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Mental Healthcare in a Clinical Setting The Role of Primary Care in Mental Health Agenda Discuss mental health and its relationship to wellness in general Statistics associated with mental illness in the US & the world

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Mental Healthcare in a Clinical Setting

The Role of Primary Care in Mental Health


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Agenda

  • Discuss mental health and its relationship to wellness in general

  • Statistics associated with mental illness in the US & the world

  • Explore treatment for mental illness through primary care service providers

  • Implementing mental health services in the free clinic setting


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History of a stigmatized term: “Mental” Health

  • What is it?

    • In the mid-19th century, Isaac Ray, one of the founders of the American Psychiatric Association, defined “mental hygiene” as: AN ART TO PRESERVE THE MIND AGAINST INCIDENTS AND INFLUENCES WHICH WOULD INHIBIT OR DESTROY ITS ENERGY, QUALITY, & DEVELOPMENT

    • Currently, the Surgeon General defines mental health as: A STATE OF SUCCESSFUL PERFORMANCE OF MENTAL AND PHYSICAL FUNCTION RESULTING IN PRODUCTIVE ACTIVITIES AND FULFILLING RELATIONSHIPS WITH OTHERS AND THE ABILITY TO ADAPT TO AND COPE WITH ADVERSITY

  • On the flip side: The World Health Organization defines health as: A COMPLETE STATE OF PHYSICAL AND MENTAL WELL-BEING

  • Once society understands and accepts that mental health is part of physical health and vice versa, the stigma associated with mental illness will lessen


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“Mental” Health: Just another aspect of health

  • Due to the stigma attached to the term “mental illness” (indeed, the word “mental” alone), people often don’t consider that we all have mental health

  • A continuum, where a person’s mental health may have many possible values – people can reach enhanced levels of mental health, even if they don’t have a diagnosable mental illness

  • Must stop separating physical and mental health, as it is all intertwined in health in general

    • For example, physical ailments occur as a result of stress – a mental health issue that the World Health Organization labeled as a “workplace hazard”

  • There is no health without mental health!


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Dissecting Mental Health

  • We all need and should work toward the best mental health possible:

    • Emotional well-being

    • Capacity to live a full and creative life

    • Flexibility to deal with life’s inevitable challenges

  • Like diseases of various organs in the body (i.e., diabetes, heart disease, arthritis) that limit our physical health, there are diseases of the brain that limit our mental health


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Mental Illness does not Discriminate

  • Like physical ailments, mental illness is very prevalent and affects all populations in all countries:

    • Children

    • Adults

      • Workplace

      • Men

      • Women

    • Elderly

    • Of all races, colors, creeds, national origins, sexual orientations

  • The good news: like physical illness, mental illness IS treatable – often more treatable than physical illness

    • THE PROBLEM: It’s often left untreated for various reasons


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Statistics: More Prevalent than You Might Think

  • About 30% of the US population meet criteria for one or more behavioral disorders in any given year (over 90 million people)

    • Highest prevalence of mental illness worldwide

    • Fewer than half receive any mental health care

  • Depression alone affects more than 21 million Americans, and is the leading cause of disability for the 15-44 age group

    • Lost productivity among US workers is estimated to be $31+ billion annually

    • Fewer than half of those with depression get treatment – those that do often go a decade or longer before receiving it

    • World Health Organization: Depression more damaging to everyday health than asthma, diabetes, angina, and arthritis

    • If individuals are ill with other conditions, depression makes them worse

      • Example: Diabetes and depression – a vicious cycle

  • Disability from mental illness is projected to rank second only to cardiovascular illness as the leading cause of disability worldwide by 2020


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Statistics: Children & Adolescents

  • 10% of children and adolescents in the US suffer from serious emotional and mental disorders that cause significant functional impairment - Left untreated, can lead to:

    • Youth suicide (3rd leading cause of death in 10-24 age group) - more in this population die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease COMBINED

    • School failure – 50% of students with a mental disorder age 14+ drop out of high school – the highest dropout rate of any disability group

