Improving mental health status: environment versus services

Background and Purpose: Mental health service access and effectiveness are pressing concerns. Social work researchers have become leading players in an NIMH agenda that focuses on three issues: identifying those with mental illness, access to services, and effective mental health services. This paper combines literature reviews with data from an NIH funded longitudinal study of American Indian Adolescents to challenge extant mental health paradigms that ignore an old but key issue for social work: environment

There is much evidence that environment (personal, familial, peer, community, and even society) is important in mental health and illness. We know that the brain can be shaped by environment (changes can be visualized); rates of many disorders (depression, conduct disorder, antisocial behavior, anxiety disorders, addictions, violence) are higher when the environment is difficult; genes for mental illness often need to be triggered by environmental stresses; and when environment is improved, mental health problems decline. Diagrams illustrating this literature review will be presented.

Methods: The data comes from interviews of a stratified random sample of 401 (205 reservation and 196 urban) American Indian youths, aged 13 to 19, yearly for 4 years. Youth behavior, mental health (addictions and mental health), environmental problems (family, peer, community, and services), and services were tracked over time. Latent class trajectory models identified longitudinal patterns of mental health changes, and multiple regressions identified correlates of the different patterns.

Results: The youths fell into five distinct trajectory groups: two groups started and ended below the clinical cutting point (n=317): one stayed the same and the other got even better. Three groups started above the clinical cutting point: One small group (n=5) started at the top of the problem range and stayed there; two other groups started moderately above the clinical cutting point: One improved over time (n=30), and one stayed in the clinically significant range (n=30) The youths who improved were more likely to be from the reservation (odds ratio 5.94) and have greater family satisfaction (1.13), and fewer school problems (.84). Services were offered to all youth in direct proportion to their problems, and were unrelated to the trajectory groups. Focus groups with reservation leaders and agency heads showed potential reasons for the reservation effect: the reservation experienced increases in wealth during this period (initiation of casinos and sale of lands) that they used for prevention activities and increasing youth opportunities. No such changes took place in the urban areas.

Conclusions. Environmental changes, but not services were associated with positive changes in mental health. They moved a substantial group of youths from clinical to subclinical levels. These environmental changes included economic opportunities, free time activities, alcohol and drug use prevention, and leveraged responsibility (payouts contingent on staying in school).

Implications. Mental health researchers need a new paradigm that recognizes environment and includes a narrower perspective on who cannot survive without mental health services, accompanied by a wider perspective on community problem solving for the others. Who better than social workers to take this approach?