Public Mental Health is the application of the principles of medicine and social science to prevent the occurrence of mental and behavioral disorders and to promote mental health of the population. This course illustrates the principles of public health applied to depressive disorder, including principles of epidemiology, transcultural psychiatry, health services research, and prevention. It is predicted that by 2020 depressive disorder will be the most important cause of disease burden in the entire world! Every human being suffers from feeling depressed at some point or other, but only about one fifth of the population will experience an episode of depressive disorder over the course of their lives. This course illuminates the public health approach to disease, and the particular complexities of applying this approach to mental disorders, using depression as the exemplar.
Lecture 5B: Barriers and Solutions
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Do curso por Johns Hopkins University
A Depressão na Sociedade: Uma Abordagem de Saúde Pública
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Unmet Need for Care, Barriers, and Programs to Improve Access
In this module, we discuss unmet need for treatment and treatment seeking and present a public health view of depression treatment.
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William Eaton, PhDProfessor, Mental Health
Bloomberg School of Public Health
Wietse A. Tol, PhDAli & Rose Kawi Assistant Professor, Mental Health
Bloomberg School of Public Health
Ramin Mojtabai, MDAssociate Professor, Mental Health
Bloomberg School of Public Health
So welcome to the second section of this lecture which deals
with barriers, and solutions to these barriers, to seeking care for depression.
I will talk about some of the major
barriers to treatment-seeking in this part of the lecture.
As we saw before, a sizable portion of the group of individuals with major
depression do not seek treatment, because they
do not perceive the need for treatment.
They may not be aware that what they are going through is depression.
Or as it happens commonly they may believe that they should be
able to deal with their symptoms on their own, and without professional help.
These data are based on a 1981 study by Ron Kessler, and
his colleagues, and shows that women are overall more likely than men to
feel a need for help when dealing with depressive symptoms.
On the horizontal axis, are the scores on the CES-D, which stands for the
Center for Epidemiologic Studies Depression scale, and
is a rating scales for depressive symptoms.
On the vertical axis, is the probability of recognizing a need for help.
You notice that individuals
with the highest CES-D score, both men and women, are more likely to perceive
a need for help as both curves tend go up, as the CES-D
scores increase. You'll also notice that, at almost every
CES-D scale score, the curves for women is higher than the one for men.
Which indicates that women are more likely to perceive
a need for help than men.
This sex difference in experiencing need and in treatment seeking
has been repeatedly reported in surveys in industrialized countries, and
has been attributed to a number of factors including differences
in socialization of women compared to men, and other factors.
Now, based on your own readings and experiences
in the field, what do you think is the cause of this difference?
Another set of barriers to treatment seeking for depression
and other common mental disorders, are negative attitudes towards treatments.
People may feel that treatment will not help.
That they may become dependent on treatment, especially medications,
or that they may be hospitalized against their will.
Some people may have had previous experiences that were negative.
Others may have heard about
negative experiences that others have had with treatments,
and all of these could act as barriers.
In the previous slide, I mentioned
racial and ethnic differences in treatment seeking.
Past research has shown significant differences between
racial and ethnic minorities, and the non-Hispanic
white majority in the United States with
regard to the use of mental health services.
The data that you see in this slide are from a study by Lisa Cooper and
colleagues and are based on a survey of
individuals with major depression in primary care settings.
The investigators asked the opinions of individuals with
major depression who are from three racial ethnic groups.
They found that, while a majority of all three groups
believe that they needed treatment for
depression, non-Hispanic Whites were more likely than
minorities to believe that medication are
beneficial for treatment of depression, less likely
to believe that antidepressants are usually
addictive, and also less likely, than Hispanics,
to believe that counseling is as affective as medication for treatment of depression.
Nevertheless, non-Hispanic whites were less likely than other racial ethnic
groups to believe that counseling brings up too many bad feelings,
and African Americans were more likely than both other groups in
the study to believe that prayer can help to heal depression.
We can speculate about the reasons for this
diversion of beliefs and attitudes toward treatment of depression,
but one thing is clear and that is there are differences across socioeconomic
as well as racial ethnic groups with regard to attitudes towards treatment.
One attitude towards treatment seeking are
important stigma towards people with mental illness
is also an important attitudinal factor that
acts as a barrier to treatment seeking.
Here I'm going to talk a little bit
more about stigma.
Evan Goffman who was an influential 20th Century sociologist, defines stigmas as a
discrediting that reduces the person having that
attribute to a tainted and discounted individual.
Needless to say, stigmatizing attitudes are not limited to
people with mental illness and are common in our society.
Over time and in different societies racial, ethnic, religious, or other
attributes have been the target of stigma. As has physical handicap.
Knowing how stigma manifests itself may help
understand how it influences treatment seeking as well.
Some researchers have identified two aspects of mental illness stigma.
First there is a suicidal
aspect, what they call sometimes social stigma, and these are
stigmatizing attitudes of the society towards mental illness, for example.
For instance, some individuals may believe that people with depression are
lazy or that they like to complain too much about their hardships.
When the person with mental illness internalizes these stigmatizing attitudes,
then we talk of self stigma, which is the other aspect of stigmatizing attitudes.
For example, a person with depression may come to believe
that his illness is a result of a weak willpower.
These data from a survey of the general population
in the United States shows the extent of social stigma.
