Lesson 13: Policy Considerations for Special Populations

NOTE: The Cochran et al. (2003) article in the syllabus has been replaced with the Mustanski, Garofalo & Emerson (2010) article below.
McGuire, T., & Miranda, J. (2008). New evidence regarding racial and ethnic disparities in mental health: Policy implications. Health Affairs 27(2): 393-403.

Mustanski, B., Garofalo, R. & Emerson, E. (2010). Mental health disorders, psychological distress, and suicidality in a diverse sample of lesbian, gay, bisexual, and transgender youths. American Journal of Public Health, 100(12), 2426-2432. Http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2978194/

Vogt, D. (2011). Mental health-related beliefs as a barrier to service use for military personnel and veterans: A review. Psychiatric Services, 62(2), 135-142. http://ps.psychiatryonline.org/article.aspx?articleid=102171
This week’s lesson below focuses on the particular challenges facing certain groups who have specific challenges in accessing mental health services. These groups include, but are not limited to older adults, people living in rural areas and the homeless. Our readings address three other groups with significant challenges: the LGBTQ community, military personnel and veterans Much of the lesson focuses on the needs of Missourians but the issues are applicable to the rest of the nation as well.

Older Adults

Approximately 20% of all adults aged 65 and older have been classified as having a mental disorder, including dementia (Karel, Gatz & Smyer, 2012). Issues related to aging can exacerbate mental health disorders when factors such as chronic illness, institutionalization, isolation, and grief are more likely to be present. Some mental problems, such as depression, also are associated with an increased risk for suicide. Data presented in Lesson 12 demonstrated that older adult white males have the highest suicide rate of any age/gender group in the state.
The majority of older adults receiving mental health care are treated by their primary care physicians (Administration on Aging (AA), 2001). While many primary care physicians provide excellent care, there are also many who confuse mental health problems with the debilities caused by chronic physical disease or may consider late onset mental illnesses to simply be a part of normal aging. When mental health treatment is attempted by these physicians, older adults commonly receive inappropriate prescription of psychotropic medications (AA, 2001). Despite these problems, both substance abuse and mental health problems in older adults are treatable and can often be prevented (Choi, N. G., & DiNitto, D., 2013). In addition to mental health treatment, activities geared toward preventing depression and suicide have proven to be effective. Specifically, both support groups and peer counseling have been shown to be effective for older adults at risk for depression. Bereavement support groups, in particular, can help improve mental health status for widows and widowers (CMHS, 2005).

