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Mental Healthcare in a Clinical Setting

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  1. Mental Healthcare in a Clinical Setting The Role of Primary Care in Mental Health

  2. 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

  3. 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

  4. “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!

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. WHY is this happening? ---ACCESS TO BEHAVIORAL HEALTHCARE • STIGMA • Logistical barriers • Economic disincentives

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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