At the Intersection of Health, Health Care and Policy Cite this article as: David Mechanic More People Than Ever Before Are Receiving Behavioral Health Care In The United States, But Gaps And Challenges Remain Health Affairs, 33, no.8 (2014):1416-1424 doi: 10.1377/hlthaff.2014.0504
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Mental Health By David Mechanic 10.1377/hlthaff.2014.0504 HEALTH AFFAIRS 33, NO. 8 (2014): 1416–1424 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
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David Mechanic (mechanic@ rci.rutgers.edu) is the René Dubos University Professor at the Institute for Health, Health Care Policy, and Aging Research at Rutgers University, in New Brunswick, New Jersey.
More People Than Ever Before Are Receiving Behavioral Health Care In The United States, But Gaps And Challenges Remain ABSTRACT The high prevalence of mental illness and substance abuse disorders and their significant impact on disability, mortality, and other chronic diseases have encouraged new initiatives in mental health policy including important provisions of the Affordable Care Act and changes in Medicaid. This article examines the development and status of the behavioral health services system, gaps in access to and quality of care, and the challenges to implementing aspirations for improved behavioral and related medical services. Although many more people than ever before are receiving behavioral health services in the United States— predominantly pharmaceutical treatments—care is poorly allocated and rarely meets evidence-based standards, particularly in the primary care sector. Ideologies, finances, and pharmaceutical marketing have shaped the provision of services more than treatment advances or guidance from a growing evidence base. Among the many challenges to overcome are organizational and financial realignments and improved training of primary care physicians and the behavioral health workforce.
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ith the passage and implementation of federal mental health parity legislation in 2008 and the many supportive provisions for behavioral health in the Affordable Care Act (ACA), there appears to be a turning point in the recognition of the centrality of mental health status and function for the nation’s health. But many challenges remain in developing services responsive to the realistic needs of people with serious mental health and substance abuse disorders. Central to the challenge is timely access to services and needed referrals, appropriate organization and coordination of services, and greater commitment to providing evidence-based services of high quality. As the late John Eisenberg so appropriately challenged the field of medicine more generally: “We need to respect experience and expertise, but not accept the doctrines of those who would have physicians follow the 1416
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lead of self-proclaimed experts and authorities, whose assertions often lack the strength of scientific evidence. We need to move away from ‘eminence-based’ medicine, and toward evidence-based medicine.”1 In this article I review the damaging effects of serious behavioral disorders and the forces that shaped the evolution of the current system, including the disarray of services, the status of financing, and the essential role of Medicaid. I then examine pathways to evidence-based practice, particularly for people with the most serious and incapacitating disorders. I conclude with the challenges of reform and discussion of implementation of opportunities of the ACA and extensions of Medicaid.
The Costs Of Behavioral Disorders Behavioral health is a central aspect of health status, and serious behavioral disorders have
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devastating effects on the well-being of individuals, families, and communities. They contribute importantly to mortality not only through high risks of suicide but through deaths from the wide spectrum of causes of mortality. Studies vary in their estimates from eight to thirty years of life lost depending on populations studied and methodological approaches.2–4 The consequences of behavioral disorders extend well beyond the affected individuals: to their families, to the development of children, and to the welfare of the wider community. Behavioral disorders are a major cause of disability in the population and can be responsible for the inability to work or reduced work performance. From an economic perspective, such disorders not only have high costs of reduced productivity but have been for some time the largest contributor to Social Security disability status other than musculoskeletal disorders.5,6 Increasingly, research finds that behavioral disorders, while not a direct cause of many important disorders such as diabetes and cardiovascular disease, contribute to these conditions through lifestyles; use of substances; and, unfortunately, even treatment. Behavioral disorders also induce great pain and distress, which studies find are comparable to the most serious of physical disorders.7(p8-9)
