Policy and Advocacy in Mental Health Care

Policy and Advocacy in Mental Health Care

Mona Shattell and Gail Stuart

Policy affects every aspect of a person’s life and wellbeing, including the way a society organizes its health care system, how it finances it, the priorities of care it establishes, and the resources it makes available to individuals, families, and communities to promote and preserve health. The best interventions are of little benefit to patients if they cannot gain access to them.

Nowhere is this more important than in the area of mental health care. Each day, policies shape, support, challenge, and block how well the mental health care needs of individuals, families, and communities are met. Competent psychiatric nurses need to understand mental health policies and the advocacy role they can play in the broader mental health care environment.

A Compelling Need

The Global View

Mental illnesses are significant worldwide health problems. The World Health Organization’s (WHO) global burden of disease study revealed that mental disorders are the second most disabling category of illnesses around the world (Murray & Lopez, 1996). The study compared a range of physical and mental disorders to determine their contribution to the overall burden of disease. The data showed the following:

This study raised a global awareness of the impact that mental illnesses have on the everyday lives of people around the world.

The National View

In 2009 there were an estimated 20%, or 45 million, adults ages 18 or older in the United States with any mental illness in the past year. The percentage having serious mental illness in the past year was about 5%, or 11 million adults (Substance Abuse and Mental Health Services Administration [SAMHSA], 2010).

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.

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.

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.”

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.


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

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:

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).

Persons with serious mental illness are more likely to be uninsured, and even insured persons often receive no treatment or inadequate mental health treatment because of policies and societal values that are discriminatory (Khaykin et al, 2010; Compton et al, 2011). Some policies and laws have been enacted that attempt to address these issues.

Insurance coverage for mental health care has not been equal to that for physical illnesses. Persons with mental illness who had health insurance usually had to pay higher premiums and co-pays, had higher deductibles, and had drastic limits on outpatient and inpatient mental health care compared to coverage for non–mental illness, that is, other physical illnesses.

There have been two main policy approaches to equalizing care: mandated coverage for mental health care and mental health parity.

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Feb 25, 2017 | Posted by in NURSING | Comments Off on Policy and Advocacy in Mental Health Care

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