Reducing stigma to access mental health

The WHO defines health as “a state of physical, mental, and social well-being and not merely the absence of disease or infirmity.” This definition implies that mental health is more than just the absence of mental disorders or disabilities.

Mental health is a state of well-being in which an individual realizes their fundamental and cognitive abilities, can cope with the normal stresses of life, can work productively and earn a living and enjoy life. On this basis, the promotion, protection and rehabilitation of mental health can be a major concern of individuals, communities and societies throughout the world.

WHO recognizes the 10th of October as World Mental Health Day, the overall objective of this day is to raise awareness of mental health issues around the world and to encourage efforts in support of mental health. This provides an opportunity for everyone to talk about their work, and what more needs to be done to make mental health care a reality for people all over the world.

The theme for World Mental Day 2021, announced by the World Federation for Mental Health is ‘Mental Health in an Unequal World’. This theme will enable everyone to focus on the issues that perpetuate mental health inequality locally and globally, as well as highlight the inequality in access to mental health, with high-income countries having some access to mental health to low- and middle-income countries with 75% to 95% people with no access to mental health services. This is mainly because of the improper planning and lack of investment in mental health being disproportionate to the overall health budget.

Factors that limit patients’ access to mental health care

People across the globe experience various mental illnesses but unlike physical pain, there are actual barriers limiting people from accessing mental health care. According to the National Alliance on Mental Illness (NAMI), one in four individuals experience mental illness every year, which is seriously undermined by the number of resources that are available to these individuals. This is an alarming issue in the current world and needs as much attention as other chronic diseases receive.

Many of us think that there is a lack of patient motivation but a 2018 survey by the National Council on Behavioural Health showed that 56% of patients want to seek help but face various obstacles.

1. Shortage of mental health care providers: There are not enough qualified professionals in this field to keep up with the demand. This can reduce access because the few mental healthcare providers that are present are very in demand and may also set their prices higher because of this monopolistic view and are themselves facing job burnout. The NCBH survey revealed that 31% of patients faced a mental health appointment wait time longer than one week, which can have a severe impact on a patient who is in crisis. Patients may also have to travel long distances to visit a clinician, this can be especially troublesome for people who do not have reliable access to transportation or other social aspects like time off from work, childcare, and so on.

2. Limited acceptance: Many individuals fear that their health insurance does not cover mental health care and even when it does, narrow networks make it harder for them to access care at an affordable price. It was found that patients had to access out-of-network care for mental health more times than physical health (13% and 5% respectively). Out-of-network care is known for being extremely expensive for patients.

 3. Fragmented access: Many organisations do not have an integrated physical and mental health care system, and even if they do, they are unequal systems resulting in sub-optimal care given to clients. According to a 2018 paper in NEJM Catalyst, 77% of organisations having some sort of mental health offering within their clinics, are not extensive and do not provide a holistic view of wellness. Overall, 33 percent of providers say care fragmentation is a barrier to sufficient mental healthcare access.

4. Social stigma and lack of awareness: Most of the time patients feel the pressure of societal stigma and completely avoid going to a professional to not feel embarrassed. Many want to reach out for help but are worried about what others might think of them or would have to lie about going to therapy. This social stigma is varied among age groups as well, with 50%of younger Gen Z’s admitting to fear social stigma whereas this is 40% in millennial patients and 20% of baby boomers, according to the NCBH survey.

This stigma is not just keeping patients from accessing care but also obstructing awareness about the same, making it difficult for people to navigate and find resources to help themselves and their loved ones.

This kind of stigma affects low-income patients the most because they do not know where to find good mental health care and might just go to a primary health care centre instead of a specialized mental health clinic.

Strategies to promote mental health

As individuals:

• Talking about mental illnesses openly- can ease the burden on the individual along with creating awareness and inspiring others going through the same to speak up.
• Educating oneself and those surrounding us- by providing proper authentic knowledge, creating mental health awareness, handling myths on mental illness and thus slowly reducing the stigma.
• Encouraging equality between physical and mental illness- talking about mental illness the same way that physical health is talked about help to reduce stigma and also normalise asking for help.
• Choosing to empower rather than shame-owning to the illness and being honest about treatment without feeling judged can help others reach out for help.
• Being kind to those who have mental illness-this can be a model to others to learn that simple acts of kindness can have a huge impact on people going through a disease like depression.

