Mental Health and Public Health
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The recently released U.S. Surgeon General's report on mental health outlines the scope and nature of mental health problems in the U.S.. It notes that these problems, in addition to causing immense human suffering and family disruption, are financially costly to society. In fact, mental health disorders are the second most disabling conditions, second only to cardiovascular disease. The report clearly defines these disorders as public health issues, requiring public health approaches to prevention, early identification and coordinated treatment.
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The recently released U.S. Surgeon General's report on mental health outlines the scope and nature of mental health problems in the U.S.. It notes that these problems, in addition to causing immense human suffering and family disruption, are financially costly to society. In fact, mental health disorders are the second most disabling conditions, second only to cardiovascular disease. The report clearly defines these disorders as public health issues, requiring public health approaches to prevention, early identification and coordinated treatment.
A review of the literature on the recognition of mental health problems and the provision of mental health services clearly indicates that the majority of children, adolescents and adults who have mental health problems receive no treatment. The vast majority of those who are treated are not seen by mental health professionals; they are treated by primary care physicians. At the state and county levels, their role in providing this treatment is neither supervised by Human Services (they supervise mental health professionals only), nor by Public Health. Thus, the majority of mental health treatment goes unsupervised.
In Minnesota, mental health issues have been traditionally addressed at both the state and county levels under departments of Human Services or Social Services rather than by Health departments. However, numerous research studies support the conclusion that state and county agencies should either have shared responsibilities between these departments, or should reassign mental health issues to the public health agencies, by integrating mental health issues into the overall field of health. If mental health issues are to be addressed effectively on a societal basis, a public health approach would be required to accomplish this.
Various studies describe a significant degree of unrecognized and untreated psychiatric and chemical health problems in the primary care population. A number of studies [1,2,3,] note that approximately twenty five percent of patients seen by primary M.D.s have a psychiatric disorder. (This compares to eighteen percent of the general population.) Some studies have noted even higher percentages. One study [4] noted that over one half of the patients seen at a primary care clinic had an anxiety or depressive disorder. Another study [5] found that approximately ten percent of primary physicians' patients had very significant depression, with as many as forty one percent having at least mild depression. Approximately thirty percent of medical inpatients are noted to have significant symptoms of depression. [6]
As many as twenty percent of patients seeing primary care physicians have alcohol abuse or dependence. [7] A summary of several studies indicated that up to thirty three percent of medical outpatients and up to sixty one percent of medical inpatients had some problems with alcohol. Medicaid clients are noted to have higher rates of both mental health and chemical dependency problems than are noted in the general population.
Unfortunately, primary care physicians do not have a good track record of diagnosing mental health and chemical health problems. One study [9] noted that only ten percent of patients meeting criteria for substance abuse were recognized by their primary care physician. Only twenty to thirty percent of patients with emotional distress, family problems, behavioral problems or sexual dysfunction are noted to communicate these issues to their primary care physician. [3] Another study [10] noted that general physicians missed half of the psychiatric disorders seen in their clinic. Family practice residents were noted to miss eighty five percent of cases of depression of at least mild severity, and seventy percent of cases with severe depression. [5] Medical patients receiving care financed by pre-payment were significantly less likely to have their depression detected or treated during their visits than were similar patients receiving fee-for-service care. [11] In a University primary care clinic, twenty five of eighty seven randomly selected patients were noted to have an anxiety disorder based on a structured clinical interview, but when medical charts were reviewed only one of the twenty five of the patients had documentation of anxiety. [12] It has been estimated that one of every eight patients in primary care have an undetected psychiatric disorder. [2]
Medical problems are often missed by mental health professionals as well. Up to eighteen percent of patients thought to have psychiatric disease have an underlying medical cause of their psychiatric symptoms. One study indicated that nearly seventy five percent of organic illness was first unrecognized by mental health professionals but was finally diagnosed by judicious attention to history, physical examination and screening laboratory tests. [13] The most common psychological manifestation of organic disease is depression. [14]
This is of great concern, since the majority of people who have mental health problems receive their care from primary care physicians. One study found that twenty percent of people who had mental illness received no care, sixty percent received their care from primary care physicians and twenty percent received it from mental health professionals. In 1981, of 57 million psychotropic medication prescriptions written in the U.S., 66% were written by primary care physicians, 17% by medical specialists, and only 17% by psychiatrists.[15] Unfortunately, mental health disorders are often inadequately treated by primary care physicians. [16] For example, antidepressants may be prescribed in inadequate doses and/or for inadequate periods of time. Contributors to inadequate mental health care include physicians' lack of training about mental health diagnosis and treatment, the relatively brief treatment appointments, poor financial compensation for treatment of mental health problems and physicians' attitudes. [3]
Patients who have mental health disorders tend to have higher health care costs than those without mental health disorders. One study noted that primary care patients with anxiety or depressive disorders had base line annual medical costs of $2390 compared to $1,397 for those with no anxiety or depressive disorders. [17] Another study found that patients diagnosed as depressed had higher annual health care costs ($4,246 versus $2,371) and higher costs for every category of care (e.g. primary care, medical specialty, medical inpatient, pharmacy, laboratory) than patients without depression. [18] In addition to the clinical suffering of depression, there is a large financial burden as well. Eleven million Americans suffer from depressive disorders, and this is estimated to cost the U.S. economy an estimated $44,000,000,000.00 a year. [19] Substance abuse related conditions have been estimated to account for almost eight billion dollars a year in Medicaid expenditures.[20]
