Unfortunately, many of these persons never receive treatment. Barriers to receiving mental health care are presented in Figure 9-1. For individuals with mental illness who received treatment, 20% quit before completing treatment recommendations (Olfson et al, 2009). Yet untreated and mistreated mental illness costs American business, government, and taxpayers an estimated $113 billion each year.

FIG 9-1 Reasons for not seeking treatment. (From Substance Abuse and Mental Health Services Administration: *Results from the 2009 national survey on drug use and health: mental health findings,* Series H-39, HHS Pub. No. SMA 10-4609, Rockville, Md, 2010, Office of Applied Studies, NSDUH.)

Critical Reasoning

Given that mental illness is so prevalent, why do you think there are so many barriers to adequate and appropriate mental health care?

Four important reports released in the United States are having an impact on the delivery of mental health care. The most recent is Healthy People 2020, which identifies a list of leading health indicators that reflect the major public health concerns in the United States (U.S. Department of Health and Human Services [USDHHS], 2010). Those related to mental health include tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, and access to health care.

For each of the leading health indicators, specific objectives derived from Healthy People 2020 have been identified. The objectives related to mental health are presented in Box 9-1, providing a snapshot of the mental health issues in the United States.

BOX 9-1 HEALTHY PEOPLE 2020—OBJECTIVES RELATED TO MENTAL HEALTH AND MENTAL ILLNESS

Mental Health Status Improvement

• Reduce the suicide rate.

• Reduce suicide attempts by adolescents.

• Reduce the proportion of adolescents who engage in disordered eating behaviors in an attempt to control their weight.

• Reduce the proportion of persons who experience major depressive episodes (MDEs).

Treatment Expansion

• Increase the proportion of primary care facilities that provide mental health treatment on-site or by paid referral.

• Increase the proportion of children with mental health problems who receive treatment.

• Increase the proportion of juvenile residential facilities that screen admissions for mental health problems.

• Increase the proportion of persons with serious mental illness (SMI) who are employed.

• Increase the proportion of adults with mental disorders who receive treatment.

• Increase the proportion of persons with co-occurring substance abuse and mental disorders who receive treatment for both disorders.

• Increase depression screening by primary care providers.

• Increase the proportion of primary care physician office visits that screen adults ages 19 years and older for depression.

• Increase the proportion of homeless adults with mental health problems who receive mental health services.

Retrieved July 2011 from www.healthypeople.gov/2020/topicsobjectives2020/.

The second national report is Improving the Quality of Health Care for Mental and Substance-Use Conditions (Institute of Medicine [IOM], 2006). This report describes a multifaceted and comprehensive strategy for ensuring access, improving quality, and expanding mental health and substance abuse treatment services.

The third was the report from the New Freedom Commission on Mental Health (NFCMH), Achieving the Promise: Transforming Mental Health Care in America (NFCMH, 2003). The commission was formed to address the problems in the mental health service delivery system that allow Americans to fall through the system’s “cracks.”

Critical Reasoning

Why are the “cracks” in the mental health care system so large and what can be done to narrow them?

The commission found that the current system is unintentionally focused on managing disabilities associated with mental illness rather than promoting recovery. This is because of fragmentation, gaps in care, and uneven quality in mental health services. The commission thus recommended a focus on promoting recovery and building resilience—the ability to withstand stresses and life challenges (Chapters 12 and 14).

Six goals and a series of recommendations for federal agencies, states, communities, and providers nationwide were identified. These are listed in Box 9-2.

BOX 9-2 GOALS AND RECOMMENDATIONS IN A TRANSFORMED MENTAL HEALTH SYSTEM

Goal 1: Americans Understand that Mental Health Is Essential to Overall Health

Recommendations

1.1. Advance and implement a national campaign to reduce the stigma of seeking care and a national strategy for suicide prevention.

