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.
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.
The mental health of children and young people can be disproportionally affected and easily overlooked in the context of emergencies and disasters. Child and adolescent mental health services can ...contribute greatly to emergency preparedness, resilience and response and, ultimately, mitigate harmful effects on the most vulnerable members of society.
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.
To examine barriers to initiation and continuation of mental health treatment among individuals with common mental disorders.
Data were from the World Health Organization (WHO) World Mental Health ...(WMH) surveys. Representative household samples were interviewed face to face in 24 countries. Reasons to initiate and continue treatment were examined in a subsample (n = 63,678) and analyzed at different levels of clinical severity.
Among those with a DSM-IV disorder in the past 12 months, low perceived need was the most common reason for not initiating treatment and more common among moderate and mild than severe cases. Women and younger people with disorders were more likely to recognize a need for treatment. A desire to handle the problem on one's own was the most common barrier among respondents with a disorder who perceived a need for treatment (63.8%). Attitudinal barriers were much more important than structural barriers to both initiating and continuing treatment. However, attitudinal barriers dominated for mild-moderate cases and structural barriers for severe cases. Perceived ineffectiveness of treatment was the most commonly reported reason for treatment drop-out (39.3%), followed by negative experiences with treatment providers (26.9% of respondents with severe disorders).
Low perceived need and attitudinal barriers are the major barriers to seeking and staying in treatment among individuals with common mental disorders worldwide. Apart from targeting structural barriers, mainly in countries with poor resources, increasing population mental health literacy is an important endeavor worldwide.
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.
A minority of children and adolescents with mental health problems access treatment. The reasons for poor rates of treatment access are not well understood. As parents are a key gatekeeper to ...treatment access, it is important to establish parents’ views of barriers/facilitators to accessing treatment. The aims of this study are to synthesise findings from qualitative and quantitative studies that report parents’ perceptions of barriers/facilitators to accessing treatment for mental health problems in children/adolescents. A systematic review and narrative synthesis were conducted. Forty-four studies were included in the review and were assessed in detail. Parental perceived barriers/facilitators relating to (1) systemic/structural issues; (2) views and attitudes towards services and treatment; (3) knowledge and understanding of mental health problems and the help-seeking process; and (4) family circumstances were identified. Findings highlight avenues for improving access to child mental health services, including increased provision that is free to service users and flexible to their needs, with opportunities to develop trusting, supportive relationships with professionals. Furthermore, interventions are required to improve parents’ identification of mental health problems, reduce stigma for parents, and increase awareness of how to access services.
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