Better But Not Well Frank, Richard G; Glied, Sherry A
2006, 2006-09-08, 20060101
eBook
The past half-century has been marked by major changes in the treatment of mental illness: important advances in understanding mental illnesses, increases in spending on mental health care and ...support of people with mental illnesses, and the availability of new medications that are easier for the patient to tolerate. Although these changes have made things better for those who have mental illness, they are not quite enough.
In Better But Not Well, Richard G. Frank and Sherry A. Glied examine the well-being of people with mental illness in the United States over the past fifty years, addressing issues such as economics, treatment, standards of living, rights, and stigma. Marshaling a range of new empirical evidence, they first argue that people with mental illness—severe and persistent disorders as well as less serious mental health conditions—are faring better today than in the past. Improvements have come about for unheralded and unexpected reasons. Rather than being a result of more effective mental health treatments, progress has come from the growth of private health insurance and of mainstream social programs—such as Medicaid, Supplemental Security Income, housing vouchers, and food stamps—and the development of new treatments that are easier for patients to tolerate and for physicians to manage.
The authors remind us that, despite the progress that has been made, this disadvantaged group remains worse off than most others in society. The mainstreaming of persons with mental illness has left a policy void, where governmental institutions responsible for meeting the needs of mental health patients lack resources and programmatic authority. To fill this void, Frank and Glied suggest that institutional resources be applied systematically and routinely to examine and address how federal and state programs affect the well-being of people with mental illness.
Objective Given problems and disparities in the use of community-based mental health services for youth, school personnel have assumed frontline mental health service roles. To date, most research on ...school-based services has evaluated analog educational contexts with services implemented by highly trained study staff, and little is known about the effectiveness of school-based mental health services when implemented by school professionals. Method Random-effects meta-analytic procedures were used to synthesize effects of school-based mental health services for elementary school-age children delivered by school personnel and potential moderators of treatment response. Forty-three controlled trials evaluating 49,941 elementary school-age children met the selection criteria (mean grade 2.86, 60.3% boys). Results Overall, school-based services demonstrated a small-to-medium effect (Hedges g = 0.39) in decreasing mental health problems, with the largest effects found for targeted intervention (Hedges g = 0.76), followed by selective prevention (Hedges g = 0.67), compared with universal prevention (Hedges g = 0.29). Mental health services integrated into students' academic instruction (Hedges g = 0.59), those targeting externalizing problems (Hedges g = 0.50), those incorporating contingency management (Hedges g = 0.57), and those implemented multiple times per week (Hedges g = 0.50) showed particularly strong effects. Conclusion Considering serious barriers precluding youth from accessing necessary mental health care, the present meta-analysis suggests child psychiatrists and other mental health professionals are wise to recognize the important role that school personnel, who are naturally in children's lives, can play in decreasing child mental health problems.
COVID-19 presents significant social, economic, and medical challenges. Because COVID-19 has already begun to precipitate huge increases in mental health problems, clinical psychological science must ...assert a leadership role in guiding a national response to this secondary crisis. In this article, COVID-19 is conceptualized as a unique, compounding, multidimensional stressor that will create a vast need for intervention and necessitate new paradigms for mental health service delivery and training. Urgent challenge areas across developmental periods are discussed, followed by a review of psychological symptoms that likely will increase in prevalence and require innovative solutions in both science and practice. Implications for new research directions, clinical approaches, and policy issues are discussed to highlight the opportunities for clinical psychological science to emerge as an updated, contemporary field capable of addressing the burden of mental illness and distress in the wake of COVID-19 and beyond.
Public Significance Statement
Clinical psychological science must lead a national response to address mental health issues following COVID-19. This article highlights urgent challenges to confront, and timely opportunities to contemporize a field to better address mental health issues now and long after. The article concludes by discussing implications for new research directions, clinical approaches, and policy issues.
Objectives
To describe reasons for unmet need for mental health care among blacks, identify factors associated with causes of unmet need, examine racism as a context of unmet need, and construct ways ...to improve service use.
