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Ruth C White Ph.D.

Preventing Mental Illness: A Primary Care Approach

Mental health checkups should be part of physical checkups

The premise of this article is that mental health is health, as our brains are parts of our bodies.

The Cost of Mental Illness

The CDC estimates the cost of mental disorders to the US economy at $300 billion! in 2002 (Adult Mental Illness Surveillance Report, 2011). They report that about 25% of adult Americans reported having a mental illness in the previous year. The Center for Prevention and Health Services estimate that more than 215 million workdays are lost to mental illnesses each year. For illnesses like depression, treatment costs are recouped in increased productivity alone. A report by Pilette* (2005) on presenteeism and productivity reported in the Annals of the American Psychotherapy Association found that depressed workers lose an average of 5.6 hours of productivity per week as compared to 1.5 hours per week for workers without depression.

The data presented above show that investing in risk assessment and detection of early symptoms would significantly reduce the cost of treatment by reducing incidence of illness, reducing costs by treating at early stages, reducing disease burden, and significantly increase productivity in the workplace. Prevention and early detection/intervention would also significantly reduce the disruptive impact of mental illness on patients and their loved ones.

Integrating Mental Healthcare into Primary Healthcare

It is a travesty that health insurance will pay for maintaining physical health but most health insurance plans will only pay for the treatment of mental illness and not the maintenance of mental health and the prevention of mental illness.

Regular checkups with primary care physicians usinig simple-to-use, short assessment tools that screen for risks and symptoms could prevent the development of mental illness through behavioral and environmental changes and catch mental illness in its early stages. Primary care physicians could intervene with a holistic approach to mental health and well-being and refer patients to specialized care if risks are high or symptoms have started. Just as early detection of chronic illness risks allow doctors to help patients change health behaviors and prevent disease so could early detection of risks for mental illness allow for behavioral change to prevent onset of symptoms and promote health and well-being.

Almost all health insurance plans cover preventive check-ups that measure our weight, height, pulse, and blood pressure but few, if any, cover preventive mental health screenings but cover care for mental illness. Many strategies that promote physical health, such as exercise and good sleep, also promote mental health and well-being. Linking the physical to the mental would take a whole-body approach to health. (Note that I view mental health as physical health but am separating them only for the purposes of proposing policy change to existing systems).

Dental insurance also covers care that maintains dental health. Regular cleanings and x-rays that detect problems before they start allow dentists to recommend interventions that maintain good oral health and intervene early (cleanings, prescription toothpaste, fillings) before major, and more expensive, interventions are needed (root canals, crowns, extractions).

Primary Care and Mental Well-Being

However, it is the rare primary care provider who gives a mental health assessment at the same time as they measure our weight, height and blood pressure. Completing a simple short questionnaire that assesses for stress, anxiety or depression could allow doctors to keep track of mental health, provide advice to patients to support mental well-being, and make referrals before people met the diagnostic criteria for mental illness.

Paying for Mental Illness

Instead, medical billing practices pay for INTERVENTION not PREVENTION of mental illness. People visit mental healthcare providers when they can no longer cope and are at the end of their mental ropes. Waiting until people are depressed, anxious or psychotic is an expensive way to deal with mental illness. The loss in work productivity, disruption to daily life for people and their loved ones and the pain and suffering that people experience could be prevented if early signs of mental distress were addressed before people meet the criteria for mental illness.

Stigma and Mental Health

Prevention of mental illness usually involves out-of-pocket expenses for what has been snidely called caring for the 'worried well'. The stigma of mental illness prevents people from seeking help when they need because mental health care is marginalized from 'regular' healthcare. If we took a holistic approach to health that included our bodies from head to toe, then mental well-being would be considered part of being healthy and mental healthcare would not be something that people dreaded. Integrating mental healthcare into 'physical' healthcare would 'normalize' the maintenance of mental well-being and the treatment of mental illness.

A Holistic Approach to Health

Mental health is health. There should be no separation of mental well-being from the primary system of care that keeps us healthy with immunizations, health assessment measures, and a system of referrals as needed. The implementation challenges would be to ensure that primary care phsyicians are trained to do early screening and detection and for patients to feel comfortable in self-reporting. Furthermore, insurance companies should include mental health screening in their coverage of primary care activities. These challenges need a change of norms and training that can be addressed with education of providers and the public. Integrating mental health assessments into regular preventive care visits would reduce the burden of illness and promote a more complete experience of health and well-being.

*Pilette, P. (2005). Presenteeism & Productivity: Two reasons Employee Assistance Programs make good business cents. Annals of the American Psychotherapy Association, 8(1), 12-14.