Never before has it been so timely and important to improve health care for people with mental and substance use disorders in the US. The urgency of enhancing mental health care has been underscored by glaring social maladies, including homelessness, suicide among military personnel and veterans, incarceration, opiate addiction, and mass violence, which have galvanized public attention to mental illness. Political challenges notwithstanding, this article highlights the significant common ground that supports an agenda for transformative improvement of mental health care in the US.
Our “broken” mental health care system adversely affects large segments of the US population. People with serious mental illnesses (SMI), including depression, bipolar disorder, PTSD, schizophrenia, autism, and Alzheimer disease, experience severe distress and disability, require high levels of costly health services, and have substantially shortened lifespans due to excess medical comorbidity and increased suicide rates. Included in this population are people with addictions, such as victims of the recent opioid epidemic most prevalent in rural America. Deficiencies in mental health and addiction services are so longstanding and profound in the US that they cannot be simply characterized as unmet clinical needs or health care disparities: they represent what former Congressman Patrick Kennedy has called a “violation of civil rights.”
The economic burden of these illnesses is tremendous. The estimated annual costs of depression in 2010 totaled $210.5 billion, including both direct costs and indirect costs such as mortality arising from depression-related suicides as well as the effects of depression in the workplace (eg, absenteeism).1 The cost of opioid use disorders in 2013 was estimated at $78.5 billion.2 Furthermore, the Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that mental and substance use disorder treatment spending from all public and private sources for direct costs alone will rise to a total of $280.5 billion in 2020, an increase from $171.7 billion in 2009.3 These figures do not include additional costs to the criminal justice system, which houses large populations of people with inadequately treated mental illness and substance use disorders.4
Improving mental health care is—and has been—a bipartisan issue. The New Freedom Commission, convened by President George W. Bush in 2002, sounded a “clarion call for this and future administrations to pursue dramatic improvements in the mental health care delivery system.”5 However, “fragmentation, stigma, [and] frozen budgets” largely thwarted this effort. Since then, legislation such as the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), as well as President Barack Obama’s health care reform bill, the Patient Protection and Affordable Care Act, have pushed forward expanded funding for mental health and substance use services. Yet previous efforts to address unmet public mental health needs have not succeeded in fulfilling their goals of broad access to quality care.
Piecemeal progress in our current mental health delivery system is insufficient. That is why a comprehensive approach to mental illness and substance use disorders should be enacted, as has been done with cardiovascular and infectious disease. This strategy targets populations in need, including those affected with and at risk for mental disorders, and would provide proven interventions to reduce morbidity and mortality. Such a mental health care plan would be comprehensive, multifaceted, and diverse and include the following core elements: universal access and broad geographic distribution, dissemination and implementation of evidence-based treatments, multidisciplinary team-based care, workforce development and deployment, alignment of financing systems, and assessment of cost-effectiveness with clear and meaningful quality and outcome metrics.
Dr. Lieberman is Lawrence C. Kolb Professor and Chairman, Columbia University Department of Psychiatry, New York; Dr. Goldman is Resident Physician, Columbia University Department of Psychiatry; Dr. Olfson is Professor, Columbia University Department of Psychiatry; Dr. Pincus is Professor and Vice Chair, Columbia University Department of Psychiatry; Dr. Sederer is Adjunct Professor, Department of Epidemiology, Columbia University Mailman School of Public Health.
The authors report no conflicts of interest concerning the subject matter of this article.
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3. Substance Abuse and Mental Health Services Administration. Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010-2020. http://store.samhsa.gov/shin/content//SMA14-4883/SMA14-4883.pdf. Accessed February 25, 2017.
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6. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed February 25, 2017.
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8. Knickman J, Rama Krishnan KR, Pincus HA, et al. Improving Access to Effective Care for People Who Have Mental Health and Substance Use Disorders: A Vital Direction for Health and Health Care. 2016. https://nam.edu/improving-access-to-effective-care-for-people-who-have-mental-health-and-substance-use-disorders-a-vital-direction-for-health-and-health-care/. Accessed February 25, 2017.