BY, MSPH, AND , MPH
MENTAL HEALTH IN NUMBERS
One in every 5 U.S adults experiences mental illness. One in every 20 U.S adults experiences serious mental illness. Nineteen percent of these individuals are managing anxiety disorders, and 8% of them are struggling with depression. However, in 2020, only 46.2% of U.S adults with mental illness received any treatment (NAMI, 2021). The average delay seen between when individuals begin to present with mental illness symptoms and treatment is 11 years. This must change. These same statistics are also seen in youth, with one every in six youth, ages 6-17, experiencing mental health disorders each year, and only 50.6% receiving treatment (NAMI, 2021).
When mental health illnesses are left untreated, a ripple effect begins. Individuals with depression are at a 40% increased risk of developing cardiovascular and metabolic diseases, compared to the general population. Individuals with serious mental illness have almost twice the risk as well (NAMI, 2021). In 2020, 32.1% of all U.S adults with mental illness also experienced a substance use disorder. The unemployment rate seen in adults who struggled with mental illness was also higher compared to those who did not, at 6.4% and 5.1% respectively (NAMI, 2021).
WHAT DOES THIS MEAN FOR YOU?
Most individuals who have been seriously affected by mental illness do not have a case manager. Those caring for these individuals are often overwhelmed and under-supported without the resources or even appropriate information about the individuals they are caring for to provide them with the care they need (Department of Health AU, 2006).
Individuals with mental illness have a complex array of needs that cannot be overlooked. They require support and ongoing management from a professional, like you. The more chronic and debilitating the mental health illness is, the more important a case management approach to their continued care is (Department of Health AU, 2006). Case management for people with a history of mental illness could be exactly what is needed to escape the “revolving door” of recurring patterns of discharge and readmission to the hospital because they are not being adequately supported (Department of Health AU, 2006).
As equipped mental health case managers, you know your patients inside and out. For successful management of mental health, there is no room for informational gaps (Plan Street, 2021). Within the initial assessment done on each case, you can get a clear understanding of any previous mental health conditions, their financial status, their current support system and housing. Seeing the whole picture becomes the basis of their care plan, ensuring that it is tailored carefully to them (Plan Street, 2021).
WHAT HAPPENS IF YOUR CLIENT IS ALSO A TRAUMATIC BRAIN INJURY SURVIVOR?
Many individuals who suffer traumatic brain injuries (TBI) find themselves dealing with typical symptoms such as headaches and/or migraines, vision sensitivities, balance problems and difficulties focusing. And while these are not easy to overcome, these individuals did not expect to also be navigating through mental health struggles too. Also, if the individual was exhibiting mental health struggles prior to their TBI, they often worsened (Fong, 2021). For a case manager, the combined diagnosis makes facilitating and organizing care even harder.
A new study found that 1 in 5 individuals may experience mental health issues following a TBI (NIH, 2019). This finding suggests the importance of immediate care following a TBI, not only to address presenting brain symptoms, but also to prevent any progression toward developing or worsening mental health symptoms. This study also supports the fact that case managers will most likely manage an individual presenting new mental health struggles, on top of resulting TBI symptoms.
MISCONCEPTIONS OF MENTAL HEALTH THAT IMPACT CARE
One of the most famous cases of misconceptions on mental health and traumatic brain injury is the story of Phineas Gage. Gage was a run-of-the-mill railroad worker until one day he had a devastating accident at work. A nail pin went flying into his face right through his frontal lobe. Yet, somehow despite severe brain damage, Gage survived (Cherry, 2021). Physicians at the time were shocked. Not only did Phineas Gage survive the blow, but he also retained physical and cognitive functioning despite the nail still being lodged in his frontal lobe. However, soon after the incident, a change was noticeable. Before the accident, Gage was enjoyable to be around and a hard worker (Cherry, 2021). Afterward, Gage became irascible, argumentative, mean-spirited and impulsive. For the first time, medicine discovered the localization (i.e., the specific area of the brain that governs a specific function) of these higher order executive functions, which meant the world of medicine had finally discovered that a large portion of the skills required in tasks such as self-control and flexibility (known as executive functions) occur in the frontal lobe. This case study is the backbone behind current thought in personality changes in TBI (Cherry, 2021). With the help of this case study, modern science is slowly getting closer to understanding and treating personality changes in those who have had a TBI.
Although this famous neuroscience case happened in the mid 1800s, we still experience misconceptions and an overall lack of understanding on the confounding effect of mental health and TBIs. One of the most common TBI misconceptions that lead patients to delay seeking care is that TBI symptoms are only physical (Emory Healthcare, 2021). Showcased in Gage’s accident is that not only do TBI survivors suffer from headaches and dizziness, but they can also suffer from personality changes, irritability and anxiety. Another misconception is that once you’ve experienced a head injury, you will never function normally again, and must accept your “new normal.” The same way that you can’t immediately un-sprain a sprained ankle, you can’t un-injure a brain right after a TBI. It takes time and access to the right care and support. Brains are incredibly resilient, and with help from a professionally trained case manager, patients do go on to live fulfilling and functional lives again (Emory Healthcare, 2021).