The Social Trajectory Of Behavioral Health Any serious historical examination of the evolution of behavioral health must conclude that so-
cial forces, ideologies, finances, and more recently pharmaceutical marketing have shaped the system of services more than treatment advances or improved care. Prior to the mid-1950s most patients with serious disorders were treated in public mental hospitals, often with long lengths-of-stay. In the mid-1950s more than a half-million people were in public mental hospitals, when the population of the United States was 167 million. As the myth goes, antipsychotic drugs were introduced in the early 1950s, and the availability of these new effective treatments allowed the emptying of mental hospitals (Exhibit 1). The introduction of antipsychotic drugs did have utility in sedating patients, making them easier to manage, and it gave hospital administrators, hospital personnel, and family members confidence that patients could leave the hospital. But as Exhibit 1 shows, these drugs did not in the main empty public mental hospitals. Between 1955 and 1965 public mental hospital populations decreased by about 15 percent. These populations were reduced by an additional 65 percent during 1965–85 (Exhibit 1). This decrease primarily was made possible by Medicaid and Medicare, and other government safety-net programs such as the expansion of disability insurance, and by large incentives to the states to move patients to settings where the federal government, and not states, would assume much of the costs. During this two-decade period large numbers of patients were moved from state mental hospitals, which were the full financial responsibili-
Exhibit 1 Resident Patients In State And County Mental Hospitals: Total Population As A Percentage Of 1955 Base, 1955–2000
SOURCES For 1955–74: President’s Commission on Mental Health. Task panel reports: submitted to the President’s Commission on Mental Health, volume 2. Ann Arbor (MI): University of Michigan Library; 1978. p. 94, Appendix Table 3. For 1975–2000: Center for Mental Health Services. Mental health, United States, 2004. Rockville (MD): Substance Abuse and Mental Health Services Administration; 2006. (Report No. SMA-06-4195). p. 208, Table 19.5. NOTES The number of state hospital residents in 1955 was 558,922. SSI is Supplemental Security Income. SSDI is Social Security Disability Insurance.
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Mental Health ty of the states, to board-and-care facilities, which were typically privately run residential care homes providing minimal care and, commonly, low living standards. Many patients with behavioral health problems were transferred to nursing homes. Most hospital care for patients with behavioral health problems was transferred to general hospitals, either in specialized psychiatric units or scattered among medical and surgical beds, all substantially reimbursed through federal programs.8 After 1985 managed care reinforced the deinstitutionalization trend by way of stricter utilization management, but the effects were modest relative to the powerful financial incentives to the states and the federally supported safety net. As inpatient care moved to general hospitals, over time mostly to specialized psychiatric and chemical dependency units, strict managed care reduced admissions and kept lengths-of-stay short, largely to stabilize symptoms. The theory was that care would now be provided in an integrated community program in which the hospital played a coherent part—an aspiration largely unfulfilled. Patients were commonly returned to community settings without adequate follow-up or access to the range of services needed to facilitate function and allow a decent quality of life. After some fifty years this is a failure that mental health professionals, policy makers, and much of the public still aspire to correct for those with the most severe and incapacitating disorders. Advocates for the mentally ill complain that jails and prisons have become the new mental hospitals; many people arrested and incarcerated have a range of behavioral disorders. These populations also include a disproportionate number with serious mental disorders, substance abuse disorders, and comorbid mental illness and substance abuse.7(p298-300),9,10 Comorbidities—particularly substance use and abuse, both legal and illegal—greatly increase arrests and incarceration as well as homelessness, emergency department visits, unemployment, and nonadherence to treatment.11(p17),12 These disorders are inadequately treated in most correctional institutions, and people with serious mental illnesses are commonly victimized.
Anatomy Of The Behavioral Health Services System Many people at some point in their lives have behavioral problems that go beyond the common stresses of daily life and may require some treatment. At any point in time, as many as 5– 10 percent of the population has disorders that are serious and involve substantial impairment and a critical need for treatment and care.7(p79-81),13 1418
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A great deal of treatment occurs exclusively in the primary care sector even for those with very serious disorders.
