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HEALTH & SCIENCE

Report calls for "quiet revolution" in mental health

The recent surgeon general's report challenges physicians and the health care system to reconfigure the delivery of mental health services.

By Stephanie Stapleton, AMNews staff. Jan. 3/10, 2000. - Additional information.

Washington -- Upon its release last month, a landmark report on mental health issued by Surgeon General David Satcher, MD, PhD, received high praise from physicians, policymakers and mental health advocates for helping to address the lingering stigma that prevents those who suffer from getting the care they need.

But the report also triggered difficult conversations about how well physicians and the health care system are equipped to respond to the nation's mental health needs.

"Even more than other areas of health and medicine, [this one] is plagued by disparities in the availability of and access to services," Dr. Satcher wrote. The disparities are closely linked to financial status and health insurance coverage and apply across racial, cultural, gender and age divisions.

About one in five Americans experiences some form of mental disorder in a year. An estimated 15% of American adults use some type of mental health service; about half of those people in need of care never seek it. Thus, the report begins with a single, explicit recommendation: People who think they have a mental health problem should seek help.

The report also seeks to educate the public about the connection between mental and physical health, and to dispel culturally held negative perceptions of mental health problems. The 500-page document, in the works since Dr. Satcher took office in early 1998, also highlights the negative effects of existing barriers to receiving mental health treatment and the specific mental health issues of children, adults and the elderly.

"Clearly, surgeon general's reports have taken unappreciated but substantially important subjects and put them in the headlines," said Nancy W. Dickey, MD, AMA immediate past president. This was no exception.

Specifically, the report gives a tremendous amount of information and highlights important themes -- the impact of not having mental health parity in insurance coverage and the effects of continued public perceptions and stigmas attached to the diagnosis of mental illness, Dr. Dickey said. But some of the problems can be attributed to the health care system -- and sometimes to doctors.

"In practice, the mind and body are sometimes treated separately," said Geneva Riley, the National Mental Health Assn.'s director of primary care outreach. Her organization does an outreach program to primary care physicians to try to help bridge this separation with seminars and educational materials to provide resources to physicians on a range of subjects, including local referrals. "We are attempting to assist physicians with the missing links," Riley said.

But the problem is not a simple one, because it reaches deep into the consciousness of both patients and physicians, she said. "The stigma works both ways." Many physicians try to assess for mental illness, but patients don't always cooperate because they don't want to be tainted. Meanwhile, other physicians may not be as comfortable with mental concerns and are less likely to think about the biological component of mental illness, Riley said.

An example: the well-being of an elderly person who recently lost a spouse. Grief, mourning, sadness and even mild depression are natural responses, she said. "But that shouldn't preclude a physician from doing a thorough assessment for clinical depression," she added.

Some of the break can be attributed to medicine's institutions, according to Allan Tasman, MD, president of the American Psychiatric Assn. and chair of the department of psychiatry at the University of Louisville.

There is inadequate curriculum time devoted in medical school to psychiatric illness and treatments, he said. When physicians enter their residency, they have a fairly rudimentary understanding -- just like with most facets of medicine. But the likelihood that they will be exposed to more during residency is small.

"This lack of information and time leads to an inadequate knowledge base," explained Dr. Tasman. And when a physician does not grasp completely the illness, its diagnosis and treatment, it is hard to recognize something as a true illness, he added.

Sometimes, though, the problem is not rooted in a lack of understanding.

Dr. Dickey, a family physician, said most doctors in her specialty receive a considerable amount of training in this area. The challenge is putting what they know into practice.

One of the most basic reasons is the increased time pressures that primary care physicians face. "They are expected to see patients every six or seven minutes," she said. It is difficult, even impossible, to do a meaningful mental health assessment in that amount of time, she added.

Also problematic is the managed care concept of "the carve-out," in which a certain set of practitioners is selected apart from the primary care physician to provide mental health services. Barry Herman, MD, a child and adolescent psychiatrist who now practices in Amarillo, Texas, said this approach is deeply flawed. "It ultimately leads to reinforcing the stigma of mental illness," said Dr. Herman, who has also worked as an HMO medical director. The carve-out creates "a disconnect" from all those patients receiving care in the primary care setting. It also makes collaboration difficult between primary care and mental health professionals, he said.

And so many people slip through the cracks. Treatment for patients with eating disorders is often not covered by health plans. Yet, mental disorders often result in severe physical illnesses. Still, it's difficult for these patients to get integrated, multidisciplinary treatment, Dr. Herman said.

Children with attention deficit and hyperactivity disorder suffer a similar plight. ADHD often is not covered by a carve-out, he explained. Thus, children and their parents rely on primary care physicians for treatment, diagnosis and medication. The complication comes because there's significant comorbidity with this illness and others, such as depression. "But the children don't get the care they need," he said.

Filling the gaps

These anecdotes represent ways in which the health care delivery system sometimes fails to address very specific treatment needs. But what the surgeon general's report also provides is hard scientific information highlighting another part to the story -- the inroads that have been made in finding effective treatments for a whole range of mental disorders. And this knowledge makes even more stark the gaps between what science has provided and the availability of these therapies to people in need.

"Part of the problem certainly is that enough people don't seek care," said Clarke Ross, the associate executive director for public policy at the National Alliance for the Mentally Ill. Another part is discrimination in health insurance benefits. But "some of the gap is a result of medical practice," he said.

There are primary care and even mental health specialists who are not familiar enough with recent advances -- classes of drugs such as selective serotonin re-uptake inhibitors -- to help their patients take advantage of them, he said. Sometimes the blame can be placed on restrictive formularies, but it is also attributable to a lack of awareness. Even when practitioners have a cursory understanding, they may not have tuned into subtleties regarding dosage or other concerns, he added.

Nonetheless, in the discussion triggered by the surgeon general's report, much of the focus has been on how to expand access and ensure complete parity. However, there are contrary voices even on these subjects.

For instance, representatives of the managed care and insurance industry have long warned that leveling the field between physical and mental benefits would lead to dramatic increases in health coverage costs. But there are additional perspectives within this debate, too.

"My reaction is that [this report] missed an opportunity to set priorities," said Sally Satel, MD, a senior associate at the Washington-based Policy and Ethics Center. "Its definition of mental illness is too broad," added Dr. Satel, also a staff psychiatrist at the Oasis Clinic. Her preference would have been to distinguish between severe and more mild forms of mental disturbances. "A lot of the people at the mild end of the spectrum don't need professional help. ... We're pathologizing what's in the normal range," she said.

Her position is that it does make sense to have limits for the milder conditions. The concept of more treatment, more programs and more access cannot be considered the only answer. "Believe me, we do need more of that," she said. But policymakers need to go a step further and recognize that some people need protection and asylum. "We need to take seriously the idea that some people can't live in the community and don't want to," she said. And in the world of scarce resources, what is available should be targeted to these people first.

But most people do not consider this point to be the appropriate focus of this surgeon general's report. Instead, it is viewed as a gold standard of information and a document that will provide advocacy groups with ammunition to take to legislators and the general public with information to help them become more comfortable with discussing this kind of illness.

In addition, the report sets a foundation for a standard of care in which age, gender and ethnicity are taken into consideration.

"The 1999 surgeon general's report can do for mental illness what the surgeon general's 1964 [report] did for smoking and health," said Dr. Tasman. "We just hope it won't take as long."

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See the Surgeon General's site for full text of "Mental Health: A Report of the Surgeon General."

See the NMHA site for information about National Mental Health Assn.'s primary care outreach program

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