The way we treat mental health in the United States needs to change.

As many patients seek help from their primary care doctor, or more often end up in the Emergency Department (ED), it is not enough for those with mental health issues to be solely the responsibility of specialists in mental health hospitals. 

It’s therefore vital that all healthcare workers hone their skills in mental health assessment so they can begin looking at the problem from a whole human perspective – taking a holistic approach – enabling patients to access the right care at the right time no matter where that may be. 

What are the Barriers We Face?

Despite it being 2021, there is evidence that some still view those with mental health problems as “morally broken”¹ rather than ill.

One plausible reason for this stigma is the perception that mental health conditions are less “real” than physical ailments. This societal stigma appears to hold true across the healthcare professional as well as within the general public.

For example, a study published in the Health Affairs journal found that doctors were less likely to follow up with their patients who have been diagnosed with depression than those with congestive heart failure, asthma, and diabetes.

This lower priority associated with mental health conditions can lead to substandard medical care² with 44% of adults with mental illnesses reporting being discriminated against or dismissed by their physician when accessing treatment.

But stigma is not the only reason. Healthcare professionals are under enormous time pressures, frequently have a lack of adequate mental health training and, as such, often feel that mental health care is outside their scope of practice. 

Many emergency departments and general clinicians are therefore ill-equipped to meet the needs of patients with mental health issues.

Accessing Treatment

Obtaining treatment for mental health is also too difficult for patients in the US. Mental health care can be delayed by up to 23 years from first symptoms³ and it has been reported that 62% of people with mood disorders and 76% of those with anxiety do not receive treatment at all⁴.

According to a survey carried out by the National Council for Behavioral Health, 42% of respondents cited cost and poor insurance coverage as key barriers to accessing mental health care⁵ – with most insurance plans viewing mental illness and addiction as exceptions to standard care, rather than part of it.

Furthermore, Americans have reported saying they do not have the same access to mental health providers as they have for other medical providers. For example, 89.3 million Americans live in federally designated “mental health professional shortage areas”⁶, with 55% of US counties not having a single practicing psychiatrist⁷. Plus, even in states with the greatest access, more than 38% are not receiving the services they need⁸.

And this is only set to get worse, with the Health Resources and Services Administration reporting that by 2025, the US will be short on an estimated 250,000 mental health professionals⁹.

The Link Between Mental and Physical Health

Around 30% of all people with a long-term physical health condition also have a mental health problem¹⁰; Those with depression have a 40% higher risk of developing cardiovascular and metabolic disease than the general population¹¹, and psychological stress can down-regulate various parts of the cellular immune response¹².

This correlation between mental and physical health should encourage practitioners to take a holistic approach in looking after the whole human, and yet so often mental health is overlooked. 

Take a clinician in emergency care for example. If a patient attends with a broken leg and then is also noted to have a chest infection, the clinician wouldn’t just treat the initial problem – they would also look after the infection.

Why should it be any different for those with mental health problems? We need to be attuned and sensitive to those with underlying mental health issues, to identify and manage conditions alongside other healthcare problems.

It’s time to open up a dialogue with healthcare professionals around gender identity and mental health. 

Though we are becoming acutely aware of the importance of mental health, transgender patients continue to suffer significant barriers to appropriate care, including discrimination and a “lack of cultural competence”. This is especially concerning given the prevalence of mental illness amongst transgender individuals – recent research has found that the community are six times more likely than the general population to have a mood or anxiety disorder. How can we improve the care we provide transgender patients?

At OMS, we’ve created a new mental health scenario to challenge clinicians’ unconscious biases. Here, users encounter an adolescent patient, with the birth name Oscar, who has been admitted to hospital after a suicide attempt. Through a supportive and understanding dialogue, we learn that she is gender transitioning and prefers to go by the name of Ola.

We spoke to Dana Plank, RN – a nurse in New Hampshire – and Dr Bex Thompson – a physician in the UK –  to get a better understanding of its significance. Both are clinical authors at OMS and have been instrumental in the scenario’s development.

We know how important mental health is, and how impactful these scenarios can be. In fact, mental healthcare and health inequalities are areas OMS actively works to improve. But this one resonates with so many people – we’d love to hear how it got started.

Bex: One of our authoring team (Kelly) had a great background in mental healthcare and was very passionate about making scenarios that aren’t just out of a textbook, but really bringing them to life and making them a bit more real-world. Kelly had worked with transgender people before and had first-hand knowledge and recognized how important the topic was. It’s one that’s not talked about enough in healthcare, and we saw an opportunity to change that.

What had been your experience of training on transgender awareness before working on this scenario?

Bex: Certainly when I went through med school (UK) we didn’t receive any formal training about how to approach topics around gender identity.

Dana: It’s the same here (US). LGBTQ issues aren’t something that we’re very good at—we’re not very good at using the right terminology and consistently demonstrating compassion towards these issues. But it’s just because we haven’t had the practice. The idea behind this scenario was to give people the opportunity to learn how to interact compassionately, and to ask the right questions so that you don’t alienate your patient.

You received input from people with first-hand experience of transgender issues to help develop the scenario. How did their expertise influence the finished product?

Dana: We mainly asked for our subject matter expert’s input to ensure we were representing the patient sensitively, and to find out whether we’d overlooked any issues they’d faced in the patient’s care. They have experience with transgender patients and mental health care as an RN, but they also identify as non-binary, which meant that they were able to offer both professional and personal insight. They certainly helped us with some background that we would’ve never thought of. For example, how the parents refer to this gender transitioning adolescent. If you’re calling the parents, it gives you an idea of how they feel. They might either be accepting of the situation that the patient is going through, or they might still refer to them as Oscar.

Bex: I also consulted with a colleague of mine who is training to be a psychiatrist. She helped us to narrow down the scenario and remove any unnecessary elements that could distract users from focusing on the patient’s mental health.

You mentioned taking out unnecessary elements. Can you tell us more about how the scenario developed to focus on the patient’s mental health?

Dana: Originally the patient had ligature marks – they weren’t gruesome, just a minor abrasion or burn. But Bex mentioned that from a doctor’s perspective, any kind of mark like that would suggest a more serious suicide attempt, needing a more serious physical examination. We didn’t want to go down that path – we wanted it to be mental health-focused – and our authoring approach got us there.

Bex: The patient was also originally drinking and using drugs, but we had to pare it back or it would’ve ended up being a child safety issue. It’s difficult because in real life, people do present with lots of things, but we have to be mindful that this is only a 20-minute scenario. At the end of the day, it’s a mental health scenario, so all the objectives are about understanding your patient and what led them to feel the way they do.