Why study mental health separate from general health?

1. Differences in how the disorders are defined and ascertaining need for treatment (policy implications)
2. Differences in perception of need for care and stigma
3. Differences in historical development of services
4. differences in financing mental health care (private/public mix) and responsiveness to cost sharing

What are mental health problems?

(DSM)

“Clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and is associated with present distress or disability or with significantly increased risk of suffering death, pain, disability, or an important loss of freedom.”

…a clinically recognizable set of symptoms or behaviour associated with in most cases with distress and with interference with personal function.”

What are mental health problems?

(Government)

More symptom focused 

SPMI: NIMH

SMI: state mental health block grant funding can be used for this population

SED: emotional problems and serious impairment in social/educational functioning (no specific diagnosis) 

Screening measures 

(Highly sensitive/low specificity) Tested against the gold standard of clinical interviews using semi-structured instruments. these type of screening measures lead to a lot of false positives

SMI

“…mental disorders that interfere with some area of social functioning.” (Surgeon General Report, 1999)

SPMI

“…a history of serious acute episodes, continuing residual disability, and high level of medical and psychological need.” (Mechanic, 1999)

Prevention Scheme

Primary: preventing mental illness before they occur

Secondary: Intervening early in the course of the disease and reducing the chance of full-blown illness

Tertiary: Preventing disability associated with illness and chronicity

Mental Health Policy

a specifically written document of the Government or Ministry of Health containing the goals for improving the mental health situation of the country, the priorities among those goals and the main directions for attaining them.

Components of Mental Health Policy

Mental Health Legislation

legal provisions for the protection of the basic human and civil rights of people with mental disordersand deals with treatment facilities, personnel, professional training and service structure. Mental health legislation includes provisions concerned with the restraint and protection of individual patients, regulation of compulsory admission, discharge procedures, appeals, protection of property, etc.

Any type of care, supervision and rehabilitation of mental patients outside the hospital by health and social workers based in the community

Global Burden of Disease

Barriers to seeking treatment

1. Lack of perceived need
2. Attitudes towards treatment seeking and mental health "literacy"
3. Stigma
4. Structural barriers (distance, insurance, lack of providers) 

Andersen's Socio-behavioral model

• Predisposing factorsmake certain people more likely to use health services even though these factors are not directly responsible for health service use (e.g., age, gender).
• Enabling factors make health service resources available to the individual  (e.g., insurance).
• Need (illness) factorsare the individual or the family’s perception of illness or the probability of its occurrence (perceived) and the clinical evaluation by the formal health care system (evaluated).

Evaluation of Andersen Model

Theory of reasoned action 

• The most proximal cause of behavior is behavioral intention (what one intends to do or not to do).
• Behavioral intention is predicted by the person’s attitudes toward that behavior and how he/she thinks other people would view them if they performed the behavior (norms).
• The effect of attitudes and norms differ for different behaviors, situations and persons. 

Evaluation of reasoned action

Differences in treatment seeking (factors) 

Age: Younger and Older adults are less likely to seek treatment than middle-age individuals

Sex: Women are more likely to seek treatment than men

Race: ethnic minorities seek are less likely to seek treatment

Legislative initiatives 

Legislation: Over 30 state currently have parity laws; the 2008 federal parity law (going into effect in 2010)

Aim:reduced financial barriers

Mental Health Campaigns 

Aim: greater recognition of mental illness and more positive attitudes toward treatment seeking

Causes of Deinstitutionalization

1. Chlorpromaxin- Introduced in 1954
2. Negative Publicity and the Civil Rights Movement
3. Introduction of Medicaid/Medicare and SSI & SSDI

Consequences of Deinstitutionalization

• Shift of the site of care from inpatient to outpatient.
• Transfer of financial burden from the states to the Federal government (Medicaid/Medicare/SSI), Community Mental Health Centers (CMHC).
•  Expansion in the population with psychiatric problems who seek and receive treatment.
• Shift in the role of patients into “consumers”

Perspectives of Cost

Societal Perspective: cost to society

Third Party Payer Perspective: Insurer or government

Patient Perspectives: co-pays

Canada Healthcare System

Why health care is cheaper in Canada?

UK Health Care System

Why is UK cheaper?

Price Elasticity of demand

Moral Hazards: occurs when a party insulated from risk behaves differently than it would behave if it were fully exposed to the risk. 

The demand for mental health care is more responsive to cost sharing than the demand for physical health care (“price elasticity of demand”).

Cutting Costs: Financing Controls

Cutting Cost: reimbursement 

Controlling quantity (P x Q=C).

How are premiums decided?

Experience rating: Insurance company setting premiums based on individual or group health risks: sick pay more than healthy, high risk jobs pay more than low risk. Can lead to adverse selection.

Community rating: Everyone in the community pays the same (e.g., employer based insurance). 

Insurance

• “Health insurance provides a mechanism to distribute health care more in accordance with human need rather than exclusively on the basis of ability to pay. To achieve this goal, funds are redistributed from the healthy to the sick, a subsidy that helps pay the costs of those unable to purchase services on their own.” 
• In economic terms Health insurance distributes (equalizes) the risk to a group of individuals.

Burden of Mental Health

Neuropsychiatric illnesses are responsible for 13% of the total burden of disease globally 

Barriers to improving Global Mental Health

1. Scarcity of Resource

2. Inequality-distribution of resources within and between countries 

3. Inefficiencies

Mental Health Policy

Definitions: a specifically written document of the Government or Ministry of Health containing the goals for improving the mental health situation of the country, the priorities among those goals and the main directions for attaining them.

May include:

Definitions: legal provisions for the protection of the basic human and civil rights of people with mental disordersand deals with treatment facilities, personnel, professional training and service structure. Mental health legislation includes provisions concerned with the restraint and protection of individual patients, regulation of compulsory admission, discharge procedures, appeals, protection of property, etc.

Consequences of Deinstitutionalization 

• Expansion and diversification of the mental health workforce.
• Practice innovation: New medications with fewer side effects and new therapies (CBT).
• Expanded use of pharmaceuticals.
• Expansion of the role of general medical sector in treatment of mental disorders.