Behavioral health services are provided in a variety of primary care and specialty care settings and by a range of different providers. Most problems are initially recognized in informal settings and usually first become formally identified by non-mental health specialty providers. There have been many efforts extending over the past fifty years to increase interests and capacities of primary care practitioners to manage these problems,7(p161-3) primarily referring people with more serious disorders to the mental health specialty sector. This remains a priority under the various provisions of the ACA, such as medical homes. The National Comorbidity Survey, which examined the prevalence of many major mental illnesses over the period 1990–92 to 2001–03 using comparable measures, found little change in prevalence but increases in treatment rates of about two-thirds.13 About a third of people with a measured disorder in 2001–03 received some care.13 The more serious the disorder, the greater the likelihood of treatment and referral to the mental health specialty sector.7(p79-81),13 Yet a great deal of treatment occurs exclusively in the primary care sector even for those with very serious disorders. At least a third of people with a mental disorder and serious functional impairment in the period 2009–11 received no mental health care in the prior year.11(p96) Access to services, of course, depends on insurance coverage, and about 21 percent of people with mental illnesses in the period 2010–11 did not have insurance. This group was less than half as likely as those on Medicaid or the Children’s Health Insurance Program (CHIP) to receive any mental health care.11(p37,p94) Studies find that approximately three-fifths of all psychiatric drugs are prescribed by general medical practitioners, although psychiatrists account for the majority of prescriptions for antipsychotic and antimania prescriptions.14 A study of office visits to office-based clinicians other than psychiatrists for the period 1996–2007
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found that an increasing proportion of visits involving an antidepressant medication documented no psychiatric diagnosis, and by 2007 this characterized a large majority of such visits.15 In another study, using MarketScan claims data, 58 percent of patients receiving a psychotropic medication had no documented psychiatric diagnosis, but this was largely among non–mental health specialty providers.16 These patterns of use of antidepressants among nonpsychiatrists are not fully understood but raise concerns about appropriate use in accord with evidence-based practice. Many patients in primary care have mild or moderate symptoms of depression, and the research literature suggests little efficacy of antidepressants for these populations.17,18 Nevertheless, psychotherapeutic treatments, which in many instances may be useful and appropriate, have declined. Moreover, the care of patients who meet clinical criteria for depression typically complies poorly with American Psychiatric Association (APA) Practice Guidelines. An epidemiological analysis of some 15,762 patients reporting on their treatment for depression found guideline-concordant therapy varying from a high of 12 percent among non-Latino white patients to less than 1 percent among Caribbean black patients.19 Even allowing for disagreement about the appropriateness of APA guidelines for primary care practice and possible reporting errors, performance is far off the mark. As the nation embarks on many new ventures to provide improved care through medical homes and accountable care organizations (ACOs) depending greatly on primary care providers, the experience over the past several decades should suggest caution in making assumptions and preparations. Primary care providers face increasing expectations within a context of increasing financial and time pressures.20 Many patients with behavioral disorders are difficult to
manage quickly, requiring careful evaluation, listening, and support; and they pose uncertainties for primary care clinicians because of limited training and knowledge of behavioral issues. Thus, it is hardly surprising that patients with behavioral problems are given medications without a thorough evaluation or follow-up. The expectation is that a well-organized and integrated team practice can manage these challenges, but experience makes clear that doing so requires strong commitment and excellent management.
Economic Realities Of Behavioral Health Care Given increased attention to behavioral health issues in recent decades, and more people seeking behavioral health assistance, many assume that behavioral health accounts for an increasing proportion of health expenditures over time or at the very least not losing ground. As Exhibit 2 indicates, however, in the past twenty-five years behavioral health has lost ground relative to other types of health expenditures, falling from 9.3 percent of US health expenditures in 1986 to 7.3 percent in 2009. Perhaps this should not be a surprise. Behavioral health is a low-technology enterprise. In other areas of care, such as cancer and cardiovascular disease, there have been dramatic and expensive advances in imaging and treatment technologies and strong interest groups supporting their dissemination. Behavioral health therapies have not advanced dramatically, and behavioral health care proponents, other than the pharmaceutical industry, mainly focused on the promotion of drugs, have a relatively weak political voice. There have been large changes, however, in the distribution of behavioral health expenditures, allowing more people to obtain some services. Traditionally, mental health was a state responsibility, and most funding was devoted to state mental hospitals and the most severely
7.3
◀ %
Of US spending
Behavioral health accounted for 7.3% of US health spending in 2009– down from 9.3% in 1986.
