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This Special Report on premature mortality provides a review of current research as well as clinical and policy innovations to improve the physical health of patients with serious mental illness. Living with a mental illness is all too often accompanied by poverty and social disadvantage, stigma, adverse health behaviors, and poor access to medical care. Taken together, these factors contribute to shortened life spans and reduced quality of life. The articles in this Special Report present approaches for addressing many of the preventable causes of poor health and mortality in this patient population.

Numerous studies from the general medical literature have demonstrated the benefits of exercise in increasing physical fitness, promoting weight loss, optimizing cardiovascular health, and improving mood. As Martino Belvederi Murri, MD, and Panteleimon Ekkekakis, PhD, note, while the literature among individuals with major depression is more limited, there is every reason to expect that exercise would confer similar-if not greater-benefits as those seen in general populations, given the elevated risks. As long as a regimen is appropriate to a patient’s fitness level-150 minutes of moderate activity is a good starting point for most individuals-exercise provides one of the most favorable risk-to-benefit profiles of any treatment that is currently available. The authors highlight the value of focusing on enjoyment as a strategy to engage patients in initiating and adhering to exercise programs.

The social determinates of health have been referred to as the “causes of causes” of preventable mortality. As Lilanthi Balasuriya, MD, Eliza Buelt, MD, and Jack Tsai, PhD highlight in their overview, individuals with serious mental illness who also experience homelessness are at extremely high risk. For these patients, stigma, medical comorbidity, and challenges in meeting basic daily needs can lead to adverse physical health outcomes and early death. Successfully addressing the housing and basic economic needs of this population can provide a foundation for engagement in mental and general medical services.

Finally, these interventions require federal and state policies to support their broader uptake in clinical practice. Emma E. McGinty, PhD, MS, and Gail L. Daumit, MD, MHS highlight how a number of legislative and regulatory interventions beginning with the Affordable Care Act have increased opportunities to facilitate the more widespread adoption of integrated services for individuals with serious mental illness. The majority of these innovations have occurred within Medicaid, the most important funder of services for this population.

We hope that this Special Report provides you with an overview of the impressive and growing array of interventions available to improve the physical health of individuals with serious mental illness. As you read, please think about ways in which you can incorporate these strategies into your practice. By doing so, you can play an important role in helping to improve the duration and quality of your patients’ lives.

Dr Druss is Professor (Graduate Faculty), Rosalynn Carter Chair in Mental Health, School of Public Health: Health Policy and Management, Emory University, Atlanta, GA. He reports no conflicts of interest concerning the subject matter of this Special Report.

Living with a mental illness is all too often accompanied by poverty and social disadvantage, which contribute to shortened life spans and reduced quality of life. However, there approaches for addressing many of the preventable causes of poor health and mortality in this patient population.

Addressing Premature Mortality: Living With Serious Mental Illness

People with serious mental illnesses (SMIs) like schizophrenia, bipolar disorder, and major depressive disorder pass away 10 to 20 years prematurely relative to the overall population.

 This excess mortality is driven by cardiovascular disease and other medical conditions including cancer, liver disease, chronic lung disease, and HIV/AIDS. The high burden of these conditions among people with SMI is driven by multiple factors, including the metabolic adverse effects of psychotropic medications. Social risk factors for chronic disease include poverty, unemployment, housing instability, and criminal justice involvement-all of which are overrepresented among people with SMI.

 Cognitive and communication impairments experienced by some people with SMI, as well as low social support, can present challenges for patient-provider communication, shared decision-making, and navigation of complex health care systems.

Effective interventions to address medical conditions in the population with SMI exist. Evidence-based screening, diagnosis, and treatment of chronic medical conditions is largely the same for people with versus without SMI, and tailored behavioral interventions have been shown in clinical trials to support weight loss and tobacco smoking cessation in SMI.

 Clinical trial evidence also shows that supportive employment and housing programs tailored to SMI can reduce unemployment and housing instability, important social determinants of chronic disease among people with SMI and the overall population. Many people with SMI, particularly the 70% covered by Medicaid, do not receive guideline-concordant medical care.

 Moreover, tailored health behavior and supportive employment and housing interventions have not been widely implemented in the US.

State and federal policies have a key role in scaling up evidence-based interventions to prevent and treat the medical conditions driving premature mortality in SMI. Policies at multiple levels, ranging from federal laws to clinic-level policies, delineate the rules by which interventions are financed and delivered. In this article, we focus on federal and state-level policy initiatives.

To date, federal and state policy efforts have predominantly focused on supporting integration of primary care and specialty mental health services for people with SMI. The collaborative care model of integrated care can improve both physical and mental health care quality and outcomes. Collaborative care is a primary care-based model in which primary care physicians collaborate with a mental health care manager and a psychiatric consultant to proactively identify, treat, and monitor mental illness.

 The evidence supporting collaborative care is strongest for depression, although findings from limited clinical trials suggest this model may also benefit people with schizophrenia and bipolar disorder.

 Specialty mental health-based integrated care models that operate in a manner conceptually similar to collaborative care but with the specialty mental health program as the locus of care, have the potential to improve quality of medical care and physical health outcomes for people with SMI.

Insurance reimbursement challenges have been cited as a major barrier to adoption of integrated care models.

 Three federal and state policy initiatives are designed to address insurance reimbursement challenges: Centers for Medicare and Medicaid (CMS) behavioral health integration billing codes, the Affordable Care Act Medicaid health home waiver, and removal of same-day billing laws (

CMS behavioral health integration billing codes

CMS introduced four new billing codes for behavioral health (mental health and substance use) integration services in 2017. Three of these codes reimburse services provided within the collaborative care model and the fourth code reimburses services provided under other integrated care models. These codes can be billed by primary care or other general medical clinicians. To be eligible to bill the collaborative care codes, practices must be able to demonstrate that they have implemented the core elements of the collaborative care model.

The elements of the model include: a care team consisting of a general medical clinician, a behavioral health care manager, and a psychiatric consultant; use of validated instruments to identify and monitor mental illness; measurement-based treatment that uses a registry to monitor and track adjustments to patients’ care; and regular case reviews.

 To bill for care management that is not embedded in collaborative care, practices must demonstrate that their integrated care model includes systematic patient assessment and monitoring using validated instruments and behavioral health care planning, monitoring, and coordination.

