“Serious psychological distress” refers to a mental health problem that is severe enough to require treatment.
People in serious psychological distress are three times more likely to be too poor to afford general health care, and 10 times more likely to be too poor to pay for medications, compared with people who are not mentally ill, according to research published Monday in the journal Psychiatric Services.
Judith Weissman, lead author of the study and a research manager at New York University’s Langone Medical Center, found that 3.4% of adult Americans, or more than 8.3 million people, suffered serious psychological distress in 2014.
Nearly a decade earlier, only 3% or less were reported to have suffered in the same way.
“What’s been most surprising isn’t necessarily that the overall numbers have increased but that the cohort that is most impacted has changed,” Weissman said. “There’s a newfound high-risk group: middle-aged adults; that’s adults from about the age of 45 to 59 in the US, who previously had not been thought to be at high risk for mental illness or suicide, and now we’re finding that they are.”
The Great Recession
Weissman and her co-researchers based their analysis on data from the National Health Interview Survey, conducted annually by the Centers for Disease Control and Prevention. More than 35,000 households participate, including more than 200,000 people between the ages of 18 and 64 from all 50 states and across all major ethnic and socioeconomic groups.
The researchers examined responses from national surveys conducted in 2006 through 2014. Specifically, they looked at 11 indicators of health care for 207,853 adults, of whom nearly 60% were between the ages of 18 and 44. Roughly two-thirds were white, while nearly a third had a college education or more. About 38% had an annual family income of 400% or higher than the federal poverty level.
The surveys also measured serious psychological distress.
“Serious psychological distress is a validated scale — it’s well-regarded — that is used in national surveys to measure the mental health of the community,” Weissman said. Respondents are asked about six negative emotional states: sadness, feeling worthless, being unable to make efforts, nervousness, feeling fidgety and exhaustion.
When validating this scale, psychologists have found that the number of people in serious psychological distress corresponds to the number of people with a diagnosis of a serious mental illness.
“So it is picking up on mental illness within the community,” Weissman said.
Over the course of the surveys from 2006 to 2014, she and her colleagues found that access to health care services deteriorated for people suffering from psychological distress compared with those without serious distress.
About three in 10 with serious psychological distress did not have insurance, compared to about two in 10 without mental illness, the researchers found.
Excluding all but those with serious psychological distress, the team estimated that 9.5% distressed Americans in 2014 still did not have health insurance that would give them access to a psychiatrist or counselor, a slight rise from 2006, when 9% lacked any insurance.
And 10.5% in 2014 experienced delays in getting professional help compared with 9.5% in 2006, while 9.9% could not afford to pay for psychiatric medications in 2014, up from 8.7% in 2006.
The study may help explain why the suicide rate is up to 43,000 people each year, said Weissman, who noted that the affected groups are late baby boomers and Generation Xers — those “that some have described as experiencing not a better horizon but a worse horizon than their parents,” she said.
“The obvious pointer is economics,” she said. “The Great Recession of 2008 had a tremendous impact on adults with serious psychological distress.” About 2008 and through the years of the Great Recession, Weissman saw “dramatic decreased utilization” in health care among people with serious psychological distress.
“Now, this is not true of the non-mentally ill. The non-mentally ill are doing much better than they were in 2006,” she said, attributing this to the “positive impacts” of the Affordable Care Act. The Great Recession held back the mentally ill from beginning to see the progress that the non-mentally ill are seeing.
Weissman added that 2014 was the first year the ACA was fully implemented, and the Mental Health Parity Act was implemented in 2008. The latter, which requires equality in health care coverage concerning mental illness and other chronic diseases, was a predecessor to the Affordable Care Act, she said.
Overall, then, the study was meant to update the data and to get a benchmark by which to measure how the mentally ill are using and responding to the ACA.
Dr. Christina Mangurian, an associate professor of psychiatry at UCSF Weill Institute for Neurosciences, described the study as “important.”
‘Chaotic health care use’
“A study examining health care utilization among adults with serious psychological distress is important for a number of reasons,” said Mangurian, who was not involved in the new research. “First, serious psychological conditions (e.g., depression) are medical conditions and require treatment. Second, it is well-established that improving mental health treatment of people with (both) psychiatric and medical problems improves medical outcomes and reduces costs.”
She added that stigma about psychiatric conditions probably impedes health care utilization, but the study included evidence of structural factors, such as lack of coverage and lack of finances, that compounds the problem.
Her own research focuses on improving the care received by people with serious mental illnesses, including schizophrenia and bipolar disorder. “Those people die 25 years earlier than the general population, often from cardiovascular disease,” Mangurian said. “There are huge problems based on siloed care between the public mental health and primary care systems, which are separate culturally, electronically, geographically and fiscally.”
Weissman added that we’re at a moment of seeing increased mental illness and increased suicide among middle-age adults. Researchers understand too little about the reasons for what is anecdotally called the “suicide belt”: the West and the South.
The lack of availability of mental health care providers in those regions may be the reason for higher suicide rates in these areas, she suggested.
“I got this picture from looking at the data that there’s kind of this chaotic health care use with the mentally ill,” Weissman said. “The middle-aged adults that are experiencing this uptick in suicide, the concern is that it’s going to go on with the next generation and that it’s going to continue.”