Jeffrey A. Lieberman, MD

Our mental health system is facing something of a perfect storm. The stress of the 

 contagion, the civil strife and social disruption, and economic insecurity is causing an increased demand for mental health treatment.

 Yet, government agencies and health care institutions are incurring budget deficits, and without government funding to cover these losses, existing treatment programs are in jeopardy. 

 have already announced reductions in mental health care funding, and other states are expected to follow.

The simultaneous increased demand and decrease in available services could generate a second phase of the 

 crisis. This is particularly true for racial and ethnic minorities and those in lower socioeconomic groups, who faced an 

 of psychiatric disorders before the pandemic and have been hardest hit by the virus.

 For children, the situation is more dire. Mental health services were deficient for this patient population prior to COVID-19 and are now worse. In the context of the pandemic, the rates of mental illness can be expected to rise precipitously.

This country has been struggling with mental health care problems even before COVID-19. Deaths from suicide, drug overdose, and alcohol-related liver disease, 

 the combined mortality of all infectious diseases combined in the United States.

 According to recent projections, we can expect up to 

 from suicide and addiction as a result of COVID’s ripple effects without additional interventions.

We were caught unawares by the COVID-19 pandemic, and we are suffering the consequences. We cannot afford a repeat failure.

The good news is that there are evidence based, cost-effective interventions to address public mental health needs.

 But let us start with what we should not do. We should not—as we repeatedly do out of habit—continue talking about our “mental health system.” The truth is that we do not have a system but rather a patchwork or mosaic that is far from comprehensive and not close to being adequate. The same is true for all of health care; there are many systems, organizations, clinics, and practices delivering mental health services under many auspices (from governments to nonprofits to for profit investor-owned). However, these neither meet all health care needs nor provide the requisite evidence-based services or ensure uniform quality of care. Given the wide range of stakeholders and the lack of leadership and political will, it is doubtful we will see one system emerge from the COVID-19 crisis. Yet, we can use this opportunity to accelerate the coordination of services for communities, including adequate mental health services that will provide a template for post-COVID care.

Accountable care organizations, medical homes, and Medicaid waivers have all inched coordinated care forward. We have also seen expanded use of telehealth due to the elimination of regulatory and reimbursement barriers. Virtually overnight, this resulted in unfettered adoption of online mental health treatment. We can do the same for coordinated care by removing regulatory barriers and offering payments that incentivize hospitals and their services, community-based organizations, and local primary care providers to create a no-wrong door, seamless continuum of mental health and substance abuse services.

This is our vision for the Northern Manhattan Mental Health Initiative, targeting one of the most severely affected areas by the COVID-19 virus. It gives health care providers and communities the opportunity to strengthen existing relationships, build new partnerships, and create a safety net for patients.

Other systemic problems can be addressed to meet the increasing demand for mental health care. For example, there are 

 The inpatient bed is the ICU of mental health care: for the most severe cases, it can be the difference between life and death. Well-meaning but flawed deinstitutionalization policies in the second half of the 20

 century left many people with serious mental illness on the streets, in homeless shelters, or incarcerated. Deinstitutionalization policies, compounded by 

, incentivized hospitals to close inpatient units and created a critical bed shortage.

 As a result, patients can wait in emergency departments for days—or 

In the midst of this pandemic, many inpatient beds, including those in our institution, have been converted to medical units to meet the deluge of patients with COVID-19, and it is unclear when or how they will return.

While such developments are regrettable, they are incentivized by the health care financing system that provides far higher reimbursements for procedural interventions than for preventative health measures like mental health. For example, according to the Centers for Medicare & Medicaid Services Physician Fee Schedule, payment for an emergency hour-long session by a psychiatrist with a patient who is acutely suicidal, homicidal, or floridly psychotic is only $147, while a 10 minute skin biopsy and 20 minute cataract surgery are reimbursed at rates of $150 and $765, respectively.

 These disparities are 1 reason there are so many surgery centers with an average profit of $2 million profit per year are popping up, while nearly half of patients with mental health disorders go without treatment.

 Leveling the playing field with reimbursement will incentivize health systems to emphasize mental health treatment.

Of course, mental health, like physical health, does not exist in a vacuum. When people’s basic needs are met, they are healthier in mind and body. The previously noted interventions will be most effective if we do all we can to address social determinants of health, including nutrition, housing, education, community safety, and employment. Being poor is bad for your health. This certainly holds true in New York City, where black and Latinx people are disproportionately vulnerable to the coronavirus.