Exhibit 2 Mental Health And Substance Abuse Expenditures As A Proportion Of Health Expenditures, United States, Selected Years 1986–2009 Mental health as a proportion of health expenditures Mental health share Substance abuse share Medicaid share of mental health spending
1986 9.3% 7.2 2.1 17
1992 8.1% 6.4 1.7 21
1998 7.3% 6.0 1.3 25
2002 7.5% 6.2 1.3 27
2005 7.3% 6.1 1.2 28
2009 7.3% 6.3 1.0 30
SOURCE Adapted from the following sources: Mark TL, Levit KR, Vandivort-Warren R, Buck JA, Coffey RM. Changes in US spending on mental health and substance abuse treatment, 1986–2005, and implications for policy. Health Aff (Millwood). 2011;30(2):284–92. Mark TL, Levit KR, Buck JA, Coffey RM, Vandivort-Warren R. Mental health treatment expenditure trends, 1986–2003. Psychiatr Serv. 2007;58(8):1041–8. Substance Abuse and Mental Health Services Administration. Behavioral health, United States, 2012 (Note 11 in text), p. 3 and Tables 123 and 124.
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Mental Health ill patients. With deinstitutionalization and the growth of the Medicaid program, funding has substantially moved to outpatient and community care and dispersed among a broader range of clients. As late as 1990 two-fifths of mental health expenditures went to hospital care, but as of 2009 hospital care accounted for only a quarter of mental health expenditures.11(p263) Studies suggest that managed care, while providing services to a larger proportion of clients, achieves this in part by decreasing the intensity of care for those most severely disabled.21 A large transformation came in the increase in use of pharmaceuticals, for which expenditures increased from 8.6 percent of mental health expenditures in 1990 to 28.5 percent in 2009. Selective serotonin reuptake inhibitors (SSRIs) and the new generation of antipsychotic drugs were aggressively and successfully marketed to physicians and the general public. While welcomed for their seemingly less aversive side effects than earlier medications, they have been no more effective and, especially in the case of many of the new antipsychotic drugs, associated with unanticipated metabolic side effects.22,23 Nevertheless, persistent and often misleading marketing and a supposedly more positive profile of side effects persuaded general physicians to use them more readily and often excessively, encouraging the use of multiple medications for the same patient that may be unnecessary and inappropriate. Ironically, expenditures for the range of other sources of care, including psychiatrists and other professionals and psychotherapeutic interventions, decreased.
The behavioral health system is one increasingly dominated by dependence on pharmaceuticals.
The Ascendency Of Medicaid
The behavioral health system is one increasingly dominated by dependence on pharmaceuticals. Studies of services repeatedly find a decrease in alternative or complementary services, such as established psychotherapies, and little increase if any in the array of evidence-based treatments that facilitate function and quality of life and help contain many of the impairments associated with serious mental illness through psychoeducation, self-management, and coping strategies. The neglect of these services, among other limitations, undermines hope—an essential aspect of the recovery movement. Yet pharmaceuticals should not be denigrated. They are vitally important to improvements in behavioral health. It is necessary to develop a better understanding of the brain and opportunities for developing more effective and less aversive drugs. But hype does not substitute for reality, and the advances in medications have been less impressive than pharmaceutical advertising and marketing suggest. Problems are exacerbat-
The federal safety net, and the incentives embodied in Medicaid, substantially transformed the system of mental health services. By 2009 Medicaid was the single largest source of expenditures for mental health services, accounting for 30 percent of all mental health expenditures and likely to increase appreciably with the implementation of the expansions and innovative opportunities of the ACA. Even more important, Medicaid became the mental health safety net for the most disadvantaged and most impaired people in the population. In many states optional services under Medicaid provide a broader and more appropriate set of care opportunities for those with severe and persistent mental illnesses than is available in other public and private insurance programs. The challenge with the federal-state partnership that defines Medicaid is the large differences among states in support of the Medicaid program, the willingness to fund many important 1420
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optional services that are central to behavioral health, and the tendency in many states to reduce behavioral health expenditures more readily than other services during fiscal crises. It is estimated that states reduced their mental health spending by $4.35 billion between 2009 and 2012.24 This challenge is further evident in the unwillingness of many states to accept expansion of Medicaid despite the large incentives to do so or to take advantage of the incentives in the ACA to improve provision of mental health care such as health homes (a longitudinal delivery model, integrating interdisciplinary services for clients with serious mental illnesses and others with multiple chronic disease conditions).
