Time to Stop Stigmatizing Mental Illness

Charles DeShazer, M.D.

Chief Quality and Health Advocacy Officer, Cigna Healthcare

Published Jan 27, 2017

Transforming our healthcare system from one focused on illness and rescue care to one focused on health and prevention of illness will require dramatic redesign in how we provide care. Care that truly provides value for patients should be evidence-based, proactive, efficient and patient-centered. This is “Value-Based Care,” the goal of care redesign. Reimbursement mechanisms must also change so that we pay for and reward these more comprehensive and proactive methods of care. Most importantly, the patient must be at the center surrounded and guided by an effective primary care system. However, there is a pervasive "elephant" in the room. Our system tends to split physical and mental conditions. And if the treatment of physical illness is fragmented, expensive and in need of emergency repair, our treatment of mental illness is in critical condition on life support. This artificial separation exacerbates the problem by leaving each care system to struggle alone with something that could be done better together. There is now abundant evidence that collaborative care with behavioral and primary care integration is a better model of care that improves quality and patient experience as well as decreases costs (1).

Along with the need to better integrate care, there is also a critical need to de-stigmatize and improve the treatment of mental health disorders. In 2013 mental disorders topped the list of the most costly conditions with spending over $201 billion a year (2). Not only are mental health disorders costly alone but they are also an important comorbid condition. The costs of chronic physical illnesses such as diabetes or hypertension go up dramatically when there is also an additional mental health disorder such as depression or anxiety disorder (3). It is important to recognize that increased costs that occur when a patient develops depression in addition to diabetes or heart disease are a proxy for increased suffering. The need for increased care and attention often reflects a struggle with coping with new and challenging change striking at the core of life, one's health. Untreated mental disorders alone lead to distracted, fragmented and chaotic lives often leading to self-medication with alcohol and illegal drugs. When combined with a chronic condition that you now have to “live with” the rest of your life, there may be worsening of the physical condition because distressed patients often don't take care of themselves. This interplay continues the vicious cycle by creating more mental stress. Mental and physical care cannot be separated although our delivery system, as it is currently designed, often pretends that it can. This chaos is all happening within one individual and one family and the interplay cannot be separated nor ignored if we really want to make a difference.

Let's drill down on one condition, depression. A recent study (4) depicts the failed state of the treatment of depression. In the study, based on an evaluation of over 45,000 patients, over 8% of the population had depression as validated by the two question depression screening test. Unfortunately, although known to be depressed, only 28% received treatment. On the other hand, according to the same study, of the population being treated for depression with medications or psychotherapy, only 29% had a positive depression screening test. Therefore, we have patients who need treatment who are not receiving it and patients who are receiving treatment who may not need it. The evidence shows that treatment of mild depression with medication is no better than placebo. However, in contradiction to the evidence, patients with mild depression were more likely to be treated with medication than those with more severe mental distress.

The treatment of this one mental illness, depression, is widely variable, inconsistent and, most importantly, not matching the needs of the population. And primary care is our best hope of improving the situation. However, as currently structured, primary care is not doing the job that it could. In the study, of adults with screen-positive depression who were not being treated, most (78.5%) had one or more medical visits during the survey year. Primary care visits represent the opportunity to identify and treat those with depression. However, primary care is severely under-supported and over-taxed.

The primary care “Patient-Centered Medical Home” (PCMH) model is building the necessary team-based, and technology-enabled infrastructure to create capacity and support to improve a physician's ability to provide more comprehensive care. There should also be an effort to better enable the “Medical Neighborhood” of mental health providers as well as facilitate integration with primary care. Patient-centered care is well established to be a high quality and efficient model of care. Integrated care which brings together primary care and mental health professionals is more patient-centered care because it recognizes the interdependence of mental and physical disorders.

Integrated care and team-based care will help transform and improve the quality of care, but there is still another problem that needs to be addressed. The stigma of being treated for a mental illness is the other issue that rarely burdens the treatment of physical illnesses. In the US we have been trying to erase the stigma of mental illness for over 50 years, including the 1999, first-ever, U.S. Surgeon General’s Report on Mental Health. Unfortunately, we have had varying levels of success.

The stigma operates at two levels which creates additional barriers to care (5). Public stigma leads to social distancing where people with mental health illnesses are more isolated. This prejudice, discrimination, and distancing by the general public, and often family members is frequently based on misinformation and sensational media portrayals of the rare severe forms of mental illness. In general, as physical illnesses, such as hypertension or diabetes become worse, family members draw closer for support, and there is public sympathy. The opposite tends to occur due to the stigma of mental illness. This stigma leads to less support and compassion that is so vital to healing, getting better and staying healthy.

Even worse is the second level at which stigmatization operates. This is when the individual with the condition internalizes the social distancing or buys into the media portrayals and develops “self-stigma.” This may include lowered self-esteem, self-blame, denial or avoidance of dealing with the illness, and apathy about trying to get better, all of which can lead to increased depression and anxiety. A vicious cycle is created that feeds on itself which can lead to a downward spiral of not seeking care, non-compliance with care provided and increasing self-deprecation and isolation. This same type of vicious cycle can occur with people with physical illness who don't take care of themselves. However, the stigma of mental illness adds an additional issue and barrier. And, of course, they often occur together.

We have much work to do to turn the tide on this complex, pervasive and important issue. As noted, our healthcare system needs to dramatically change and integrate medical and behavioral care as well as become more competent at treating mental illnesses. But a good place to start is to battle the stigma and stereotypes associated with mental illness. It is just as important to treat, embrace and support someone with a mental illness as we typically do someone with a physical illness. The mental health parity laws and the more recent passing of the “21st Century Cures Act” will help. There are several helpful and important provisions in the act including support for primary care and behavioral health integration. Hopefully, the care system can and will transform to integrate mind and body care. At the same time, we all can contribute to the overall betterment of care for mental health disorders. Many of us have friends or relatives with mental health conditions, if not ourselves. We can help reduce any stigma or issues they may have about getting and staying in treatment. Reach out, talk and encourage. They need as much non-judgmental support, empathy and understanding for their depression as they do for their diabetes.