Studies consistently show nearly one out of five people will experience diagnosable symptoms of a mental illness in their lifetime, and less than half of them will ever seek the treatment they need.
According to polls from organizations like the American Psychiatric Association (APA) and National Alliance on Mental Illness (NAMI), a majority of adults reported increased symptoms of anxiety and depression throughout the pandemic, adversely impacting their daily lives. Parents are now reporting more worry and anxiety related to their children’s health. The necessary safety restrictions, such as social distancing, have exacerbated social stressors including financial distress, job instability and food insecurity. These subsequent stressors have disproportionately impacted our BIPOC communities. More people are feeling isolated and disconnected as mental health providers are overwhelmed with referrals.
With mental illnesses so prevalent, why don’t more people get help? Nearly one in 13 people suffer from asthma and nearly one in 10 from diabetes; almost all get care or help managing their symptoms. Nearly one in 10 people suffer from depression, and more alarmingly, nearly one in five adults suffer from some form of anxiety, yet less than half will get professional care. At least half of all cases of mental illness onset before age 14, meaning many people struggle with symptoms from a very early age.
We can all become advocates and speak out against stigma.
Comparatively speaking, most people will never experience the breathing difficulties associated with asthma or the tingling hands and feet that diabetes may cause. Yet everyone knows what it is like to feel depressed and anxious. It is when these feelings begin to impact our daily functioning that we need to get professional help. An acquaintance recently shared with me that she wanted to get involved in mental health advocacy, but had a hard time relating since she did not know anyone with a mental illness. I simply told her, “Yes, you do actually know several people with a mental illness; you may just not know they have an illness.” Many people may be effectively managing their symptoms, but sadly, many are not getting any help at all and are not talking about it. There are three main reasons people don’t get the mental health care they need, when they need it.
These are real, often tangible barriers that prevent someone from getting help. They can range from such things as financial barriers, lack of reliable transportation, geographical isolation, poor internet and more. Some of these barriers can be more easily overcome than others, but in general they only add to functional impairment and create more frustration. Some access barriers may simply be not knowing who to call or where to go. Sadly, many individuals access care only through a crisis with an emergency room as their entry point.
Across the nation, we estimate that there is one mental health professional for every 378 people. This includes psychiatrists, psychologists, psychotherapists, advance practice nurses and drug and alcohol counselors. Of course, many of these are specialists and not trained to treat all conditions. Some specialties may focus on treating certain age range or certain conditions, while some are focused on research and may not care for patients directly. On average, psychotherapists carry caseloads of 40 to 60 patients, while psychiatrists carry caseloads closer to 400 and even upwards of 1,000 patients. Minnesota ranks in the middle of the nation, with an average of one mental health professional for every 365 people. Minnesota also ranks above the national average in alcohol and drug abuse, as well as racial inequities. Furthermore, our state has comparatively vast rural areas endearingly referred to as greater Minnesota. In these rural areas, the ratio of mental health providers to the population is close to one for every 1,500 people. Many people in these regions will struggle to find the right mental health provider, if any at all. While telehealth services have been extremely successful in many places, it requires reliable internet and tech-savvy patients.
Unlike other health care providers, mental health providers are more likely to be out-of-network with insurance plans as a result of poor reimbursement rates. Many people report being underinsured, so the costs of care become a barrier. It is estimated that nearly one of four psychotherapists do not accept insurance plans, and even fewer psychiatrists are in-network. Paying out-of-pocket for regular health care is a luxury that very few can afford. Financial insecurity can only exacerbate feelings of depression or anxiety about financial matters. In addition, poverty and low income are risk factors for mental illness. This inequity is widening a gap in our communities, disproportionately impacting BIPOC individuals.
Accessing some services, such as residential treatment or substance use disorder (SUD) treatment, can require extra steps for approval and are subject to scrutiny of utilization throughout treatment. At the end of 2020, a monumental lawsuit found one of the nation’s most profitable insurance companies was intentionally and methodically denying coverage for psychiatric services. The investigation revealed denials for care led to people dying as a result of an identified, but untreated mental illness. There is little oversight of mental health parity laws, and the behavior of insurance companies to ensure comparable coverage between medical and mental health services is discriminatory at best. A large part of the access problem is that insurance companies pay so poorly for mental health care that many providers cannot afford to be in-network.