As a society:

• Early childhood interventions by providing opportunities for interactive learning.
• Social support for elderly and socio-economic empowerment of women.
• Programmes targeted at vulnerable people including minorities, indigenous people, migrants and people affected by natural calamities.
• Mental health interventions which are responsive, emotionally supportive and stimulating interactions in educational institutions and workplaces
• Community developmental programmes like integrated rural development, housing improvement.
• Anti-discrimination laws and campaigns, promotion of rights, opportunities and care of individuals with mental disorders.

Mental health promotion should be mainstreamed into governmental and non-governmental policies and programmes and must focus on mental disorders and broader issues with the involvement of the health sector and other sectors like education, labour, environment, justice and other welfare sectors.

As a mental health care provider:

As mental health care professional, the therapy can be more affordable, accessible, and inclusive than for people to find accessible therapy. A few ways could be:

• Offering sliding scale options where there are discounts for students and the marginalised community. Asking them their budget and finding out a little about their financial condition can help plan a budget and set a price according to each patient.
• In case the patient is unable to pay and needs psychological first aid, then offering very low budget or pro bono sessions can help.
• Providing online therapy either on-call or through video chat can help make therapy more accessible to patients living far away.
• Providing therapy bundles for a fixed number of sessions at a reduced upfront fee and then offer an extension if needed.
• Creating a web page where regular content about mental health and its various aspects are spoken about, can aid in spreading awareness (Instagram, Facebook, private blogs).
• Offering free workshops and hosting talks about how to channel emotions and resources to use if they or someone they love is seeking help.
• As a therapist educating oneself on what factors play in limiting access to therapy and finding creative solutions from the grassroots level.
• Learning more about how to be a more inclusive therapist- like making our own website more inclusive to the LGBTQ community, adding pronouns, de-gendering conversations with clients, finding local resources and recommending them to clients.
• Hiring freshers /interns from related fields and training them can help them gain hands-on experience along with reducing the psychologists’ overall costs.
• Collaborating or panelling with certain health insurance companies to make their service more accessible at a lower rate for the clients while the therapists can also be financially compensated for their service.

As Organisations:

• We cannot rely only on putting more psychologists into the task force, rather we can try and shift tasks to other health care workers. Physician assistants can be given specialized training where they handle non-emergency cases and patients that need a straightforward clinical prescription; this can also reduce costs.
• Integration with primary health care- more people visit primary health care centres, and more often so there can be a collaborative effort where health care providers are given basic training and patients are screened and if required referred to a psychologist/psychiatrist for further evaluation.

As a nation:

In the context of national and global efforts to develop and implement health policy, it is vital to not just protect and promote the mental well-being of its citizens, but also to address and assist the needs of people with defined mental disorders.

WHO supports governments in the goal of strengthening the advancement by evaluating evidence for mental health promotion and is working with various governments to circulate this information and to integrate effective strategies into policies and plans.

• The mental health Gap Action Programme (mhGAP) was launched by WHO, in 2008 as a response to the wide gap between the resources available and the resources urgently needed. The action plan was to assist with the large burden of mental, neurological and substance use (MNS) disorders for countries, especially with low and lower-middle incomes. This has produced evidence-based guidance for non-specialists to enable them to better identify and manage a range of priority mental health condition.
• To promote psychological well-being, an environment that supports mental health is essential. This may include creating an environment that secures and approves of the basic human rights that are fundamental to mental health. In 2013, the World Health Assembly approved a “Comprehensive Mental Health Action Plan for 2013-2020 for all the member states of WHO to take specific actions for the betterment of mental health and to contribute to the attainment of a set of global targets. This action plan emphasizes the protection and promotion of human rights and empowering of civil society and to the central place of community-based care.
• In India, The Mental Healthcare Act was passed in April 2017 and implemented in May 2018. The act ensures healthcare for people suffering from mental illnesses through government-funded health services and it effectively decriminalised attempted suicide, which was punishable under Section 309 of the Indian Penal Code.

