Rahn Kennedy Bailey, M.D., D.F.A.P.A.
113th President National Medical Association
Chairman & Professor
Dept. of Psychiatry and Behavioral Sciences
Elam Mental Health Center
Meharry Medical College
Nashville TN
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Barriers to Mental Health Treatment
November 7th, 2014
2014 Gulf Coast of Texas African
American Family Support Conference
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Disclosures

Programs at Elam Mental Health
Center

Private Grants

Eli Lilly

Adolescent Day Treatment

Janssen

Rainbow Unit

Sunovian

SISTER’S Story (Supported Intensive System of Treatment,
Empowerment, & Recovery)

Ortho McNeil

Tennessee Psychiatric Association Innovative Grant

Project COPE (Community Outreach Prevention Education)

REACH (Recovery is for Everyone Accepting a Change in Health)

Adult Continuum

Detoxification

Residential Rehabilitation

Intensive Outpatient

Outpatient

Federal Grant

Treatment Access Project II

5th Annual Lloyd C. ELAM Symposium
NIH Grant

NIMHD Translational Health Disparities
Training August 2013
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Disclaimer
 The Health Policy Writing Collaborative is
sponsored in part by the Robert Wood Johnson
Foundation for Health Policy at Meharry, and
the Department of Health and Human Services’
Health Resources and Services Administration
(HRSA), D76HP20862 grant award.
 The content is solely the responsibility of the
author(s) and does not necessarily represent
the official view of the Robert Wood Johnson
Foundation or the Department of Health and
Human Services.
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Learning Objectives

At the conclusion of this presentation the attendees will be able
to:

Explain top five barriers to seeking Mental Health Care

Stigma and its impact on help-seeking for mental
disorders

Explain the need of Mental Health Treatment Barriers

Implications for Public Policy to address the Mental
Health Issues

The impact of Affordable Care Act in improving mental
health treatment
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The burden and prevalence of
mental disorders

Depression and anxiety are highly prevalent mental
disorders with estimates indicating they affect up to
almost one fifth of the population in high income
countries worldwide.

Prevalence of mental disorders is greatest among
younger people aged 16-24 years than at any other
stage of the lifespan.

Common in childhood and adolescence with 14% of
those aged between 4 and 17 years affected.

High susceptibility in adolescents and young adults
to developing a mental disorder is coupled with a
strong reluctance to seek professional help.
Rickwood D, Deane F, Wilson C: When and how do young people seek
professional help for mental health problems? Med J Aust 2007, 187(7
Suppl):S35-39.
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Barriers To Mental Health

System-level barriers:
Access issues :




Inaccessibility
location,
Transportation problems
Lack of health insurance

Availability of services:


Few opportunities for group counseling
In-home services

Social issues: lack of child care
Ward et al. (2009) Quality Health Res. 2009 November ; 19(11): 1589–1601.
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System-level barriers:

Poor quality of care:

Limited access to culturally competent
clinicians and case management

Cultural matching: few opportunities to
work with racial and ethnic minority
clinicians
Ward et al. (2009) Quality Health Res. 2009 November ; 19(11): 1589–1601.
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Individual-level barriers:


Internalized stigma of mental illness
Shame and embarrassment about mental illness

Lack of knowledge of mental illness

Cultural norms
Ward et al. (2009) Quality Health Res. 2009 November ; 19(11): 1589–1601.
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Attitude

Attitudinal barriers commonly caused Americans to
not seek mental health care.

These barriers include believing that the mental
illness will resolve on its own and not believing
that psychiatric care is beneficial.

Evidence that suggests that athletes may have
even less positive attitudes towards seeking help
from a counsellor than non-athletes.

In particular, male and younger athletes have been
reported to have less positive attitudes towards
seeing a sport psychologist than female and older
athletes
Sareen et al. Perceived barriers to mental health service utilization in the United
States, Ontario, and the Netherlands. Psychiatr Serv. 2007 Mar;58(3):357-64.
Watson J: College student-athletes' attitudes toward help-seeking behavior and
expectations of counseling services. J Coll Stud Dev 2005, 46(4):442–449.
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8
Limited Availability of Medication and
Health Professionals

Unavailability of essential medicines is particularly prevalent
in developing countries, and severely restricts access to
treatment for psychological disorders.

