Mental Health
Mental health is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. In this positive sense, mental health is the foundation for individual well-being and the effective functioning of a community.
About half of adults will meet criteria for a mental health disorder over their lifetime. Mental health diagnoses include mental illness and substance abuse. Traditionally, mental illness has been conceptualized as disorders of mood or thought. Examples are depression, bipolar disorder, anxiety disorders, and psychotic disorders. It may seem tidy to be able to categorize conditions into seemingly dichotomous groups for physical or mental disorders. In reality there is an increasingly recognized biologic basis for mental illness, and for all individuals body and mind exist on a continuum. We know mental illness is not the consequence of poor character, but significant stigma remains. Even more stigmatized are the substance use disorders (SUDs). Persons with dependence on alcohol or illicit drugs are often unable to stop using without support. Sources of this support include peer groups, medical care providers, and counselors with training in addiction medicine. From a clinical perspective the SUDs are mental health disorders, but systems of treatment are generally separate.
The term "behavioral health" is sometimes used for mental health and substance use services. One could argue that behavioral health is a less stigmatizing term. One could also argue that it has more of a negative connotation and attributes blame to the person with the illness - as though a cure is merely a matter of will-power. The bottom line is that words matter. For more information read this excellent fact sheet from NAMI titled, Facts about Mental Illness and Stigma in Diverse Communities.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association (APA).The APA is a large and powerful interest group. The DSM provides the diagnostic criteria used to classify mental illness, SUD, and intellectual disorders. Revisions have been underway and the 5th edition is expected to be released in May 2013. Revisions are always controversial as these criteria often define eligibility for services. Adults with mental health disorders are more likely to have chronic, physical illnesses. This serves to further fragment care as systems of care for medical and mental disorders have both separate and different systems for organization, provision of services, and finance.
Mental health is an integral and essential component of health. The World Health Organization (WHO) constitution states: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." An important consequence of this definition is that mental health is described as more than the absence of mental disorders or disabilities."
Determinants of Mental Health
Multiple social, psychological, and biological factors determine the level of mental health of a person at any point of time. For example, persistent socio-economic pressures are recognized risks to mental health for individuals and communities. The clearest evidence is associated with indicators of poverty, including low levels of education.
oor mental health is also associated with rapid social change, stressful work conditions, gender discrimination, social exclusion, unhealthy lifestyle, risks of violence and physical ill-health and human rights violations.
There are also specific psychological and personality factors that make people vulnerable to mental disorders. Lastly, there are some biological causes of mental disorders including genetic factors and imbalances in chemicals in the brain.
From: The World Health Organization. Mental Health: Strengthening our Response. Fact sheet N°220, September 2010
Substance Abuse
Substance Use Disorders (SUD) are also classified by the DSM. In the new version of the DSM (DSM-5) it is expected that the categories of abuse and dependence will be replaced by the umbrella of SUD. Alcohol, cocaine, opioids anThis is important because the formal diagnosis with DSM criteria is necessary to qualify an individual to receive services. Payers require documentation to reimburse for services.
Substance Use in the United States (2011, SAMHSA Survey)
It is estimated that 8.7 percent of the population aged 12 or older used illicit drugs within the past month. Illicit drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics (pain relievers, tranquilizers, stimulants, and sedatives) used non-medically.
- 8400 people (youth and adult) use an illicit drug for the first time each day. 65% of the time is it marijuana.
- In youth (ages 12 to 17 years) the rate is about 1 in 10.
- At least half of the youth and adults reporting non-medical use of a pain reliever received the drug from a friend or relative without payment.
Alcohol use:
- Nearly one quarter of youth and adults reported having at least 5 drinks on one occasion in the past month. This is defined as binge drinking.
- Reported illicit drug use varied by race: highest in blacks and Native Americans/Alaskan Natives.
Alcohol use followed a different pattern. Binge drinking and heave use were highest (> 20%) in whites and Native Americans/Alaskan Natives.
What about treatment for alcohol and drug dependence?
- One in ten with alcohol or illicit drug dependency received treatment at a specialty facility (hospital inpatient, drug or alcohol rehabilitation, or mental health centers).
- Of those not receiving treatment for dependence, about 5% reported perceived need for treatment. Almost one third of them were not able to access care, see chart below.
|
Figure 7.11 Reasons for Not Receiving Substance Use Treatment among Persons Aged CREDIT: www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.htm#High |
Dual Diagnoses
Estimates vary, but there is significant known overlap between mental illness and substance use populations. This is k, i.e., dual diagnoses. These individuals present unique treatment needs as facilities designed for either population may not have the capacity to provide appropriate treatment for both.
Now think about the co-occurrence with physical health problems. The systems of care for mental illness, substance abuse, and medical care often operate in silos. The challenges of providing quality (or even minimally acceptable) care to this vulnerable population can be overwhelming.
Potential Impact of the ACA
- Medicaid expansion and the individual mandate are expected to decrease both individual and state costs for behavioral health services, as more patients will have coverage.
- Expect an increase in demand for services from newly insured individuals.
- Persons with pre-existing behavioral health conditions may not be denied coverage.
- Minimum benefit requirements will include coverage for behavioral health conditions.
- Prescription drug coverage for persons with Medicare part D has improved (remember that Medicare covers many of the permanently disabled, including psychiatric disability).
- The information below is from Kaiser Family Foundation and the Substance Abuse and Mental Health Services (SAMHSA) 2011 National Survey on Drug Use and Health.
Additional Resources
- SAMHSA 2011 National Survey on Drug Use and Health.
www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.htm - Kaiser Commission on Medicaid and the Uninsured. Mental Health Financing in the United States: A Primer. 2011 www.kff.org/medicaid/8182.cfm
- The HBO Documentary Addiction. The Addiction Project is produced by HBO in partnership with the Robert Wood Johnson Foundation, the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The Centerpiece Documentary and Supplementary Series are Excellent. The videos are broken into small segments so you can select ones to watch.
www.hbo.com/addiction/thefilm/centerpiece/612_segment_1.html