1.2. Address mental health with the same urgency as physical health.

Goal 2: Mental Health Care Is Consumer and Family Driven

Recommendations

2.1. Develop an individualized plan of care for every adult with a serious mental illness and every child with a serious emotional disturbance.

2.2. Involve consumers and families fully in orienting the mental health system toward recovery.

2.3. Align relevant federal programs to improve access and accountability for mental health services.

2.4. Create a comprehensive state mental health plan.

2.5. Protect and enhance the rights of people with mental illness.

Goal 3: Disparities in Mental Health Services Are Eliminated

Recommendations

3.1. Improve access to quality care that is culturally competent.

3.2. Improve access to quality care in rural and geographically remote areas.

Goal 4: Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice

Recommendations

4.1. Promote the mental health of young children.

4.2. Improve and expand school mental health programs.

4.3. Screen for co-occurring mental and substance use disorders and link with integrated treatment strategies.

4.4. Screen for mental disorders in primary health care, across the life span, and connect to treatment and supports.

Goal 5: Excellent Mental Health Care Is Delivered and Research Is Accelerated

Recommendations

5.1. Accelerate research to promote recovery and resilience and, ultimately, to cure and prevent mental illness.

5.2. Advance evidence-based practices using dissemination and demonstration projects and create a public-private partnership to guide their implementation.

5.3. Improve and expand the workforce, providing evidence-based mental health services and supports.

5.4. Develop the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care.

Goal 6: Technology Is Used to Access Mental Health Care and Information

Recommendations

6.1. Use health technology and telehealth to improve access and coordination of mental health care, especially for Americans in remote areas or in underserved populations.

6.2. Develop and implement integrated electronic health record and personal health information systems.

From New Freedom Commission on Mental Health (NFCMH): Achieving the promise: transforming mental health care in America, final report, DHHS Pub. No. SMA-03-3832, Rockville, Md, 2003, U.S. Department of Health and Human Services.

The fourth report, published in 1999, was the first issued by a U.S. surgeon general on the topic of mental health and mental illness, Mental Health: A Report of the Surgeon General (USDHHS, 1999). This landmark document concluded the following:

• Mental health is fundamental to health.

• Mental disorders are real health conditions that have an immense impact on individuals and families.

• The efficacy of mental health treatments is well documented.

• A range of treatments exists for most mental disorders.

• People should seek help if they have a mental health problem or think that they have symptoms of a mental disorder.

These studies and reports underscore the critical importance of mental health care, and through improved policies and legislation, they help advocate for a more effective and efficient mental health delivery system.

Policy and Legislation

Access is the degree to which services and information about health care are easily obtained. It is a critically important part of an effective mental health care delivery system. An ideal comprehensive health care system would provide the full array of high-quality, community-based, culturally and linguistically competent, integrated mental health and substance abuse services, regardless of ability to pay, including access to the full range of the most effective medications and treatments. It would have multiple points of entry for treatment, including direct access through self-referral, by a wide variety of providers.

Currently, two thirds of the people who seek mental health care are treated by primary care providers (Chapter 34). However, many who need care do not receive it, from either a primary care or a specialty provider. The major reason for not receiving treatment is cost. Unmet needs for treatment are greatest in traditionally underserved groups, including the elderly, racial and ethnic minorities, those with low incomes, those without insurance, and residents of rural areas (Giled and Frank, 2009; Garfield et al, 2011).

When access to mental health care is made difficult, the overall costs of general medical care increase because those with behavioral health problems are frequent users of medical services. For example, people with panic disorder typically are seen by 10 different medical care providers before they are properly diagnosed.

Some access problems apply to the entire health care system, such as the lack of providers in rural areas and the absence of care for people who lack health insurance. Other problems are unique to mental health care. These include the stigma associated with seeking care, the lack of knowledge about how to find the right clinician for a highly personal problem, and the shortage of general medical settings to adequately respond to mental health and substance use disorders. A significant barrier to access is the major decline in the states’ funding of mental health services (Figure 9-2).