These behavioral health integration billing codes have been adopted by Medicare and some state Medicaid and commercial plans. However, Cross and colleagues

 found that only 0.1% of Medicare beneficiaries with a mental health or substance use disorder diagnosis received behavioral health integration services billed with these codes from 2017 to 2018. The majority of behavioral health integration codes were billed for general care management services as opposed to collaborative care services. While use of these codes may increase over time, these findings suggest that the primary care and other general medical practices allowed to bill these codes face challenges meeting the staffing, infrastructure, and workflow requirements, particularly for the intensive collaborative care model.

The Patient Protection and Affordable Care Act (ACA) of 2010 included a provision that allowed state Medicaid programs to apply for a waiver to use Medicaid funds to create health homes. The homes were for high-cost, high-need subpopulations of Medicaid beneficiaries, including but not limited to people with SMI. In practice, this waiver allowed states to bill Medicaid for 6 previously non-billable services: comprehensive care management; care coordination; health promotion; transitional care; individual/family support; and referral to community and social support services.

As of November 2019, 17 states and the District of Columbia had used the waiver to implement health home programs for people with SMI. Of these 18 total programs, 10 are specialty mental health care-based and 8 allow either primary care or specialty mental health settings to implement health homes for Medicaid beneficiaries with SMI.

 Early research on waiver-established health homes suggest limited benefits. For example, Maryland’s waiver was associated with increased rates of cancer screening but had no effects on receipt of guideline-concordant cardiovascular care for participants with SMI.

The federal 21st Century Cures Act of 2016 clarified that federal law does not prohibit organizations or individual clinicians from billing Medicaid for both primary care service(s) and mental health service(s) delivered to a single patient on the same day. Prior to this clarification, the federal Medicaid statute was frequently interpreted as prohibiting same-day billing. Despite the clarification at the federal level, the same-day billing prohibition persists in many state laws.

In the most recent comprehensive assessment of state Medicaid laws that was conducted in 2015, 24 state Medicaid programs prohibited same-day billing by some or all settings and provider types.

 Since the clarification to federal law in 2016, some states have introduced and passed legislation to do away with the same-day billing prohibitions in state Medicaid laws. Medicaid is the largest payor of mental health services in the US, and same-day billing prohibitions have been cited as an important barrier to delivery of integrated care for people with SMI. No studies have assessed the effects of eliminating same-day billing requirements on care quality or health outcomes among people with SMI.

Federal and state policy gaps and next steps

To date, federal and state policies have focused on insurance billing for integrated care. However, new behavioral health integration billing codes have had low uptake and early research shows that the Medicaid health home waiver had limited effects on quality of physical health care for people with SMI. These findings suggest that the existing billing policies are insufficient to support adoption and high-fidelity implementation of the complex integrated care models that improved the physical health conditions driving premature mortality in SMI as shown in clinical trials.

There are many challenges to implementing integrated care for patients with SMI. One-sided financial incentives, lack of accountability, and carved-out financing of general medical and specialty mental health services are barriers to implementation. The behavioral health integration billing codes and most Medicaid health home waivers reimburse only one side of the general medical/specialty mental health duo. For example, the entire reimbursement for the collaborative care billing codes goes to the billing general medical provider, despite the central roles of the behavioral health care manager and psychiatric consultant on the care team.

Alternative financing arrangements, such as bundled payments or hub-and-spoke models, may alleviate this issue. Lack of accountability for physical health outcomes in SMI among either medical or mental health providers may impede care integration. Accountability could be improved through models tying payment to performance metrics, particularly models such as accountable care organizations, which can be structured so that both general medical and specialty mental health providers are subject to the same incentives.

Finally, carve-out of mental health insurance benefits so that such benefits are administered by a different organization than general medical benefits may obstruct delivery of integrated care. Carve-outs are particularly common in Medicaid, and many states are considering policies to integrate, or carve-in, mental health and general medical benefits. The effects of such policies on quality of care and health outcomes among people with SMI have not been rigorously studied.

In addition to these financing challenges, insufficient health information technology (IT) infrastructure and provider training have been identified as barriers to integrated care in multiple studies. Shared electronic medical records across general medical and specialty mental health care providers as well as electronic patient registries that track patients’ health indicators and needed/used services are core components of effective integrated care models but lacking in many settings. Policy models, such as the federal HITECH Act, could be used as the basis for new policies specifically focused on incentivizing health IT infrastructure for integrated care. Siloed primary care and specialty mental health training could be addressed through policies requiring incorporation in medical, nursing, and social work training curricula.

Critically, better integration of specialty mental health and general medical care for people with SMI is not enough to reduce premature mortality in the SMI patient population. Policies must also support delivery of effective health behavior interventions and address social determinants of health.

Obesity is a major driver of excess mortality in SMI, and tailored behavioral interventions have been shown to lead to clinically significant weight loss in this group. Financing strategies to support the weight management and group exercise sessions included in such interventions are needed. Medicare’s reimbursement strategies for its Diabetes Prevention Program sets a precedent for coverage of weight loss interventions that could be adapted.

Accreditation policies could be used to require health care or other types of organizations (eg, psychiatric rehabilitation programs) to have an on-staff trainer certified to deliver tailored behavioral weight loss interventions for SMI. Policies addressing the social determinants contributing to premature mortality from cardiovascular disease and other medical conditions in SMI are also needed. While some policies could be society-wide (eg, expansions of federal cash assistance or nutrition benefits policies) other policiess could target SMI specifically. For example, federal and state laws can allocate resources to evidence-based supportive housing and employment programs.

Dr McGinty is Associate Professor, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, and Associate Director, Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness; Dr Daumit is Professor, Division of General Internal Medicine, Johns Hopkins School of Medicine, and Director, Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness, Baltimore, MD. The authors report no conflicts of interest concerning the subject matter of this article

1. Olfson M, Gerhard T, Huang C, et al. Premature mortality among adults with schizophrenia in the United States. 

2. McGinty EE, Baller J, Azrin ST, et al. Interventions to address medical conditions and health-risk behaviors among persons with serious mental illness: a comprehensive review. 

3. McGinty EE, Baller J, Azrin ST, et al. Quality of medical care for persons with serious mental illness: a comprehensive review. 

