By Dr. Thomas Young

Early identification of mental illness has long been a struggle. To this day, mental illness remains highly stigmatized, so individuals are often hesitant to seek screening for family members and themselves. Providers on the front lines lack good tools for early identification. There's the ongoing issue of how payments are made for healthcare services, including those provided in the mental health space. The lack of coverage for routine screening is a barrier that further contributes to the struggle.

Then there are broader screening challenges. For example, consider screening for mental illness in schools, which rarely happens. Why? If schools screened for and identify mental illness, they're then required under educational mandates to provide services to meet the needs of these individuals. Schools often do not want that responsibility, in part because they lack the resources to provide those services.

As another example, consider the employer space. Screening should occur at workplaces, yet employers, like schools, don't want to take on the responsibility of performing screening and needing to act upon the results. In addition, employees often don't want their employers to know they have a mental illness because of a fear that this knowledge will potentially affect employment.

The underlying issue of “what comes next” if screening indicates an individual has mental illness drastically affects efforts around early identification and screening. Where are providers, schools, employers and everyone else who should be involved in early identification and screening supposed to send these individuals? If I'm a provider and I don't know how to diagnose, treat and manage people with schizoaffective disorder, I'm much less likely to do it. That's why we see so many people with serious mental illness go untreated.

It doesn't help that the infrastructure and support services for management and treatment of mental illness are simply not available. We're lacking the physical bodies needed for management and treatment, and we're lacking the services pivotal to helping those with mental illness improve. Our healthcare system doesn't pay for professionals who can provide support. We don't pay to ensure those in need have the adequate housing, comfort and security so they can focus on their mental health. We don't pay for professionals who can help those with mental illness achieve purpose in their life (e.g., gainful employment), which has been identified as a pivotal facet of successful treatment.

What Needs to Happen

While the barriers to early identification and screening are plentiful, there are ways we can work to overcome them. First, the federal government must continue pushing for early identification and screening. We've seen progress here. Recently, the U.S. Preventive Services Task Force (USPSTF) recommended screening children aged 8-18 for anxiety and children aged 12-18 for depression. The USPSTF also has updated draft recommendations on adult screening for depression and anxiety in progress.

The pandemic has served to bring our country's mental health crisis further into the spotlight. In doing so, the need for screening for mental illness and potential suicide risk has become more understood and accepted. That's good news. While we have this positive momentum, we must ensure those performing screening for mental disorders have the right tools. The tools typically used today screen for some more common disorders but can easily miss less common disorders. Once a disorder is missed, time is lost that could be used toward starting treatment and monitoring outcomes.

Providers need the appropriate tools to do complete screenings and achieve early identification. Then they need access to appropriate follow-up tools. These tools allow those performing the screening to know what steps they should take following identification of an individual with mental illness. Such follow-up tools are essential. So much of the hesitation around screening is a fear of discovering an individual has mental illness and not knowing what to do next. The right follow-up tools can help eliminate such fear and hesitation.

Our healthcare system must also consistently pay for mental health screening. If health plans didn't pay for pap smears, mammograms and colonoscopies, those would not be performed as routinely. We would still have rising rates of cervical, breast and colon cancer. Since health insurers saw the cost benefits associated with early identification and treatment, they pay for these cancer identification and prevention services.

We must carry this approach over to mental health screening. Consider that screening adults for high blood pressure is often included in a bundle of covered services during office visits. For providers to get paid for the office visit, they must perform all services included in the bundle. Blood pressure screening is easy to do, doesn't cost much to complete, and the results — with their determined treatment pathways — can be tracked and followed.

The same is true for a mental health screening. A mental health screening tool that can identify multiple behavioral health conditions might take a few minutes for somebody to complete — not much more time than getting one's blood pressure checked. If the mental health screening leads to identification of bipolar disorder, for example, the provider can begin the patient on treatment and then follow and track their progress. If health plans required providers to check mental health as part of an office visit’s bundle of services, screenings would be completed and paths to recovery would be started sooner.

We know such an approach works thanks to Medicare. Several years ago, Medicare told accountable care organizations (ACOs) they were required to screen all people over 65 in the ACO for depression annually. If the ACO couldn't show it performed this screening, it risked losing some of the payment. A few years later, Medicare expanded the requirement: ACOs needed to initiate treatment. Then came the final requirement: show at the end of 12 months that patients diagnosed with depression and received treatment demonstrated improvements. Individuals 65 and older who are part of an ACO population now consistently receive a depression screening, treatment and monitoring — all because Medicare made it part of its payment system.

We know early identification and screening are important. We understand the barriers, and we understand ways to bring about positive changes. Now we need to make those changes a reality.

Thomas R. Young, MD is a board-certified family physician with more than 35 years of medical experience. He is also a recognized thought leader on ways to better identify and manage mental health disorders, especially among adolescents and teens. Dr. Young is also the Founder and Chief Medical Officer of Proem Behavioral Health (https://www.proemhealth.com/), formerly nView Health, developer of the evidence-based clinical workflow software engine that helps providers triage patients and produce better mental health outcomes.