Recently, Mental Health America
She didn’t engage her parents, or the school, or the police, she called Mental Health America
By being in the schools and teaching age-appropriate lessons on issues relating to cyber bullying and relationship violence and media literacy, Mental Health America provided that student with the tools to recognize that she had gotten herself into a dangerous situation and we were a resource to decrease the impact on her and her family, not to mention the potential risk to her personal safety.
The authors of a 2004 World Health Organization (WHO) summary report entitled Prevention of Mental Disorders: Effective Interventions and Policy Options include a definition of mental disorder prevention from Mrazek & Haggerty:
Mental disorder prevention aims at “reducing incidence, prevalence, recurrence of mental disorders, the time spent with symptoms, or the risk condition for a mental illness, preventing or delaying recurrences and also decreasing the impact of illness in the affected person, their families and the society. (WHO, 17)[1]
It might be argued that receiving a photograph of male genitalia is not a public health risk, but mental illness is and trauma and trauma-related stress can be contributing factors to mental health conditions. In the same WHO report, the authors write: “Adverse conditions such as child abuse, violence, war, discrimination, poverty and lack of access to education have a significant impact on the development of mental ill-health and the onset of mental disorders” (WHO, 14).
We have reached a point where the deterioration in available resources has intersected with the process of responding to a growing public health concern, i.e. mental illness. No longer, it seems, can we consider a broad portfolio that would permit tailored responses based on the condition of an individual, but we must adopt a one-size approach based on a medical model where patients are assessed, prescribed and allotted targeted engagements with a counselor.
It seems less a medical model than a factory model.
Responding to mental illness is a huge problem and getting bigger, no question about it. It is forecast that by 2020, behavioral health disorders will surpass all physical diseases as a major cause of disability world-wide (Harding, p. 21)[2]. One forecast quoted in a paper called “Mental health promotion and mental illness prevention: the economic case,”[3] prepared by the London School of Economics and Political Science looked at the expected costs of mental illness by condition in a 20 year period from 2007 to 2026. Their findings indicate that costs of depression, anxiety, schizophrenia, bipolar, eating disorders, personality disorders, child and adolescent mental health and dementia will increase by an average of 79% (Knapp, McDaid & Parsonage, eds. 2011).
Higher prevalence and more costs with no clear sense of when there will be more resources in the public system with which to respond.
A reasonable person might conclude that the medical model is the wisest choice in that it stands the greatest chance of impacting the largest number of people. But, just as there is no single mental illness and not everyone with the same diagnosis will respond to the same treatment, there has to be room in our response to the challenge of these disorders to offer a variety of responses.
Cost containment is a laudable goal, but it is not a patient goal and it should not be our only goal in designing the next generation of public health care.
A generation ago, we convinced ourselves that the state hospitals were a draconian response to those who experience mental health conditions. Our leaders felt that it was better for the patient that they be returned to their communities where they could be closer to family. Prior to that time, conventional wisdom held that persons with these conditions should be locked away where they could not harm themselves, or others and where the general public would not have to encounter them.
Time and circumstance have combined to bring about significant changes in community attitudes toward those who experience mental health conditions. We have come to understand that, instead of being the “other” and different from us, persons with mental health conditions are our friends, neighbors and even our family members.
And, just as we have become more comfortable with the prevalence of mental health conditions, we are also learning that there is much we can do to mitigate their impact.
Health promotion/education and disease prevention are tools that also come from the medical model and have enabled us to respond to and prevent all manner of medical events.
Prenatal and perinatal care are clear determinants in childhood development. We know expectant mothers should be monitored during pregnancy and we know that their children should get vaccinated because there is risk to both mother and child, but that risk is manageable.
By the same token, we know that while “there are genetic and biological components to mental illness…emerging evidence suggests that certain behavioral health problems can be prevented, while in others onset may be delayed and severity of symptoms decreased” (San Mateo, p.1)[4].
Mental health promotion/education and mental illness prevention can play an important role in supporting the psychiatrist-counselor-case manager relationship. Educating the public about the signs and symptoms of mental illnesses and their contributory factors supports help-seeking behavior, as in the case of the student who contacted our office following the inappropriate contact. Education also empowers those who engage with medical personnel to make better informed decisions about their care. Anti-psychotics are powerful tools in response to mental illnesses but they can come with significant side effects and an informed consumer is a more equal partner in their own recovery.
The returns on investments in health promotion/education and prevention are more difficult to evaluate than other mental health expenditures because their impact is in that which is not seen. Ideally, the outcome of an effective program would be an increase in patients not seen, prescriptions not written, persons not arrested and children without behavior problems.
What is easy to see is their cost. Prevention and health promotion/education can be delivered in a variety of formats, but there is evidence suggesting that they are most effective when they include a personal contact between the program recipient and an advocate. Anecdotally, we know that the 14-year old student remembered MHA’s classroom presentation.