4. Miller CJ, Grogan-Kaylor A, Perron BE, et al. Collaborative chronic care models for mental health conditions: cumulative meta-analysis and meta-regression to guide future research and implementation. 

5. O’Neill EA, Black DR. Collaborative care for individuals with bipolar disorder or schizophrenia and co-occurring physical health conditions: a systematic review. 

6. Carlo AD, UnÃ¼tzer J, Ratzliff AD, Cerimele JM. Financing for collaborative care: a narrative review. 

7. Centers for Medicare and Medicaid Services. Behavioral Health Integration Services. Medical Learning Network. Publication ICN MLN909432; May2019.

8. Cross DA, Qin X, Huckfeldt P, et al. Use of Medicare’s behavioral health integration service codes in the first two years: an observational study. 

9. Centers for Medicare and Medicaid Services. Health Home Information Resource Center. Medicaid Health Homes: SPA Overview. November 2019.

10. Murphy KA, Daumit GL, Bandara SN, et al. Association between the Maryland Medicaid behavioral health home program and cancer screening in people with serious mental illness. Psychiatr Serv. February 2020; Epub ahead of print.

11. McGinty EE, Stone EM, Kennedy-Hendricks A, et al. Effects of Maryland’s Affordable Care Act Medicaid health home waiver on quality of cardiovascular care among people with serious mental illness. 

12. Roby DH, Jones EE. Limits on same-day billing in Medicaid hinders integration of behavioral health into the medical home model. 

Policy initiatives can improve both physical and mental health care quality and outcomes for those with serious mental illnesses.

Early Mortality in SMI: Federal and State Policy Initiatives

The increase in repeated disasters and associated social stressors linked to global warming is likely to affect the mental wellbeing of billions of persons in the 21st century, increasing risk for depression, anxiety, PTSD, anger and violence, social disruption and displacement, and social conflict. This means that our current conceptual frame of disaster response will be too narrow to address the many problems created and exacerbated by climate change-disaster mental health no longer should remain the sole model guiding our preparation and response. We need an expanded view that encompasses diverse responses to match a greatly expanded set of threats.

The importance of strengthening disaster mental health response system

Disaster mental health response in the US commonly includes a stepped care system that includes community outreach and delivery of psychological first aid (PFA), crisis counseling, and, for those most greatly affected, formal treatment. The brief education and support included in PFA is offered to as much of the affected population as possible, with more intensive services made available for those at greatest risk for problems. Brief crisis counseling programs offer support and, increasingly, teach skillsets to improve coping (eg, problem-solving, relaxation, positive activity scheduling).

Most communities only develop the ability to implement these disaster response elements after they find themselves affected by a disaster. Prior to such emergent need, these services seem relatively optional and have not, to date, been able to compete with other political priorities. As a result, they do not attract significant organizational focus and allocation of resources. Moreover, after external funding goes away, the various organizational structures used to respond often disappear. If we are to improve our ability to respond to repeated events, an effort to transform acute response systems into enduring, sustainable programs is needed. Given the heightened awareness of disaster in the face of climate change, greater levels of preparation are needed for responding to mental health requirements as well as a way to sustain the capacities developed in response to specific disasters for ongoing use in future events.

The problems created by global warming (including recurrent disasters) are multifaceted. The all-hazard community-based resources and capabilities will enable more effective action in the face of climate-induced problems and will also spill over into the many challenges already troubling our communities (eg, family problems, work stress, drug addiction, suicide). In this sense, actions to increase climate change resilience tie in with other existing programs and services for social problems and life improvement.

Towards resilient communities: some components of a more adequate response

Improving disaster mental health programs will not be adequate to meet upcoming challenges. Rather, these programs will need to be supplemented by novel initiatives and combined into an integrated program of community support and resilience. They will require creativity and significant contributions from many quarters.

Coping skills training and support. Individuals who have effective coping and stress management skills, such as problem-solving, mindfulness, physical relaxation, and conflict resolution, will more successfully manage their experiences of disaster and exposure to climate-related stressors. Dissemination of these skills across larger populations in neighborhoods and regions is feasible and can include several strategies. Perhaps the most straightforward strategy is to develop, deploy, and maintain internet and mobile technologies for resilience. These technologies can include educational content and brief, interactive training materials that can serve as stand-alone resources or supplements to other support offered by mental health professionals and peers.

Findings from research suggest that internet-facilitated interventions can be effective in addressing a range of mental health problems especially when supplemented by human support.

 Mental health apps such as Calm and PTSD Coach are widely used and can reach large numbers of individuals; similar approaches are being harnessed for disaster response. For example, the Sonoma County Wildfire Collaborative deployed MySonomaStrong, an internet-based self-management tool (

Another strategy for strengthening effective coping and spreading key skills is to expand training for health care professionals as well as lay community members on effective coping and and crisis counseling. Primary and acute care medical clinicians can provide disaster response and critical incident stress management.

In addition, trained laypersons can be deployed to support clinical caregivers in disaster response. However, the capacity to train laypersons and paraprofessionals in delivery of effective interventions to address such adversity must be developed. This involves identifying effective interventions and training mental health professionals who would then train a large cadre of lay community members in these interventions.

Capacity to supervise trainees and administer training programs also would need to be established. While there are many evidence-based treatments for mental health problems, there continues to be a large gap between routine care and best practices, because of limited availability of trained providers. Expansion of access to training would help spread coping skills among disaster- and climate-affected populations while also increasing access to effective treatments in many mental health and social service settings.

Beyond psychological coping: actions for climate solutions. While a focus on coping and emotional wellbeing is necessary, it is also critical that direct actions to address the realities of climate change and mitigate its effects are undertaken as part of community response. In fact, involvement in activities intended to reduce global warming and address proximal climate problems is likely to bring direct psychological benefits, in addition to creating a safer and sustainable local environment.

Cumulative exposure to media coverage of the impacts of climate change compound stress responses via increases in perceived threat to our environment and our wellbeing. Already observable are increases in “eco-anxiety” as we worry about the future for ourselves, our children, and future generations. Adoption of behavioral changes (eg, use of public transportation, development of green spaces, adoption of clean energy technologies), efforts to take on problems that exacerbate the effects of climate change (eg, poverty, inequality), and participation in political actions to address climate change can help reduce stress and anxiety associated with a climate change. Making such changes can build confidence in one’s ability to cope (self-efficacy) and help reduce distressing thoughts and beliefs.