Medical patients often receive unnecessary medical care while their underlying mental health disorders remain untreated. For example, clients who have panic disorder frequently seek medical treatment for their episodes of shortness of breath, heart palpitations, dizziness, etc., only to have extensive and expensive medical assessments by pulmonary specialists, cardiologists, neurologists and primary M.D.s that do not identify their very treatable and disabling disorder. Research on the topic of cost offset indicates that there is evidence that increased awareness and treatment of mental health disorders frequently results in decreased costs in medical treatment. Thus, the use of effective screening tools by primary care physicians can result in a significant cost savings in medical expenditures. Screening tools can identify both the presence of mental health and chemical health disorders, and the level of their pathology. For example, the PRIME-MD can be administered by paraprofessionals, takes approximately eight minutes to fill out, and identifies several mental health disorders including anxiety and mood disorders. The Zung self-rating depression scale and the CAGE Alcoholism screening tool are other very effective screening tools for primary care physicians. [21, 22]
These statistics support general screening of all primary medicine clients. Even if general screening of primary medicine patients is seen as too time intensive or not cost effective, screening could focus on clients most likely to have mental health or chemical health disorders. For example, in one study of distressed high utilizers of medical services, twenty four percent of the patients had Depression, seventeen percent had Dysthymia, twenty two percent had Generalized Anxiety Disorder and twenty percent had Somatization Disorder. Two thirds of the patients had life time histories of Depression. [23] Another study noted that patients with multiple pains (rather than pain severity or pain persistence) were correlated with an elevated risk for Major Depression. [24] A number of medical symptoms are highly correlated with Depression. for example, complaints that discriminate between depressed and non-depressed patients include sleep disturbance, fatigue, multiple complaints, non-specific musculo-skeletal complaints, back pain, shortness of breath, amplified complaints and vaguely stated complaints. [25] Another study [6] noted that the most common physical complaints associated with Depression are insomnia, appetite changes, impaired concentration, weakness, drowsiness, headaches, agitation and excessive perspiration. Other common symptoms include chest pain, low back pain, polymenorrhea, slurred speech, sexual dysfunction and chronic pain. Substance abusers often present with tell-tale signs, symptoms and laboratory findings. [7,8,9] Patients with Obsessive Compulsive Disorder frequently present with eczematoid hands, trichotillomania (hair pulling), nail picking, gingival bleeding or tics. [26] Children who have ADHD frequently have academic and behavioral problems.
A number of policy recommendations have been made regarding guidelines for mental health treatment and referral by primary care physicians. In December, 1989, Congress mandated that medical disorders with high frequency and cost be reviewed, and guidelines be established to improve the quality of care nationally for patients being treated with these disorders. One of the seven mandated disorders was Depression in primary care. Clinical guidelines have been established for treatment of Depression by primary care physicians. [27, 28] These guidelines assume a reasonable degree of diagnostic sophistication by the primary care physician and the ability to distinguish between primary mood disorders and mood disorders related to secondary issues such as general medical disorders, concurrent medication, substance abuse, and causal, non-mood psychiatric disorders. They also expect the primary care physician to recognize the different types of disorders such as Major Depression, Dysthymia, Bipolar I and Bipolar II Disorders, Cyclothymia and Depressive Disorder Not Otherwise Specified. Although these recommendations are commendable, they will not be able to be successfully implemented unless there is a greater emphasis on training of mental health issues to primary care physicians, the use of effective screening tools, establishment of equitable insurance reimbursement rates for treatment of Depression, and effective oversight by governmental and medical agencies.
Although the business community has resisted parity coverage for mental health treatment, recent studies indicate that there is actually a cost benefit to employers in ensuring that mental health disorders are recognized in primary care. The Twin Cities StarTribune recently featured a front page article [29] noting that most people who suffer from Depression get their treatment from primary care doctors at community clinics, the disease goes unrecognized half the time, and is properly treated only one fourth of the time. It described a recent study by the Rand Corporation that measured how quality improvement programs affected the diagnosis and treatment of 913 patients at 46 primary care clinics in five states. In addition to significant improvement in depressive symptoms, there was a five percent increase in patients who were maintaining employment in the quality improvement group. Given that worker absenteeism from serious depression costs employers seventeen billion dollars a year, Dr. Kenneth Wells, the study's lead researcher stated, "If that finding were extrapolated across all of those disabled by depression, it would move the stock market."
The Minnesota Department of Health has initiated a suicide prevention effort. This provides an excellent opportunity to explore the Department's potential role in the issue of recognition and treatment of Depression and other mental health disorders in primary care medicine. Since fifteen percent of patients who have Depression commit suicide, and since it is not possible to accurately predict which fifteen percent will do so, if the Health Department addresses suicide, it will also have to address the larger issue of Depression as well. Since other disorders also have significant suicide rates (e.g. the suicide rate for Panic Disorder is also fifteen percent), the issue of suicide prevention goes beyond addressing the diagnosis and treatment of Depression. Given that at least half of the people who commit suicide have been seen by their primary care physician in the last thirty days, it is essential for suicide prevention efforts to target primary care physicians if they are to be successful.
Public health should have a primary role of overseeing mental health issues for the following reasons:
1) Most mental health treatment is provided by primary care physicians, whose mental health screening, diagnostic and treatment efforts are not overseen by the Mental Health Division of the Department of Human Services.
2) DHS has an even narrower focus in regards to oversight of mental health disorders, even when treatment is provided by mental health professionals. It's focus, in adults, is on addressing only four mental health disorders- Depression, Bipolar Mood Disorder, Schizophrenia and Borderline Personality Disorder. This is an arbitrary group of disorders, outlined by legislation, and does not reflect the epidemiological impact of other disorders. For example, anxiety disorders are the most common psychiatric disorders, and are not considered in the SPMI category. Many people who have Obsessive Compulsive Disorder or Panic Disorder are as disabled as those with Depression. The Department of Health functions on a model that addresses all health disorders without using these arbitrary distinctions.
3) DHS tends to focus on individuals served in the public sector, whereas the Department of Health addresses health problems in the general population.
4) Human Services agencies at the state and local level tend to have a high threshold for services, and tend to focus services on the most seriously disabled individuals. Many of these individuals would not have reached this level of severity if earlier interventions had been utilized. Public Health operates on a model that emphasizes early identification, intervention and prevention efforts.
