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Mental Health, Stigma and Barriers to Care 13 increased dramatically. Based on that dramatic increase it is probably no surprise that the treatment of mental illness has skyrocketed since the early 1990s. I want to discuss aspects of the National Comorbidity Survey (NCS) and the National Comorbidity Survey Replication (NCS-R). In 1992 and 2002, we did national surveys and looked at rates of mental illness and treatment for mental illness. There was no increase at all in the prevalence of mental illness over the decade. When you see changes in treatment it is not because there are more people who need it. It is the same people who are changing their probability of getting help. In 1992 we looked at specialty treatment, general medical treatment, and human services treatment for mental illnesses among people who have a severe mental illness and those who have a less severe mental illness. The treatment went from about 4% to 6% in a decade, up 50%. It is actually about a 60% increase overall in specialty treatment from a psychiatrist, psychologist, psychiatric social worker or psychiatric nurse. General medical treatment increased from 3% to 9%, about a three-fold increase in treatment in 10 years. The human services treatment, which is treatment by a minister, priest, rabbi, social worker, or counselor increased by about 50%. What is striking about this is when you look at the people who have a serious mental illness such as schizophrenia, other nonaffective psychoses, bipolar disorder, atypical psychosis, severe depression, and severe OCD, the changes are quite different from people who have more garden variety disorders. Those who watch television a great deal are influenced by this advertising. If you look at specialty treatment, the percent of people with a severe mental illness who received treatment from a psychiatrist did not change much. However, treatment for the people with less severe illnesses doubled. What may be happening due to the advertising boom is that people who may not need treatment are going to see their psychiatrist. When you look at the general medical sector, people with a severe mental illness are twice as likely to get treatment with their family doctor. The percent of people with less severe disorders who sought treatment almost tripled. One big difference is that in the early 1990s, of the people with severe illness, more were being treated by a mental health professional than by a general medical doctor. It flipped and it stayed flipped. If you look at more recent data, people who have a serious mental illness are much more likely to be treated in the general medical sector than in the specialty sector. As a result, the proportion of people in treatment has gone up over time. Conversely, the quality of treatment has gone down over time. There has been a decrease in the quality of care for mental disorders since the early 1990s. As people with severe disorders have gone to see their family doctor there has been a dramatic increase in the proportion of those in treatment who are being treated with pills and not with talk. As we know, combined therapy works better than either alone but there has been a big shift toward treatment with psychopharmacology, particularly for men. It is clear that men do not want to talk about it: “Just give me the pill. Thank you.” That is probably better than nothing, but it has implications. Now, we need to ask, “How much of this dramatic increase in treatment was due to a decrease in perceived stigma” Were people less embarrassed about going to care “Everybody has this illness. After all it is on the front page of Time magazine and I read this article that says that zillions of Americans have it. Treatment is available. Why am I letting myself suffer” We were also interested in the possibility that people recognized that they had an illness more so than in the past. In our early work with the NCS one of the most
14 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism If you pull the NCS and NCS-R data and put in a variable for time you see an 80% increase in the odds of getting treatment in the decade, controlling for the disorder. striking things we found was that when we asked people with disorders, “How come you didn’t get treatment for this problem” They said, “What problem” This is more true for some illnesses than others, such as excretion disorders. The real poster child for this is social phobia. People who are painfully shy tend to say, “I’m shy. I’m not sick.” That is not coded as an illness. Many people who have depression before it gets severe feel that it is not an illness. Rather, it is simply, “I have an awful life.” People who have panic disorder, on the other hand, go for treatment. They might think they are having a heart attack so they get evaluated because it is clear that there is something wrong. For many mental disorders it is not so clear. Now, we looked at three things in our data that might have influenced this change. First, to determine increases in recognition of a problem we asked people, “Was there ever a time in the last year when you thought that you might need treatment for some kind of emotional problem” Second, to assess perception that effective treatment was available we asked people, “How much do you think these treatments for mental disorders help Out of every hundred people who have an emotional problem and go for treatment, what number out of a hundred is helped” Third, to assess perceptions about stigma we asked people, “How embarrassed would you be if your friends or neighbors knew you had a mental illness How much do you worry that you would be discriminated against by your coworkers or you wouldn’t get a promotion” We found that after a massive amount of money was spent on direct-to-consumer advertising in the 1990s the perceived helpfulness of treatment had not changed much a decade later. Forty percent of people versus 38% said it was very effective. Thirty-five percent versus 37% said it was moderately effective. “It doesn’t really help many people at all” changed from 5% to 7%. The perception that you have a problem did go up even though the percent of people in the population who had a mental disorder did not change. What we are calling stigma, i.e., these perceptions of concerns about somebody knowing about you having a problem, showed only a modest reduction but it was not statistically significant. If you pull the NCS and NCS-R data and put in a variable for time you see an 80% increase in the odds of getting treatment in the decade, controlling for the disorder. The more serious your disorder, the more likely you are to get treatment. Getting treatment from a psychiatrist, other mental health professionals, and general medical providers all moderately or robustly increased. Treatment from human services and self-help groups remained flat over the decade. The question is, if we introduce measures of perceived need, stigma, and perceived effectiveness, does this change The answer is no, which is not surprising given that these things have not changed much over time. To review, the more severe your disorder, the more likely you are to get treatment. If you are not worried about what people think, you are more likely to get treatment. Perceived need for treatment is an enormous factor. Perceived helpfulness of treatment is not very salient in getting people the treatment. It is noteworthy that whether you have a serious disorder or not the perception is obviously more important than the reality. Turning to the second of our two surveys, we found that many people are in treatment. Among those with a disorder in the last year, 41% were in treatment. Of the people with a serious disorder, nearly two thirds were in treatment. Treatment rates were actually quite high. We asked the people who did not get treatment, “How come you didn’t get treatment” You see that a very high percent of them said, “I didn’t need it. It wasn’t
Page 1 and 2: FORUM ON HEALTH AND NATIONAL SECURI
Page 3 and 4: From the Conference Series: FORUM O
Page 5 and 6: 9 Day 1 Discussion ................
Page 7 and 8: ii Bruce G. Link, Ph.D. Professor,
Page 9 and 10: iv Alisha H. Creel, Ph.D. Assistant
Page 11 and 12: vi Kenneth W. Schor, D.O., M.P.H. C
Page 14 and 15: Executive Summary 1 Executive Summa
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