Self-efficacy can be expected to increase when individuals take practical actions to address aspects of a problem (eg, develop family emergency plans, participate in activities of the climate change movement, practice energy-conserving personal behaviors). Some climate-related actions, such as increasing commuting via bicycle and walking, may help reduce stress by increasing cardiovascular health and reducing physical tension. Increasing recreation and work in green spaces might reduce personal stress levels while at the same time increasing positive social interactions. Increased use of public transportation might increase perceptions of community cohesion. If individuals increase their engagement in such activities, it will help transform the negative thinking associated with worry about environmental problems into effective action, building hope and resilience in place of anxiety and depression, fatigue and despair.

Community-based readiness and sense of community. Over time, global warming is likely to increase social relationship stress, substance abuse, interpersonal aggression, violent crime, and social instability, the combined effects of which are likely to decrease community cohesion and, potentially, divide the global community. While social cohesion and social capital are thought to protect communities against mental and physical health impacts of disasters, it is not clear how to rapidly or reliably build these. However, even in the face of limited knowledge, it seems prudent to invest in and expand community mental health infrastructures; take steps to reduce disparities in resources and increase supports for vulnerable subgroups; strengthen capabilities for public mental health communication related to disasters and emergency incidents along with capacities to harness social media in the service of wellbeing; develop and strengthen preparedness planning; and establish and develop online communities for mutual support.

In addition to these specialized community-wide mental health activities, some more general initiatives will improve the wellbeing of community members. One key step is to increase the availability and use of public transportation, which in turn can be expected to increase community cohesion, recreational activities, neighborhood walkability, and physical exercise, all of which are likely to reduce symptoms of depression and stress. A second step is to increase the availability of contact with nature. More time spent interacting with nature can improve health and lower stress via several mechanisms including exposure to better air quality, increased exercise, the calming effects of natural environments, and increased social cohesion. Increased exposure to nature might also help to create commitment to environmentally positive behaviors and actions to reduce global warming.

Collaboration and community: toward resilient communities

Critical to a comprehensive response to climate change is bringing together climate activists, health care organizations, local government, self-help groups, educational institutions, business groups, and technology providers, to create a sustainable focus on these issues. Such a “big tent” approach is needed to ensure community buy-in and enable the kind of multidisciplinary expertise required for the various tasks.

Existing institutional structures may create barriers to needed collaboration. The various scopes of practice of disaster response personnel may make it difficult to jump the corridors of professional identity. The institutions in which mental health professionals work might have difficulty in expanding their missions to encompass the broader sets of activities. In fact, it seems likely that the expanded threats associated with climate change call for new kinds of interprofessional and interdisciplinary collaboration within the context of new kinds of organizational structures and alliances. Different perspectives on the problems (eg, climate change versus disaster response, political versus professional, economic versus mental health, social justice versus governmental responsibility) will need to be combined to reach an alignment on common goals and processes. It this can be achieved, it will bring into being many facets of a more robust public health system.

The process of community building needed to accomplish the objectives outlined here represents a significant strengthening of resilience within the participating communities and constituent organizations. The challenge is to mobilize wide, sustained support when climate change, for many, continues to feel like something that will happen to others, in far off places, in some distant future.

Because so many of the primary effects of climate change will be on mental health and psychosocial functioning, our current set of responses must evolve with much greater involvement of health care organizations. Hospital environments represent major opportunities to increase readiness for the mental health aspects of disaster and expand delivery of evidence-based mental health interventions. Increased capacity to deliver these interventions after disasters will also result in improved behavioral medicine services and capacity to more effectively address the wide array of traumas routinely seen in hospitals.

Mental health professionals, with their disciplinary expertise, are needed to help make the link between mental health and climate. They are central to any attempt to improve the emotional regulation skills and problem-solving abilities of the citizenry, whether they deliver such training as part of post-disaster support efforts or, more proactively, before disaster strikes, in schools, workplaces, community centers, hospitals, and social service organizations. As mental health professionals, we must become more climate-literate and serve as community leaders for this relatively ignored aspect of climate change. We also must step beyond our professional identities and work-related roles to facilitate greater community collaboration and help innovate to develop more effective individual and community-wide interventions.

A particular challenge is to identify which organizations might take responsibility for leading efforts and undertake population-based mental health monitoring and intervention as part of a more adequate and comprehensive response to climate change. The fight against climate change and its incumbent disasters must include mental health and social service organizations, community and national public health entities, worksite wellness programs, school-based mental health education, climate change organizations that can incorporate new areas of work to include mitigation of mental health difficulties, technology companies interested in improving the wellbeing of their communities, and mental health professionals.

Dr Ruzek is Co-Director Center for m2 Health, Palo Alto University and Adjunct Professor, Department of Psychiatry and Behavioral Sciences, Stanford University, CA. He reports no conflicts of interest concerning the subject matter of this article.

 Andrews G, Basu A, Cuijpers P, et al. Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: an updated meta-analysis. 

 Kuester A, Niemeyer H, Knaevelsrud C. Internet-based interventions for posttraumatic stress: a meta-analysis of randomized controlled trials. 

The increase in repeated disasters and associated social stressors linked to global warming is likely to affect the mental wellbeing of billions of persons in the 21st century.

Disaster Response, Mental Health, and Community Resilience

Patients with severe mental illness (SMI) routinely have no access to adequate medication, psychological counseling, social support, and/or housing. The horrible result is that 600,000 patients are either prisoners or homeless-or rotate between the two. The past 50 years of neglect and criminalization have made the US one of the worst places in the world to have a mental illness.

Meanwhile, on the mild end of the psychiatric symptom spectrum, we have the opposite problem of massive over-treatment. About 20% of the general population regularly use psychotropic medications, most often prescribed unnecessarily and carelessly after brief visits with rushed primary care doctors eager to get the patient out of the office as quickly as possible.

 And, perhaps for too many of these patients, psychiatric medications may be no more than expensive placebos, wasteful and carrying the added burden of harmful adverse effects. With that in mind, I offer some advice to policymakers on how to solve the cruel paradox that haunts our mental health “nonsystem”-we are massively overtreating people who do not really need it, while callously neglecting those who desperately do.

