The Commission's work and the attention given to mental health care issues by the White House are positive, Steven S. Sharfstein, M.D., APA vice president, told Psychiatric Times. Sharfstein was also chair of the APA task force that wrote the APA's blueprint on the mental health care system.
Speaking as a psychiatrist and as president and CEO of Maryland-based Sheppard Pratt Health System, Sharfstein said, "To argue that there are enough resources in the system, which is implicit in the report, and not to say that we need more resources, is wrong."
We need to advocate and articulate a greater devotion of society's resources in the care and treatment of the mentally ill," Sharfstein added. "And they missed an opportunity to advocate for that."
The resource issue includes advocating a larger share of the private insurance premium devoted to mental health care and more equitable treatment under Medicare, which charges a 50% co-pay for mental health treatment versus 20% for other health care services.
The Commission's report relied on the statistics presented by the U.S. Surgeon General and other federal sources in citing the incidence of mental illness: in any given year, 5% to 7% of adults have a serious mental illness and 5% to 9% of children have a serious emotional disturbance.
It also pointed out that mental illness is the leading cause of disability in the United States, Canada and Western Europe. A 2002 report by WHO stated that suicide causes more deaths every year worldwide than does homicide or war.
The Commission identified six goals for transforming the U.S. mental health care system (Table).
"Far too often, treatments and services that are based on rigorous clinical research languish for years rather than being used effectively at the earliest opportunity," the report stated.
The solution is to use research to develop evidence-based practices for the prevention and treatment of mental illness and to put these discoveries immediately into practice. The report stated, "Translating research into practice will include adequate training for frontline providers and professionals, resulting in a workforce that is equipped to use the latest breakthroughs in modern medicine. Research discoveries will become routinely available at the community level."
The existing knowledge base lacks information on at least four key areas of mental health care and delivery:
- Disparities in mental health care for minorities.
- The long-term effects of psychotropic medications.
- The impact and treatment of trauma.
- Treatment gaps and clinical standards in acute care.
On the technology front, the Commission recommended developing an integrated electronic health record and personal health information system.
Involuntary TreatmentAccording to Sharfstein, the report does not do justice to individuals in the most dire straits in society. It emphasized choice, "but there are a large number of individuals who aren't able to choose." That population includes people who are homeless and those who have been incarcerated.
The treatment these people need has to be provided with due process, in order to protect civil liberties, but with a compassionate understanding that certain people need treatment and not punishment. Sharfstein added, "If they don't want treatment, that doesn't mean they shouldn't get treatment."
The issue of involuntary commitment, especially outpatient commitment, has proven to be a divisive one within the mental health care community. Consumers and other mental health care advocates oppose coercive means of bringing people into treatment.
Sharfstein, who prefers the term "compassionate coercion," said that involuntary or assisted treatment is sometimes necessary, especially with people who have schizophrenia. "Sometimes you need to go in and compassionately treat them against their will," he said. "And that is not reflected in this report."
In general, involuntary commitment is a result of inadequate crisis planning, Marty Raaymakers, chair of the NAMI Consumer Council, told PT.
Involuntary commitment results from people who are not in the system or are in the system but are not being treated adequately, explained Raaymakers, who also serves as chair of the Recipients Rights Advisory Committee for the Michigan Department of Community Health. In general, these people need more treatment over a longer period of time than the system is able to give them.
In addition to supporting choice over forced treatment, the report also made an important statement regarding the use of seclusion and restraint, Raaymakers said. "Seclusion and restraint will be used only as safety interventions of last resort, not as treatment interventions," the report stated.
Michigan has been engaged in person-centered planning for years, according to Raaymakers. Consumers write their own treatment plans, using the essential lifestyle-planning model. That approach has helped make the state's system of local mental health care systems significantly better than they were five years ago.
Michigan's Medicaid waiver program, like other public sector mental health care programs around the country, has its share of problems. "It's hard to provide care in a community," Raaymakers explained. "It's easy to provide care in an institution." The trade-off has been that more people have their lives now than they did before the local system switched to a consumer-focused approach.
