Insurance, Stigma, and Women’s Mental Health

Suppose you are poor, unemployed, and poorly educated. You cannot afford health insurance. You are depressed, and even if you knew where to go for help and could get there, you are afraid your family and friends will label you crazy or foolish. How would you get help? In this issue, Katon et al. (1) present the results of their research on whether attendance at an obstetrics-gynecology collaborative care clinic can effectively help disadvantaged women with no insurance or with only public coverage who meet criteria for major depression or dysthymia. The study’s comparison group were depressed women with commercial health insurance. Women at two different sites were assessed at intake and then followed up 18 months after initial recruitment. Not only did all of the women in the study show improvement in their depression scores, the disadvantaged group demonstrated a much greater effect size in depression improvement than the group with commercial insurance (0.81 compared with 0.39). The marked difference between the two groups may have occurred because the disadvantaged group started with higher levels of depression as a result of the greater number and variety of personal stressors they have. Nevertheless, the study showed that socially disadvantaged women can obtain and benefit from help received in such a collaborative care setting. Collaborative care models vary. In this case, master’slevel socialworkerswere trainedto act asthe care providers. Depressed women were given initial education about depression, and a semistructured interview was used to obtain a history. Women had choices as to whether they preferred psychotherapy or medication and whether they wished to be followed up in person or by telephone. The social workers helped with barriers to care, such as transportation and housing problems and inability to afford medication. Consulting psychiatrists advised the clinic physicians about medication changes. Collaborative or integrative care appears to function best when case management is involved to provide a strong clinician-patientrelationship(2).Casemanagementisdefined as “a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes” (3). Although research on the benefits of system-level integration is limited (2), the combination of case managers and a psychiatrist consultant to recommend treatment seems to yield the best results. The Katon et al. study therefore used an ideal approach.Itisalso one ofthe fewstudiesofcollaborativecare for depression that have looked at reimbursement issues. The study highlights a number of issues regarding health insurance, stigma, and women’s mental health. Concerning the insurance issue, it may not have been possible to carry out this study in any other major developed country, as most have a health insurance scheme that covers all patients. In Canada, for example, every citizen and anyone legally in the country may apply for health insurance to cover all necessary visits and procedures. Insurance status is not an obstacle to care. The Affordable Care Act may correct some of these obstacles in the United States, providing millions of uninsured people with mental health coverage. Universal health coverage does not, however, eliminate stigma. For many individuals, negative feelings, fears, and misinformationaboutpsychiatric illness interfere with access to care (4, 5). Whilehighlyeducatedin