The overall thrust of badly needed policy reform must be to correct this wasteful and inhumane misallocation of resources. We should be spending much less money on long-term medications for the worried well and for those with mild, transient problems. Watchful waiting and brief psychotherapy would be a much better (and cheaper) alternatives for them. And, we should also spend much less money on misallocated jail, prison, and police services. In contrast, we must spend much more money on psychiatric and addiction services to help patients avoid becoming prisoners or homeless. The following are my suggestions for policymakers in seven key areas.

1 The top and urgent priority must be to deinstitutionalize 350,000 mentally ill patients who are now inappropriately warehoused in jails and prisons and to rehouse 250,000 who are homeless. If we fail to correct this barbarity, nothing else we succeed in doing really matters.

2 Serious mental illness should be the focus of all publicly funded psychiatric treatment, social services, and housing-with a full push to provide universal and easy access to free services for the poor and the uninsured.

3 A high level and/or high priority mental illness (including addiction) task force composed of senior representatives from all pertinent federal agencies should be charged with developing a joint action plan to provide a nationwide system of community psychiatric, social, and housing services (along the lines of the Kennedy Community Mental Health Act of 1963). Legislation should receive urgent priority, speed through Congress with overwhelming bipartisan support, and be a feather in the cap of whichever president has the honor of signing it.

4 The funding mechanism should provide strong incentives for states and local jurisdictions to participate in the planning and implementation of the new programs and to provide matching funding over the long haul. Because there are so many stakeholders and moving parts, it is premature to speculate on precisely how funding would work and how it would be integrated with, or replace, current funding sources. It is essential that funding sources be bundled so that psychiatric, social, and housing services are integrated in seamless, wrap-around fashion. The chain of care is only as good as its weakest link.

5 Reallocate expenses to address today’s mental health issues. The US spends about $100 billion on corrections; more than one-third of which is for people with mental illness, many of whom would have avoided arrest and incarceration had adequate treatment and housing been available.

Ironically and tragically, jails and prisons have become the main providers of mental health services in the US. Mental illness is also the most worrying problem facing police officers, whose job has expanded to be the responsible first responders for untreated and potentially unpredictable patients.

Moneys saved from reduced expenditures for currently bloated jails, prisons, police, and emergency services should provide ongoing funding for community psychiatric, social, and housing services that will replace them. Deinstitutionalization from psychiatric hospitals failed so miserably 50 years ago, precisely because the large sums of money saved from closing hospital beds did not follow the patients once they were discharged into the community. After eliminating prison beds, there must be an increase in community services and psychiatric beds.

6 Integrated psychiatric, social, and medical services in the community should include enhanced emergency department (ED) psychiatry; 24-hour crisis teams that replace police first responders; walk-in clinics; easily accessed long term follow-up treatment; prompt and thorough medical care; job training; and specialized programs for the most severe mental disorders. Continuity of care must be emphasized every step of the way.

7 The number of short-term inpatient psychiatric beds needs to be increased. Preferably these should be in non-profit, general hospital settings-and not in free-standing, for-profit private psychiatric hospitals (which often deliver overpriced and less competent care).

8 Encourage dual diagnosis programs. The mentally ill are at increased risk for having comorbid substance abuse problems, and vice versa. It is vital to integrate treatment of mental illness and accompanying substance abuse. This is an especially high priority because the combination of untreated mental illness and addiction is the best predictor of violence, suicide, and other poor outcomes.

9 Increase the availability of Housing First programs, which are an essential response to the simple fact that it is impossible to adequately treat people who have no stable place to live. Homelessness is rapidly growing in cities throughout the country due to the shortage of affordable housing and the recent sharp and widespread rise in rents. The mentally ill constitute more than one third of our homeless population, now estimated at about 600,000 and are particularly vulnerable to our national housing crunch.

Warning note: President Trump recently suggested clearing the streets of the homeless by forcing them into what would amount to federal “concentration camps.” Hopefully, this unconstitutional proposal to involuntarily incarcerate hundreds of thousands of blameless people was no more than a transient publicity stunt.

10 Encourage the use of special courts for patients who are mentally ill and addicted to substances to ensure proper referral of minor offenders to rehabilitation programs that help remedy the problems that led to arrest and avoid inappropriate incarceration in jails. Diversion programs are especially crucial in the interim before easy access to integrated care protects patients from committing the minor crimes that currently get them jail time.

11 Integrate psychiatric and medical care with housing programs. People with severe mental illness usually die prematurely-on average 20 years before the general population.

 This is largely a function of psychiatric, medical, and social neglect and can be improved only by increasing access to integrated care.

12 Increase the availability and use of vocational and job placement programs, both of which can be great investments for the individual as well as the economy. Work is often the best therapy.

13 Tighten quality control and financial audits to ensure good care and value for money spent. Currently, there is the potential for waste and mismanagement in psychiatric and addiction programs-particularly in the private system where the profit motive may drive more decisions than optimum care.

High standards must be set for allowable billings and accountable treatment. It is especially important to monitor easy access to care and continuity of care (eg, by auditing number of days before first outpatient appointment after an ED visit or hospital discharge).

14 Encourage assisted outpatient treatment, which reduces incarceration, homelessness, relapse, suicide, and violence. The coercion of court-mandated psychiatric treatment is ever so much gentler and more temporary than the cruel and extended coercion of jail or homelessness.

15 Loosen confidentiality laws in the emergency and long-term management of serious mental illness. Although appropriate in other medical settings, strict laws can be detrimental in this setting. Family support and participation in decision making is needed to help patients whose judgment may be impaired. Laws must balance the value of confidentiality against the need for clinical common sense.

16 Temper the enthusiasm for universal screening for psychiatric disorders. This is a terrible idea in the general population, although it is extremely popular. The harms done (eg, overdiagnosis, excess medication, stigma, misallocation of scarce resources away from the severely ill) far outweigh the benefits. In contrast, screening in high-risk groups has a very good benefit-to-risk ratio (eg, mothers perinatally, victims of extreme stress, high risk families).

17 It is past time to stop fighting the long-lost supply side “war against drugs.” Instead, it is time to reduce demand by providing adequate treatment and prevention. All attempts at interdiction and prohibition have failed in the past and will always fail in the future. Where there is a strong will to get drugs, a clever way will be found to provide them.