World Health Organization reports that nearly 20% of
countries do not have at least one common antidepressant,
one antipsychotic, and one antiepileptic medication
available in primary care settings.

Lack of mental health care professionals in low- and middleincome countries

Low-income countries have a median of 0.05 psychiatrists
and 0.16 psychiatric nurses per 100,000 people.
Saxena, S., Thornicroft, G., Knapp, M., Whiteford, H. (2007). Resources for
mental health: scarcity, inequity, and inefficiency. Lancet, 370: 878-89. 111/3
8
Limited Affordability

In many low- and middle-income countries, the high cost of
psychiatric treatment, often due to high medication prices,
poses significant financial barriers to patient care.

Psychological disorders are not covered by insurance policies
in many countries, making mental health care unaffordable
for many people.

WHO reports that 25% of all countries do not provide
disability benefits to patients with mental disorders.

One-third of the world’s population lives in countries that
allocate less than 1% of their health budget to mental
health.

31% of countries do not have a specific public budget for
mental health.
World Health Organization. “Investing in mental health”. Retrieved 29 June 2012.
Saxena, S., Thornicroft, G., Knapp, M., Whiteford, H. (2007). Resources for mental
health: scarcity, inequity, and inefficiency. Lancet, 370: 878-89.
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Policy Limitations

Global lack of comprehensive mental health policies, which
are crucial for implementing and coordinating mental health
care services, a key barrier to public access to mental health
care.

Nearly one-third of all countries, and almost half of all
African nations, have no comprehensive mental health care
policy or plan

22% of countries do not have laws that offer legal protection
of the human and civil rights of people with mental illnesses.

In many low- and middle-income countries, the localization
of mental health care resources in large cities has also been
cited as a key barrier to providing mental health care to the
entire population.
Saraceno, B., van Ommeren, M, Batniji, R., Cohen, A., Gureje, O., Mahoney, J.,
Sridhar, D., Underhill, C. (2007). Barriers to improvement of mental health
services in low-income and middle-income countries. Lancet, 370: 1164-74.
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Lack of Education

Limited knowledge about mental illness can prevent
individuals from recognizing mental illness and seeking
treatment.

Poor understanding of mental illness also impairs families’
abilities to provide adequate care for mentally ill relatives.

The majority of individuals with an untreated severe mental
illness did not seek care because they believed they did not
have a condition that required treatment.

Of responders with a severe mental illness who did not
receive care but recognized that they needed treatment,

52% reported situational barriers to care

46% cited financial barriers

45% dropped out of care because they felt that treatment had
not been effective.

72% of respondents who did not seek treatment chose to do so
because they wanted to “solve the problem on their own”
Kessler et al (2001). The prevalence and correlates of untreated serious
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mental illness. HSR: Health Services Research, 36(6): 987-1007.
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Stigma

Stigma associated with mental illness often
prevents patients from seeking and adhering to
treatment, as patients may “attempt to distance
themselves from the labels that mark them for
social exclusion”.

Stigmatisation of those with mental illness has
been conceptualised as a process ultimately
resulting in status loss and discrimination.

Three levels of discrimination:

Individual

Structural

Discrimination qua self-stigmatisation.
Wahl, O.F. (2012). Stigma as a barrier to recovery from mental illness.
Trends in Cognitive Sciences, 16(1): 9-10.
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Stigma

Self-stigmatisation occurs when members of a minority
group internalise the stigmatising ideas of their social
environment and start to believe that they are of less
value and will be rejected by most people.

The stigma attached to mental illness often leads to
underestimation, underdiagnosis and undertreatment of
mental disorders.

A lack of knowledge of causes, symptoms and treatment
options of mental disorders and a lack of personal
contact with persons suffering from these disorders, can
lead to prejudices and negative attitudes towards
them – and subsequently to stigmatization, social
exclusion and discrimination.
Riecher-Rossler et al., 2006;
Sartorius & Schulze, 2005;
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Stigma

Stigma is a risk factor leading to negative
mental health outcomes.

Stigma is responsible for treatment seeking
delays and reduces the likelihood that a
mentally ill patient will receive adequate care.

It is evident that delay due to stigma can have
devastating consequences.