Conclusion:

In conclusion, taking into consideration the factors which prevent access to mental health care and some of the solutions discussed above, it is found that there is so much that can be done as an individual and society as a whole. There are also great examples of countries from whom we can take inspiration that has already implemented new and advanced policies. One such case is Switzerland whose model of health care covers comprehensive psychiatric and substance abuse treatment. They also ensure appropriate services with a high inflow of psychiatric inpatient facilities while maintaining affordable care for all citizens. In India, 14%of the population suffers from mental health ailments and the recent covid-19 pandemic has only aggravated this crisis.

The World Health Organization (WHO) estimates the economic loss to India on account of mental health disorders to be US$ 1.03 trillion. As the knowledge of what to do about this burden of mental disorders has improved substantially over the past decade, there is a visible increase in both the efficacy and the cost-effectiveness of key interventions for priority mental disorders in countries with varying economic levels. Therefore, the interventions made should be cost-effective, feasible and affordable. Acknowledging the extent of this issue would be the first step towards reducing the stigma around mental health.

References:

Approaches to Reducing Stigma. Retrieved on Oct 3rd 2021 from https://www.ncbi.nlm.nih.gov/books/NBK384914/

Breitinger, S. (2018). 3 ways to expand access to mental health care beyond adding more psychiatrists. Retrieved on September 28th 2021 from https://www.statnews.com/2018/04/20/expand-access-mental-health-care/

Greenstein, L. (2017). 9 ways to fight mental health stigma. Retrieved on Oct 1,2021 from https://www.nami.org/blogs/nami-blog/october-2017/9-ways-to-fight-mental-health-stigma

Heath, S (2019). Key Barriers Limiting Patient Access to Mental Healthcare. Retrieved on September 30th 2021 from https://patientengagementhit.com/news/key-barriers-limiting-patient-access-to-mental-healthcare

How to: ways therapists can make therapy more affordable & accessible (2020). Retrieved on Oct 3rd 2021 from https://www.inclusivetherapists.com/blog/how-to-ways-therapists-can-make-therapy-more-affordable-accessible

IBEF (2021). India’s mental health policy. Retrieved on October 8th 2021 from https://www.ibef.org/blogs/india-s-mental-health-policy

Ivbijaro, G (2021). 2021 World Mental Health Global Awareness Campaign World Mental Health Day Theme – World Federation for Mental Health. Retrieved from https://wfmh.global/2021-world-mental-health-global-awareness-campaign-world-mental-health-day-theme/ on 8th September 2021.

Schneeberger, A.R. & Schwartz, B.J (2017). The Swiss Mental Health Care System.
Psychiatry services,69(2), 126-128. https://doi.org/10.1176/appi.ps.201700412

Stigma, Prejudice and Discrimination Against People with Mental Illness. Retrieved on Oct 1st 2021 from https://www.psychiatry.org/patients-families/stigma-and-discrimination

Top five barriers to mental health care access. Retrieved on Oct 4th 2021 from https://www.socialsolutions.com/blog/barriers-to-mental-healthcare-access/

WHO (2018). Mental health: Strengthening our response. Retrieved on September 22nd 2021 from https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response

WHO. Improving mental health care. Retrieved on September 25th 2021 from https://www.uniteforsight.org/mental-health/module8

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Authors:

1. Ms Ashel Castelino and Ms Srigowri Prabhu, are presently BSc Psychology graduate students, Department of Clinical Psychology, Manipal College of Health Professions (MCHP), Manipal Academy of Higher Education.

2. Dr. Deepa Marina Rasquinha, Assistant Professor, Department of Clinical Psychology, Manipal College of Health Profession (MCHP), Manipal Academy of Higher Education. Received Ph.D. in Psychology from Mangalore University for working in the area of Gerontology.

3. Dr Kavyashree K B, Assistant Professor, Department of Clinical Psychology, Manipal College of Health Profession (MCHP), Manipal Academy of Higher Education. Received Ph.D. in Psychology from Mangalore University for working in the area of Adolescent Psychology.