18 Adopt harm reduction models-this is the only rational approach for street drugs. Fentanyl is an irrevocable game changer. There has never been a time when illegal street drugs have been so ridiculously cheap, lethally potent, varied, and convenient to smuggle and distribute.

By a combination of design and accidental contamination, illegal fentanyl now has become almost ubiquitous in street drugs and counterfeits. In just 6 years, it has grown from minor threat to disaster drug-responsible for almost half of all the exponentially growing overdose deaths.

Current drug policy is impotent to stop, or even limit, the rush toward fentanyl death and destruction.

19 Free market competition, not interdiction, is the best way to defeat cartels and reduce drug crime. Legalizing drugs (

) should be seen both as a safety measure for the users and an economic weapon against the cartels-not a revenue-raiser for states. For legalization to work, legalized drugs must be priced low enough to compete successfully against street drugs. Legalization can help states save big money on corrections; it becomes self-defeating if it also is used as a tax opportunity.

20 Get rid of the one-size-fits-all notion in treating drug addiction. Puritanical abstinence ideology should not be an exclusive guide to policy. The previous (morality-driven) emphasis on 12-step abstinence has created a great shortage of harm reduction programs using medically assisted treatment. Paradoxically and stupidly, government inaction in regulating the overuse of prescription drugs facilitated the opioid epidemic, while excessive government restrictions prevented the widespread use of the very medications (eg, suboxone) needed to reduce impairment and deaths. Abstinence is possible for some, an aspirational goal for many, but not a foundation for sensible drug policy.

21 Take control of the vaping crisis. The e-cigarette epidemic among young teenagers (started via candy-flavored nicotine products)
	has already become a gateway to the vaping of much more dangerous pot synthetics. The next logical step in this dangerous progression may
	be the lethal vaping of hard street drugs. We must hope that this cat is not already out of the bag.

Unscrupulous vaping companies must be sued and fined; schools need to regain control of their bathrooms; and well-funded public education campaigns should make vaping as uncool as smoking. Drug prevention has never been very successful in the past, but it has never been tried on the same massive scale that worked in making smoking tobacco a dirty habit rather than a rite of passage to adulthood.

22 It is crucial that opioid money awarded to state and local jurisdictions be used exclusively to fund addiction programs. There will be massive fines and settlements (my guess about $100 billion) imposed on the drug companies, distributors, and retailers that knowingly promoted the opioid epidemic. The tobacco settlement money (more than twice as much) never found its way to the victims, as states instead used it to reduce taxes or fund other programs (notably prisons).

23 We must not allow political and commercial foxes to guard the public health henhouse. Regulatory capture by industry contributed greatly to the damage done by the tobacco, opioid, and vaping epidemics. The FDA is 45% financed by the drug industry.

 Its staff and leadership may have a much-too-intimate, revolving door relationship with it.

The FDA’s independence and monitoring authority has also been steadily eroded by political pressure and Congressional statute. The Drug Enforcement Agency was a toothless tiger in controlling the prescription opioid epidemic because its leadership was subservient to industry.

24 Manage sociocultural and political issues that influence suicide risk. Suicide rates have increased 24% during the past 20 years, accounting for almost 50,000 deaths/year.

 Factors outside psychiatry probably have the most influence, particularly increased accessibility to the most common means (eg, guns, drugs); increasing economic inequality and job insecurity; and the contagious perils of social networking.

There will never be one solution to suicide and most of the effective measures taken to reduce overall rates are outside mental health policy and practice. The best suicide prevention is reducing access to guns and drugs; providing a better social safety net; and good treatment for people who are at high risk.

25 Reconceptualize Zero Suicide programs, which are poorly named because they set an unrealistic expectation and imply that caregivers or loved ones could have prevented the suicide had only they been smarter or tried harder. Suicide can be reduced, but never completely eliminated.

26 Keep in mind that the simple things work best in reducing suicide in high-risk groups: continuity of care; easy access to treatment; close follow-up every step of the way with timely and frequent appointments; involvement with family and other supports. There is no magic way to prevent suicide, but good care and caring go a long way.

27 Don’t forget the basic fact: guns kill people. The US has a remarkably high rate of gun death compared with peer countries. Each year guns are responsible for about 24,000 deaths by suicide, 15,000 deaths by homicide, 1000 deaths by accident, and an additional 70,000 non-lethal gun injuries. We do not have higher rates of mental illness than peer countries, but we do have remarkably lax gun regulation and 400 million guns in circulation.

28 Red flag laws that restrict gun access for people with severe and persistent mental illness or addictions make great clinical and policy sense, particularly in reducing deaths by suicide. However, such laws will not come close to solving America’s gun violence problem because only a tiny percentage of murders are committed by people with mentally illness (who are much more likely to be victims of gun violence than perpetrators).

29 Be wary of the National Rifle Association’s political support for better mental health care, which is a great good being done for a great evil. The NRA is attempting to distract attention from desperately needed gun control laws with the absurd and stigmatizing claim that most people who misuse guns are mentally ill.

Mental health advocates are understandably delighted to exploit powerful NRA political support for more mental health services. But we must not be deterred from simultaneously continuing the fight for desperately needed gun control. America would still have terrible gun violence statistics even if we could suddenly cure everyone with a mental illness. We need both much improved mental health services and better gun control laws.

30 Direct to consumer marketing of pharmaceuticals needs more oversight. The US is the only country in the world (aside from New Zealand) that allows direct-to-consumer advertising. This privilege has been abused and should be eliminated. Rules governing marketing to doctors should be tightened. The public needs to learn that a pill for every problem does not exist.

31 Ensure a separation of church and state-industry and the FDA.

There is a revolving door that creates an inherent pro-pharma bias-FDA leadership and staff are often recruited from industry and return to it.

 The result-ineffective, unsafe, and expensive new drugs are almost never rejected and, once approved, drugs are inadequately monitored for harm or not monitored at all. The only way to protect patients and taxpayers is to restore complete FDA independence from industry and political influence.

32 Ensure proper training of other specialties. Primary care doctors now prescribe 80% of all psychiatric medications-often after very brief visits for patients who do not need them.

 They would prescribe fewer unnecessary medications if they had more time to talk to their patients. Most of the emotional problems mistreated with medications may be better handled with advice, support, and watchful waiting.