The Challenge Of Building An Evidence-Based Behavioral Health System
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ed by widespread dispensing without careful evaluation and follow-up and the neglect of the array of services repeatedly found to improve function and client-preferred outcomes. A major principle of medical care is that priority be given to people with a more serious illness and greater need. Epidemiological studies find that approximately half of all services used are for those who do not meet criteria for the disorders measured.13 While it would be inappropriate to jump to the conclusion that these people have no need for care and cannot benefit, their needs for treatment should be balanced against the one-third of people with mental disorders and most serious functional impairments who receive little care. Moreover, those with mild and moderate disorders who commonly receive antidepressant drugs, typically no more effective than placebos for this population,17,18 would probably benefit more from psychosocial interventions such as cognitive behavioral therapy.
Care For People With The Most Serious Mental Illnesses The most challenging clients are those with serious disorders and impairments, often with other comorbidities, who require a range of integrated psychiatric and medical services linked to social and rehabilitative supports.7(p244-5) Since homelessness is common among those with such disorders, attention to stable housing and linkage with housing authorities is essential. Substance abuse exacerbates many of the problems and negative outcomes of serious mental illness; thus, substance abuse screening and treatment is an essential component of care. Most of these patients require long-term medication. Also in these patients, careful medication management and medication education are crucial. Patients with serious disorders often get into trouble when they discontinue their medications. Thus, maintaining adherence is a continuing challenge. Many of those most seriously ill have little
family support. Whenever possible, it is important to involve families meaningfully in the treatment and rehabilitation processes. Family psychosocial groups that provide illness education and help families share their experiences and coping efforts have been found to be helpful.25 Most patients aspire to meaningful activities, especially work, and many randomized trials have demonstrated the value of supported employment in facilitating usual competitive work for wages and fulfilling the important objective of meaningful activity.26,27 From a systems perspective, there are a variety of organizational challenges in coordinating and integrating the various important elements of care, many of which often fall outside the usual array of medically reimbursable services. Even bringing together mental health, substance abuse, and medical care is demanding, and studies repeatedly show large neglect of general medical care among people with serious behavioral disorders. Keeping people in the services system and providing adequate access, maintaining stable and appropriate housing, and providing opportunities for useful activities and participation are all part of the necessary complex mix. These components of service are carried out in the broader context of seeking to reduce stigma, diverting arrests and criminalization of people with mental illnesses, and managing aggressively the most challenging patients who have substance abuse comorbidities and poor treatment adherence. The effectiveness of many elements of care remain uncertain, but over recent decades considerable evidence has accumulated to document the value of particular treatment and rehabilitation interventions, especially when they follow closely the standards established in randomized controlled trials and related studies. Most of these interventions are not conventionally reimbursed through even good health insurance, although many state Medicaid programs acknowledge their importance, as shown in Exhibit 3.
Exhibit 3 Basic Evidence-Based Services For Adults In Medicaid, 2007 Service
Number of states
Supported employment Supported housing
15 9
Family psychoeducation Illness/disability self-management
13 19
Integrated mental health/substance abuse treatment Assertive community treatment
19 34
SOURCE Adapted from Substance Abuse and Mental Health Services Administration. Behavioral health, United States, 2012 (Note 11 in text), Table 118.
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Mental Health However, the fact that they are covered services in some states does not ensure access, and good information on the extent of such care is lacking. This reinforces the need for monitoring, accountability, and quality assurance and the successful implementation of information technology.