Given our awareness of the looming mental health repercussions of the COVID-19 pandemic, we cannot remain idle in the anticipation of 75,000 excess deaths from the complications of mental disorders. It is morally wrong to condemn those who have the least to suffer the most, and it is irresponsible for us not to plan for a public mental health initiative to stem this imminent crisis.

 is a resident in psychiatry at the New York Presbyterian Hospital, Columbia University Irving Medical Center. 

 is assistant professor of medical sociology at Columbia University Vagelos College of Physicians and Surgeons and past president of the National Council for Behavioral Health. 

 is chairman of psychiatry at Columbia University Vagelos College of Physicians and Surgeons, past president of the American Psychiatric Association, and the author of 

The coronavirus pandemic is pushing America into a mental health crisis

https://www.washingtonpost.com/health/2020/05/04/mental-health-coronavirus/

Doctors urge governor to reconsider cuts to maternal mental health care.

 KQED. May 15, 2020. Accessed August 25, 2020. 

https://www.kqed.org/news/11818800/doctors-urge-governor-to-reconsider-cuts-to-maternal-mental-health-care

Some mental health resources could be cut from Colorado's budget because of COVID-19.

 9news.com. May 15, 2020. Accessed August 25, 2020. 

https://www.9news.com/video/news/local/next/some-mental-health-resources-could-be-cut-from-colorados-budget-because-of-covid-19/73-cb8ab247-76d7-46d2-a371-7a0d17284e64

Budget cuts to hit schools, colleges, mental health services hard

. April 23, 2020. Accessed August 25, 2020. 

https://www.dailypress.com/government/local/dp-nw-budget-20200423-u3puda5or5cl3dwyrh6f4qynu4-story.html

5. Kivimäki M, Batty GD, Pentti J, et al. 

Association between socioeconomic status and the development of mental and physical health conditions in adulthood: a multi-cohort study “Deaths of despair”: The deadly epidemic that predated coronavirus

. 2020 Mar;5(3):e140-e149. Accessed August 25, 2020. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(19)30248-8/fulltext

“Deaths of despair”: The deadly epidemic that predated coronavirus

. April 15, 2020. Accessed August 25, 2020. https://www.vox.com/2020/4/15/21214734/deaths-of-despair-coronavirus-covid-19-angus-deaton-anne-case-americans-deaths

Deaths from infectious diseases drop in United States

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https://www.pharmacytimes.com/news/deaths-from-infectious-diseases-drop-in-united-states

The COVID pandemic could lead to 75,000 additional deaths from alcohol and drug misuse and suicide.

 Accessed August 25, 2020. https://wellbeingtrust.org/areas-of-focus/policy-and-advocacy/reports/projected-deaths-of-despair-during-covid-19/

Draft menu of cost-effective interventions for mental health.

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https://www.who.int/mental_health/WHO_Discussion_Paper_Draft_Menu_of_cost-effective_interventions_for_mental_health.pdf?ua=1

10. Arango C, Díaz-Caneja CM, McGorry PD, et al. 

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How the loss of U.S. psychiatric hospitals led to a mental health crisis

November 30, 2017. Accessed August 25, 2020.

https://www.npr.org/2017/11/30/567477160/how-the-loss-of-u-s-psychiatric-hospitals-led-to-a-mental-health-crisis

12. National Council for Behavioral Health. 

The psychiatric shortage: causes ad solutions. National Council Medical Director Institute.

 March 28, 2017. Accessed August 25, 2020. 

https://www.thenationalcouncil.org/wp-content/uploads/2017/03/Psychiatric-Shortage_National-Council-.pdf?daf=375ateTbd56

Teenager in psych crisis waits 25 days in ED for admission

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https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

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American Psychological Association Monitor

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Articles

The COVID-19 pandemic reveals existing weaknesses in the mental health system, but also presents opportunities for reform. 

Preparing for the Mental Health Repercussions of the COVID-19 Pandemic

How do we provide stress management and professional support to health care providers? When the contagion is contained, how will we fare if a sustained crisis of mental health, family conflict, or social disruption ensue? Those topics and more are discussed in this video with Jeffrey A. Lieberman, MD, and Mark Olfson, MD, speaking from the epicenter of the COVID-19 disaster, New York City.

