Another reason for lack of mental health care is widespread bias against mental health , internalized by those who are affected , as well as their families . I saw these biases reflected in my patients ’ dismissal of recommendations for treatment in favor of the idea that resolution of their symptoms was within their control : “ I can will my depression away ,” “ I won ’ t have debilitating anxiety if I get more sleep , meditate more , change jobs …” Meanwhile , the symptoms and disruptions to their quality of life persisted . I highlighted one example of this prejudice in my video discussion on social determinants of health . 8 Janet * was depressed , and initially refused both counseling and medication . After considerable cajoling , she finally agreed to try an anti-depressant medication , and her symptoms notably improved . We were both pleased with her success . Unfortunately , her husband did not believe in treatment for depression , and Janet discontinued pharmacologic therapy at his insistence . When I saw her in follow up , she was depressed again . While admitting that she felt better with treatment , she was unwilling to override her husband ’ s objections and resume her medication . Her demonstrable improvement was insufficient to overcome the negative beliefs surrounding mental health .
Yet a third obstacle to care is the dearth of mental health providers , particularly in non-metropolitan and rural areas . 9 Given the number of patients requiring treatment , the limited number of mental health professionals , and the stigma attached to engaging the services of specialized mental health professionals , many patients with depression and anxiety are managed by primary care providers , such as internists and family practitioners , as well as by pediatricians and OB-GYNs . However , when we “ non-psychiatrists ” have reached the limits of our psychiatric expertise , it can be difficult to convince our patients to pursue expert consultation . The patients protest : they are comfortable with me , they do not want to start over with someone new , it would be too expensive , the location / appointment times of the ( referral ) aren ’ t convenient , they are fearful of change . The net result is the same , suboptimal control of their symptoms .
A facet of mental illness that is not always acknowledged is the impact that certain personality disorders , and mental conditions , particularly if they are untreated or inadequately controlled , have on communication and compliance as patients interact with the medical system . Patients ’ anxiety can affect their ability to absorb , retain and process information accurately . Depression may affect judgement and decision-making . Psychosis can preclude rational discussion . Borderline personality can alter interpersonal relationships . When mental health issues affect medical or surgical management in the inpatient setting , it can be extremely challenging to obtain urgent psychiatric evaluation , not to mention appropriate post-discharge care . Our health care system does not provide adequate tools or resources to address these issues .
Medical management of psychiatric conditions is often imprecise . Although testing is becoming available to predict individual responsivity to classes of psychotropic medications , historically trial and error methods have been used in the effort to control symptoms . A number of these medications , especially anti-psychotics , can produce undesirable side effects , such as grogginess , sleepiness , seizures , and problems with sexual function , as well as life threatening problems such as heart arrhythmias and sudden death . 10 Unpleasant side effects reduce compliance with therapy , and consequently , suboptimal control of the mental illness . Conversely , some patients , when they are successfully treated and feel well , decide that they no longer require medication , discontinue treatment , and relapse , setting up a vicious cycle of affliction and remission . This is a frustrating and exhausting situation for patients , their families and their providers .
Attitudes toward mental illness , as well as the US health system ’ s incentives and structure , fail these patients , and will continue to do so until we value health and healing over profit and expediency . The protections afforded by mental health parity laws , and the ACA , have improved the quality of life for many people . However , the ACA ’ s benefits are currently threatened by litigation currently before the US Supreme Court . Having a substantial proportion of Americans untreated , or inadequately treated for mental illness is deleterious not only for the affected individuals , but for their families , their employers and for society as a whole . We must provide adequate pharmacologic , psychologic and social support to those who are affected . We must de-stigmatize and address mental illness socially , financially and operationally to have a happier and healthier population .
* Name changed to protect the patient ’ s privacy
A version of this article was previously published in Dr . Bornstein ’ s blog , which can be found at www . susanbornsteinmd . com .
References :
1 https :// www . nimh . nih . gov / health / statistics / mental-illness . shtml
2 https :// www . cdc . gov / mmwr / volumes / 69 / wr / mm6932a1 . htm
3 https :// www . commonwealthfund . org / publications / issue-briefs / 2020 / aug / americans-mental-health-and-economic-consequences-COVID19
4 https :// pdas . samhsa . gov /#/
5 https :// www . mayoclinic . org / diseases-conditions / mental-illness / symptoms-causes / syc-20374968 #:~: text = Untreated % 20mental % 20illness % 20can % 20 cause , Family % 20conflicts
6 https :// www . ncbi . nlm . nih . gov / pmc / articles / PMC3358553 /#:~: text = Elevated % 20total % 20scores % 20on % 20mental , high % 20numbers % 20of % 20sexual % 20 partners
7 https :// www . commonwealthfund . org / blog / 2020 / aca-10-how-has-it-impactedmental-health-care
8 https :// www . susanbornsteinmd . com / 2020 / 10 / 03 / social-determinants-of-health /
9 https :// www . goodtherapy . org / for-professionals / personal-development / become-a-therapist / is-there-shortage-of-mental-health-professionals-in-america #:~: text = The % 20Substance % 20Abuse % 20and % 20Mental ,( 172 % 2C630 % 20 needed % 3B % 20145 % 2C700 % 20available )
10 https :// www . aafp . org / afp / 2010 / 0301 / p617 . html
MENTAL HEALTH
Dr . Bornstein retired from her gynecologic practice to focus on health care delivery system advocacy and reform .
MARCH 2021 21