33 Remove the diagnostic requirement for insurance coverage. Insurance companies require doctors to jump to premature diagnosis and treatment as the precondition for reimbursement. Instead, allowing for an extended period of evaluation would result in much more careful diagnostic and prescribing habits and less long-term use of unnecessary medications.

34 Deprescribing should be extensively taught during medical school and residency training as well as continuing medical education. Physician training includes extensive teaching on how to prescribe drugs and almost no teaching on how to deprescribe them. This is backwards-prescribing is fairly easy to learn and requires relatively little skill. Deprescribing is complicated and requires the finest clinical judgement.

35 There is an urgent need for unified medical care, which is essential and generally lacking. The more doctors a patient has, the more medications will be prescribed-particularly when each doctor neither knows nor cares what the others are doing. Medication adverse effects are the most common cause of new symptoms in someone taking multiple drugs, particularly common among the elderly, who clear and metabolize drugs much more slowly.

36 Make brief psychotherapy easily accessible. Psychotherapy is preferable to medications for most mild to moderate psychiatric problems. It is just as effective, much safer, and with an enduring positive impact.

 The misleading mantra that psychiatric problems all result from a chemical imbalance and therefore everyone requires a chemical cure is misleading.

37 Research budgets should be rebalanced to provide adequate funding for projects that contribute practical findings to improve people’s lives-even if they do not further scientific understanding of brain or gene functioning. The massive budgets of the National Institute of Mental Health, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism are focused on brain mechanisms-not on clinical and services research.

Not surprisingly, we have learned a great deal about brain function and genetics, which has very little of value in helping patients. The past 30 years of intense research and fascinating discovery has made it abundantly clear that the brain and genetics are far too complex to yield any simple answers or breakthrough cures. We must reduce patient suffering now, not wait for promised breakthroughs that never happen.

38 Top priority should be given to research studies and demonstration projects that reduce the incarceration and homelessness of people with serious mental illness and addiction. Public health significance, not just scientific interest, should be an important factor in selecting which projects are funded.

39 Keep in mind that there is an enterprise-wide bias hype positive results, ignore negative studies, and neglect to replicate study results. This distortion leads to tried-and-true treatments for mentally ill patients to be overlooked while the untried and untrue are prematurely promoted.

40 Advocacy has failed in the past and, unless radically changed, is likely to continue to fail in the future. We are the richest country in the world, but we shamelessly and barbarically neglect our most vulnerable citizens in a way that would not be tolerated in any of our peer countries. Politicians respond only to money, votes, and public shaming-patients with serious mental illness and addiction are often poor, don’t or can’t vote, and have no public voice.

41 Our current crisis makes this a potential moment of rare opportunity-don’t waste it. The armies of homeless living desperate lives in plain sight in most major cities are impossible to ignore. The “not in my neighborhood” reflex against treatment programs and housing becomes much less powerful when the homeless are already in your neighborhood.

The opioid crisis, that afflicts millions, and kills tens of thousands every year, is also impossible to ignore. The push for correctional reform occasioned by frequent police shootings and the prison crisis have made police officers and sheriffs the most effective advocates for better services and housing for those suffering from serious mental illness and addiction.

42 Remember that mental illness and addiction strike families indiscriminately across the political divide. This is one issue that can and should achieve universal bipartisan political support.

I would love to end on an uplifting “Yes we can” inspirational note. But the past 60 years of neglect would make it ring hollow. Our best (only) hope is that the most concerted efforts, occurring in what is now the most inescapably desperate context, will end the complacency and achieve what has heretofore been impossible: at long last, to force our country to do the simple and right thing, which also happens to be the smart thing.

 What advice would you share with policymakers, patients, and family members? What do you wish your colleagues in psychiatry or general medicine knew or did? And, what advice did you wish someone had shared with you? Send your thoughts to 

Dr Frances is Professor Emeritus and former Chair, Department of Psychiatry, Duke University; Chair, DSM-IV Task Force. He is the author of Saving Normal and Essentials of Psychiatric Diagnosis. Twitter: @AllenFrancesMD. The views expressed in this article are those of the author and do not necessarily reflect the opinions of

1. Miller SG. One in six Americans takes a ssychiatric drug. 

2. Treatment Advocacy Center. Research Weekly: Homelessness Increases Among Individuals With Serious Mental Illness. January 11, 2018.

3. National Institute of Health. Combating Early Death in People With Serious Mental Illness. November 4, 2015.

4. Centers for Disease Control and Prevention. Fentanyl.

5. US Food and Drug Administration. Fact Sheet: FDA at a Glance. October 2019.

6. Kaiser Health News. KHN Morning Briefing: Justice Department Report: DEA Let Painkiller Production Surge Even as Opioid Epidemic Alarm Sounded. October 2, 2019.

7. Centers for Disease Control and Prevention. Suicide Rising Across the US.

8. Pew Research Center. What the Data Say About Gun Deaths in the US. August 16, 2019.

9. Piller C. FDA’s revolving door: companies often hire agency staffers who managed their successful drug reviews. 

10. Cuijpers P, Quero S, Dowrick C, Arroll B. Psychological treatment of depression in primary care: recent developments. 

Repairing Our Broken Mental Health Care System: Advice for Policymakers

Its Current Status and Collective Responses From Mental Health Professionals in Hong Kong

The 2019 Hong Kong protests, also known as the Anti-Extradition Law Amendment Bill (or Anti-ELAB) movement, are an ongoing series of demonstrations in Hong Kong that were triggered by the introduction of the Fugitives Offenders amendment bill by the Hong Kong Government. If enacted, the bill would allow local authorities to detain and extradite criminal fugitives who are wanted in territories with which Hong Kong does not currently have extradition agreements, including Taiwan and Mainland China.

This aroused concern and suspicion that the bill would subject Hong Kong residents and visitors to the Mainland Chinese jurisdiction and legal systems, undermining Hong Kong’s autonomy and its civil liberties. At the time of this writing, there continue to be serious confrontations between the police and protesters, so much so that many major highways linking key areas of Hong Kong are blocked by barricades and the city’s Mass Transit Railway ceases regular service after 10 pm daily.

Negative impact of social unrest on mental health

This unprecedented political crisis affects everyone in Hong Kong. There has been a deterioration in mental health among the people to its worst level in 8 years, 41% of survey respondents said that their mental health is being negatively affected by social unrest.

