The delivery of mental health services in the United States is undergoing substantial changes as a result of mental health parity laws and increases in the number of insured individuals resulting from the Affordable Care Act. More people should be able to afford mental health care. However, access to mental health care services remains a challenge, especially in rural and underprivileged areas. A substantial national shortage of psychiatrists contributes to this problem.

In a paper published in the Journal of Clinical Psychiatry, Beth Han and colleagues describe the use of mental health care services by 3 different generational cohorts over a 5-year period. In particular, these investigators were interested in changes in mental health care utilization during the period 2008 through 2013 in the Silent Generation (those born between 1925 and 1945), baby boomers (1946 through 1964), and Generation X (1965 through 1980).

Han and colleagues used data from almost 275,000 adults who participated in the 2008 through 2013 National Surveys on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration. The investigators examined trends in the use of outpatient mental health services and psychotropic medications by individuals with mental illness. During the 5 years of the study, the prevalence of mental illness during the previous 12 months remained stable for each of the three generations: 11 to 12% in the Silent Generation, 17 to 18% in baby boomers, and 21 to 22% in Generation X.

Utilization of mental health services did not change in the Silent Generation during the 5-year study period. In the baby boomer generation, the prevalence of outpatient treatment remained constant, but there was a 28% increase in receipt of psychotropic medications without utilization of mental health care services. In Generation X, the use of mental health care services decreased by 16% while receipt of psychotropic medications without mental health care treatment increased by 34%.

The suggestion that individuals in Generation X receive more psychotropic medications but less psychiatric mental health services is disturbing. Psychotherapeutic approaches, either without or with medications, can be very helpful. Medications, when prescribed appropriately, can aid in the treatment of mood disorders, anxiety disorders, and psychotic disorders. However, psychiatric medications can have significant side effects and patients should be carefully evaluated to determine if they are ill with conditions for which there is evidence that drugs are effective. 

A recent trend in mental health care delivery is “integrated care.” Although different models of integrated care exist, the essence of this movement involves the integration of mental health care expertise into the primary care setting. This care may involve non-physician mental health specialists interacting with primary care doctors and their patients. Psychiatrists often review patient care with the on-site mental health specialists, talk with primary care doctors as needed, and see patients when informal consultation is not leading to improvement. The intent of this tiered, teamwork approach is to allow appropriate levels of expertise to reach a larger number of patients in need.

Hopefully, as parity laws become fully enforced and as integrated care models are implemented, more individuals will benefit from the expertise of mental health professionals. Often, psychotherapeutic interventions can help patients and may allow for more judicious use of medications.

This column was written by Eugene Rubin MD, PhD and Charles Zorumski MD.

References

Han, B., Compton, W.M., Eisenberg, D., Milazzo-Sayre, L., McKeon, R., & Hughes, A. (2016 Jun). J Clin Psychiatry. 77(6):815-824. 

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