Implementation Of Health Reform The terrible school shootings in Colorado, Connecticut, and elsewhere by young males who were apparently mentally ill has led to considerable concern about mental health services. The school shootings have also led to some additional mental health funding. Much of the discussion surrounding these events has exaggerated the role of mental illness in violence and has oversimplified the complexity of identifying potential assailants and the serious problem of incorrectly intervening with people who would not cause problems, having possible adverse effects on them.28 Advocates welcome any public interest in improving the mental health services system, but the direction of the public discussion may further stigmatize people with mental illnesses, the vast majority no more dangerous or violent than the average citizen of comparable age and gender.7(p300-5) One of the ironies of many of these terrible events that grab the attention of the media and the public is that commonly people who commit these crimes do so after seeking psychiatric help and being turned away. It must be understood that there is no quick fix for improving access or providing high-quality services short of a major revision of the US behavioral health system. An earlier Health Affairs article29 discussed the opportunities made possible by Medicaid changes, passage of federal comprehensive mental health parity legislation (the Mental Health Parity and Addiction Equity Act of 2008), and especially the ACA. Although there have been unexpected problems in the implementation of the ACA, it offers a constructive framework for addressing many of the needs for a more meaningful behavioral health system that is better allied with general medical care and other important social and rehabilitative services. Central is the inclusion of mental health and substance abuse services as essential health benefits; broader access to Medicaid in states that participate; subsidies for people to acquire insurance on the exchanges up to 400 percent of the federal poverty level; and many efforts to promote improved chronic care management, services integration, and medical and health homes. The concept of health homes is closest to the types of long-term services integration that is especially 1422
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Despite advances in the neuro- and behavioral sciences, there remains a lack of fundamental understanding of the major mental illnesses.
necessary for people with severe and persistent disorders,30 and it is heartening that increasing numbers of states are seeking to take up the challenge. As of April 2014 fifteen states had health home state plan amendments approved by the Centers for Medicare and Medicaid Services, and eleven additional states and the District of Columbia have planning requests approved. Twenty-four states have not as yet submitted such proposals, but some may still be in a planning phase.31 It is too early to assess implementation, but enthusiasm for the concept in many states is heartening. With increasing entitlement to services among many people with great need, a pressing issue is the size and qualifications of the behavioral health workforce and its preparation for the demands that lie ahead. There are extraordinary disparities in the availability of well-trained behavioral health professionals among states and between urban and rural areas. In many parts of the country access to psychiatrists, and particularly child and adolescent psychiatrists, is very difficult, and with a few exceptions, it is almost impossible to gain access to informed evaluation and treatment for specialized problems such as autism. There has been little growth in the number of psychiatrists over many years, and psychiatry remains a relatively unpopular specialty among medical graduates. Between 2000 and 2008 there was a 14 percent reported decline of graduates from psychiatry training programs, and more than half of all psychiatrists are now age fifty-five or older.32 Moreover, psychiatrists are the least likely of all specialists to accept insurance of all kinds and especially Medicaid.32 Nor has psychiatric nursing prospered in recent decades given the growth of other new opportunities in nursing.
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Continuing research and practice built on the basis of evidence provides a hopeful pathway.
