President Trump recently had his annual physical exam, and though he did undergo (and pass) cognitive screening tests to detect memory issues and dementia, there's no evidence that he received a full mental health evaluation. Some medical experts argue that a psychological workup is in order for Trump — but let's put the Commander in Chief aside for a minute and ask: What about the rest of us?
During my last annual physical, my mental health was addressed ... to a degree. I was asked about my sleep habits, my relationship status and my alcohol intake. My appointment was with a doctor I'd never met, but I still I opened up about my ongoing fight with depression and anxiety. He was sympathetic, but slightly helpless, suggesting I see a therapist to discuss it. It all made me wonder, why aren't psychological screenings part of our annual wellness checkups? After all, our brains are part of our bodies, and mental health issues can cause or contribute to serious physical diseases.
Approximately 1 in 5 Americans, or 18 percent of the population, experience a mental illness in a given year.
Poor Mental Health Can Lead To Physical Illnesses
According to the National Institute for Mental Health, approximately 1 in 5 Americans, or 18 percent of the population, experience a mental illness or disorder in a given year. "Mental health issues are often very closely tied to physical health issues," says Dr. Joseph Cilona, a clinical psychologist. "Mental illness is associated with increased occurrence of chronic diseases such as cardiovascular disease, diabetes, obesity, asthma, epilepsy and cancer."
Wouldn't screening yearly for mental health problems be just another integral branch of preventive care, as is the case with our annual physical, vision and dental exams (albeit the latter are covered under their own respective insurance packages)? There's certainly a financial argument to be made here; Cilona notes that "mental health issues cost the U.S. economy close to $200 billion dollars in lost wages alone, plus about $100 billion in healthcare costs." Not to mention, suicide is the 10th leading cause of death in America, costing the US $51 billion a year.
The Hefty Prices and Runaround of Mental Wellness
It may seem gauche to talk about the cost of suicide, but it's important because the answer to why annual mental health screenings aren't the norm is largely a money issue.
"Insurance companies have made it so difficult to obtain reimbursement for mental health treatment, that it's just not good business to accept insurance when you can't get paid," says clinical psychologist Dr. Patricia A. Farrell. "Doing some work pro bono is okay, but most of the work where you spend an hour with the patient and three hours [on the phone] and god only knows how many phone calls to get paid? Makes no sense."
The patient is of course, also feeling the pains of the runaround as they try to find a professional who can help them with their mental health (this is of course, the people who are actually looking for services; nearly half of Americans with severe mental illness do not seek treatment).
"Access to specialty mental health care is limited," notes Dr. Clare Purvis, a psychologist. "In most settings, wait times for an appointment are prohibitively long for providers who accept the consumer's insurance plan, and the out-of-pocket cost for care is often too high for this to be a realistic option for most consumers."
The Mental illness Stigma Abounds and Complicates Everything
The healthcare system has strong blockades up to narrow the accessibility of mental health services, which is the simple answer. But there's another reason to consider: the old but enduring stigma around mental illness.
"Historically, mental healthcare and assessing for mental wellness has held a stigma in our society," says Dr. Scott Hall, professor of clinical mental health counseling at the University of Dayton. "This has contributed to yearly mental health assessments being left out of mainstream preventative care."
Dr. Brooke Myers Sorger, a clinical psychologist, finds that "it is still difficult for individuals to be forthcoming about their emotional challenges." That difficulty in opening up can extend to the PCP who may be asking all the right questions during a routine physical exam. Furthermore, the PCP may not want to overstep her professional boundaries, or get into a situation they aren't equipped to handle.
"If a patient becomes tearful and overwhelmed by their provocation, do they have the time and/or expertise necessarily to send them on their way? Are they then legally, ethically responsible for what their patient has told them?" says Dr. Myers Sorger.
An annual is so extensive a visit — with so many topics to visit — that the physician often finds herself strapped for time to complete everything.
Some PCPs Are Really Trying, But They're Strapped
And many of these PCPs really are balancing a lot on their plates, while still trying to give due diligence to a patient's mental health concerns.
"Mental health disease takes up a large chunk of patient visits in primary care," says Dr. Dana Corriel, a PCP. "I see adults of all ages battling things like depression and anxiety, no matter the age, sex or race. At this point in time, we cover the topic with a few simple questions at every patient's annual. However, an annual is so extensive a visit — with so many topics to visit — that the physician often finds herself strapped for time to complete everything."
We're Making Progress, But We Have Work To Do
Dr. Corriel, like every other doctor I consulted, believes that our society would benefit from annual mental health visits. And we have been making some progress — but it's been slow and stymied.
"Prior to the Affordable Care Act and even the Mental Health Parity Act of 2008, mental health coverage was far less common and providers such as psychologists often worked without billing through insurance," says Dr. Melissa Thomasson, Julian Lange Professor of Economics & Director of Graduate Studies at Miami University in Ohio. "Even though the ACA made mental health an 'essential health benefit,' the supply of providers has not kept up with the demand, so networks are not expanding as rapidly as they need to eliminate the shortage."
Dr. Ramani Durvasula, a clinical psychologist and professor of psychology notes that there are emerging models of integrated primary care that "co-locate mental health services right there and then at the point of physical health service delivery," but adds that these models are "infrequent and there is still pushback."
It could be a while before we see positive change here, especially if we don't evolve our societal conversation around mental health.
"If we had yearly mental health evaluations, we would have to vastly change the conversation around mental illness," says therapist Racine R. Henry, PhD, a marriage and family therapist in New York City. "In short, yearly mental health evaluations will force a normalization of mental illness in a culture which perpetuates the idea that a lack of mental health functioning is a rare, personal problem."
Do An At-Home Mental Health Screening
In the mean time, we must persistently be our own advocates, open up as much as we're willing about mental health, and do our homework. Many mental health professionals who don't take insurance will work on a sliding scale.
We can also perform minimal mental health check-ups on ourselves; here's a screening the American Psychiatric Association recommends that you can do right from the comfort of your own home.