Meeting the Mental Health Challenge of the COVID-19 Pandemic

Dr Lieberman is Chair of the Department of Psychiatry, Columbia University, Vagelos College of Physicians and Surgeons, and Director of New York State Psychiatric Institute, New York, NY; Dr Olfson is Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law and Professor of Epidemiology, Columbia University Irving Medical Center. The authors report no conflicts of interest concerning the subject matter of this video.

Videos

Jeffrey A. Lieberman, MD, and Mark Olfson, MD, speak from the epicenter of the COVID-19 disaster, New York City.

Psychiatric Ramifications of the COVID-19 Pandemic

The public is gripped by fear of the novel coronavirus of 2019 (

) and by worry over whether the health system will be able to treat them or their loved ones should they become ill. Consequently, clinical and public health efforts have focused on acute medical care needs of those who are severely affected, while containing the virus’s spread in the population. Urgent priorities have included expanding hospitals’ capacities to care for sick patients and equipping health care providers to meet the unprecedented medical demands while keeping them safe. Meanwhile, concerted efforts are underway to validate diagnostic tests and bring them to scale while developing effective acute and preventive treatments, including vaccines.

Understandably, much less attention has been paid to the mental health consequences of the pandemic. Yet while the urgent emphasis is and should be on containing the virus and its physical threat, when the pandemic has subsided and we begin to resume normal life, it is the psychological sequelae that will emerge and persist for months and years to come.

During the acute crisis, everyone, to varying degrees, will experience fears of infection, somatic concerns, and worries about the pandemic’s consequences. Compounding personal distress are the disruption of usual daily routines and the social isolation imposed by the “stay at home orders” adopted by most US states.

 Longer periods of physical isolation, especially if experienced as involuntary, without an adequate and convincing explanation, or accompanied by financial losses can compound risks of adverse mental health consequences of 

People with pre-existing or constitutional vulnerabilities to psychiatric disorders including anxiety, depression, obsessional symptoms, substance use, suicidal behavior, and impulse control disorders will be especially vulnerable to stress-related symptom exacerbations.


	While we know these psychological effects are permeating the population, we do not yet know their extent or impact. We have previously experienced naturally occurring and human-made disasters, but nothing in our lifetimes compares to the scope of the COVID-19 crisis. The last comparable event was the 

. Subsequent epidemics including polio, HIV, Ebola, MERSA, SARS, and Swine Flu, though in some cases more virulent, were much smaller in scale, shorter and less disruptive to society.

While the polio and HIV epidemics may bear some similarities to COVID-19, they did not approach the magnitude of population-wide psychological impact. Therefore, studies of the mental health effects of recent epidemics offer limited guidance about after-effects of the COVID-19 pandemic. Similarly, recent disasters, such as 

 or 9/11, were more constrained in space and time than the COVID-19 pandemic.

Perhaps a better comparison is to the Great Depression of the early 1930s. This economic crisis caused a population-wide experiential trauma of the US population whose form and severity varied with individual constitution and circumstances. Psychological and behavioral reactions that exceeded clinical diagnostic thresholds were reflected as increase in rates of 

 In a variety of contexts, economic crises have been found to be associated with an increase in 

, substance use, and PTSD disorders have been found to follow natural disasters, such as earthquakes, hurricanes, tsunamis, or floods.

 If similar patterns hold for the COVID-19 pandemic, long after the physical threat of infection has subsided, psychological sequelae-inducing or exacerbating mental disorders in vulnerable people, and behavioral effects of persistent distress within the general population-will be a major consequence.


	The up-tick in incidence of various mental disorders and cumulative psychological stress our population will endure will further strain the mental health and primary care systems and expose limitations of its infrastructure, work force, and accessibility. Should national rates of specific conditions (like depression, suicidal behavior) increase, it will add to the trend of steadily rising national rates of suicide that we’ve seen over the past two decades.

To stem this tide, efforts should begin with those who are at increased risk of adverse mental health outcomes including patients with pre-existing mental disorders vulnerable to such stressors. Such persons may need adjustments in their treatment and increased frequency of contact with their mental health providers.

