How to Think Upstream
In the field of public health, the term “upstream” is often heard. This stems from a popular parable that highlights the importance of looking at health issues from a preventative perspective.
The parable, credited to Sociologist Irving Zola, goes as such: Zola is walking down the bank of a strong-flowing river and suddenly hears a cry for help. A man is drowning, and Zola jumps into action. He jumps into the cold river and saves the man, giving him artificial respiration. Just as he starts to breathe, there is another cry for help, and another and another. The sociologist is so busy pulling the drowning people to the shore that he has no time to think who is pushing the people in the river.
Providers Can’t Keep Pace with Volume
Most mental health strategies aim at the downstream approach- catching people down the river when they are already in crisis. Unfortunately, this is not sustainable in our current mental health climate. The prevalence of mental health issues is increasing, paired with an increased shortage of mental health providers. According to a 2016 Health Affairs report, more than half of U.S. counties have zero psychiatrists. More recently, providers themselves are struggling with mental health issues, as sixty-one percent of physicians reported experiencing burnout in 2021, up from 40 percent in 2018. These high levels of burnout could impact the shortage further.
Just directing everyone to a provider isn’t a good strategy when there aren’t enough qualified providers. Instead, most people believe mild-to-moderate anxiety and depression cases should be directed to self-management approaches, opening up access to care for those with more severe cases. This is where preventative approaches should come into play in mental health.
Unfortunately, we haven’t implemented primary prevention approaches in mental health- not how we have with physical illnesses. With diabetes, for example, intentional weight loss through lifestyle interventions of a healthy diet and physical fitness can help prevent the onset. The National Diabetes Prevention Program showed prediabetic people following the structured program can cut their risk of developing type 2 diabetes by 58% and by 71% for people over 60 years old.
How to Think Upstream: Start With a Baseline
To shift upstream and prevent or delay mental illness, one must understand the risk factors faced and ways to reduce the risk. One way to understand modifiable risk factors is through health assessment. Assessments can stratify risk and provide a holistic picture of one’s mental health state. As mental illness risk is cumulative, one might even be able to draw a connection between two seemingly unrelated factors.
As public health professionals taking a preventive approach, here is an example of an assessment that highlights areas of greater concern for an individual:
This assessment examines key risk factors and protective factors. In this example, this individual probably needs to focus on sleep habits, coping with the loss of a loved one, and social isolation. The assessment also shows this person is at a high risk of anxiety and depression. It is clear that assessments can help bridge the mental health gap.
Assessments are but one aspect of an “upstream” preventative mental health approach and upcoming articles will explore other aspects. For now, it is clear that our current mental health care system is not sustainable, and it’s imperative that we focus on catching people before they get caught in the downstream river current.
Other Posts of Interest:
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