Mental health treatments have come a long way in the last fifty years. During this time, researchers have developed hundreds of evidence-based mental health treatments. There now exist evidence-based treatments for most common children’s mental health problems. But how accessible are these interventions for those who need them?
Sadly, in the United States, approximately 70% of people who have a mental health problem do not receive any treatment, much less an evidence-based one. For children, depending on where they live, this figure may be closer to 80%. In short, we have powerful psychosocial interventions, but they only reach a fraction of the children who need them. Further, of those who receive any mental health treatment, only a third receives minimally adequate treatment as defined by existing treatment guidelines.
Defining Access to Healthcare
The World Health Organization outlines three primary components of access to healthcare: physical accessibility, financial affordability, and acceptability. Physical accessibility involves healthcare being available geographically close and at times that are convenient for the people who need it. Affordability means that those who want healthcare can get it without financial hardship. Acceptability means that people believe healthcare is effective and respectful of their social and cultural background.
Challenges Accessing Evidence-Based Mental Health Treatment
For the past two decades, there has been optimism that implementation science might help address the problem of access to evidence-based care. Implementation science is the study of systematically developing and testing strategies for implementing, scaling, and sustaining evidence-based practices. Connecticut is a leader in using implementation science to spread evidence-based children’s mental health treatments throughout the state.
For example, the Child Health and Development Institute (CHDI) collaborated with the Department of Children and Families (DCF) to implement Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) with good outcomes to help 4,500 children. CHDI and DCF have worked to ensure that TF-CBT providers are available in most areas of the state. If we apply the World Health Organization’s definition of access, this service is physically accessible to many Connecticut children. CHDI is also working to ensure that Child First, an evidence-based, dyadic intervention for at-risk young children and their parents is available throughout the state. Similarly, CHDI recently received a Substance Abuse and Mental Health Services Administration grant to implement Attachment, Regulation, and Competency (ARC), an evidence-based treatment for young children who have had a traumatic experience. All of these are outstanding interventions with good outcomes for the children fortunate enough to get the treatments. I am proud that the Agency that I lead, the Child Guidance Center of Southern Connecticut, provides all three of these interventions, as well as another home-based evidence-based treatment, Multidimensional Family Therapy.
Last year, of the approximately 1,500 children the Child Guidance Center served with outpatient and home-based psychosocial treatment, 8% (114) of these children received an evidence-based intervention that adheres to strict standards established by the developers of these treatments. The numbers served are small because of the extensive training and consultation that is required to deliver an evidence-based intervention with fidelity to the treatment model. I believe that every child we serve should receive an evidence-based intervention because research suggests that outcomes are superior, but this is not financially feasible. None of the grants we receive to implement and sustain evidence-based practices come close to covering their costs. A recent article that examined the costs of sustaining TF-CBT in Connecticut calculated an incremental per patient annual cost of $1,896. The researchers admonished that “reimbursement models for supporting evidence-based practices must consider the costs of sustainment.”
Indeed, for the Child Guidance Center of Southern Connecticut to treat all children in need of outpatient or home-based services with an evidence-based practice like TF-CBT would cost an additional $2,627,856 ($1,896 per patient x 1,386 patients). This would increase our $5.2 million annual budget by more than 50% and would require twice the amount of funding we currently receive from the state of Connecticut to deliver these services. Even if Connecticut weren’t in dire budget circumstances — we are three months into the current fiscal year and the state has not passed a budget — this would never happen. Thus, while some evidence-based practices might be physically accessible, they are clearly not affordable.
While there is considerable scientific support for evidence-based psychosocial interventions for children’s mental health problems, this support is based primarily on studies of Caucasian, European American children. There is considerably less evidence supporting these interventions for ethnic minority youth. It is likely that cultural factors — perceived stigma or different conceptions of mental illness or treatment — influence the effectiveness of existing evidence-based interventions. Further, there is a dramatic shortage of ethnic minority mental health clinicians. Approximately 90% of mental health clinicians in the U.S. are non-Hispanic White, but 30% of people in the U.S. belong to a racial or ethnic minority. In states like Connecticut that have growing immigrant populations, competition is fierce amongst nonprofit mental health agencies seeking to hire qualified bilingual clinicians because there simply aren’t enough of them to serve the expanding population.
To summarize, it would appear that, with great effort, it is possible to make select evidence-based interventions physically accessible – at least for select populations in a small New England state – but making them affordable and acceptable remains elusive.
Expanding Access to Evidence-Based Treatment: New Solutions
The shortage of racial and ethnic minority mental health clinicians is part of a much larger problem. Given the prevalence of mental health concerns, there are not enough clinicians of any race or culture. As noted earlier, only a small fraction of children in the United States in need of mental health treatment receive it. Dr. Alan Kazdin, an internationally renowned psychologist and long-time developer of and advocate for evidence-based treatments, has recently concluded that it is not possible to use the dominant model of psychosocial treatment, individual psychotherapy, to address the gap between those who need mental health treatment and those who receive it:
To read the full blog post on Children’s Mental Health Network, click here