Why We Wait to Initiate Mental Health Treatment

We sometimes delay mental health treatment out of ignorance and fear

Mental illness has lasting consequences for the patient, their family, and the community. Mental illness decreases the likelihood of completing school and gaining full-time employment. It can also result in a poor quality of life and increases the risk of physiological illness. In one study, people with mental illness were shown to have a shorter life expectancy of up to 20 years compared with healthy individuals (1). Despite the availability of effective treatment, over half of those who need mental health treatment do not obtain help (2). Patients sometimes wait several years before requesting mental health treatment. In another study, patients with anxiety took 3 to 30 years before initiating treatment (3).

Delayed treatment means worse symptoms over time which increases the impact on the health and welfare of the individual. People delay initiating treatment due to a variety of reasons including availability and affordability of a mental health provider, insurance and the lack of structural resources to obtain help when needed. Below, we briefly discuss how stigma and the lack of knowledge about mental illness lead to delays in the initiation of treatment.

Stigma persists

Stigma refers to the negative feelings, behaviors, and expectations associated with people with mental health disorders. In recent years, many organizations, celebrities, political leaders and advocates have helped to increase awareness about mental illness. However, people continue to have negative beliefs about mental illness. Some of these include that people with mental illness are "stuck" and will not improve or recover, can not be employed, are violent or erratic, can “snap out of” their condition, cannot have healthy relationships or get married or that mental illness only affects adults. Some people simply do not believe that mental illness can happen to them (4). These notions are false and do not encourage people to initiate treatment. 

The facts prove the contrary. Half of mental illnesses show signs before the age of 14 and three-quarters of mental illnesses start before 24 years of age. Also, people with mental health issues are nonviolent with only 3 to 5 percent of violent acts being attributable to mental health issues. Furthermore, people with mental illness are a vulnerable group and are 10 times more likely to be a victim of violent crime compared to healthy individuals. With treatment, many patients improve and those with mild and moderate symptoms often go on to make full recoveries (4).

Cultural taboo

In some cultures, mental illness is stigmatized by even the most well-meaning members of family, friends and even faith communities. Family members with mild to moderate forms of depression or anxiety may be left isolated, or have to deal with accusations of insubordination or lack of appreciation of one’s privileges. They may be labeled as stubborn, lazy, weak, or stupid. In more serious cases such as bipolar disorder or schizophrenia, mental illness may be seen as a sign of bad luck, bewitchment, or demonic possession. Such views increase stigma, decreasing the likelihood that an individual would seek treatment. This is sad because it is usually the person who is in the most need of care who ends up being punished for what they themselves do not understand. As a result, symptoms may become worse and, as discussed below, more difficult to treat.

The mainstream media may increase self-stigma

The mainstream media and social media strongly influence our sense of reality. The media shapes our perception about people who seek mental health services as well as those who provide care such as therapists, nurse practitioners, psychologists, and psychiatrists. Popular movies like “Good Will Hunting” and TV programs such as “Dr. Phil” may introduce viewers to the idea of therapy and mental wellness. (5) However, some programs may have the paradoxical effect of increasing self-stigma and the discomfort of obtaining help for oneself. Self-stigma is when the negative feelings, expectations, and beliefs about mental illness are directed towards oneself. The person may, though erroneously, consider obtaining mental treatment as a threat to their self-esteem and a sign that something is wrong with them. One study found that seeing people with mental illness in movies and TV shows, not in therapy, who were successful suggested weakness in those who sought treatment (5). Also, there was a negative perception that anyone seeking mental health assistance was thought to have mental illness (5). Furthermore, the mainstream news media's coverage of gun violence and suicides strongly associates mental illness with violence and extreme behaviors. These negative perceptions increase self-stigma and prevent people from initiating treatment. 

Childhood-onset mental illness gets worse over time

In the Diagnostic Statistical Manual 5 text, used by professionals to diagnose mental illness, there are hundreds of mental health disorders. The variety and severity of symptoms differ from person to person depending on age, gender, culture, genetic disposition, and environment. Many symptoms start subtly at an earlier age where behaviors may be overlooked or excused. Caregivers of children then may not quickly recognize symptoms until there is a significant decline in a person’s function such as poor grades, trouble making and keeping friends, difficulty obtaining and maintaining employment, divorce, or even the onset of a medical condition. Mild emotional or behavioral issues may gradually become entrenched habits. For childhood-onset mental disorders, caregivers may normalize the child's behavior and coping strategies such as social withdrawal and phobia which result in more treatment-averse attitudes later in life. Some studies suggest that this process of neural kindling can result in untreated disorders becoming more spontaneous, repetitive, severe and difficult to treat over time (6). Caregivers who do not know what to expect or who may themselves be stressed out may delay initiating treatment because they do not recognize the early signs of mental illness or how to take action to prevent it. Early intervention is important in preventing the worsening symptoms and improving the trajectory of recovery.

