Why do so few people with mental health problems seek treatment? What can be done to improve the use of mental health services?
Introduction
Worldwide, a large majority of those with mental illness fail to receive adequate treatment and hence undergo unnecessary suffering. Arguably as tragic is the suffering experienced by the family members who agonize about the inexplicable and seemingly never ending mental anguish of their loved one.
In Singapore, for example, although depression is the most common mental health issue and there are a variety of treatments for it, only 31.8% of those with mental health problems such as depression receive professional treatment and do so only after years of delay e.g. four years for depression, 13 years for alcohol abuse. This means that 68.2 % of those needing help do not receive it and the 31.8 % of those who receive treatment wait 4 to 13 years before receiving it.
These statistics come from a recent nationwide survey called the Singapore Mental Health Study initiated in 2009 with Dr. Chong Siow Ann as the principal investigator and the Institute of Mental Health as the chief supporting organization (initial results reported in online article by Ng Jing Yng, 2011).
Why is there such poor treatment utilization for depression and other mental health problems?
There has been relatively little research conducted in Singapore about why so few with mental health problems are receiving adequate treatment. However, Professor Chong in another recent newspaper article (The New Paper, 2011), provided three reasons for the long delay between onset of a mental health problem and entering into treatment. These were “failure to identify the illness, stigma, and the lack of access to help.”
Relevant is a previous study of Singaporeans .jpg)
(Ng et al, 2003) which provided additional information as to the causes of underutilization of mental health services. In the Singapore Mental Health Study, Ng et al found a small minority (5.9%) to have sought treatment. Because of different criteria used in the two studies, one cannot compare exact percentages but both studies indicated very low utilization of mental health services. The great value of the Ng et al study was that it also investigated the attitudes towards seeking help and found that most people were reluctant to do so.
They found that “Only a little more than one third of the people (36.8%) in the community viewed mental health services as a source of help to solve their mental health problems”. Most astonishingly, only 10.4% of the people who needed help and who had stated a preference to seek it, actually did so. Ng et al found that although needing professional help and stating a preference to seek it were statistically predictive of actually seeking professional help, they were insufficient to explain why a large majority of the population, including even those who needed help and stated a preference for seeking help, failed to actually utilize existing mental health services.
What can be done to improve the use of mental health services and reduce the suffering of the mentally ill and their families?
When considering how to increase the utilization of mental health services, it is useful to consider the three factors suggested by Professor Chong as being responsible for the long delay in seeking treatment. While all three mentoned factors are likely involved in the underutilization of resources, many researchers in the field have suggested that stigmatization plays the most important role (Brown et al, 2010). Hence reducing the stigma associated with mental health issues is one of the important means to reducing adversion to treatment in patients.
Stigmatization consists of two types: stigmatization by the general public and self-stigmatization. Public stigmatization involves hurtful behaviour or popular misconceptions by society towards individuals with mental health problems e.g. job discrimination, social avoidance. Self-stigmatization happens when the individual, who has been chronically exposed to stigmatization by others, unfortunately gradually internalizes the stigma and demeans himself or herself. Both types of stigmatization reduce utilization of mental health resources.
Ways to reduce stigmatization
There are various ways in which stigma can be reduced or eliminated completely but three of the most important ways are described below.
1. Decrease stigmatization by the general public
Public health approaches can be extremely effective in improving the attitudes of the general public towards those with a mental health issue. This can involve the use of television and radio public service announcements, billboards, and free pamphlets on mental illness such as depression. A particularly effective way is by famous personalities publically share their own stories of having a mental health problem e.g. depression and how they have recovered using professional help. The recent book by Seng Lee Chua “My Voice: Overcoming” has several such stories by courageous persons both ordinary and famous. There is a need for many more such books appealing to specific audiences e.g. young persons with depression.
2. Decrease self-stigmatization
There is abundant evidence that one of the most powerful ways to reduce or remove entirely internalized stigmatization, is by joining a self-help group (Millen & Walker, 2002). A self-help group is a group of individuals who meet regularly to share with each other about some common problems - usually one strongly stigmatized by society e.g. mental illness, alcoholism, or sex addiction. Once the group member no longer engages in self-stigmatization and hence no longer feels shame and or embarrassment about having a mental illness, they are free to seek professional treatment. Also helpful are support groups lead by a mental health professional and directed towards those with a specific mental health problem.
3. Be aware of and change our attitudes and casual comments regarding those with mental health problems
We can reduce stigmatization of those with mental illness by changing our behaviour in our everyday life. One way is by being very careful of the words we use when talking about mental illness. Do you ever castigate someone for a mistake by labelling them as nuts or crazy or mad? Using such terms in everyday conversation tends to reinforce a negative conception and attitude towards those with a mental illness. In the otherwise objective and balanced article cited above, Ng Jng Yng chose the unfortunate title, ‘I am not mad’, quoting a psychiatrist she had interviewed. I think it was Sigmund Freud who said the unconscious does not see negatives. I am sure that the psychiatrist who said this, probably in an offhand comment, was a bit upset when he saw that it was made the headline of the article. I think this title, although perhaps chosen to reduce stigmatization had quite the opposite effect by reinforcing the false and stigmatizing belief that having a mental health problem is being “mad”.
Summary
Most persons with mental health problems fail to seek professional treatment or wait years before doing so. One of the main reasons for this is the stigma around mental illness. There are three main ways to reduce stigmatization:
- Educate the public about the facts of mental illness.
- Recommend that those with a mental health problem attend an appropriate self-help group or support group.
- Change our own attitudes and behaviours so as to create a new culture in which mental health problems are viewed with the same compassion as physical health problems.
References
Brown C., Conner, K.O., Copeland, V.C., Grote, N., Beach, S., Battista, D, & Reynolds III, C.F. (2010). Depression, stigma, race, and treatment seeking behavior and attitudes. Journal of Community Psychology, 38, 350–368. doi:10.1002/jcop.20368.
Chua, S.L. (2011). My Voice: Overcoming. Write Editions, Singapore.
Millen, N. & Walker, C. (2002). Overcoming the stigma of chronic illness: strategies for normalisation of a 'spoiled identity'. Health Sociology Review, 10, 89-97.
Ng Jing Yng, N. J. (2011). “I am not mad” Today online
Ng, T.P., Fones, C.S.L., & Kua, E.H. (2003). Preference, need and utilization of mental health services, Singapore National Mental Health Survey. Australian and New Zealand Journal of Psychiatry, 37, 613–619.
Singapore Mental Health Survey
The New Paper, Mon, Nov 21, 2011
Dr. Scott is a clinical psychologist based in Singapore with three decades of counseling and psychotherapy experience in helping adults with many kinds of psychological difficulties. These include anxiety, depression, addictions (cybersex, love), and Adult Attention Deficit Hyperactivity Disorder (Adult ADHD).