Healthcare for Americans with mental illnesses worsened after recession

Six years after the recession, Americans with mental illness still had limited access to treatment, according to researchers.

US laws meant to improve that access, including the Affordable Care Act (ACA), were unable to overcome the crippling financial impact of the recession on the millions of Americans seeking care, according to a study published Monday in the journal Psychiatric Services.

“The study creates this picture of people who may have been marginally functioning, who were pushed over the edge and they just couldn’t get back: they couldn’t get jobs, they couldn’t back to the life they had before,” said Judith Weissman, the study’s lead investigator.

More than 8.3 million people have serious psychological distress (SPD), which indicates a person is likely to have a mental health problem that interferes with their life.

In 2014, the year the ACA was fully implemented, 9.5% of Americans with SPD did not have access to health insurance that could connect them with a counselor or psychiatrist, a small rise from 2006, when 9% of the population reported the same thing, according to the study.

Weissman, a research manager at New York University’s Langone medical center, said this population was worse off in 2014 than it was in 2006 when it comes to healthcare utilization, which is measured by things including an inability to get needed prescription drugs or delays in accessing treatment. “There is something very broken about the way we provide mental healthcare in the country,” she said.

Patterns in access to care between 2006 and 2014 were similar among adults with and without SPD. Both groups experienced a steep rise in lack of health coverage after the recession in 2008 and experienced a return to 2006 coverage levels in 2014.

But from 2006 to 2014, adults with SPD who could not afford medication continued to increase, which the study said “suggests they may not have had as complete an economic recovery as adults without SPD”.

Weissman said that while this early analysis suggests the mental health system has failed to bounce back from the economic recession, people are using available healthcare at increasing rates because of changes made under Obamacare. “I think that what we’re seeing now is that – really, likely the impact of the recession on people with mental illness,” Weissman said.

She was one of several researchers at Langone to conduct the analysis, which took four years to complete and is thought to be the first of its kind in more than a decade.

Their study provides a conservative estimate of mental healthcare access and utilization because it does not include the homeless population. In January 2016, one in five people experiencing homelessness had a serious mental illness, according to the Substance Abuse and Mental Health Services Administration.

John Snook, executive director of the Treatment Advocacy Center, a mental health advocacy organization, said he hopes the benefit of the ACA and other laws that expanded mental healthcare access will show up “more robustly” in future studies.

“What you hear from families all the time is it is still a really difficult process to get mental illness treatment – even in states that have expanded Medicaid,” he said. “There may be only one psychiatrist that’s available; she may be an hour and half away.”

He said this analysis provides data that the group has been seeking – and pushing policymakers to collect – for years, to support things the group has observed anecdotally.

Snook said: “As we get better and better data, what we are overwhelmingly finding is that we are doing a terrible job of prioritizing their care and we, as a result, are costing ourselves a huge amount of money and not benefitting this population.”

Healthcare for Americans with mental illnesses worsened after recession

Antidepressant use soared during recession in England, study finds

The use of antidepressants rose significantly in England during the financial crisis and subsequent recession, with 12.5m more pills prescribed in 2012 than in 2007, a study has found.

Researchers from the Nuffield Trust and the Health Foundation identified a long-term trend of increasing prescription of antidepressants, rising from 15m items in 1998 to 40m in 2012. But the yearly rate of increase accelerated during the banking crisis and recession to 8.5%, compared to 6.7% before it.

The report also found that rises in unemployment were associated with significant increases in the number of antidepressants dispensed and that areas with poor housing tended to see significantly higher antidepressant use.

Nick Barber, director of research at the Health Foundation, said that the report, published on Wednesday, was the “most accurate and insightful study of medication in this area in this country” and raised questions about whether people were being treated appropriately.

“The rate of increase in prescribing had been still for some years and does seem to have increased from 2008 so it would suggest that recession and some of the associated problems such as unemployment could be part of it,” he said. “If depression has increased as well as the prescribing the question is: ‘Is it being treated properly?’ There’s also an economic question at the time of recession as to whether we’re using our medicine resources as well as we could be.”

The report says a rise in unemployment and in the cost of living during the recession “could have an impact on the prevalence of mental health problems and require changes in the service delivered”, although it does not specify what those changes should be.

The increase in prescribing was despite the coalition government providing extra funding for the Improving Access to Psychological Therapies (IAPT) programme, introduced by Labour in 2008 to help people in distress access talking therapies. “The question is whether that is just because it’s a relatively young service or whether it reflects that there are delays [in accessing IAPT],” said Barber. “If you’re a prescribing GP with a distressed patient, if you know there’s a delay in this service, I am sure you will be more likely to prescribe antidepressants.”

An NHS report published in January found that while GPs made 883,968 referrals for psychological support in England in 2012-13, only 49% of them led to someone suffering from mental health problems starting treatment.

The Focus on Antidepressants prescribing report, part of the Nuffield Trust and Health Foundation’s QualityWatch programme, which is tracking the quality of health and social care in England, found that over the 14 years covered by the report, the increase in prescription of antidepressants outstripped the rise in depression.

Dr Cosmo Hallström, a fellow at the Royal College of Psychiatrists, said that while the figures were likely to raise concern in some quarters about over-prescription of antidepressants, he saw their increased use as a positive development on the whole, reflecting increased awareness of depression and how to treat it. “There needs to be a spectrum of treatments available,” he said. “Whereas antidepressants won’t be the best treatment in all cases they are of proven benefit and shouldn’t be denied to people who are waiting for something else.”

But he cautioned that they should not just be prescribed without follow-up. “You should review over a few weeks to see whether they are really working or not,” he said.

The researchers also observed wide variation in prescriptions between areas and different GP practices. For example, Blackpool residents were prescribed more than four times as many of the tablets each month per 1,000 people as Brent, in north London.

The report found that areas with more white people, more women, and more people over the age of 65 had the heaviest use of antidepressants, while GPs who prescribed more antibiotics also tended to prescribe more antidepressants, which Barber said “confirmed that some doctors are more inclined to reach for the prescription pad”.

London had a lower level of prescribing, which the authors put down to its younger and more ethnically diverse population, while the north-east, which has high rates of unemployment, had higher levels.

Adam Roberts, senior research analyst at the Nuffield Trust, who was one of the report’s authors, said: “The variation isn’t explained by rates of depression, which is what you would think. Someone with more expertise should look at defining what the appropriate rate is and how the variation is explained. We tried to explain it to a certain extent but we couldn’t fully explain it.”

The authors have created a modelling spreadsheet for GPs and clinical commissioning groups to calculate their expected level of prescribing of antidepressants, based on factors such as the profile of patients in their area and socioeconomic indicators, and compare that with their actual prescriptions.

Researchers also discovered that a 1% rise in unemployment over time typically meant one and a half more tablets were given out per person on a GP list per year. By contrast, comparing practices in different geographical areas, rather than analysing trends over time, did not show clear links to unemployment, although areas with worse housing tended to see significantly higher antidepressant use.

Antidepressant use soared during recession in England, study finds