Addressing the most severely disturbed individuals does not tend to have an impact on mental health problems on a societal level. Generally, most of the severely disturbed individuals do not receive services, and many do not request them. (For example, In Hennepin County, the Children's Mental Health Collaborative focuses only on severely emotionally disturbed individuals, and does not provide for screening, early intervention or prevention services. In 1998, it provided "wraparound" services to 368 individuals. Estimates indicated that there were at least 13,000 severely disturbed children and adolescents in Hennepin County that year.)
A public health model that emphasizes early intervention efforts, with research-based epidemiological models of services, would have a much greater impact on mental health issues in the State.
5) Research indicates that there is a biological basis for the severe and chronic mental health disorders such as Depression, Bipolar Mood Disorder, Schizophrenia, Obsessive Compulsive Disorder, Panic Disorder, Attention Deficit Hyperactivity Disorder, etc. As noted above, many medical disorders also have psychiatric manifestations. Psychiatric disorders are public health problems, and need to be addressed as such. Although social problems such as poverty and prejudice can result in adjustment related psychological problems, putting the oversight of mental health in the social services realm tends to blur the distinctions between these social problems and primary mental illness. Resources also tend to be directed toward social interventions, despite lack of evidence that this has a significant impact on mental health disorders in a community.
6) For many patients, there is a significant stigma attached to mental health problems, seeing mental health professionals, etc. They are more comfortable addressing mental health issues, at least initially, with primary health care providers. Other patients are interested in seeing mental health professionals, but have limited access to them. Since health professionals either are generally the referral source for treatment by mental health professionals, or provide the treatment themselves, oversight of mental health issues has to be provided by an agency that provides oversight to these professionals.
7) Health programs already mandate mental health screening, although at the present time it is rarely done effectively. For example, EPSDT (Early and Periodic Screening, Diagnosis and Treatment) is a mandated service for children ages 0-21 covered by Medical Assistance or MinnesotaCare. It is supposed to include a mental health screen and a comprehensive mental health history. Research studies indicate that 25-30% of children and adolescents on Medical Assistance have mental health problems. However, Minnesota data indicates that only 1-4% of those screened by EPSDT are referred for mental health assessments. (Imagine if 25-30% of kids on M.A. had tuberculosis, but only 1-4% were referred for assessment!) If mental health screening was addressed like other public health screening interventions, and overseen by the Health Department, one would expect a significantly higher early recognition of these disorders, with a markedly positive societal impact in the education, social services and correctional systems as well as the health and mental health systems.
8) As noted above, there is a significant cost offset benefit resulting from treating mental health disorders. In other words, medical care costs decrease when mental health treatment is provided. When mental health is "carved out" of the health care system, it is difficult to track this cost offset effect, and difficult if not impossible to address program planning and development issues related to cost effective mental health treatment provision.
9) Public Health nurses across the state repeatedly note that mental health problems are the number one unserved or underserved issues in their patient population. This results in a significantly negative impact on their patients' physical health.
10) Mental health professionals are an essential component in the provision of high quality mental health services. Health Department oversight of mental health issues can result in increased training to health professionals regarding criteria for referrals to mental health professionals, payment for mental health consultation to primary care physicians, cooperative relationships between mental health professionals and primary care providers, and increased sensitivity to unaddressed medical problems in individuals with mental health disorders.
11) The Surgeon General's report indicates that half of individuals who have mental health disorders have problems with chemical abuse or dependency. The reverse is also true. Thus, screening for and treatment of one type of disorder requires the need to address the other problem. Given the health impact of chemical health problems, the overlap with health and mental health disorders, and the fact that chemical health problems are public health problems, chemical health issues also need to be addressed as primary health problems by the Department of Health.
Recommendations
These issues suggest that the Department of Health should, at the very least, take on the responsibilities to:
1) Encourage expanded continuing medical education to health care professionals. The Family Practice and Pediatrics residency programs do not provide the level of training about mental health issues necessary for these physicians to accurately identify, diagnose and treat mental health disorders, and to have the ability to effectively identify patients who require referrals to mental health professionals.
Educational programs need to be initiated or expanded in schools of nursing, medicine, physicians assistant programs, and in the school of Public Health. Continuing medical education programs for primary health care providers need to be developed, and the Department should encourage the Department of Human Services to provide continuing medical education credit to health care professionals who attend DHS mental health conferences.
2) Encourage the use of reliable, valid, sensitive and specific screening tools to be used by health care professionals treating children, adolescents and adults. Given the extra time necessary to administer, score interpret and communicate the results of the screens, the Department will also need to identify funding streams to cover the extra costs. Cost offset data indicate that screening will more than pay for itself in health care savings, and suicide research indicates that many lives will be saved in the process as well.
3) Address the mental health component of EPSDT screening. The Minnesota Mental Health Ombudsman's office has addressed this issue, and their report can be obtained from Bill Wyss (651) 215-1331. Although DHS's Medical Assistance and Childrens Mental Health divisions are beginning to address this issue, the screening is provided by health care professionals (M.D.s or nurses).
4) Address the issue of inequity of insurance coverage for treatment of mental health problems. For example, some insurance companies pay an M.D. less for treating Depression than for treating "real medical problems." M.D.s may respond by submitting the diagnosis of "unspecified aches and pains" on billing forms. From a Public Health standpoint, this makes the tracking of the treatment of mental health disorders very difficult. Present reimbursement rates discourage medical professionals from effectively addressing mental health issues, and the results are illustrated in the above literature search.
5) Encourage insurance reimbursement for consultation from mental health professionals to medical professionals. (E.g. the UCare HMO provides psychiatric consultation to primary M.D.s). This could include payment for consultation via telecommunications or telephone to primary care professionals in Greater Minnesota.
6) Advocate for parity in mental health coverage, and work to encourage federal legislation to remove self-insured companies' loopholes that allow them to not provide mental health coverage, or to avoid parity when coverage is provided.
