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The authors outline the ingredients for the transformation of mental health care in America.
Never before has it been so timely and important to improve health care for people with mental and substance use disorders in the US. The urgency of enhancing mental health care has been underscored by glaring social maladies, including homelessness, suicide among military personnel and veterans, incarceration, opiate addiction, and mass violence, which have galvanized public attention to mental illness. Political challenges notwithstanding, this article highlights the significant common ground that supports an agenda for transformative improvement of mental health care in the US.
Our “broken” mental health care system adversely affects large segments of the US population. People with serious mental illnesses (SMI), including depression, bipolar disorder, PTSD, schizophrenia, autism, and Alzheimer disease, experience severe distress and disability, require high levels of costly health services, and have substantially shortened lifespans due to excess medical comorbidity and increased suicide rates. Included in this population are people with addictions, such as victims of the recent opioid epidemic most prevalent in rural America. Deficiencies in mental health and addiction services are so longstanding and profound in the US that they cannot be simply characterized as unmet clinical needs or health care disparities: they represent what former Congressman Patrick Kennedy has called a “violation of civil rights.”
The economic burden of these illnesses is tremendous. The estimated annual costs of depression in 2010 totaled $210.5 billion, including both direct costs and indirect costs such as mortality arising from depression-related suicides as well as the effects of depression in the workplace (eg, absenteeism).1 The cost of opioid use disorders in 2013 was estimated at $78.5 billion.2 Furthermore, the Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that mental and substance use disorder treatment spending from all public and private sources for direct costs alone will rise to a total of $280.5 billion in 2020, an increase from $171.7 billion in 2009.3 These figures do not include additional costs to the criminal justice system, which houses large populations of people with inadequately treated mental illness and substance use disorders.4
Improving mental health care is-and has been-a bipartisan issue. The New Freedom Commission, convened by President George W. Bush in 2002, sounded a “clarion call for this and future administrations to pursue dramatic improvements in the mental health care delivery system.”5 However, “fragmentation, stigma, [and] frozen budgets” largely thwarted this effort. Since then, legislation such as the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), as well as President Barack Obama’s health care reform bill, the Patient Protection and Affordable Care Act, have pushed forward expanded funding for mental health and substance use services. Yet previous efforts to address unmet public mental health needs have not succeeded in fulfilling their goals of broad access to quality care.
Piecemeal progress in our current mental health delivery system is insufficient. That is why a comprehensive approach to mental illness and substance use disorders should be enacted, as has been done with cardiovascular and infectious disease. This strategy targets populations in need, including those affected with and at risk for mental disorders, and would provide proven interventions to reduce morbidity and mortality. Such a mental health care plan would be comprehensive, multifaceted, and diverse and include the following core elements: universal access and broad geographic distribution, dissemination and implementation of evidence-based treatments, multidisciplinary team-based care, workforce development and deployment, alignment of financing systems, and assessment of cost-effectiveness with clear and meaningful quality and outcome metrics.
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.
1.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.6
2.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.7 These services must also be extended to juveniles at high risk for mental illness and substance use disorders.
3.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.
Measurement-based care, where treatment is tied to outcomes-as already developed in payment for the care of diabetes, hypertension, congestive heart failure, and other nonpsychiatric medical conditions-must be utilized throughout the mental health care system and woven into its payment models. The National Academy of Medicine has released Vital Directions, which calls for improved and innovative payment models that align with evidence-based treatments.8
4.Modernization of health information technology
Health information technology (HIT) offers a major opportunity for improvements in mental health care. Computerized clinical decision support for treating patients who are not responding to initial medication trials, telemedicine, and computer-guided adaptations of psychosocial treatments for people with SMI are innovations awaiting greater utilization. In addition, integration of and training in HIT within behavioral health settings is essential to achieve interdisciplinary and cross-provider collaboration.
Scientific advances, social progress, mental health literacy, and federal legislation have created a strong foundation for the transformation of mental health care in America. This article has laid out a viable agenda for next steps. But that is not enough: political leadership and strategy are also necessary, along with support of biomedical research in brain disorders and investment in the development of new, more effective treatments.
President Trump signaled that health care reform will be a top priority in the first year of his administration. We expect that this would include mental health care. With this article’s agenda at the ready, and the momentum from the expanded 21st Century Cures Act, the Trump Administration, with the participation and support of Congress and other stakeholders, has a unique opportunity to mobilize the necessary political will to engage in a bipartisan effort to enact a “Mental Health Plan for America” to deliver quality mental health services for all those in need.
Dr. Lieberman is Lawrence C. Kolb Professor and Chairman, Columbia University Department of Psychiatry, New York; Dr. Goldman is Resident Physician, Columbia University Department of Psychiatry; Dr. Olfson is Professor, Columbia University Department of Psychiatry; Dr. Pincus is Professor and Vice Chair, Columbia University Department of Psychiatry; Dr. Sederer is Adjunct Professor, Department of Epidemiology, Columbia University Mailman School of Public Health.
The authors report no conflicts of interest concerning the subject matter of this article.
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3. Substance Abuse and Mental Health Services Administration. Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010-2020. http://store.samhsa.gov/shin/content//SMA14-4883/SMA14-4883.pdf. Accessed February 25, 2017.
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6. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed February 25, 2017.
7. McNiel DE, Binder RL. Effectiveness of a mental health court in reducing criminal recidivism and violence . Am J Psychiatry. 2007;164:1395-1403.
8. Knickman J, Rama Krishnan KR, Pincus HA, et al. Improving Access to Effective Care for People Who Have Mental Health and Substance Use Disorders: A Vital Direction for Health and Health Care. 2016. https://nam.edu/improving-access-to-effective-care-for-people-who-have-mental-health-and-substance-use-disorders-a-vital-direction-for-health-and-health-care/. Accessed February 25, 2017.