Others include people who reside in high COVID-19 prevalence areas, who live with someone affected by COVID-19, who have a family member or close friend who has died of COVID-19, who are socially isolated and who have little available emotional support. Adverse mental health consequences of social isolation can be mitigated by keeping the period of isolation as short as is consistent with personal and public health safety, providing accurate information concerning the rationale and personal and public health benefits of physical isolation, and improving social communication. Alongside negative effects, there may also be some countervailing positive mental health effects of living through a pandemic. One study of the 

 found that most individuals reported caring more about their family’s feelings during the SARS period than before it.

Health care professionals, especially those whose work brings them into close contact to patients infected with COVID-19, are also vulnerable to adverse mental health consequences. Feelings of futility, working with inadequate personal protective equipment, extensive involvement in end-of-life care without being able to connect patients and their families, and practicing outside their areas of confident clinical expertise can result in psychological stress.

For health care professionals, mitigating adverse mental health effects involve ensuring adequate protective personal equipment, access to COVID-19 testing, providing education concerning the disease, and training in COVID-19 management. It may also include providing emotional and physical support, developing more flexible work schedules, and a commitment to support and care for workers who become ill.

During the pandemic, health care professionals have been celebrated for their bravery and commitment to patient care. Yet the pandemic has also created a sobering moral dilemma as an innate desire to preserve their own lives and awareness of their vulnerability to the disease conflicts with their call to duty and identity as healers. Thus, stress management and counselling may need to include discussions of ethical principles and practices.

Increased primary care mental health surveillance through routine screening for depression, anxiety, and 

 coupled with greater availability of mental health services within primary care will enable larger numbers of affected individuals to receive mental health treatment within a familiar primary care context. In some practices, it may be feasible to train medical nurses and social workers in brief evidence-based psychotherapy techniques to manage complicated grief, adjustment disorders, and mild to moderate depression.

Psychiatry is particularly suited to use of virtual methods of providing mental health services. While telemedicine technology has existed for almost three decades, it took the impetus of the COVID-19 crisis to overcome the inertia of practitioners and health systems, and relax the regulatory, legal, and reimbursement impediments to utilization. Effecting the changes needed to sustain the use of telemedicine coming out of this pandemic should be a priority.

The COVID-19 pandemic presents new challenges to health and mental health care delivery. In the US, national, state, and local governments alongside the private health care sector have important roles to play in increasing the availability of mental health care in hard hit and underserved areas. Developing support groups and peer counseling services, crisis helplines, expanding services and enhancing accessibility through the use of telemedicine, and formalizing linkages between primary care and specialty mental health services may help address some of the emerging mental health needs. Careful planning and integration of basic mental health services into outpatient primary care will be critical to minimizing the adverse mental health effects of the COVID-19 pandemic.

 is Chair of the Department of Psychiatry, Columbia University, Vagelos College of Physicians and Surgeons, and Director of New York State Psychiatric Institute, New York, NY; 

 is Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law and Professor of Epidemiology, Columbia University Irving Medical Center. The authors report no conflicts of interest concerning the subject matter of this article.

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The public is gripped by fear of COVID-19 and by worry over whether the health system will be able to treat them or their loved ones should they become ill. Consequently, clinical and public health efforts have focused on acute medical care needs of those who are severely affected, while containing the virus’s spread in the population.

In the wake of the recent Veterans’ Day observances (November 11, 2018), I had a strangely disquieting feeling. At first, I attributed it to binge-watching too many war movies that had been broadcast for the occasion (including 

All Quiet on the Western Front, Saving Private Ryan, Platoon, Patton

). But there was also the fact that the holiday coincided with the 100th anniversary of the Armistice of WWI, the “Great War,” punctuated by the indignity of our POTUS being deterred by the weather from attending the ceremonies at the French cemetery where US soldiers were buried. But then, in a burst of insight, I realized what so upset me was when George C. Scott slaps the soldier with PTSD in 

 and calls him a “yellow-bellied coward.” This iconic scene resonates with the historic and continued ambivalence of the military toward the psychological wounds of war. It is the military equivalent to the stigma of mental illness that pervades our society-but on steroids.

Because of this stubborn aversion to the reality of psychic injuries in the military, active duty and veteran military personnel have been denied effective mental health care, and limited progress has been made in understanding the pathological basis of psychologic trauma and developing more effective treatments. Consequently, our active and veteran military personnel suffer and die unnecessarily.

More than 2 million troops have already been deployed to the wars in Iraq and Afghanistan with no end in sight. Almost a third of all service-persons in these ongoing conflicts suffer from some clinically significant mental condition, the poster child for which is PTSD, and their complications of suicide, addiction and domestic or other-directed violence.