7) Develop partnerships between Public Health nursing and programs that serve individuals who have mental health problems. For example, school based clinics that serve children and adolescents who have underlying untreated mental health problems are an ideal setting for Public Health interventions of screening, identification, referral and advocacy for treatment of mental health problems. It is important to recognize that school districts discourage school professionals from making referrals of students for mental health treatment (for reasons of financial liability), and that, if these referrals are to be made, they need to be made by co-located professionals. In my opinion, Public Health nurses are the ideal professionals to do this.
8) Work with insurance companies and DHS to track billing data that will clarify data about mental health treatment in Minnesota. A computer analysis of prescriptions of psychotropic medication, cross referenced with DEA numbers of psychiatrists and primary care physicians and with billings for treatment by mental health professionals can provide anonymous group data that will give an overview of the present state of mental health treatment in Minnesota. It could provide data, for example, that would clarify the degree to which health care professionals provide treatment of mental health disorders, and would provide baseline information about rural vs. urban treatment, fee-for-service vs. pre-paid plans, etc. Data could be cross referenced with EPSDT screening/referral data and hospitalization data to clarify whether mental health problems are identified early enough to prevent more costly and restrictive interventions such as hospitalization.
Tracking of diagnostic and treatment data is a natural part of the Public Health system. If we were discussing meningitis instead of Depression, and were describing Public Health efforts to address this problem, we would note a vastly different approach than is now provided for mood disorders. Without accurate epidemiological data describing the incidence, prevalence, identification, referral rates, treatment modalities, individual and group outcomes, and financial impact of mental health issues, no effective public policy regarding mental health issues can be initiated.
Obviously, if the Department of Health is to take on the role of addressing mental health and chemical health issues as public health issues, there will be a need for both increased funding and increased staff to accomplish this task. There will also be the need for an expanded Department vision of health that incorporates mental health as an integral part of overall health. The Department will need technical expertise to accomplish this task, and the willingness to address interdepartmental turf issues that might result from a transfer of responsibilities.
The issues outlined above provide a compelling argument for mental health issues to be addressed on a societal level as public health issues, with oversight provided accordingly. The need to address these issues effectively should drive system change, support access to funding, and overcome resistance to system redesign.
A review of the literature on the recognition of mental health problems and the provision of mental health services clearly indicates that the majority of children, adolescents and adults who have mental health problems receive no treatment. The vast majority of those who are treated are not seen by mental health professionals; they are treated by primary care physicians. At the state and county levels, their role in providing this treatment is neither supervised by Human Services (they supervise mental health professionals only), nor by Public Health. Thus, the majority of mental health treatment goes unsupervised.
In Minnesota, mental health issues have been traditionally addressed at both the state and county levels under departments of Human Services or Social Services rather than by Health departments. However, numerous research studies support the conclusion that state and county agencies should either have shared responsibilities between these departments, or should reassign mental health issues to the public health agencies, by integrating mental health issues into the overall field of health. If mental health issues are to be addressed effectively on a societal basis, a public health approach would be required to accomplish this.
Various studies describe a significant degree of unrecognized and untreated psychiatric and chemical health problems in the primary care population. A number of studies [1,2,3,] note that approximately twenty five percent of patients seen by primary M.D.s have a psychiatric disorder. (This compares to eighteen percent of the general population.) Some studies have noted even higher percentages. One study [4] noted that over one half of the patients seen at a primary care clinic had an anxiety or depressive disorder. Another study [5] found that approximately ten percent of primary physicians' patients had very significant depression, with as many as forty one percent having at least mild depression. Approximately thirty percent of medical inpatients are noted to have significant symptoms of depression. [6]
As many as twenty percent of patients seeing primary care physicians have alcohol abuse or dependence. [7] A summary of several studies indicated that up to thirty three percent of medical outpatients and up to sixty one percent of medical inpatients had some problems with alcohol. Medicaid clients are noted to have higher rates of both mental health and chemical dependency problems than are noted in the general population.
Unfortunately, primary care physicians do not have a good track record of diagnosing mental health and chemical health problems. One study [9] noted that only ten percent of patients meeting criteria for substance abuse were recognized by their primary care physician. Only twenty to thirty percent of patients with emotional distress, family problems, behavioral problems or sexual dysfunction are noted to communicate these issues to their primary care physician. [3] Another study [10] noted that general physicians missed half of the psychiatric disorders seen in their clinic. Family practice residents were noted to miss eighty five percent of cases of depression of at least mild severity, and seventy percent of cases with severe depression. [5] Medical patients receiving care financed by pre-payment were significantly less likely to have their depression detected or treated during their visits than were similar patients receiving fee-for-service care. [11] In a University primary care clinic, twenty five of eighty seven randomly selected patients were noted to have an anxiety disorder based on a structured clinical interview, but when medical charts were reviewed only one of the twenty five of the patients had documentation of anxiety. [12] It has been estimated that one of every eight patients in primary care have an undetected psychiatric disorder. [2]
Medical problems are often missed by mental health professionals as well. Up to eighteen percent of patients thought to have psychiatric disease have an underlying medical cause of their psychiatric symptoms. One study indicated that nearly seventy five percent of organic illness was first unrecognized by mental health professionals but was finally diagnosed by judicious attention to history, physical examination and screening laboratory tests. [13] The most common psychological manifestation of organic disease is depression. [14]
This is of great concern, since the majority of people who have mental health problems receive their care from primary care physicians. One study found that twenty percent of people who had mental illness received no care, sixty percent received their care from primary care physicians and twenty percent received it from mental health professionals. In 1981, of 57 million psychotropic medication prescriptions written in the U.S., 66% were written by primary care physicians, 17% by medical specialists, and only 17% by psychiatrists.[15] Unfortunately, mental health disorders are often inadequately treated by primary care physicians. [16] For example, antidepressants may be prescribed in inadequate doses and/or for inadequate periods of time. Contributors to inadequate mental health care include physicians' lack of training about mental health diagnosis and treatment, the relatively brief treatment appointments, poor financial compensation for treatment of mental health problems and physicians' attitudes. [3]