However, there are many barriers hindering the utilization of mental health services by older adults. In addition to stigma, cost and transportation are also significant issues for seniors. While the 2008 Mental and Substance Abuse Parity Act has resulted in greater equity in mental and physical health care costs, Medicare has been slow to catch up with the reductions in cost that occurred in private health care plans. Furthermore, some older adults cannot access services because of lack of transportation and isolation; others are homebound or largely homebound and are physically, are unable to leave the home. Finally, some are simply unaware of the Medicare benefits that are available to them both in terms of physical and mental health care and have no one to help them to navigate the mental health care system.
Nursing Facilities. The number of older adults residing in nursing facilities suffering from mental health needs is very high. In the United States it has been suggested that up the 88 percent of all nursing home residents suffer from some mental health problem, including dementia (AA, 2001). So common is mental illness in American nursing facilities that “nursing homes have become the de facto mental health care institution as a result of the dramatic downsizing and closure of state psychiatric hospitals, spurred on by the deinstitutionalization movement” (Grabowski et al., 2009, p. 689). However, a large majority of residents do not receive the mental health care they need. Specific barriers to appropriate mental health assessment and treatment for residents of nursing facilities include lack of adequate reimbursement to secure the services of psychiatrists and other mental health professionals, a shortage of mental health professionals trained in geriatric mental health, lack of nursing facility staff training and knowledge of the mental health needs of residents, and a lack of housing alternatives to nursing facilities (Friedman and Steinhagen, 2006). This lack can include a paucity of less restrictive environments, such as assisted living facilities, but also may be due to a lack of affordable housing and/or home and community-based service supports to make community living possible.
Rural Missourians
According to the 2013 National Survey on Drug Use and Health (NSDUH), around 18% of Missourians living in rural areas have had a mental illness in the past year. Generally, the prevalence of mental illness is virtually the same for rural and urban areas with the exception of youth’s alcohol use, adult stimulant use, depression in women and suicide which are higher in rural areas (Van Gundy, 2006). While the number of suicides in rural counties is relatively low compared to larger cities, 100% of the counties in which suicide rates are greater than the state rate are rural (DHSS, 2014).
Problems of accessibility, acceptability and availability cause many rural consumers to enter into treatment at a later stage than urban consumers, by which time their symptoms are more persistent, serious and disabling, requiring more expensive and intensive care. Accessibility of services is a barrier in rural areas because of the distances between residents and services, the limited number of emergency and regular services, difficulties recruiting and keeping mental health service providers, and inadequate transportation. Services tend to be located in the larger towns and cities within an area with some satellite offices spread throughout the region. Although some agencies provide transportation for people in outlying regions or even provide in-home services, it is insufficient to meet the need. In a study of health care utilization, it was found that individuals with their own transportation made significantly more health care visits than did people who had to rely upon public transportation or others forms of transportation (Arcury, Preisser, Gesler, and Powers, 2005). Telehealth has shown promise as a means to provide services to individuals in medically underserved areas and allow consumers in those areas more service options.
Shortage of specialists. The need for mental health specialists is great in rural Missouri. A little more than one-third (37%) of Missouri state and local rural health leaders responding to a survey selected mental health and mental disorders as one of their top rural health priorities, after access, oral health, and diabetes (Gamm, Hutchison, Bellamy, et al., 2002). Most rural Missouri counties have been designated as mental health shortage areas with a severe shortage of psychiatrists, particularly geriatric and child psychiatrists (Health Resources and Services Administration, 2014).
Due to the shortage of specialists, primary care physicians are the principal mental health providers in many rural areas. Nationally, 60% of the rural population lives in areas of shortage of professionals (both mental and physical health) and 65% receive mental health treatment from primary care physicians (Gale & Lambert 2006). Many rural physicians may intentionally under-diagnose mental illness due to doubts about the patient’s acceptance of a mental disorder diagnosis, stigma, or a concern about the patient’s future insurability (Gamm, Stone and Pittman 2003). According to a national study, rural doctors detected depression 50% less than physicians in urban areas (Mental Health and Rural America: 1994-2005, 2006).
Inpatient and Crisis Care. People in rural areas have to travel to larger towns or cities to access inpatient care. Hospitals find it too expensive to maintain units for children and youth, so children are often transported long distances if there is need for hospitalization (Redfedder, 2005). The distance from the hospital also makes it difficult for family members to visit or participate in treatment conferences.
Availability of Substance Abuse Treatment. Care for substance abuse in rural areas is limited with few substance abuse treatment centers in small towns in Missouri and few substance abuse detox facilities. Approximately 25% of urban hospitals offer substance abuse treatment compared to 11% of rural hospitals. Additionally, the federal government provides greater funding for treatment to urban areas (Hutchison and Blakely, 2003). Alcoholics Anonymous (AA) is a source of support, but often people have to travel considerable distances to attend meetings. Additionally, adult drug abuse is prevalent in rural areas and there are few, if any, Narcotics Anonymous groups in rural areas.
Homeless Community
According to the Governor’s Committee to End Homelessness, the Missouri homeless population increased 67% between 2007 and 2012. A significant proportion of people who are chronically homeless have a mental illness or substance use disorder. Recent figures from SAMHSA indicate that 20-25% of homeless suffer from a severe mental illness, compared to rates of 6% in the general population (National Institute of Mental Health, 2009). In a study of homelessness in 25 cities, mental illness was found to the third leading cause of homelessness among single adults (U.S. Conference of Mayors, 2008). In 2001 it was reported that 28% of the sheltered homeless population in Missouri had a severe mental illness, 34% were addicted to drugs or alcohol, and 10% were both mentally ill and addicted (Gould et al., 2002).
There are several barriers to obtaining mental health care among people without permanent housing, some of which have been mentioned above and others that are more unique to this population. Provider stigma about serving people who are homeless, the inability to maneuver the mental health system, a lack of knowledge of available services, long waiting lists for services, cognitive dysfunction, a lack of financial resources to obtain care and/or medications, few psychiatrists, and a lack of or poor transportation have all been cited as deterrents to obtaining quality care (Foster, Gable & Buckley, 2012).
Assignment and Group Discussion
The groups described above and well as those in the readings are just some of the groups who have greater difficulties obtaining mental health care than the general population. Others with specific barriers include people who are chronically ill, immigrants and refugees, people with developmental disabilities, people living in poverty, and people with substance abuse disorders.
Select a specific population for whom access to services is a significant issue. This can be one of the groups mentioned above or some other group suffering from mental health disparities. Find two programs or policy initiatives currently being undertaken that are designed to overcome barriers to receiving mental health care for this population. You can get your information from journal articles, newspapers, the Web, etc. Describe these initiatives and discuss the merits and challenges of each.
Again, please try to have your initial answers to the question on the Discussion Board by Friday so that you can respond to others in the class by Sunday night.

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Arcury, T. A., Preisser, J. S., Wilbert, M. G., & James, M. P. (2005). Access to transportation and health care utilization in a rural region. Journal of Rural Health, 21(1), 31-38.

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Friedman, M. B., & Steinhagen, K. A. (2006a). Barriers to Meeting the Mental Health Needs of Older Adults. New York, NY: Mental Health Association of Westchester.

Friedman, M. B., & Steinhagen, K. A. (2006b). Geriatric Mental Health: The Need for Change. New York, NY: Mental Health Association of Westchester.

Gale, J. A., & Lambert, D. (2006). Mental healthcare in rural communities: the once and future role of primary care. North Carolina Medical Journal, 67(1), 66-70.

Gamm, L., Hutchison, L., Bellamy, G., & Dabney, B. J. (2002). Rural healthy people 2010: Identifying rural health priorities and models for practice. Journal of Rural Health, 18(1), 9-14.

Gould, T., & Langton, A. (2002). Homelessness in Missouri: The Rising Tide. Jefferson City, MO: The Missouri Association for Social Welfare (MASW) Task Force on Affordable Housing and Homelessness, 1-3. Retrieved from http://vtls-kcpl-app.iii.com:9020/vital/access/services/Download/kcpl:9299/PDF_SOURCE?view=true.

Grabowski, D.C., Aschbrenner, K.A., Feng, Z. and Mor, V. (2009). Mental Illlness in Nursing Homes: Variations Across States. Health Affairs, 28, no.3 (2009):689-700.

Hanrahan, N. P., & Sullivan-Marx, E. M. (2005). Practice patterns and potential solutions to the shortage of providers of older adult mental health service. Policy, Politics, & Nursing Practice, 6(3), 236-245.

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