Hindsight is not always 20/20.

For many people who end up getting mental health services later in their lives, they often underestimate how long they have struggled with mental health issues. In cognitive psychology, this is an error in thinking referred to as telescoping (6). The telescoping effect refers to our tendency to inaccurately remember how often and how far back (backward telescoping) events occurred. As a result, the person may lack a sense of urgency in obtaining treatment and would tend to wait even longer to get treatment.

Lack of insight or anosognosia

Mental illness affects the brain which governs our thoughts, feelings, and behaviors. As a result, the same brain with aberrant patterns is not always capable of recognizing the faultiness of these patterns. An imperfect analogy is to consider how an adult caregiver may view their toddler throwing a tantrum. To the toddler, they are experiencing upsetting emotions without understanding the cause. However, the parent knows that they may be tired, hungry, in need of affection or simply searching for new stimuli to satisfy their curiosity and rapidly growing brains. Anosognosia is the medical term for the lack of awareness about a disease by a patient. As seen in the analogy above, this is not a case of denial or lack of will to change. Anosognosia is one of the reasons why many people may delay, resist, interrupt or even stop mental treatment altogether. It often leads to worsening mental health conditions, inconsistencies in treatment and frequent hospitalizations (7)

Lack of mental health literacy

The term mental health literacy refers to the “knowledge and beliefs about mental disorders which aid their recognition, management or prevention” (8). Mental health literacy is affected by a person’s social, economic and cultural backgrounds. In one study, it was noted that being female, more educated, financially stable and having more severe symptoms were associated with earlier initiation of treatment. Mental health literacy does not mean reading about mental health in a book but more importantly, the empowerment of people to use available resources, collaborate and organize to address or prevent mental health issues in families and communities. Important components of mental health literacy include knowledge about, (a) how to prevent mental health disorders, (b) recognizing early signs of mental illness, (c) help-seeking and treatment options, (d) self-help strategies for milder problems, and (e) skills to support others with mental illness or in a mental health crisis (8). The availability of resources that support mental health literacy empowers people to seek treatment early while the lack of these resources or the knowledge that they are available, prevents people from seeking early treatment. 

Knowing is not enough; we must apply. Willing is not enough; we must do.

- Johann Wolfgang von Goethe

Conclusion

In summary, stigma and our lack of knowledge about the process, prevention and the resources available for the management of mental illness can make people delay initiating treatment. Obtaining care is an act of self-love and self-care. Promoting mental wellness helps to better ourselves, our families and our communities by improving health outcomes, improving quality of life, increasing productivity, decreasing crime, lowering healthcare costs, and creating stronger economies. 

So there’s no need to wait. There are resources available.

Speak to a loved one or your health provider about obtaining help. Get involved with community efforts to decrease stigma and increase awareness. 

At Neb, mental health providers come to you so you don’t have to go into an office or clinic. Ask for information on how to find mental health assistance. See therapists at a nearby coffee shop, park or in the comfort of your home.

Other resources include the National Alliance on Mental Illness, Mental Health America, and Mentalhealth.gov. If someone you know is in danger related to mental health issues, please call 1-800-273-8255 for the National Suicide Prevention Lifeline

Arnold Fosah is a Psychiatric Mental Health Nurse Practitioner and a co-founder of Neb.


References

1 A review of the economic impact of mental illness. (Christopher M. Doran A B and Irina Kinchin A)

https://doi.org/10.1071/AH16115 

2 Many mental illnesses reduce life expectancy more than heavy smoking. University of Oxford.

http://www.ox.ac.uk/news/2014-05-23-many-mental-illnesses-reduce-life-expectancy-more-heavy-smoking

3 Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization's World Mental Health Survey Initiative

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174579/

4 Mental health myths and facts

https://www.mentalhealth.gov/basics/mental-health-myths-facts 

5 Media influences on self-stigma of seeking psychological services: The importance of media portrayals and person perception

https://search-proquest-com.ucsf.idm.oclc.org/docview/1492506234/fulltextPDF/6B6EC4C0AAA14908PQ/1?accountid=14525 Maier, Julia A; Gentile, Douglas A; Vogel, David L; Kaplan, Scott A.Psychology of Popular Media Culture Vol. 3, Iss. 4,  

6 Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization's World Mental Health Survey Initiative

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174579/

7 Assessing and improving clinical insight among patients “in denial”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4538978/

8 Mental health literacy: empowering the community to take action for better mental health

https://search-proquest-com.ucsf.idm.oclc.org/docview/901639932/fulltextPDF/C81214DABA724305PQ/1?accountid=14525