Patients who have mental health disorders tend to have higher health care costs than those without mental health disorders. One study noted that primary care patients with anxiety or depressive disorders had base line annual medical costs of $2390 compared to $1,397 for those with no anxiety or depressive disorders. [17] Another study found that patients diagnosed as depressed had higher annual health care costs ($4,246 versus $2,371) and higher costs for every category of care (e.g. primary care, medical specialty, medical inpatient, pharmacy, laboratory) than patients without depression. [18] In addition to the clinical suffering of depression, there is a large financial burden as well. Eleven million Americans suffer from depressive disorders, and this is estimated to cost the U.S. economy an estimated $44,000,000,000.00 a year. [19] Substance abuse related conditions have been estimated to account for almost eight billion dollars a year in Medicaid expenditures.[20]
Medical patients often receive unnecessary medical care while their underlying mental health disorders remain untreated. For example, clients who have panic disorder frequently seek medical treatment for their episodes of shortness of breath, heart palpitations, dizziness, etc., only to have extensive and expensive medical assessments by pulmonary specialists, cardiologists, neurologists and primary M.D.s that do not identify their very treatable and disabling disorder. Research on the topic of cost offset indicates that there is evidence that increased awareness and treatment of mental health disorders frequently results in decreased costs in medical treatment. Thus, the use of effective screening tools by primary care physicians can result in a significant cost savings in medical expenditures. Screening tools can identify both the presence of mental health and chemical health disorders, and the level of their pathology. For example, the PRIME-MD can be administered by paraprofessionals, takes approximately eight minutes to fill out, and identifies several mental health disorders including anxiety and mood disorders. The Zung self-rating depression scale and the CAGE Alcoholism screening tool are other very effective screening tools for primary care physicians. [21, 22]
These statistics support general screening of all primary medicine clients. Even if general screening of primary medicine patients is seen as too time intensive or not cost effective, screening could focus on clients most likely to have mental health or chemical health disorders. For example, in one study of distressed high utilizers of medical services, twenty four percent of the patients had Depression, seventeen percent had Dysthymia, twenty two percent had Generalized Anxiety Disorder and twenty percent had Somatization Disorder. Two thirds of the patients had life time histories of Depression. [23] Another study noted that patients with multiple pains (rather than pain severity or pain persistence) were correlated with an elevated risk for Major Depression. [24] A number of medical symptoms are highly correlated with Depression. for example, complaints that discriminate between depressed and non-depressed patients include sleep disturbance, fatigue, multiple complaints, non-specific musculo-skeletal complaints, back pain, shortness of breath, amplified complaints and vaguely stated complaints. [25] Another study [6] noted that the most common physical complaints associated with Depression are insomnia, appetite changes, impaired concentration, weakness, drowsiness, headaches, agitation and excessive perspiration. Other common symptoms include chest pain, low back pain, polymenorrhea, slurred speech, sexual dysfunction and chronic pain. Substance abusers often present with tell-tale signs, symptoms and laboratory findings. [7,8,9] Patients with Obsessive Compulsive Disorder frequently present with eczematoid hands, trichotillomania (hair pulling), nail picking, gingival bleeding or tics. [26] Children who have ADHD frequently have academic and behavioral problems.
A number of policy recommendations have been made regarding guidelines for mental health treatment and referral by primary care physicians. In December, 1989, Congress mandated that medical disorders with high frequency and cost be reviewed, and guidelines be established to improve the quality of care nationally for patients being treated with these disorders. One of the seven mandated disorders was Depression in primary care. Clinical guidelines have been established for treatment of Depression by primary care physicians. [27, 28] These guidelines assume a reasonable degree of diagnostic sophistication by the primary care physician and the ability to distinguish between primary mood disorders and mood disorders related to secondary issues such as general medical disorders, concurrent medication, substance abuse, and causal, non-mood psychiatric disorders. They also expect the primary care physician to recognize the different types of disorders such as Major Depression, Dysthymia, Bipolar I and Bipolar II Disorders, Cyclothymia and Depressive Disorder Not Otherwise Specified. Although these recommendations are commendable, they will not be able to be successfully implemented unless there is a greater emphasis on training of mental health issues to primary care physicians, the use of effective screening tools, establishment of equitable insurance reimbursement rates for treatment of Depression, and effective oversight by governmental and medical agencies.
Although the business community has resisted parity coverage for mental health treatment, recent studies indicate that there is actually a cost benefit to employers in ensuring that mental health disorders are recognized in primary care. The Twin Cities StarTribune recently featured a front page article [29] noting that most people who suffer from Depression get their treatment from primary care doctors at community clinics, the disease goes unrecognized half the time, and is properly treated only one fourth of the time. It described a recent study by the Rand Corporation that measured how quality improvement programs affected the diagnosis and treatment of 913 patients at 46 primary care clinics in five states. In addition to significant improvement in depressive symptoms, there was a five percent increase in patients who were maintaining employment in the quality improvement group. Given that worker absenteeism from serious depression costs employers seventeen billion dollars a year, Dr. Kenneth Wells, the study's lead researcher stated, "If that finding were extrapolated across all of those disabled by depression, it would move the stock market."
The Minnesota Department of Health has initiated a suicide prevention effort. This provides an excellent opportunity to explore the Department's potential role in the issue of recognition and treatment of Depression and other mental health disorders in primary care medicine. Since fifteen percent of patients who have Depression commit suicide, and since it is not possible to accurately predict which fifteen percent will do so, if the Health Department addresses suicide, it will also have to address the larger issue of Depression as well. Since other disorders also have significant suicide rates (e.g. the suicide rate for Panic Disorder is also fifteen percent), the issue of suicide prevention goes beyond addressing the diagnosis and treatment of Depression. Given that at least half of the people who commit suicide have been seen by their primary care physician in the last thirty days, it is essential for suicide prevention efforts to target primary care physicians if they are to be successful.
Public health should have a primary role of overseeing mental health issues for the following reasons:
1) Most mental health treatment is provided by primary care physicians, whose mental health screening, diagnostic and treatment efforts are not overseen by the Mental Health Division of the Department of Human Services.