Intervention studies show that destigmatisation
may lead to increased readiness to seek
professional help, but other aspects like
knowledge about mental diseases seem to be
at least as important.
Schomerus G, Angermeyer MC. Stigma and its impact on help-seeking
for mental disorders: what do we know? Epidemiol Psichiatr Soc. 177/3
2008 Jan-Mar;17(1):31-7.
8
Stigma of Mental Illness:
Shrivastava A, Johnston M, Bureau Y. Mens Sana Monographs, 188/3
Vol. 10, No. 1, January-December, 2012, pp. 85-97
8
Stigma of Mental Illness:
Non-compliance and Intervention
Shrivastava A, Johnston M, Bureau Y. Mens Sana Monographs, 199/3
Vol. 10, No. 1, January-December, 2012, pp. 85-97
8
Stigma of Mental Illness:
Non-compliance and Intervention
Shrivastava A, Johnston M, Bureau Y. Mens Sana Monographs,
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Vol. 10, No. 1, January-December, 2012, pp. 85-97
Barriers to help-seeking for mental health
problems reported by elite athletes.
Gulliver et al. BMC Psychiatry 2012, 12:157
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Barriers to Mental Health Treatment
 Globally, more than 70% of people with mental illness receive
no treatment from health care staff.
 Evidence suggests that factors increasing the likelihood of
treatment avoidance or delay before presenting for care
include
 Lack of knowledge to identify features of mental illnesses
 Ignorance about how to access treatment
 Prejudice against people who have mental illness
 Expectation of discrimination against people diagnosed
with mental illness.
Thornicroft G. Most people with mental illness are not
treated. Lancet. 2007;370(9590):807-808.
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Reasons for Not Receiving Mental Health Treatment
in the Past Year among Adults aged 18 or Older
Results from the 2006 National Survey on Drug Use and Health.
DHHS/SAMSHA Office of Applied Statistics
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The relationship between vulnerability, mental
health conditions and adverse development
outcomes
Mental health and development: targeting people with mental health
conditions as a vulnerable group / Michelle Funk … [et al].
World Health Organization 2010
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Mental Health Treatment by
Race/Ethnicity
SAMHSA, National Survey on Drug Use and
Health, 2008
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Adherence to Psychiatric Treatments
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Disparities in Treating Depression

Traditional masculinity norms contribute to Men’s
under-utilization of health care services.

Seeking mental health treatment is perceived by many
men to be in conflict with traditional gender norms.

Even though medical services are provided free of
charge, most men would still not seek treatment.
Mackenzie CS, et al. Age, gender, and the underutilization of mental health services: The
influence of help-seeking attitudes. Aging & Mental Health. 2006;10(6):574-582.
Griffith DM, Gunter K, Watkins DC. Measuring Masculinity in Research on Men of Color:
Findings and Future Directions. American journal of public health. 2012;102(S2):S187-S194.
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Disparities in Treating Depression

only 14% of African American men received mental
health care from professional services , while 29% did
not seek any help.

Underutilization of mental health services lead to
disproportionate burden of morbidity and mortality
compared to other racial/ethnic groups.

African American Men have highest rates of chronic
medical disorders in the U.S. and die approximately
6years younger than White Americans.
Woodward AT, Taylor RJ, Chatters LM. Use of Professional and Informal Support by Black Men
with Mental Disorders. Res Soc Work Pract. Jul 2011;21(3):328-336.
Satcher D, et al. What if we were equal? A comparison of the black-white mortality gap in 1960
and 2000. Health affairs. Mar-Apr 2005;24(2):459-464.
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Disparities in Treating Depression

African American Men are twice as likely to be
unemployed compared to White Americans.

Factors preventing African American Men from
getting Mental Health Care
Socioeconomic inequities
 Stigma of Mental Illness
 Lack of Access to Care
 High Incarceration Rates
 Low levels of education

Holden KB, et al. Journal of men's health. Jun 1 2012;9(2):63-69.
Ayalon L, Alvidrez J. Issues in mental health nursing. 2007;28(12):1323-1340.
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Alegria, M. et al. (2008) Disparity in Depression Treatment Among Racial and Ethnic
Minority Populations ion the United States. Psychiatric Services, 59(11), 1264-72
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ACA and Mental Health

Prior To Affordable Care Act:

one-third of those who are currently covered in the
individual market have no coverage for substance use
disorder services