Data Sources
Data from the 2011‐2015 National Survey on Drug Use and Health were pooled to create an analytic sample of black adults with unmet mental health need (N = 1237). Qualitative data came from focus groups (N = 30) recruited through purposive sampling.
Study Design
Using sequential mixed methods, reasons for unmet need were regressed on sociodemographic, economic, and health characteristics of respondents. Findings were further explored in focus groups.
Principal Findings
Higher education was associated with greater odds of reporting stigma and minimization of symptoms as reasons for unmet need. The fear of discrimination based on race and on mental illness was exacerbated among college‐educated blacks. Racism causes mistrust in mental health service systems. Participants expressed the importance of anti‐racism education and community‐driven practice in reducing unmet need.
Conclusion
Mental health systems should confront racism and engage the historical and contemporary racial contexts within which black people experience mental health problems. Critical self‐reflection at the individual level and racial equity analysis at the organizational level are critical.
In the wake of China's massive economic development, attention has only recently turned to the enormous treatment gap that exists for mental health problems. Our study is the first comprehensive, ...national examination of the levels and correlates of the public's ability to recognize mental illness in the community and suggest sources of help, setting a baseline to assess contemporary Chinese efforts.
Data were collected in China as part of the Stigma in Global Context - Mental Health Study (SGC-MHS) through face-to-face interviews using vignettes meeting clinical criteria for schizophrenia and major depression. Our analysis targets the Han Chinese participants (n = 1812). Differences in the recognition of mental health problems were assessed using a chi-square test and further stratified by vignette illness type and urban vs. rural residence. Adjusted regression models estimated the effects of each predictor towards the endorsement three types of help-seeking: medical doctor, psychiatrist, and mental health professional.
As expected, recognition of mental health problems is low; it is better for depression and most accurate in urban areas. Perceived severity increases endorsement of the need for care and for treatment by all provider types. Recognition of a mental health problem specifically decreases endorsement of medical doctors while increasing recommendations for psychiatrists and mental health professionals. Neurobiological attributions decrease recommendations for mental health professionals as opposed to general or specialty physicians.
Continued efforts are needed in China to promote mental illness recognition within rural areas, and of schizophrenia specifically. Promoting recognition of mental illness, while balancing the special challenges among individuals who understand the neurobiological roots of mental illness, may constitute a key strategy to reduce the sizeable mental health treatment gap in China.
This book examines the phenomenon of social withdrawal in Japan, which ranges from school non-attendance to extreme forms of isolation and confinement, known as hikikomori. Based on extensive ...original research including interview research with a range of practitioners involved in dealing with the phenomenon, the book outlines how hikikomori expresses itself, how it is treated and dealt with and how it has been perceived and regarded in Japan over time. The author, a clinical psychologist with extensive experience of practice, argues that the phenomenon although socially unacceptable is not homogenous, and can be viewed not as a mental disorder, but as an idiom of distress, a passive and effective way of resisting the many great pressures of Japanese schooling and of Japanese society more widely.
Most autistic adults struggle with mental health problems, and traditional mental
health services generally do not meet their needs. This study used qualitative
methods to identify ways to improve ...community mental health services for
autistic adults for treatment of their co-occurring psychiatric conditions. We
conducted semistructured, open-ended interviews with 22 autistic adults with
mental healthcare experience, 44 community mental health clinicians, and 11
community mental health agency leaders in the United States. The participants
identified clinician-, client-, and systems-level barriers and facilitators to
providing quality mental healthcare to autistic adults. Across all three
stakeholder groups, most of the reported barriers involved clinicians’ limited
knowledge, lack of experience, poor competence, and low confidence working with
autistic adults. All three groups also discussed the disconnect between the
community mental health and developmental disabilities systems, which can result
in autistic adults being turned away from services when they contact the mental
health division and disclose their autism diagnosis during the intake process.
Further efforts are needed to train clinicians to work more effectively with
autistic adults and to increase coordination between the mental health and
developmental disabilities systems.