 The shocking statistics indicate that our veterans are more than twice as likely to commit suicide than their peers in the civilian population.

The reasons for the burgeoning rates of mental health problems among military personnel deployed to the Middle East-more than in any other war-are as yet undetermined. The possibilities include the asymmetric type of warfare, repeated tours of duty, lack of clearly defined mission. But then the rates had begun to rise during Vietnam when the army was conscripted and possibly beforehand and gone unnoticed. Regardless, the unique psychological dangers faced by our military personnel take their toll and make re-entry into civilian life difficult.

The mental health consequences of military trauma are often distressing, disabling and persistent unless there are timely interventions. Symptoms of PTSD include re-experiencing the traumatic event, avoidance of thoughts of the traumatic event and people, places, or other stimuli that evoke the trauma; changes in cognitions regarding the world and one’s self; hypervigilance; hyperarousal (including irritability, concentration difficulties, and disrupted sleep); and increases in disturbing thoughts and negative feelings. PTSD is commonly associated with functional impairment, substance abuse, suicidal ideation, impulsivity and violence, as well as increased utilization of medical care.

Treatments: too few, too late, and not good enough

Despite treatment with the available psychotherapies and pharmacotherapies, PTSD never fully remits in more than half of patients. Meta-analyses of psychotherapy for PTSD has found short-term improvements compared with baseline only in about 50% to 60% of patients, with the majority continuing to have substantial residual symptoms.

 The efficacy of medication in PTSD is also sub-optimal, with few patients experiencing a complete remission following pharmacotherapy.

 Moreover, there is a lack of psychopharmacologic advances in its treatment.

Because early symptoms of combat-related mental problems are a reliable predictor of chronicity and impaired social and occupational functioning, early treatment is most advantageous. Early intervention can increase functional capacity, rapid symptom recovery, prevention of maladaptive coping behaviors, and prevention of chronic PTSD and other psychopathology, including complicated grief.

 Unfortunately, while models of early intervention have been tested in non-military populations, they have rarely been implemented in military personnel.

Coming home: reconnecting and reintegrating

Research indicates that as many as 50% of veterans experience significant difficulty acclimating with a third developing mental health problems including PTSD, anxiety disorders and depression.

 Reconnecting with loved ones after repeated exposure to traumatic events and combat stress, coping with physical injuries sustained during combat, and renegotiating roles as civilians in the midst political, social, and economic crises can present an emotionally challenging experience for service members and their family members. If the psychopathology causing these problems goes untreated, chronicity develops that leads to significant social impairment, marital dysfunction, job instability, suicide, substance abuse, and violent behavior.

To compound the problem, there is an acute shortage of services, trained clinicians, and lack of expertise in evidence-based treatments, which limits the care of large numbers of redeployed veterans and their families. Moreover, the quality of services and the effectiveness of treatments are not optimal and limited federal funding has impeded much needed progress that could derive from psychobiological research on the effects of physical and psychological trauma on the brain.

 Indeed, current treatments for trauma-related mental health disorders, such as PTSD, suicidality, and traumatic brain injury, have yet to be proven effective for large populations of war veterans.

The lack of available quality mental health care is compounded by the fact that active duty personnel and veterans are too often reluctant, indeed overtly deterred from seeking mental health care because of shame, stigma, and adverse career impact. For those who do seek help, a variety of logistical, cultural, and professional barriers may interfere with care access and delivery.

8 To add insult to injury, family members of military personnel are not eligible for mental health care in VA settings. Ignoring the needs of these populations is both unfair, given their great sacrifices, and unwise, as family support is critically important for optimal adjustment of returning veterans.

Given the scope of mental health problems among military personnel, better and more accessible mental health services must be developed. Evidence-based interventions are needed in multiple and diverse settings (in basic training, on the battlefield, following injury and upon and after discharge) and special efforts must be made to address and overcome the deterrents of stigma, guilt and impact to career by at least ensuring that all are informed how and encouraged to obtain services if needed. Provision of social services and establishment of resource- and resilience-building programs would facilitate treatment and reintegration into effective social and occupational roles.

It has long been known that war produces overwhelming psychological stress that can indelibly alter a person’s brain function and mental state. Despite the long history of PTSD (previously known as “Soldier’s Heart,” “Shell Shock,” “Battle Fatigue,” and “Combat Neurosis”), and the increasing number of psychological casualties, there has been limited progress in the scientific understanding and ability to treat PTSD.