Nearly 20 percent have no coverage for mental health
services, including outpatient therapy visits and inpatient
crisis intervention and stabilization

47.5 million Americans lack health insurance coverage

25 percent of uninsured adults have a mental health
condition or substance use disorder or both
ASPE Issue Brief, "Essential Health Benefits: Individual Market Coverage," ed.
U.S. Department of Health & Human Services (2011).
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ACA and Mental Health

ACA will expand coverage of mental health in three distinct ways:
1. By including mental health and substance use disorder benefits in the
Essential Health Benefits :

About 3.9 million people currently covered in the individual market will gain either
mental health or substance use disorder coverage or both

An estimated 1.2 million individuals currently in small group plans will receive
mental health and substance use disorder benefits under the Affordable Care Act
2. By applying federal parity protections to mental health and substance
use disorder benefits in the individual and small group markets :

Under this approach, 7.1 million Americans currently covered in the individual
market who currently have some mental health and substance use disorder
benefits will have access to coverage of Essential Health Benefits
ASPE Issue Brief, "Essential Health Benefits: Individual Market Coverage," ed.
U.S. Department of Health & Human Services (2011).
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ACA and Mental Health

ACA will expand coverage of mental health in three distinct
ways:
3. By providing more Americans with Access to Quality Health Care that includes
coverage for mental health :

Affordable Care Act will expand insurance coverage to a projected 27
million previously uninsured Americans

Access to private health insurance in the individual and small group
markets, the Marketplaces, and Medicaid.

In total, 32.1 million Americans will gain access to coverage that
includes mental health and/or substance use disorder benefits

An additional 30.4 million Americans who currently have some mental
health and substance abuse benefits will benefit from the federal
parity protections.

By building Mental Health Parity and Addiction Equity Act, the
Affordable Care Act will extend federal parity protections to 62 million
Americans.
ASPE Issue Brief, "Essential Health Benefits: Individual Market Coverage," ed.
U.S. Department of Health & Human Services (2011).
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Parity Protection for Behavioral Health

Parity law — the Mental Health Parity and Addiction
Equity Act (MHPAEA);

Rules to fully carry out the law were issued in Nov.
2013. Effective July 1, 2014; for some plans, effective Jan
2015.

In the past, when health plans offered mental health
coverage, it was often at less generous levels than
benefits for medical care. These discriminatory
practices kept people from getting mental health care,
and they are no longer allowed under the parity law.

When health insurance plans provide coverage for
mental ailments, it must be comparable to coverage
for physical ailments.
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Parity Protection for Behavioral Health

Plans cannot set higher deductibles or charge higher
co-payments for mental health visits than for medical
visits, and cannot set more restrictive limits on the
number of visits allowed;

Plans cannot limit mental health care to a specific
geographic region, if they do not do so for physical
illnesses;

Plans cannot make getting prior-approval for inpatient
mental health treatment more difficult than that for
admission to an acute care hospital;

The law also applies to “intermediate” treatment
options for mental health and addiction disorders, like
residential treatment or intensive outpatient therapy.
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Conclusion

Mental healthcare is limited by factors such as

lack of knowledge to identify mental illness

how to access treatment

prejudice against mental illness

individual negative attitudes and beliefs

perceptions of stigma

anticipated discrimination.
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Conclusion (contd..)




Sophisticated approaches are needed to
realistically eliminate these and other barriers.
Public policy should focus on criteria for need
for care and encourage interventions that
facilitate treatment when it can be helpful.
Appropriate
insurance
coverage
is
indispensable, and achieving mental health
parity will require careful management of
care.
Policymakers must help to create a trustworthy
management structure that is inclusive, that
develops and disseminates models of best
practice.
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Conclusion

A major promise of the Affordable Care Act is to improve care and
financial protection for vulnerable populations such as the many
lower-income Americans with mental disorders.

The key features of the Affordable Care Act are :

The expansions of insurance coverage through federally subsidized
health insurance exchanges

Medicaid eligibility for all individuals up to 138% of the federal
poverty line, coupled with tax penalties for forgoing insurance.

These insurance expansions are expected to increase coverage for
lower-income populations, which have a higher prevalence of
mental disorders.

Individuals with mental illness will see significant gains in insurance
coverage and access to care.
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Thank you!
Questions and Answers