preventive interventions to reduce the high occurrence of mental illness in low SES populations. Such interventions would include, obviously, reducing economic disparity. Efforts to reduce crime would help reduce anxiety-related illnesses such as post–traumatic stress disorder. Better education and socialization would serve as important preventive measures in school-aged children, thereby halting the cycle of illness that persists from generation to generation.

“Healthy People 2010” is a vital program, as health disparities in the United States continue to be a major problem. However, to further its goals, this initiative must adjust the way it approaches mental illness. Socioeconomic factors must be considered when discussing disparities of mental health, as there is much greater incidence of illness among low SES populations than among those with more economic advantages. The prevalence of stigmatization must be addressed, to the end of eliminating prejudicial behavior among health care professionals and reducing stigma-related obstacles to mental health care. The greater goal of increasing health parity will be well served by recognizing high levels of comorbidity of mental and medical illnesses. Most importantly, the societal factors that cause or exacerbate mental illness must be investigated. By implementing preventive measures that reduce rates of mental illness, public health will make more progress in its efforts to reduce health disparities in the United States by the year 2010.

References:

1) Mental Health: A Report of the Surgeon General: http://www.surgeongeneral.gov/library/mentalhealth/home.html

2) Healthy People 2010: http://www.healthypeople.gov

3) National Institute for Mental Health: http://www.nimh.nih.gov

4) Fink, P, and Tasman A. Stigma and Mental Illness, 1992

5) Thornicroft, G. Shunned: Discrimination Against People With Mental Illness, 2006,

6) Eaton, W. The Sociology of Mental Disorders, 1980

7) Greenblatt et al. Social networks and mental health: on overview, American Journal of Psychiatry 1982 139 (8), p. 977

8) Felker et al. Mortality and medical comorbidity among psychiatric patients: a review. Psychiatric Services 1996 47 (12), p. 1356

9) Langner, T, and Michael, S. Life Stress and Mental Health, 1963

10) Meade,C, and Sikkema, K. HIV risk behavior among adults with severe mental illness: A systematic review. Clinical Psychology Review 25 (4), 433-457

11) Thambirajah, M.S., Psychological Basis of Psychiatry, 2004

12) Williams DR. Socioeconomic differentials in health: a review and redirection. Social Psychology Quarterly 1990; 53: 81-99.

14) Smith, C. and Giggs, J. Location and Stigma: Contemporary Perspectives on Mental Health and Mental Health Care. 1988

15) Link, Bruce G. et al. On Stigma and Its Consequences: Evidence from a Longitudinal Study of Men with Dual Diagnoses of Mental Illness and Substance Abuse. Journal of Health and Social Behavior 1997, 38: 177-190

16) Holmberg S., and Kane, C. Health and Self-Care Practices of Persons with Schizophrenia. Psychiatric Services 1999, 50:827-829

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