Life as Usual
For many, we just feel the way we feel, and that is normal for us. The symptoms of a mental illness or deterioration of mental health may be something we don’t realize is different. We just get used to the mild but chronic pain in our hip or we learn to cope with dry skin in the winter. Just as easily, we may struggle to get out of bed each morning or we may fear meeting new people, and we assume that is just life as usual. We can tolerate these things for at least a short while, and often we are not aware that effective treatments exist. Studies have shown that upwards of 20%-50% of the population experience symptoms of a mental illness in a given year, but never identify it as such. This can be due to lack of information or educational resources. It can also be cultural or a familial tradition. We may not talk about feeling depressed, we just deal with it. This is different than stigma which is rooted in fear or shame. In these instances, people simply are unaware that things can be different.
Some may be aware of their mental health struggles, but be unaware that help is available. There are a variety of treatment methods for all conditions, ranging from psychotherapy and medication management to transcranial magnetic stimulation (TMS), equestrian programs, and more homeopathic approaches. More than 75% of individuals receiving psychotherapy report improved symptoms. The APA cites numerous studies that have identified brain changes in people with mental illness (including depression, panic disorder, PTSD and other conditions) as a result of undergoing psychotherapy. In most cases, the brain changes resulting from psychotherapy were similar to changes resulting from medication.
50%-70% of primary care visits involve a mental health concern.
We can combat this by normalizing conversations about mental health and feelings so we can gain deeper perspectives about our own. Studies have shown younger generations are more apt to talk about mental health and subsequently find treatment. The APA published a report showing that members of Generation Z were more likely to receive treatment or therapy than any other generation, and nearly twice as likely as Baby Boomers. This is largely due to increased awareness and because these kinds of conversations are more normal for them. When we don’t engage in these conversations, we lack the revelation that others may also feel this way and it can be different for us.
Stigma and Fear
While we have made significant progress in debunking myths of mental illness that have contributed to stigma, this is still a significant factor that prevents many from talking about mental health and getting treatment. Stigma can lead to discrimination resulting in barriers to care, confusion/frustration, physical harm and worsening symptoms. In some cases, stigma may stem from misunderstanding, misinformation or lack of education in our communities.
While stigma is often seen as an external factor or public force, some create their own self-doubt and shame that is equally as harmful. They may feel that mental illness is a sign of weakness or something they are unable to control. It is important for people not to become isolated and to connect with others who may also be experiencing similar feelings or symptoms. Primary care providers, school counselors and even human resource departments can help connect people with resources and care they need. This may include support groups and even trusted online forums. Learning to accept our condition is a powerful first step in allowing us to access care.
Similar to how younger generations have helped to normalize conversations about mental health, their outward advocacy and openness have made talking about mental health more of a strength than a weakness, as it used to be seen. This has been helped by social media and online apps designed to build resiliency, diagnose and even treat mental illnesses. We can all become advocates and speak out against stigma. This will help support all of those around us and provide a safe conversation if we need support ourselves.
Helping Your Patients
All health care systems and providers have a responsibility to respond to mental health needs of patients. This requires more training in mental health, including identification of symptoms, crisis management, and providing basic care to those experiencing symptoms. This also means awareness of the reasons people don’t access care when they need it. It is estimated that nearly 50%-70% of primary care visits involve a mental health concern, but it is rarely discovered. Some providers hesitate to hear the story because connecting their patients with mental health resources can be difficult. This is a systemic issue–our network of mental health resources is not broken, because it has not yet been built. When we don’t listen to the patient’s story, we erode engagement in care and we miss things.
It is estimated that nearly 70% of people with a chronic health condition also struggle with their mental health. These conditions are almost always treated separately, and the referral follow-through to a mental health provider is about 50%. This drives up costs and decreases the quality of care. For example, one common comorbidity is diabetes and depression. If treated separately, the costs of care could be three times more than if they were treated at the same time. Diet, exercise and insulin are all critical factors for both conditions, but absence of the other’s treatment plan results in different independent recommendations. Failure to effectively care for diabetes can exacerbate depressive symptoms, and increased depression can lead to worse follow-through on medical recommendations for diabetes. We need to treat them together. Local integrated health care models have shown to increase patient follow-through by 52%. In some cases, co-located therapists were able to care for 250% more patients in the integrated setting than in a stand-alone clinic by themselves.
Minnesota offers a Psychiatric Assistance Line (PAL) for any health care provider seeking consultation on a specific case. This free on-demand service is managed by clinical social workers and staffed by board-certified psychiatrists. This helps alleviate numerous access barriers and helps primary care providers treat psychiatric conditions directly in their own care setting.
While this list is not exhaustive or detailed, it helps to summarize the main factors that prevent many from getting mental health treatment when they need it. We can help connect people with service by advocating for parity and fairness in access and by talking about the signs and prevalence of mental illness. This will help to increase awareness and the likelihood that someone will get help when struggling.
Todd Archbold, LSW, MBA, is a licensed social worker and the Chief Executive Officer at PrairieCare.