Our funders recognize the value of health promotion/education and prevention and have made considerable investments in the programs of our agency and others throughout Licking County
Of course, it is our position that they cannot afford not to.
There is compelling research indicating the returns on investments in a long term education and prevention strategy. From our work on workplace mental health we know that integrating mental health into the benefits package can return $4 - $5 dollars for every dollar in expense. In the LSE paper, they calculate Year One returns on suicide prevention training for family practice doctors at more than 19:1 (Knapp, McDaid & Parsonage, eds. 2011, p. 40).
The costs associated with responding to chronic diseases such as mental health conditions are staggering. The financial costs in terms of treatment services and lost productivity are estimated at $247 billion annually (Institute of Medicine [IOM] Policy Brief, p. 1)[5]. There is a broad consensus that something must be done to “bend the curve” in health care expenditure in order to prevent a crippling burden on our economy.
Where the consensus begins to fall apart is in how to go about lightening that load.
An often-heard answer is that we should get more patient buy-in, that they should have some “skin in the game” and once they know what the real cost of healthcare is then they will be more invested in what services they purchase, not elect so many expensive tests and unnecessary procedures. Sticker shock will control costs.
This makes sense when you are evaluating accessories for your new car, or premium services for your cable TV, but not when discussing people’s health. Illness is not a choice. The uninsured cancer patient is just as sick as the insured.
It is unrealistic to expect that those two patients will receive the same level of care, but if life choices and bad luck have left a patient without insurance coverage, do we not have some responsibility to do what we can to help them be as healthy as possible for as long as possible?
This is the promise of health promotion/education, prevention and early intervention programs.
In a recent compelling article in the New Yorker[6], it was noted that a statistical analysis of hospital visits in Camden, New Jersey revealed that between January of 2002 and June of 2008, two buildings and a combined total of 900 residents were responsible for 4,000 hospital visits and some $200,000,000 in medical bills, or roughly $222,000 per person (Gawande, p. 4). The story goes on to document efforts to provide coordinated care for these and other high-cost patients, the net effect of which is to reduce their impact on health care resources. Granted, part of the response to these high-cost patients involved connecting them with more targeted health interventions, but a significant part involved lifestyle interventions designed to mitigate symptoms and delay hospitalizations.
What is clear from the New Yorker piece is that while both interventions would be impactful on the patient’s quality of life, it is in their combination that there lies the greatest opportunity to both control costs and improve health outcomes: the health promotion/education, prevention and medical models working together with everyone educated to the fullest extent possible.
We are all interested in achieving the best possible outcome for the consumer while being responsible stewards of available resources. Times being what they are, we know that we cannot do as much as we perhaps might like. What is troubling is how, during the current contraction of services, does that 14 year-old girl, or her peers, get the information they need to respond to a stressor, mitigate a potential traumatic situation and support her mental health? There isn’t a pill for that.
Mental disorders are inextricably linked to human rights issues. The stigma, discrimination and human rights violations that individuals and families affected by mental disorders suffer are intense and pervasive. At least in part, these phenomena are consequences of a general perception that no effective preventive or treatment modalities exist against these disorders. Effective prevention can do a lot to alter these perceptions and hence change the way mental disorders are looked upon by society. Human rights issues go beyond the specific violations that people with mental disorders are exposed to, however. In fact, limitations on the basic human rights of vulnerable individuals and communities may act as powerful determinants of mental disorders. Hence it is not surprising that many of the effective preventive measures are harmonious with principles of social equality, equal opportunity and care of the most vulnerable groups in society. Examples of these interventions include improving nutrition, ensuring primary education and access to the labour (sic) market, removing discrimination based on race and gender and ensuring basic economic security. Many of these interventions are worth implementing on their own merit, even if the evidence for their effectiveness for preventing specific mental disorders is sometimes weak. The search for further scientific evidence on effectiveness and cost-effectiveness, however, should not be allowed to become an excuse for non-implementation of urgently needed social and health policies. (WHO, foreward).
[1] World Health Organization. “Prevention of Mental Disorders, Effective Interventions and Policy Options: Summary Report.” United Nations, 2004. Web. 11 April 2011 <http://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf>.
[2] Harding, Fran. “Strategic Initiative #1: Prevention of Substance Abuse and Mental Illness.” Center for Mental Health Services, Draft 10/01/10. Web. 11 April 2011 < http://www.samhsa.gov/about/siDocs/prevention.pdf>.
[3] Knapp, Martin, David McDaid and Michael Parsonage, eds. “Mental Health Promotion and Mental Illness Prevention: The Economic Case.” London School
[4] San Mateo County Health San Mateo County , CA
[5] Institute of Medicine Institute of Medicine
[6] Gawande, Atul. “The Hot Spotters,” The New Yorker January 24, 2011. Web. 11 April, 2011 < http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande>
