18 Jun Taking Prevention Seriously
Written by Bart Magee, Ph.D.
It’s not news that investments in preventive health methods pay off exponentially. “An ounce of prevention is worth a pound of cure.” Certainly one of the truest of your grandmother’s sayings. Why then is prevention not taken seriously? We barely manage to consider preventative wellness in general healthcare and fail miserably in mental health. (The tragic suicides of Kate Spade and Anthony Bourdain last week were grim examples of the larger problem.) I’d like to dig into some of the reasons for this failing and propose some solutions. With a growing epidemic of mental illness (more about that below) and all of the problems related to it―suicide, schools shootings, homelessness―we urgently need to get our act together. The solutions are available and wouldn’t be costly to implement.
There are a couple of highly-cited reasons given for our negligence toward preventive health measures. One is the way the healthcare system is set up. Insurance payments for health services are based on treatment of disease and disorder and rarely cover advanced intervention. This problem is even greater in mental health. Insurers not only require a diagnosable disorder to qualify a service for payment, but many insurers require pre-authorization to before any treatment can commence. In addition, denials for coverage for mental health care occur twice as often as denials for general medical care.
Secondly, people tend to avoid devoting the time and effort to prevention until the problem becomes socially accepted as serious, life threatening, and where preventive intervention can be clearly identified. A good example of this is coronary heart disease. We forget that heart disease rose dramatically throughout the early part of the 20th century. By its peak in 1960, heart disease killed approximately one third of Americans. The death rate today is down 60% from that high, mostly due to preventive efforts. Imagine what the situation would be like today if your annual checkup did not include a cholesterol screening, there were no standards for acceptable blood pressure, and we paid no mind to diet, exercise, and smoking for those at risk. What if we only started taking a person’s heart disease seriously after a heart attack or stroke occurred? That’s basically how we are addressing mental health in America today.
What do I mean by that? We are failing to recognize that mental illness is very common. Rates are rising, along with associated social problems, and the
outcomes of untreated mental illness are growing more deadly. Consequences could be mitigated with a series of easily-implemented, preventive efforts.
Let me take it one by one. First, while people tend to consider mental illness a relative rarity, research has demonstrated that up to 85% of people will develop a mental disorder by midlife. This research has shown that people are more likely to experience mental illness than they are to acquire diabetes, heart disease, or any kind of cancer. Rates of depression and other mental illnesses have been rising steadily throughout the 20th and 21st centuries and tend to be higher in wealthier, more “modern” societies. Each generation tends to have greater mental health struggles than the last. In an earlier post, I wrote about the international study that tracked the rise of perfectionism over time and its association with increases in major mental illness, including: depression, anxiety, and suicidal behavior. The study cited competitive individualism, economic insecurity, and a decline in supportive social institutions as factors. Simply getting along in contemporary society requires extra maintenance in order to ward off anxiety, depression, and other psychological problems.
Neglecting that maintenance, we find ourselves in the middle of a mental illness epidemic. Our heads are still in the sand about it, although the signs are all around. Ever rising rates of suicide among individuals of all ages, with the highest increases for teens and young adults. More frequent and deadly school shootings perpetrated by pathologically angry, alienated, young men with easy access to guns. Plus a seemingly intractable homeless problem where mental illness is recognized as a major factor.
What would real prevention look like? First, we’d implement recommendations for routine mental health screenings. Yearly exams with primary care providers for children and adults should include basic mental health screenings. If positive results occur, a follow-up visit would be scheduled with a mental health professional, entailing a full evaluation―a clinical interview and appropriate tests. We could also make screening tests more widely available online and through mobile applications. Those tests could also be linked to resources and refer to other providers (like Access Institute) available for more thorough evaluations.
Second, we would develop real public education campaigns around the early warning signs of psychological distress. Everyone knows that smoking increases the risk of lung cancer and heart disease, but how many of us know that sleep problems are both a major sign of a mental health problem and also exacerbate any existing problems. Besides increasing public awareness, some basic tweaks to primary care could make a big difference. Today, if you show up in the doctor’s office and complain of a sleep problem, you’ll most likely leave with a prescription for Ambien. Taking sleeping pills not only masks the underlying problem (such as depression or anxiety), but also can have serious side effects. Sleep is just one example. We could do a much better job of educating the public about other signs of acute stress and psychological imbalance (i.e. headaches, chronic pain, appetite and digestive problems, changes in energy or libido, social withdrawal, irritability or angry feelings). Another obvious place to raise awareness and provide more mental health screenings and treatment would be in the public schools. Access Institute’s In-school Mental Health Program is a model for this.
Finally, we need to keep advocating for more funding. This means pushing insurance companies to reimburse for preventive care, advocating for increased government funding, and foundation giving. Compared to other health issues, mental health continues to be appallingly underfunded. We have the resources, the costs wouldn’t be great, and we can’t afford the dreadful and deadly consequences of a continued failure to take prevention seriously.