2) DHS has an even narrower focus in regards to oversight of mental health disorders, even when treatment is provided by mental health professionals. It's focus, in adults, is on addressing only four mental health disorders- Depression, Bipolar Mood Disorder, Schizophrenia and Borderline Personality Disorder. This is an arbitrary group of disorders, outlined by legislation, and does not reflect the epidemiological impact of other disorders. For example, anxiety disorders are the most common psychiatric disorders, and are not considered in the SPMI category. Many people who have Obsessive Compulsive Disorder or Panic Disorder are as disabled as those with Depression. The Department of Health functions on a model that addresses all health disorders without using these arbitrary distinctions.
3) DHS tends to focus on individuals served in the public sector, whereas the Department of Health addresses health problems in the general population.
4) Human Services agencies at the state and local level tend to have a high threshold for services, and tend to focus services on the most seriously disabled individuals. Many of these individuals would not have reached this level of severity if earlier interventions had been utilized. Public Health operates on a model that emphasizes early identification, intervention and prevention efforts.
Addressing the most severely disturbed individuals does not tend to have an impact on mental health problems on a societal level. Generally, most of the severely disturbed individuals do not receive services, and many do not request them. (For example, In Hennepin County, the Children's Mental Health Collaborative focuses only on severely emotionally disturbed individuals, and does not provide for screening, early intervention or prevention services. In 1998, it provided "wraparound" services to 368 individuals. Estimates indicated that there were at least 13,000 severely disturbed children and adolescents in Hennepin County that year.)
A public health model that emphasizes early intervention efforts, with research-based epidemiological models of services, would have a much greater impact on mental health issues in the State.
5) Research indicates that there is a biological basis for the severe and chronic mental health disorders such as Depression, Bipolar Mood Disorder, Schizophrenia, Obsessive Compulsive Disorder, Panic Disorder, Attention Deficit Hyperactivity Disorder, etc. As noted above, many medical disorders also have psychiatric manifestations. Psychiatric disorders are public health problems, and need to be addressed as such. Although social problems such as poverty and prejudice can result in adjustment related psychological problems, putting the oversight of mental health in the social services realm tends to blur the distinctions between these social problems and primary mental illness. Resources also tend to be directed toward social interventions, despite lack of evidence that this has a significant impact on mental health disorders in a community.
6) For many patients, there is a significant stigma attached to mental health problems, seeing mental health professionals, etc. They are more comfortable addressing mental health issues, at least initially, with primary health care providers. Other patients are interested in seeing mental health professionals, but have limited access to them. Since health professionals either are generally the referral source for treatment by mental health professionals, or provide the treatment themselves, oversight of mental health issues has to be provided by an agency that provides oversight to these professionals.
7) Health programs already mandate mental health screening, although at the present time it is rarely done effectively. For example, EPSDT (Early and Periodic Screening, Diagnosis and Treatment) is a mandated service for children ages 0-21 covered by Medical Assistance or MinnesotaCare. It is supposed to include a mental health screen and a comprehensive mental health history. Research studies indicate that 25-30% of children and adolescents on Medical Assistance have mental health problems. However, Minnesota data indicates that only 1-4% of those screened by EPSDT are referred for mental health assessments. (Imagine if 25-30% of kids on M.A. had tuberculosis, but only 1-4% were referred for assessment!) If mental health screening was addressed like other public health screening interventions, and overseen by the Health Department, one would expect a significantly higher early recognition of these disorders, with a markedly positive societal impact in the education, social services and correctional systems as well as the health and mental health systems.
8) As noted above, there is a significant cost offset benefit resulting from treating mental health disorders. In other words, medical care costs decrease when mental health treatment is provided. When mental health is "carved out" of the health care system, it is difficult to track this cost offset effect, and difficult if not impossible to address program planning and development issues related to cost effective mental health treatment provision.
9) Public Health nurses across the state repeatedly note that mental health problems are the number one unserved or underserved issues in their patient population. This results in a significantly negative impact on their patients' physical health.
10) Mental health professionals are an essential component in the provision of high quality mental health services. Health Department oversight of mental health issues can result in increased training to health professionals regarding criteria for referrals to mental health professionals, payment for mental health consultation to primary care physicians, cooperative relationships between mental health professionals and primary care providers, and increased sensitivity to unaddressed medical problems in individuals with mental health disorders.
11) The Surgeon General's report indicates that half of individuals who have mental health disorders have problems with chemical abuse or dependency. The reverse is also true. Thus, screening for and treatment of one type of disorder requires the need to address the other problem. Given the health impact of chemical health problems, the overlap with health and mental health disorders, and the fact that chemical health problems are public health problems, chemical health issues also need to be addressed as primary health problems by the Department of Health.
Recommendations
These issues suggest that the Department of Health should, at the very least, take on the responsibilities to:
1) Encourage expanded continuing medical education to health care professionals. The Family Practice and Pediatrics residency programs do not provide the level of training about mental health issues necessary for these physicians to accurately identify, diagnose and treat mental health disorders, and to have the ability to effectively identify patients who require referrals to mental health professionals.
Educational programs need to be initiated or expanded in schools of nursing, medicine, physicians assistant programs, and in the school of Public Health. Continuing medical education programs for primary health care providers need to be developed, and the Department should encourage the Department of Human Services to provide continuing medical education credit to health care professionals who attend DHS mental health conferences.
2) Encourage the use of reliable, valid, sensitive and specific screening tools to be used by health care professionals treating children, adolescents and adults. Given the extra time necessary to administer, score interpret and communicate the results of the screens, the Department will also need to identify funding streams to cover the extra costs. Cost offset data indicate that screening will more than pay for itself in health care savings, and suicide research indicates that many lives will be saved in the process as well.
3) Address the mental health component of EPSDT screening. The Minnesota Mental Health Ombudsman's office has addressed this issue, and their report can be obtained from Bill Wyss (651) 215-1331. Although DHS's Medical Assistance and Childrens Mental Health divisions are beginning to address this issue, the screening is provided by health care professionals (M.D.s or nurses).
