stigma and barriers to care - Uniformed Services University of the ...

Mental Health, Stigma and Barriers to Care 15
really bad enough. What problem are you talking about” This is less likely to be a
response among the people with a severe disorder than those with a mild disorder.
To the people who say they have a snake phobia, we ask, “Why didn’t you get
treatment for that” They answer, “I live in an apartment in Manhattan. What do I
need treatment for my snake phobia for” People who had suicide plans, who were
actively ruminating about killing themselves and were having a hard time functioning
on a day-to-day basis, but who did not get treatment were asked, “So how come
you didn’t get treatment for this problem” They said, “What problem” One out
of every four of them responded this way.
Structural things such as not having insurance, not knowing where to go, long
waiting lists and so forth were not really all that important. Structural barriers
become more important for people who have severe disorders, because if it is severe
enough your inclination is to go and get help. The only reason you are not going
to get help is if there is something that really gets in the way. Thus, it turns out that
attitudinal barriers are not as important among people who have severe disorders.
“I want to handle it on my own,” is something that people frequently say. They do
not say as much, “I’m embarrassed,” but they say, “I want to handle it on my own.”
If we try this with a person with a broken arm it does not happen so much.
These comments do not really come up among people who say, “I don’t have a
problem.” Really, what we should be doing is looking at the people who recognize
that they have a problem. When you survey the people who do recognize they have
a problem, structural barriers become a little more important and attitudinal issues
are overwhelming. These people have all kinds of good reasons why they cannot go
into treatment. If you figure out a way of refuting one, they have another one handy.
Elderly people, men, and those with more education are less likely to say they have
a problem. It is middle class people who say, “Oh, this is not a problem.”
Structural barriers are more prominent for young people who do not have insurance,
do not know where to go, or are married with obligations, and for people
who have more severe disorders. As I said, as the disorder gets more severe people
do not say, “I don’t need it.” They recognize they need it and practical stuff gets in
the way. These attitudinal barriers are there across the board.
Getting people to treatment is not the only place where stigma issues play a
part. For the typical person who goes to a family doctor for treatment of a mental
disorder, the average number of visits is 1.7. There are not many evidence-based
therapies that work in 1.7 visits. We reviewed our data about whether respondents
were getting medication alone, psychotherapy alone, or both in combination, as well
as who provided the treatment. We then went to the literature to define appropriate
treatment.
There are quite a few people who have a major depressive disorder who are getting
benzodiazepines alone, or people who have a bipolar disorder who are getting
Prozac without a mood stabilizer. That is not appropriate treatment. We discovered
even in these newer data that the quality of care for mental disorders in America
is absolutely abysmal. A big part of the problem is treatment dropout with people
quitting treatment before they get an adequate course of care.
For example, the median number of visits to a general medical doctor among
people who got treatment is one. They went once and they never went back. The
inter-quartile range is one to two, so one standard deviation above the mean is two
visits to the family doctor. We looked to say, “So where are you now Are you still
in treatment Did you complete the treatment You’re cured or did you drop out”
Structural things such as
not having insurance, not
knowing where to go,
long waiting lists and so
forth were not really all
that important.