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The Forgotten Chronic Disease

The Forgotten Chronic Disease

Deadly chronic conditions garner much attention from health care providers and researchers seeking to prevent cancer, diabetes, and heart disease. However, often forgotten or overlooked are mental health disorders in young people, which can lead to serious persistent conditions in adulthood.

Chronic diseases affect one in two Americans, and one in four has multiple chronic conditions. Chronic diseases cause the most overall deaths in the United States, with heart disease and cancer together accounting for 62 percent of all deaths in 2013, according to the Centers for Disease Control and Prevention. Adding to the mounting challenges of effective evidence-based management and prevention of chronic conditions are co-morbid mental health problems that commonly go undetected and untreated. People who suffer from a chronic condition such as obesity or cardiovascular disease are more likely to also suffer from depression than are people without these conditions.

The prevalence of mental health conditions in youth is higher than that of physical health conditions, such as asthma and diabetes. Not only do mental health disorders in youth cause tremendous emotional damage within families, they are the largest cost driver, accounting for greater costs than diabetes, cancer, and respiratory disorders combined. If depression and other mental health disorders are not treated effectively in our youth, research indicates that they will persist or reoccur in adulthood, or even lead to a more severe, harder to treat illness.

In an effort to inform the public about evidence-based strategies to prevent and combat chronic conditions, including mental health disorders, several experts from across the U.S. joined together for an important, inter-professional, online panel discussion in March. This expert panel was sponsored by the National Consortium for Building Healthy Academic Communities, the Partnership to Fight Chronic Disease, and The Ohio State University (the recording and slides are available online). While the panel touched on various chronic diseases, mental health issues among youth, teens, and young adults were a key topic of discussion.

Barriers To Treatment

Approximately one in five Americans—including children, teens, college youth, and adults—has a mental health problem. Yet, the overwhelming majority of children with mental health conditions are not identified and lack access to treatment. There also are significant health disparities in the receipt of mental health services, with a disproportionate number of Hispanic and African-American children untreated. Panel members discussed the many challenges that prevent people of all ages from effectively addressing mental health disorders, including:

  • Stigma: Shame and fear deter many people and their families from seeking help.
  • Inadequate screening by primary care providers: This problem is especially acute for young people. The United States Preventive Services Task Force recommends that all 12- to 18-year-olds and adults be screened for depression in primary care when systems are in place for accurate diagnosis and treatment. However, providers often do not screen because they do not have timely access to mental health services for their patients.
  • Trouble finding treatment: Due to the severe shortage of mental health providers across the country, there are often long time lags between referral and treatment.
  • Failure to implement evidence-based therapies: If people are fortunate enough to get some type of treatment for mental health disorders, it is typically medications. However, patients may also need other evidence-based treatments, such as cognitive-behavioral or interpersonal therapy.
  • Slow implementation of research findings: Although universities, nonprofits, and other research organizations are studying mental health disorders, it often takes many years between the publishing of research findings and their implementation in real world settings.

Effective Treatment Requires An Integrated Approach

Panel members agreed that integrated health care, the systematic coordination of care for physical and behavioral health (mental health and substance use), is the most effective way to improve all health outcomes and reduce barriers to care. Speakers provided several examples of unique, integrated approaches to addressing mental health and substance use among teens and young adults: the University of Wisconsin-Madison University Health Services, the COPE Healthy Lifestyles TEEN program, and the Coaching Boys into Men program.

While more typically found in community health clinics, integrated behavioral health care models also are being adopted at college health centers across the nation. At the University of Wisconsin-Madison University Health Services, behavioral health providers are co-located in primary care, supporting primary care screening for alcohol misuse, depression, and interpersonal violence and providing patients with the services they need to address these issues. Internal utilization data from the program indicate that traditionally underserved populations, including students of color, male students, and international students, are more likely to access behavioral health treatment in this integrated model than through traditional mental health care services.

The COPE (Creating Opportunities for Personal Empowerment) Healthy Lifestyles TEEN (Thinking, Emotions, Exercise, and Nutrition) Program is a school-based health promotion intervention for adolescents. The program includes a mental health component that was evaluated in a large study with 779 high school teens. (The evaluation was funded by the National Institutes of Health/National Institute for Nursing Research.) High school teachers taught the COPE program to teens as part of regular health classes. The program included seven cognitive-behavioral skill-building sessions along with eight nutrition and physical activity sessions.

The teens who received this program had a lower average body mass index; healthier lifestyle behaviors; better social skills; higher academic competence as shown in health class grades; and less alcohol use than did their peers in the control group, who received standard health content. Fewer teens in COPE moved from normal weight to overweight and from overweight to obese than teens who received the control program. Symptoms of depression also were reduced into the normal range for those teens experiencing severe depression.

These positive outcomes were sustained for several months after completion of the program. Other studies of primary care and school settings have also found that the seven cognitive-behavioral skills building sessions from the COPE program significantly reduce symptoms in teens suffering from depressive and anxiety disorders.

Another successful program targeting mental health in young people focuses on violence prevention, integrating this curriculum with athletic coaching. We know that young people who experience violence are predisposed to experiencing emotional distress and engaging in risky lifestyle behaviors.

Coaching Boys into Men, funded by the Centers for Disease Control and Prevention, is an evidence-based program designed to train and motivate high school coaches to teach their young male athletes healthy relationship skills and that violence never equals strength. After three months of participating in the program, athletes were significantly more likely to intervene when witnessing abusive or disrespectful behaviors among their peers than were those not in the program. One year later, compared to athletes who did not receive the program, participating athletes were more likely to report less abuse perpetration and less negative bystander behavior (e.g., not saying anything, or laughing) when witnessing abusive or disrespectful behavior among their peers.

Looking Forward

In moving forward, health care systems and schools must place high priority on screening and prevention of mental health problems in youth, and provide early, evidence-based interventions for those affected. Incentives must be aligned to encourage payers and health care providers to prevent and manage both mental and physical chronic conditions. Physical health and health education can no longer be separated from mental health; the two must be integrated on a consistent basis in primary care and specialty settings, as well as in classrooms and on playing fields.

We must remember that, as Abraham Lincoln said: “The only way to predict the future is to create it.” Let’s create a future in which all Americans—particularly young people—can find relief from the agony of mental health problems. Let’s rapidly mobilize systems and professionals to provide the mental health screenings and evidence-based treatments that we know to be effective. Let’s equip youth with the coping skills needed to deal with their everyday stressors. Let’s finally give mental health the attention it deserves as a chronic disease as harmful as any other, and diminish the suffering that accompanies these disorders.