    • Involvement with juvenile justice/criminal justice systems – 70% of youth involved in state and local juvenile justice systems throughout the country suffer from mental disorders


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Statistics: Co-Morbidities

  • People with mental illness are 5 times more likely to have a co-occurring medical condition than the general population

    • 3 out of 5 people with mental illness die of preventable diseases

      • People with a mental illness are more likely to suffer physical ailments AND they’re more likely NOT to take care of them

    • Adults with serious mental illness die about 25 years earlier than Americans in general

    • Huge public health concern


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WHY is this happening? ---ACCESS TO BEHAVIORAL HEALTHCARE

  • STIGMA

  • Logistical barriers

  • Economic disincentives


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Logistical Barriers

  • In large sections of America – especially rural America – there are no mental health providers

    • Over half the counties in Georgia do not have a mental health professional available

  • SO – Primary care is often used to treat mental health issues


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Economic Disincentives

  • No insurance

    • 1.5 million Georgians are uninsured (16%)

  • Those lucky enough to have insurance face discriminatory insurance coverage for mental health

    • The historical and prevailing disconnect between physical and behavioral health impedes reimbursement for mental health care

    • Mental health benefits are also subject to monetary restrictions that are not imposed for other medical conditions

  • Especially with the emergence of managed care, behavioral healthcare has been pushed more and more into primary care


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The Importance of Primary Care in Treating Mental Illness

  • So, the responsibility for providing mental health care falls increasingly to primary care providers

    • The wide reach of primary care into the general population suggests its importance as a source of access to mental health care

      • 4/5 of Americans report having a usual source of care

      • ¾ make one or more medical visits during any given year

      • While this reach is not complete, it’s broader than any existing public health infrastructure in the US

  • Given the high prevalence of mental illness (as previously discussed) and the low treatment rates, primary care settings are an important resource


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The Shift toward Primary Care

  • In 1990, more mental health services were delivered by primary care providers than by specialty mental health providers

  • Since then, primary care has continued to play a growing role in the delivery of mental health care

  • Shifts in part due to medications whose side effects and broad set of indications make them easy to prescribe


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Implications for the Free Clinic Setting

  • Free clinics, like all primary health care providers, inevitably see patients who need mental health care – even if they don’t come asking for it

  • Must have the resources to provide mental health care for those seeking it

  • As a quality of care measure, should have the resources to screen for mental health conditions as a prevention tool for those who don’t present with the condition – especially since those seeking care at a free clinic are probably more vulnerable to mental illness than the general population

    • Much like screening for TB or testing for HIV


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Free Clinic Setting (Cont’d.)

  • Unique to free clinics is that most patients get ALL of their care there, so continuity of care between physical and mental conditions (i.e., co-morbidities) will be better than for those who get such care at several different facilities

  • The Georgia Free Clinic Network has determined that mental health services are important and necessary in their clinics


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So Where are we now?

  • WE KNOW…

    • mental health services are important and necessary in a free clinic setting

    • a free clinic setting has opportunities that other healthcare facilities might not

      • Potential for better continuity of care

      • The opportunity to screen for and prevent mental illness in especially vulnerable populations

    • The Georgia Free Clinic Network is progressive, recognizes the need to provide mental health services, and has approached legislators to appropriate money for this purpose


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How to Provide Such Services?

  • Working in partnership with GFCN, MHA of Georgia is helping to determine the best way to implement mental health services

  • For some clinics, we will be able to secure volunteers, students, and retirees from Emory, Morehouse, Mercer, and Medical College of Georgia

  • For other, more rural clinics, it might be more difficult to find mental health volunteers in the area (if any exist) and/or to persuade them to travel long distances to see patients


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Tele-psychiatry

  • A potential solution is tele-psychiatry

  • Working with Medical College of Georgia in Augusta to implement

    • Would increase access

    • Inexpensive

    • Pioneering, innovative method in a free clinic setting


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Conclusion

  • In today’s challenging healthcare environment, mental healthcare is especially daunting

  • A lot of work still to be done on the patient, provider, and system levels in general

  • However, it’s a positive step in the right direction that free clinics are interested in taking on this difficult arena of healthcare



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