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

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism
challenges the title of this conference. In a preventive context, the outcome is not
necessarily clinical utilization. The goal is to abort situations where one exceeds a
clinical threshold at which mental health treatment becomes necessary. We can use
social media, Twitter, Facebook, and websites to provide education that may help
people recognize that they are starting to take on water. They are not necessarily
exceeding a clinical threshold but they are not functioning as well at work and with
their families. It is not a clinical issue, it is a public health issue unless left unattended.
If you can provide sufficient education, monitoring, and corrective steps early on in
a preventive way, that will reduce stigma issues that we have been talking about in
a more clinical context.
DR. KILPATRICK: Populations are made up of individual people and some will
need more help than others. A website may not help those at the top of the pyramid
of care who have major mental health problems. But for many people education
may desensitize them to getting treatment if they need it. It gives you the opportunity
to provide information to many more people than if you are talking about mental
health professionals meeting with people individually or even in groups. Web-based
self help tools may help get around some of the stigma of having to label yourself as
being so bad off that you need the services of a mental health professional. It may
also be a tool for self assessment to help people see they need something more and
maybe there is some education that can be included about that.
DR. WESSELY: Dean Kilpatrick mentioned Pan Am 103 and Lockerbie and
the research on the families. A professor of psychiatry at Dundee wrote a very
good account of what happened in the village of Lockerbie itself. He organized a
mental health response based on the local town hall. There were policemen who
were upset by having to stand by body parts all night right after the event. There
were also 13 killed in the town and others injured, and many people were very
shaken by Pan Am 103 disintegrating above them. Without exception, none of them
came to the mental health center. They all came to the primary care center, which
was run by three general practitioners who they knew and were people they could
talk to. I thought Ron Kessler was a bit mean to primary care, because in most
health care systems, primary care will be where the vast majority of mental health
care is going to be delivered. It is an existing structure. It is much freer from stigma
because they are the same people you also talk to about childbirth and other things.
In the U.K., general practitioners will deliver 90 to 95% of the mental health
treatment for common mental disorders, not schizophrenia or bipolar disorder. Given
that they actually will deliver the bulk and they are acceptable to the population,
we should think more about supporting the primary care practitioners who actually
are trusted and will deliver much less stigmatized service than I am afraid the folks
around this table will, including me.
DR. KILPATRICK: First of all, the families who lost somebody on the ground
in Lockerbie were included in the sample because they were included in the services
that the Office for Victims of Crime provided. Secondly, it is true that most people
go to primary care. The question is whether, aside from giving medications, primary
care doctors really are equipped to handle serious PTSD and other disorders. The
advantage is people will go to them. The disadvantage is that if you have got two,
three, or maybe 10 minutes for a complicated case, primary care doctors do not
even have the time to handle the issues for which people go to primary care in the
first place.
DR. URSANO: We have introduced the question of primary care. We have intro-