 Although the exact causes need to be elucidated by additional research studies, there are several possible reasons that explain how and why people are affected adversely by the recent social unrest.

 Both protesters and the police are directly involved in repeated and major violent conflicts.

 People working in areas where major confrontations between police and protesters happen are exposed to violent scenes or subjected to physical violence.

 Families and friends disintegrate because of different political views, which results in shrunken social roles and support network.

 Because of the socioeconomic downturn associated with traffic chaos and uncertainty among investors, many people who work in the service and tourist industries are facing salary cuts and unemployment.

Financial difficulties understandably lead to detrimental effects on housing, education, and social problems. These socioeconomic adversities are exacerbating factors for a variety of mental health problems. Moreover, there has been a negative impact on mental health caused by exposure to vivid traumatic scenes depicted in television and social media.

 A preference for visual processing may be positively related to intrusion frequency of traumatic images even when only hearing about a traumatic event.

 Therefore, the negative effect of regular and intensive exposure to vivid videos and news of street violence can affect the mental health of people even when not directly exposed to the traumatic event.

Major impact on existing mental health problems

Anecdotal accounts from various mental health facilities indicate an increase of self-reports of acute stress-disorder–like symptoms. Patients with established mental health problems report traumatic flashbacks, hypervigilance, and dissociative experiences as a consequence of regular exposure to newsfeeds and online videos of street violence.

In response to these common complaints among patients, the Hong Kong College of Psychiatrists released a set of mental wellbeing tips for dissemination to schools, social welfare agencies, community centers, health clinics, and hospitals. These tips include advice on restrictions of social media use, better sleep hygiene, balancing different roles and commitments, maintaining normal routines as much as possible, and sustaining existing social networks. With an aim of encouraging news media outlets to provide precise news reports, the College has held workshops with journalists to educate them on the symptoms of stress-related disorders and the negative impact of excessive exposure to news and videos.

Preliminary territory-wide service statistics data show no obvious surge in the number of people presenting to public mental health services for new onset mental health issues. Although stigma toward mental health and lack of mental health literacy about stress-related disorders may explain this lack of a major surge in service demand, there may be other causes.

The trajectory of stress response is highly complex. An Australian study showed that of those with PTSD onset 12 months after trauma, only 37% had symptoms at 3 months with worsening of symptoms with time.4 This phenomenon is more common among military personnel than civilian trauma survivors.5 The confrontation between protestors and police officers, as well as other responders such as journalists, emergency medical staff, firefighters, and other volunteers and counselors are not unlike military personnel being deployed to a frontline war zone. Thus, the mental health tsunami might only hit the shore weeks or months after social unrest has died down.

Apart from the possible delay in onset of stress-related disorders, there may be a delay in presentation to public mental health systems for political reasons. In past months, there have been rumors among social media and e-news that public health care workers deliberately disclosed personal information of injured protesters seeking help in public hospitals to the police force. Such personal information could be used by the police to facilitate immediate arrest and removal of individuals from hospitals to criminal detention centers.

Conversely, there have been sit-in protests among health professionals in major public hospitals in Hong Kong condemning the use of excessive violence toward the protestors by police officers. As such, many police officers are skeptical about whether they will receive proper care from health professionals. There have been sporadic news reports of confrontations between health care workers and police officers in the emergency departments of public hospitals.

Protestors and police officers also have disclosed to their trusted health care providers that they are concerned that their mental health records will be accessed by legal authorities to their disadvantage. Under the Hong Kong Personal Data Privacy Ordinance, personal data will be released to law courts upon receipt of court orders by the public health authority, even in the absence of informed patient consent. If the speculations are true, the mental health problems experienced by protestors and police will have a delay in illness presentation and wil not be obvious until mental health emergencies set in.

Because of the high costs associated with private mental health care, only a small proportion of vulnerable groups will be able to receive care in a timely manner. The results are dire with a likely increase of acute presentations of mental health emergency crises-including suicide.

Implementing mental health relief actions

Formal and informal mental health care support is available to people affected by current social unrest. Volunteer social workers, counselors, psychologists, and doctors are providing acute psychological support to protestors.

As of the writing of this article, there are no data either on the number of or the expertise and professional background of these underground mental health care workers. Nor is there an official number of persons with mental health problems. One report indicates that more than 35% have symptoms suggestive of PTSD. (Hong Kong Economic Journal, November 1, 2019).

Apart from this informal care network, the Federation of Social Services launched a program in October 2019 whereby people with mental health problems are referred to free psychosocial intervention sessions. The available therapies range from traditional Chinese medicine to clinical psychological services. Workshops and talks have been organized to educate relevant stakeholders in managing conflicts arising from political differences in schools, at workplaces, and within families.

In response to the unmet mental health needs among people from different walks of life, the Hong Kong College of Psychiatrists launched a systematic and multi-level mental health intiative, the Care4ALL Programme. Its goal is to promote mental health resilience; knowledge posters, videos, and pamphlets have been created. The objective is to increase knowledge and skills among relevant community stakeholders in early identification and referral of people with mental health problems.

The College has more than 80 volunteer psychiatric fellows who provide psychiatric care at low cost for a limited number of sessions. Through a collaboration with the Division of Clinical Psychology, the Hong Kong Psychological Society and New Life Psychiatric Association, eligible patients receive a number of protocol-driven psychological interventions in parallel with the care offered by the volunteer psychiatrists.

This program provides a new model of mental health care that addresses the usual cost barrier associated with private psychiatric care and concerns of privacy breaches and perceived discrimination by public mental health workers. The program has received widespread media coverage and has been highly regarded by the Food and Health Bureau and Hospital Authority of Hong Kong.

Although there is ongoing political crisis in Hong Kong, many people are confident that the crisis will resolve. However, the mental health crisis may last for decades.

Mental Health Systems

Addressing Premature Mortality: Living With Serious Mental Illness

Early Mortality in SMI: Federal and State Policy Initiatives

Disaster Response, Mental Health, and Community Resilience

Repairing Our Broken Mental Health Care System: Advice for Policymakers

Mental Health Crisis in Hong Kong

Beginning the Decade With 2020 Vision

Disability and the Concept of Return to Work

LGBTQ Mental Health: What Every Clinician Needs to Know

Veterans and Suicide: The Last Straw

Collaborative Care Meets Hospital Medicine: Proactive Consultation-Liaison Psychiatry