Lay Abstract
Most autistic adults struggle with mental health problems, such as anxiety
and depression. However, they often have trouble finding effective mental
health treatment in their community. The goal of this study was to identify
ways to improve community mental health services for autistic adults. We
interviewed 22 autistic adults with mental healthcare experience, 44
community mental health clinicians (outpatient therapists, case managers,
and intake coordinators), and 11 community mental health agency leaders in
the United States. Our participants identified a variety of barriers to
providing quality mental healthcare to autistic adults. Across all three
groups, most of the reported barriers involved clinicians’ limited
knowledge, lack of experience, poor competence, and low confidence working
with autistic adults. All three groups also discussed the disconnect between
the community mental health and developmental disabilities systems and the
need to improve communication between these two systems. Further efforts are
needed to train clinicians and provide follow-up consultation to work more
effectively with autistic adults. A common suggestion from all three groups
was to include autistic adults in creating and delivering the clinician
training. The autistic participants provided concrete recommendations for
clinicians, such as consider sensory issues, slow the pace, incorporate
special interests, use direct language, and set clear expectations. Our
findings also highlight a need for community education about co-occurring
psychiatric conditions with autism and available treatments, in order to
increase awareness about treatment options.
ABSTRACT
BACKGROUND
Foreign‐born children rarely use traditional school mental health services. Comprehensive programs that combine mental health services with academic, economic, and socioemotional ...supports reach more foreign‐born children and improve wellbeing. However, little practical guidance exists regarding how to best combine these diverse services.
METHODS
To identify essential service components and their organization, we interviewed 92 parents, school staff, mental health providers, and community agency staff from 5 school‐linked mental health programs designed specifically to serve immigrant and refugee youth.
RESULTS
Foreign‐born parents did not distinguish between academic, behavioral, and emotional help for their children; these western categorizations of functioning were not meaningful to them. Consequently, programs needed to combine 4 components, organized in a pyramid: family engagement, assistance with basic needs, assistance with adaptation to a new culture, and emotional and behavioral supports. Family engagement was the foundation upon which all other services depended. Assistance with economic and cultural stressors directly promoted emotional wellbeing and helped parents trust clinical mental health interventions.
CONCLUSIONS
Specific strategies to implement the 4 essential components include home visits by program staff, a one‐stop parent center located in the school to help with basic needs, working with cultural brokers, and informed consent procedures that clearly explain recommended care without requiring immigrant and refugee parents to internalize western conceptualizations of psychopathology. Future evaluations should assess the cost and effectiveness of these strategies. These data are essential to advocate payment for these nonclinical services by traditional funding mechanisms.
Transition from distinct Child and Adolescent Mental Health (CAMHS) to Adult Mental Health Services (AMHS) is beset with multitude of problems affecting continuity of care for young people with ...mental health needs. Transition-related discontinuity of care is a major health, socioeconomic and societal challenge globally. The overall aim of the Managing the Link and Strengthening Transition from Child to Adult Mental Health Care in Europe (MILESTONE) project (2014-19) is to improve transition from CAMHS to AMHS in diverse healthcare settings across Europe. MILESTONE focuses on current service provision in Europe, new transition-related measures, long term outcomes of young people leaving CAMHS, improving transitional care through 'managed transition', ethics of transitioning and the training of health care professionals.
Data will be collected via systematic literature reviews, pan-European surveys, and focus groups with service providers, users and carers, and members of youth advocacy and mental health advocacy groups. A prospective cohort study will be conducted with a nested cluster randomised controlled trial in eight European Union (EU) countries (Belgium, Croatia, France, Germany, Ireland, Italy, Netherlands, UK) involving over 1000 CAMHS users, their carers, and clinicians.
Improving transitional care can facilitate not only recovery but also mental health promotion and mental illness prevention for young people. MILESTONE will provide evidence of the organisational structures and processes influencing transition at the service interface across differing healthcare models in Europe and longitudinal outcomes for young people leaving CAMHS, solutions for improving transitional care in a cost-effective manner, training modules for clinicians, and commissioning and policy guidelines for service providers and policy makers.
"MILESTONE study" registration: ISRCTN ISRCTN83240263 Registered 23 July 2015; ClinicalTrials.gov NCT03013595 Registered 6 January 2017.
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