 So why hasn’t more been done to address the psychological wounds of war and its sequelae?

It is not for the lack of ability to achieve great progress. The military has already demonstrated its capacity to make extraordinary advances in the medical care of its soldiers. Rates of severely wounded combatants went from 80% who died to 80% who survived between WW-I and the Iraq and Afghanistan wars. Whereas wounded soldiers writhed in pain and died from infection and exsanguination in WWI, medics now stabilize soldiers in-theater, airvac them to field hospitals where they undergo emergency surgery, then airlift them when able to travel to military hospitals in Germany for more sophisticated treatments. When recovered they are transported to the US and, if further treatment is needed, to Walter Reed National Military Center.

I believe there are three reasons why the same has not been done for the psychological wounds of war. First, the idea of psychological weakness is antithetical to military culture with its ethos of strength and invulnerability. Thus, military leaders were disinclined to recognize and accept the possibility of psychic injury. As a result, many soldiers were accused of cowardice and in some cases punished, even executed, for their infirmity. Second, mental disorders are not tangible and have no visible physical signs or diagnostic tests by which they can be confirmed. Hence, they are not seen as real, and are thus minimized-you don’t get a Purple Heart for PTSD. Third, PTSD was considered a military problem and thus the responsibility of the Defense Department and Veteran’s Administration. Consequently, the NIH did not see this as within the scope of their mission and thus the best and the brightest biomedical researchers at academic medical institutions were not engaged in the research effort to address PTSD. Until recently, most funding for PTSD research was provided through the Veterans Administration and predominantly to researchers at VA hospitals.

There are two grievous flaws of logic in this scenario. One is that just because there is no physical lesion associated with PTSD, does not mean that it’s not a distressing and disabling condition. The other is that psychological trauma is not limited to the military but also occurs in the civilian population-though less commonly and dramatically. Therefore, this should be considered a medical problem of importance to the NIH and the whole biomedical research community, but that would have diverted funds from other disorders.

There is another reason why the measured response of our government to address military mental health is so tragic and reprehensible. Of the 265 disorders described in DSM-5, only two have known etiologies and can be readily studied in animal models-substance use disorders and PTSD. The biology of PTSD can be studied in the laboratory through fear conditioning paradigms and therapeutic approaches developed to alleviate the symptoms and potentially even prevent its development by “immunizing” those who regularly go into harm’s way.

What is needed is a “Manhattan Project” to elucidate the pathophysiology, develop effective treatments, and ultimately find a cure for PTSD. While this is a formidable scientific challenge, it is achievable.

The first step is for the Administration and Congress to empanel a task force of leading scientists to develop a strategic plan for research on the pathological basis of PTSD and develop treatments. Next, Congress must allocate funding to support the necessary research to be carried out under the auspices of the National Institutes of Health in partnership with the VA and Department of Defense. The NIH Director’s office would be responsible for monitoring progress and reporting to the President and the Congress. This effort would be sustained until sufficient progress has been made. The final step would entail establishing a network of medical centers in addition to the VA Hospitals to provide specialized mental health services for veterans, and mechanisms for reimbursement.

It is time for our government to right this historic wrong. Amidst the political gridlock in Washington and polarized opinions of the electorate, there is one thing on which everyone agrees, it is our respect and concern for US military personnel. Images and statistics of returning vets with lost limbs, injured brains, and traumatized psyches have seared the public consciousness and evoked an outpouring of compassion. We are light-years away from the Vietnam era vilification of the military. Let us pledge that not another Veteran’s Day shall pass without our government, biomedical research, and medical communities committing to solve the mystery of psychological trauma and remove this scourge from those who place themselves in harm’s way to defend us and our freedoms.

Jeffrey Lieberman, MD, is the Lawrence E. Kolb Professor and Chairman of the Columbia University Vagelos College of Physicians and Surgeons Department of Psychiatry and Psychiatrist-in-Chief of the New York Presbyterian Hospital-Columbia University Irving Medical Center. Dr Lieberman is a member of the National Academy of Medicine and past president of the American Psychiatric Association. He is the author of 

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The iconic scene when George C. Scott slaps the soldier with PTSD in Patton and calls him a “yellow-bellied coward” mirrors the historic and continued ambivalence of the military toward the psychological wounds of war.

