mental illness, such as dizziness and stomach disturbances, because these are more culturally acceptable (US DHHS, 2001). Even if patients begin treatment for mental illness, stigma can deter them from staying in treatment. These problems are especially relevant for older people (Sirey et al., 2001), adolescents, and certain ethnic populations. These groups are discussed later in the chapter because they are at high risk for suicide.

Stigma also extends to family members. Family members of people with mental illness have lowered self-esteem and more troubled relationships with the affected family member (Wahl and Harman, 1989). Families of suicidal people tend to conceal the suicidal behavior to avoid the shame or embarrassment, or to avoid the societal perception that they are to blame (especially with a child or adolescent suicide). After suicide, family members suffer grief as well as pain and isolation from the community (PHS, 2001).

Financial Barriers

The cost of care is among the most frequently cited barriers to mental health treatment. About 60–70 percent of respondents in large, community-based surveys say they are worried about cost (Sturm and Sherbourne, 2001; Sussman et al., 1987). Economic analyses of patterns of use of mental health services clearly indicate that use is sensitive to price: use falls as costs rise, while use increases with better insurance coverage (Manning et al., 1986; Taube et al., 1986). Rises in co-payments of mental health services are associated with lower access (Simon et al., 1996a). The demand for mental health services is more responsive to price than is demand for other types of health services (Taube et al., 1986).

Having health insurance, through the private or public sector, is a major determinant of access to health services (Newhouse, 1993). People without health coverage experience greater barriers to care, delay seeking care, and have greater unmet needs (Ayanian et al., 2000). Overall, about 16 percent of Americans are uninsured, but rates are higher in racial and ethnic minorities (Brown et al., 2000). Having health insurance, however, does not guarantee receipt of mental health services because insurance typically carries greater restrictions for mental illness than for other health conditions (US DHHS, 1999).

Over the past decade, during the growth of managed care, disparities in coverage have led to a 50 percent decrease in the mental health portion of total health care costs paid by employer-based insurance (Hay Group, 1998). Not surprisingly, insured people with mental disorders in a large United States household survey in 1994 were twice as likely as those without disorders to have reported delays in seeking care and to have reported being unable to obtain needed care (Druss and Rosenheck, 1998).

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