4) Address the issue of inequity of insurance coverage for treatment of mental health problems. For example, some insurance companies pay an M.D. less for treating Depression than for treating "real medical problems." M.D.s may respond by submitting the diagnosis of "unspecified aches and pains" on billing forms. From a Public Health standpoint, this makes the tracking of the treatment of mental health disorders very difficult. Present reimbursement rates discourage medical professionals from effectively addressing mental health issues, and the results are illustrated in the above literature search.
5) Encourage insurance reimbursement for consultation from mental health professionals to medical professionals. (E.g. the UCare HMO provides psychiatric consultation to primary M.D.s). This could include payment for consultation via telecommunications or telephone to primary care professionals in Greater Minnesota.
6) Advocate for parity in mental health coverage, and work to encourage federal legislation to remove self-insured companies' loopholes that allow them to not provide mental health coverage, or to avoid parity when coverage is provided.
7) Develop partnerships between Public Health nursing and programs that serve individuals who have mental health problems. For example, school based clinics that serve children and adolescents who have underlying untreated mental health problems are an ideal setting for Public Health interventions of screening, identification, referral and advocacy for treatment of mental health problems. It is important to recognize that school districts discourage school professionals from making referrals of students for mental health treatment (for reasons of financial liability), and that, if these referrals are to be made, they need to be made by co-located professionals. In my opinion, Public Health nurses are the ideal professionals to do this.
8) Work with insurance companies and DHS to track billing data that will clarify data about mental health treatment in Minnesota. A computer analysis of prescriptions of psychotropic medication, cross referenced with DEA numbers of psychiatrists and primary care physicians and with billings for treatment by mental health professionals can provide anonymous group data that will give an overview of the present state of mental health treatment in Minnesota. It could provide data, for example, that would clarify the degree to which health care professionals provide treatment of mental health disorders, and would provide baseline information about rural vs. urban treatment, fee-for-service vs. pre-paid plans, etc. Data could be cross referenced with EPSDT screening/referral data and hospitalization data to clarify whether mental health problems are identified early enough to prevent more costly and restrictive interventions such as hospitalization.
Tracking of diagnostic and treatment data is a natural part of the Public Health system. If we were discussing meningitis instead of Depression, and were describing Public Health efforts to address this problem, we would note a vastly different approach than is now provided for mood disorders. Without accurate epidemiological data describing the incidence, prevalence, identification, referral rates, treatment modalities, individual and group outcomes, and financial impact of mental health issues, no effective public policy regarding mental health issues can be initiated.
Obviously, if the Department of Health is to take on the role of addressing mental health and chemical health issues as public health issues, there will be a need for both increased funding and increased staff to accomplish this task. There will also be the need for an expanded Department vision of health that incorporates mental health as an integral part of overall health. The Department will need technical expertise to accomplish this task, and the willingness to address interdepartmental turf issues that might result from a transfer of responsibilities.
The issues outlined above provide a compelling argument for mental health issues to be addressed on a societal level as public health issues, with oversight provided accordingly. The need to address these issues effectively should drive system change, support access to funding, and overcome resistance to system redesign.
Mental Health and Public Health- Addendum- Why Children's Mental Health Issues Are Best Addressed Through a Public Health Approach
The issues outlined in the paper, Mental Health and Public Health, are especially pertinent to children and adolescents for the following reasons:
- The base rate of mental health problems in the child and adolescent population is approximately equal to that of adults- 18-20% have emotional disorders, and at least 5% have severe emotional disorders. The Minnesota Student survey illustrates this issue dramatically, with very significant frequencies of suicidal thoughts and behaviors, problems with family conflicts, child abuse, binge drinking, etc. These problems are remarkably common even in sixth and ninth grade students.
- Severe and persistent mental health problems experienced by adults often have their onset in childhood or adolescence. When these problems are addressed at the time of onset, through early intervention and secondary prevention approaches, there is a significant reduction in psychopathology and improvement in level of functioning in adult life. Research indicates, for example, that the longer Bipolar Mood Disorder goes untreated, the less responsive it is to treatment. ADHD is a disorder that always begins in childhood, and when it is not effectively identified and treated, often contributes to school failure, correctional problems, and/or potential involvement in the social services system.
- The majority of children and adolescents who have mental health problems receive no treatment, and the majority of those who do receive treatment receive it from primary care clinicians rather than mental health professionals. U.S. News & World Report's 3/6/2000 cover story, "The Perils of Pills" noted, "Of nearly 600 family physicians and pediatricians who responded to a 1999 University of North Carolina survey, 72 percent said that they had prescribed antidepressants to children under 18. But only 16 percent said they felt "comfortable" doing so, and just 8 percent said they have adequate training to treat childhood depression."
- In addition to lack of training in the treatment of mental health disorders, primary care physicians tend to have poor track records in identifying mental health problems in children and adolescents. For example, Costello [30] noted that 25% of children, age seven to eleven years, visiting their pediatrician were identified by the Child Behavior Checklist as having mental health problems. The children's pediatricians did not identify eighty three percent of these cases. Costello also found [31] that only one child in five who had a mental health disorder was being treated by mental health specialists, three were under the care of primary care physicians, and one received no treatment. He concluded that pediatricians were the defacto mental health service for children in need of such care.
- Primary care physicians offices are the most likely setting in which childrens' mental health problems can be identified. Although school professionals may be aware that students have evidence of mental health problems, there is often a reluctance to recommend mental health assessments to parents due to concerns about the potential financial liability of having to pay for assessments and possibly for the recommended treatment. If childrens' mental health problems are identified in the social services or corrections systems, the problems usually are not identified early, as these systems have high thresholds for services. Primary care physicians generally see children and adolescents on an episodic basis throughout their developmental stages, and are in an ideal position to identify problems before they cause a significant deterioration of functioning. The use of appropriate sensitive, specific, reliable and valid screening tools would result in early identification, treatment and appropriate mental health referrals of children and adolescents who have mood disorders, anxiety disorders, eating disorders, chemical health problems, ADHD, etc.