Solving the Mystery of Military Mental Health: A Call to Action

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).

 The cost of opioid use disorders in 2013 was estimated at $78.5 billion.

 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.

 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.

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.”

 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.

The election of Donald J. Trump to the presidency and a Republican majority in both chambers of Congress affords such an opportunity. Fortuitously, in the national election’s aftermath, an enlightened and deftly orchestrated bipartisan effort by the Senate and House leadership resulted in an extraordinary victory for both parties. The resulting legislation, 21st Centuries Cures Act (HR6), sponsored by Congressman Fred Upton, a Republican from Michigan, and Congresswoman Diana DeGette, a Democrat from Colorado, incorporated many important elements of the Helping Families in Mental Health Crisis Act (HR2646, authored by Representatives Tim Murphy, a Republican from Pennsylvania, and Eddie Bernice Johnson, a Democrat from Texas). If reconciled with the Senate’s companion bill, the Mental Health Care Reform Act (S2640, sponsored by Senators Chris Murphy, a Democrat from Connecticut, and Bill Cassidy, a Republican from Louisiana), along with the Mental Health and Safe Communities Act (S2002, sponsored by Senator John Cornyn), HR6-if fully funded and implemented-could have a transformative impact on our nation’s mental health system and enhance access to and quality of mental health services.

This extraordinary governmental action during a “lame duck” session revealed the broad understanding and strong interest of the Congress and administration in addressing this urgent and longstanding problem. Buoyed by this congressional success and with the hope of providing the Trump Administration and new Congress an agenda to continue to improve mental health care in the US, we offer the following provisional proposals.

Dissemination and implementation of evidence-based programs

Advances in behavioral and neuroscience research have led to evidence-based treatments and models of service delivery that can substantially improve outcomes and reduce the burden of illness and costs of caring for those affected by mental illness and addiction. To be effective, evidence-based treatments for mental illness and substance use disorders must be appropriately and consistently delivered. Such services are optimally implemented by multidisciplinary treatment teams (as opposed to individual practitioners) in light of shortages in the workforce and geographic distribution of mental health professionals, as well as the diverse expertise needed for management of mental and substance use disorders. To facilitate this process, mental health care education and training curricula will need to be adapted, and training and supervision provided on a range of skills integral to evidence-based practices.

Special efforts must be made to ensure access to care for people with substance use disorders, among whom currently only 1 in 10 receives any form of treatment. Medication-assisted treatments such as buprenorphine or extended-release injected naltrexone should be more widely made available, as has been demonstrated successfully in Vermont.

Creation of portals of entry for all in need

Portals of access to mental health care in the public and private sector stakeholders (providers, payers, patients, employers) must be established for each segment of the population in need. These portals would be located in, or have liaisons with, hospitals, clinics, medical practices and offices, educational institutions, work settings, and community organizations. Services for common conditions such as depression, anxiety, and alcohol and drug use disorders are more accessible when embedded in primary care settings and the workplace, while schools and universities are well positioned to detect learning disabilities, eating disorders, and early stages of psychotic and mood disorders and engage students in care.

People with SMI are more likely to benefit from dedicated, specialty mental health centers because of their complex service needs. Community institutions, such as places of worship, and clergy may provide additional points of entry. Adults and children in rural and remote areas who face regional shortages in mental health services require technology innovations such as telehealth and virtual support from academic centers. Children and adolescents may best be reached through school-based programs or pediatric and family practices.

A critical portal of entry to behavioral health care must be considered for people with SMI involved with the criminal justice system, particularly during transitions between the community and jails or prisons. For example, mental health courts are effective at diverting people with SMI from becoming incarcerated as well as reducing rates of recidivism and violence.

 These services must also be extended to juveniles at high risk for mental illness and substance use disorders.

Alignment of financing systems with assessment of outcomes and value-based care

As described, the financial burden of mental and substance use disorders for both public and private payers as well as ancillary social services and the criminal justice system should be a major incentive for pursuing payment redesign. Amendments to existing, or new, legislation can encourage alignment of insurance financing systems to new models of mental health care and services by health care providers. While this objective will initially entail reimbursement to personnel from diverse disciplines, ultimately these costs must be incorporated into new payment models, including bundled payments and risk-adjusted, population-based payments.

The authors outline the ingredients for the transformation of mental health care in America.

Author | Jeffrey A. Lieberman, MD

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