Participants from the general population are
presented with vignettes of individuals with alcohol
dependence, depression, schizophrenia, and drug dependence.
They were then asked how unwilling they would
be to interact with that person, in various situations.
For example, how unwilling they will be to move next door to that person,
spend an evening socializing, or have that person marry into their family.
Focusing on the row for depression in this table, you notice that almost 23%
of the population said that they would
be unwilling to have a neighbor with depression.
38% were unwilling to spend an evening with that person.
49% said that they would be unwilling to work closely with that person.
And more than 60% said that they would be unwilling to have that person
marry into their family. Now a question for you.
Why do you think people are more willing to have a neighbor or a friend with
depression than work with that person closely, or have him or her marry into
their family? While social stigma is probably
associated with treatment seeking, self stigma is probably as important if not
a more important barrier to treatment seeking.
The individual with depression may believe that if he or she asks
for professional help or takes medications,
the family would be disappointed in them.
Or they may feel embarrassed if their
friends find out that they're receiving treatment.
So here I'm going to talk about structural barriers
to mental healthcare, especially with regard to depression.
So far, we have talked about what we may call attitudinal barriers
to treatment seeking, including beliefs about treatment and stigma.
The structural barriers, which include availability, financial and geographical
access, and time and convenience of services are also important barriers.
Past research in the United States and other countries has repeatedly
shown that lack of insurance is a major barrier to treatment seeking.
Many low-income countries do not have enough health care providers to
meet the needs of the population, which is another structure barrier.
Even in industrialized countries, individuals who live in rural areas,
sometimes have difficulty getting to health care providers or services.
In some urban settings, the wait
time to see a mental health professional is maybe too long.
Or the services may be located in parts of the city that are not easily accessible.
Any one of these factors can act as a
barrier to treatment for depression and other mental disorders.
This figure is based on data from over 2,000 individuals with major
depression in the United States who reported an unmet need for mental health
treatment in the past year.
They were asked why they did not receive treatment.
Percentages on the horizontal access represent the
proportion of the participants who reported each reason.
As you can see in the figure, almost 50% of these
individuals reported the cost of treatment as a barrier to treatment seeking.
Approximately 20% reported lack of insurance or
inadequate insurance.
Not knowing where to go, time, lack of transportation, and
inconvenient hours of services are among the other barriers reported.
You also see that attitudinal factors, such as the
belief that the person could handle the problem without
help, or fears that others would find out or
that the person would be committed to the hospital
against their will are among the other important barriers to treatment seeking.
The percentages add up to more than
100% because a person could report multiple reasons.
So, overall we see two broad sets of barriers
that stop people from seeking and receiving treatment for depression.
One set are attitudinal barriers such as lack of perceived need, and stigma.
And another set is
comprised of structural barriers, such as cost or availability.
To improve treatment seeking, we need to address both these sets of barriers.
However we need different approaches to overcome these barriers.
Here I'm going to briefly talk about approaches that
have been used to overcome these barriers to care.
One common approach to reduce structural barriers is to
improve financial access through laws.
In the United States, two recent pieces of
legislation are being enacted with this goal in mind.
One is the 2008 Mental Health Parity
legislation, that mandated that insurance plans cover
mental health and substance abuse treatment services
to the same extent as physical health services.
For many years, insurance plans have covered
children of mental health and substance disorders at
the lower level then treatment for physical health problems.
For example insurance plans imposed a
lower maximum number of hospitalization days
or maximum number of visits for
treatment of mental disorders than physical disorders.
The aim of the parity legislation was to eliminate such differences.
The second piece of legislation, which will very likely
have a significant impact of treatment of depression and
other common mental disorders, is the Affordable Care Act
that was signed into law by President Obama in 2010.
A major initiative in this legislation is to expand insurance coverage
to those Americans who do not currently have any medical insurance.
As you saw before,
cost of care is a major barrier to treatment seeking for depression.
With this new legislation, the hope is that this barrier will be significantly
reduced and more people in need
for treatment will be receiving appropriate care.
A major approach to reducing attitudinal barriers and
especially mental illness stigma is public information campaigns.
There have been a
number of such campaigns in the United States, Australia,
Britain, and in other countries over the past few years.
Common themes among these campaigns is to remove the stigma associated
with the experience of depression and treatment seeking for this illness.
Indeed, there is evidence that these campaigns have had
an important impact on public attitudes towards depression and other
mental disorders and also impact on attitudes
towards mental health treatment seeking in general.
One of the best known of such campaigns
is the ongoing Beyondblue public campaign in Australia.
Here are online links to three videos that I would like for you to watch to get
a better sense of these campaigns, from the
Australian Beyondblue, the British Time to Change campaign, and
the American In Our Own Voice as examples of such public campaigns.
So in summary, in this lecture, we learned that a large proportion of
individuals with major depression, and other common
mental disorders, do not seek professional help.
We also learned that there are significant variations in treatment
seeking, according to social and demographic factors such as age,
sex, race, and ethnicity and culture. We briefly
discussed barriers to treatment including attitudinal and structural barriers.
Finally, we talked about initiatives that aim to reduce
or eliminate these barriers; such as laws and anti-stigma campaigns.
In the next lecture, which is the final lecture in this course, I will
discuss service use patterns and treatments for
depression and briefly talk about prevention of depression.
Thank you for listening.
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