Mental illness is also accompanied by an array of misconceptions. One of the most common is that children or youth do not experience mental health problems (MentalHealth.gov, 2017). However, nearly 17% of children experience mental health disorders annually, 50% of them exhibit their first signs before turning 14, and 75% of them before the age of 24 (MentalHealth.gov, 2017). These statistics should be a wake-up call that all individuals should be checking in on their mental health, and as case managers, it must be recognized that the young clients you may be caring for could be struggling with mental health problems and not receiving the treatment that they need. Early mental health support can help them avoid problems that interfere substantially with their development (MentalHealth.gov, 2017). A second misconception is that individuals who are managing mental illness cannot hold down a job. These individuals may face interference with their productivity and ability to work every day (MentalHealth.gov, 2017), but with the help from a case manager, this is less likely.
CIRCULAR LOGIC THAT PERPETUATES THE PROBLEM
If: Unemployment has an adverse impact on mental health.
Then: A spiraling mental state has a negative impact on employment.
What many may not realize is that both these statements make sense individually, and they make sense together. In other words, these statements, in a way, form an inescapable loop. If individuals lose their job due to a change in their mental health status, a TBI, or both, their ability to meet basic standards of living sometimes becomes out of reach, making it difficult to invest in good insurance plans to pay for their medical bills, mental health and TBI services (Institute for Work and Health, 2009). This inevitably leads the individual to avoid treatment for their severe mental health conditions and TBI symptoms altogether. Consequently, this drives up the cost of long-term medical expenses, as immediate treatment of the medical condition gets pushed behind, making the condition more serious and long-term.
You, their case manager, can help them escape this loop. Providing them with an effective care plan that can stop them from further mental health diminishment allows them to stay at work and afford the health care that they so desperately require.
THE FINANCIAL BURDEN OF TBI AND MENTAL HEALTH
Even with your help, managing mental illness and recovering from a TBI simultaneously is difficult, and the healthcare world doesn’t make it any easier. When seeking the care that your patient needs, you may be faced with barriers and unavailability.
Receiving effective treatment for a mental health condition is tough enough in itself. When paired with inadequate access to required treatment, it leads to the accumulation of more medical treatments later. The limit on physician options also drives the increase in demand for qualified medical professionals, which in turn, is matched with an increase in medical expenses (Yeo, 2021).
This same is seen with access to TBI-related healthcare services (Eliacin et al., 2018). There are significant barriers to health services for TBI patients, such as:
- Geographical boundaries
- Transportation boundaries
- Unavailability of specialized, age-appropriate, and long-term health services (Eliacin et al., 2018).
Beyond not being able to easily access TBI services, the expense to use those available is astronomical. For a single individual, the lifetime cost of a brain injury with long-term effects is estimated to be between $600,000 and $1,875,000 (Newsome Melton, 2021). The true cost of brain injury reaches much further than initial hospital bills, as proven by the half million or more dollars it costs to treat over a lifetime (Brauns Law, 2021). These costs encompass rehabilitation, long-term care, and disability services.
Financial loss can be measured. But emotional losses are intangible. The close to $1 million lifetime cost to survive a TBI doesn’t even include the years patients lose to disability and life-altering consequences, such as mental illness and learning how to become a different version of who they previously were (Brauns Law, 2021).
COVID-19 EXACERBATING ALL OF THE ABOVE
Throughout the pandemic, job loss and income loss have peaked. Both job and income-insecurity affect mental health, as seen by adults reporting higher rates of anxiety and depressive disorder (Panchal et al., 2021). Now imagine how much these rates have increased for individuals who are also trying to recover from a TBI. The compounded effects of a global pandemic, inaccessible treatment services and isolation from support systems can be incredibly damaging. Beyond struggling with exacerbated mental health struggles, individuals with brain injuries need to be especially concerned about contracting COVID-19. When infected with COVID-19, the virus attacks the weakest part of the body. So, individuals with longstanding chronic medical conditions, such as a brain injury, are at the greatest risk for complications (Luce, 2021). A recent study found that one in three individuals who contract COVID-19 will have prolonged mental health or neurologic symptoms (Luce, 2021).
It is important to note the added angst experienced by TBI survivors during this time. Case managers can validate their clients’ feelings and desperately work to listen to their patients providing support through each step of their recovery. Unfortunately, case managers are overloaded with the exponential increase in the number of cases, and patients may “slip through the cracks,” never receiving this kind of support and continuing to spiral.
WHAT CAN HELP?
As a case manager, you need to be able to anticipate unexpected problems. One of the best methods is to be equipped with knowledge about your patients’ physical, mental and external challenges. If case managers can begin to understand their patients from a more holistic perspective, which includes the clinically presenting symptoms, as well as their everyday exposures to the world, perhaps we can begin to address the mental health crisis through a more comprehensive viewpoint.
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2. Cherry, Kendra. “Phineas Gage’s Astonishing Brain Injury.” VeryWellMind, 12 Apr. 2021, https://www.verywellmind.com/phineas-gage-2795244.
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