- Although Child Teen Checkup (EPSDT) is considered an episodic medical screen, it is supposed to also include a mental health screen as well. This screening is done by health professionals, rather than mental health professionals; thus the entry to mental health services through this route is by definition through a public health approach. Given that numerous studies have indicated that approximately 25-30% of children and adolescents on Medicaid have mental health problems, EPSDT is a potentially crucial doorway into early intervention mental health services.
- Many families are more comfortable accessing mental health services from primary care physicians, due to the stigma of mental health treatment. Some families have limited mental health insurance coverage. Even when mental health specialist services are sought, the entry point generally is the primary care physician's office. Given the limited number of trained children's mental health professionals, especially in rural communities, primary care providers need to play a leading role in assessing the mental health needs of their patients, and in many situations, are the sole provider of mental health services.
Although human service agencies at the state and county levels have traditionally been viewed as the "home" of children's mental health services, there is little data to suggest that their programs have had a significant preventive impact on the community-wide effects of children's mental health problems. This is due to a combination of factors, including a tendency to focus on the more severely disturbed individuals, and a lack of emphasis on primary care physicians (who are doing the bulk of mental health care). Public health approaches stress early identification, intervention, referral and treatment, and the need to gather accurate outcome data.
Based on the above issues, I believe that childrens' mental health issues are indeed public health issues, and that a public health approach is necessary if there is to be significant overall improvement in mental health problems for children and adolescents in our communities.
The issues outlined in the paper, Mental Health and Public Health, are especially pertinent to children and adolescents for the following reasons:
- The base rate of mental health problems in the child and adolescent population is approximately equal to that of adults- 18-20% have emotional disorders, and at least 5% have severe emotional disorders. The Minnesota Student survey illustrates this issue dramatically, with very significant frequencies of suicidal thoughts and behaviors, problems with family conflicts, child abuse, binge drinking, etc. These problems are remarkably common even in sixth and ninth grade students.
- Severe and persistent mental health problems experienced by adults often have their onset in childhood or adolescence. When these problems are addressed at the time of onset, through early intervention and secondary prevention approaches, there is a significant reduction in psychopathology and improvement in level of functioning in adult life. Research indicates, for example, that the longer Bipolar Mood Disorder goes untreated, the less responsive it is to treatment. ADHD is a disorder that always begins in childhood, and when it is not effectively identified and treated, often contributes to school failure, correctional problems, and/or potential involvement in the social services system.
- The majority of children and adolescents who have mental health problems receive no treatment, and the majority of those who do receive treatment receive it from primary care clinicians rather than mental health professionals. U.S. News & World Report's 3/6/2000 cover story, "The Perils of Pills" noted, "Of nearly 600 family physicians and pediatricians who responded to a 1999 University of North Carolina survey, 72 percent said that they had prescribed antidepressants to children under 18. But only 16 percent said they felt "comfortable" doing so, and just 8 percent said they have adequate training to treat childhood depression."
- In addition to lack of training in the treatment of mental health disorders, primary care physicians tend to have poor track records in identifying mental health problems in children and adolescents. For example, Costello [30] noted that 25% of children, age seven to eleven years, visiting their pediatrician were identified by the Child Behavior Checklist as having mental health problems. The children's pediatricians did not identify eighty three percent of these cases. Costello also found [31] that only one child in five who had a mental health disorder was being treated by mental health specialists, three were under the care of primary care physicians, and one received no treatment. He concluded that pediatricians were the defacto mental health service for children in need of such care.
- Primary care physicians offices are the most likely setting in which childrens' mental health problems can be identified. Although school professionals may be aware that students have evidence of mental health problems, there is often a reluctance to recommend mental health assessments to parents due to concerns about the potential financial liability of having to pay for assessments and possibly for the recommended treatment. If childrens' mental health problems are identified in the social services or corrections systems, the problems usually are not identified early, as these systems have high thresholds for services. Primary care physicians generally see children and adolescents on an episodic basis throughout their developmental stages, and are in an ideal position to identify problems before they cause a significant deterioration of functioning. The use of appropriate sensitive, specific, reliable and valid screening tools would result in early identification, treatment and appropriate mental health referrals of children and adolescents who have mood disorders, anxiety disorders, eating disorders, chemical health problems, ADHD, etc.
- Although Child Teen Checkup (EPSDT) is considered an episodic medical screen, it is supposed to also include a mental health screen as well. This screening is done by health professionals, rather than mental health professionals; thus the entry to mental health services through this route is by definition through a public health approach. Given that numerous studies have indicated that approximately 25-30% of children and adolescents on Medicaid have mental health problems, EPSDT is a potentially crucial doorway into early intervention mental health services.
- Many families are more comfortable accessing mental health services from primary care physicians, due to the stigma of mental health treatment. Some families have limited mental health insurance coverage. Even when mental health specialist services are sought, the entry point generally is the primary care physician's office. Given the limited number of trained children's mental health professionals, especially in rural communities, primary care providers need to play a leading role in assessing the mental health needs of their patients, and in many situations, are the sole provider of mental health services.
Although human service agencies at the state and county levels have traditionally been viewed as the "home" of children's mental health services, there is little data to suggest that their programs have had a significant preventive impact on the community-wide effects of children's mental health problems. This is due to a combination of factors, including a tendency to focus on the more severely disturbed individuals, and a lack of emphasis on primary care physicians (who are doing the bulk of mental health care). Public health approaches stress early identification, intervention, referral and treatment, and the need to gather accurate outcome data.
Based on the above issues, I believe that childrens' mental health issues are indeed public health issues, and that a public health approach is necessary if there is to be significant overall improvement in mental health problems for children and adolescents in our communities.
References
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[17] Simon, G.: Health Care Costs Associated With Depressive and Anxiety Disorders in Primary Care, American Journal of Psychiatry, Vol. 152, 1995, pp. 352-357.
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