The professional workhorses of behavioral health care are clinical social workers, who number some 193,00011(p192) and administer and staff many programs dealing with people with the greatest impairments. The nearly 96,00011(p192) psychologists in the United States are predominantly in private practice, providing psychotherapy to nonpsychotic patients.7(p220-6) Many other groups make up the behavioral health workforce, including substance abuse counselors, other counselors of various kinds, and marriage and family therapists, among others, with varying training and experiences that lack any real standardization or evidence basis.33 It is not unusual for mental health organizations to employ case managers with no more than a bachelor of arts degree, and sometimes less, and give them responsibilities for some of the most impaired patients. If the United States is to truly move toward a safer and more effective and responsive system, it will be necessary to remake the behavioral health workforce; to train for more standardized evidence-based practices, but in a flexible way in relation to emerging evidence; and to attract more capable students to these varying professions. This article was adapted from the John Eisenberg Legacy Lecture presented at the University of California, San Francisco, in February 2014. It was sponsored by the California HealthCare
Conclusion The behavioral health landscape is on the threshold of major opportunities and potential changes that include new relationships between the medical and behavioral health sectors that potentially can bring increased access and improved services for many of the most disadvantaged citizens. But as the historical record of mental health services and policy reveals, promises are easy and realities difficult. Despite many advances in the neuro- and behavioral sciences, there remains a lack of fundamental understanding of the major mental illnesses. Caregivers in the field work with uncertain knowledge and contested theories, and they have less-than-ideal medications and other treatments. Serious mental illness can pose intractable problems despite our best efforts. Thankfully, successful strategies have been developed to manage treatment and rehabilitation to maintain function, prevent common secondary disabilities, and provide hope to patients and families in a way that improves patients’ outcomes and quality of life. There is a need to continue to seek more effective treatments, more timely and appropriate access, and improved ways of coordinating care including new promising applications of information technology allowing better self-management and patient instruction and understanding. The ACA and related reforms provide new opportunities to bring evidence-based practices to more patients who can benefit, but the course is not easy, and there will be many challenges ahead. Repeating the admonition of John Eisenberg, “We need to move away from ‘eminence-based’ medicine, and toward evidencebased medicine.”1 Continuing research and practice built on the basis of evidence provides a hopeful pathway. ▪
Foundation, the Clinical Excellence Research Center and Stanford Health Policy at Stanford University; the School of Public Health at the University of California, Berkeley; the Palo Alto
Medical Foundation Research Institute; and the Philip R. Lee Institute for Health Policy Studies at University of California, San Francisco.
Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis. 2006;3(2):1–14. 4 Bruce ML, Leaf PJ, Rozal GP, Florio L, Hoff RA. Psychiatric status and 9year mortality data in the New Haven Epidemiologic Catchment Area Study. Am J Psychiatry. 1994;151(5): 716–21. 5 Kouzis AC, Eaton WW. Psychopathology and the initiation of dis-
ability payments. Psychiatr Serv. 2000;51(7):908–13. 6 Social Security Administration. Annual statistical report on the Social Security Disability Insurance program, 2011. Washington (DC): SSA; 2012. (Publication No. 13–11826). 7 Mechanic D, McAlpine DD, Rochefort DA. Mental health and social policy: beyond managed care. 6th ed. Upper Saddle River (NJ): Pearson; 2013. 8 Mechanic D, Grob GN. Social policy
NOTES 1 Eisenberg JM. Evidence-based medicine. Expert voices. Vol. 1. Washington (DC): National Institute for Health Care Management; 2001. p. 1–2. 2 Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care. 2011;49(6): 599–604. 3 Colton CW, Manderscheid RW.
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and the American mental health system of care. In: Cohen N, Galea S, editors. Population mental health: evidence, policy, and public health practice. New York (NY): Routledge; 2011. p. 119–38. James DJ, Glaze LE. Mental health problems of prison and jail inmates. Washington (DC): Department of Justice, Bureau of Justice Statistics; 2006 Sep. (Special Report No. NCJ213600). Schwirtz M. New York council sees flawed mental health system. New York Times. 2014 Mar 27;Sect. A:22. Substance Abuse and Mental Health Services Administration. Behavioral health, United States, 2012. Rockville (MD): HHS; 2013. (Publication No. [SMA] 13-4797). Bradley-Engen MS, Cuddeback GS, Gayman MD, Morrissey JP, Mancuso D. Trends in state prison admission of offenders with serious mental illness. Psychiatr Serv. 2010; 61(12):1263–5. Kessler RC, Demler O, Frank RG, Olfson M, Pincus HA, Walters EE, et al. US prevalence and treatment of mental disorders, 1990–2003. N Engl J Med. 2005;352(24):2515–23. Mark TL, Levit KR, Buck JA. Datapoints: psychotropic drug prescriptions by medical specialty. Psychiatr Serv. 2009;60(9):1167. Mojtabai R, Olfson M. Proportion of antidepressants prescribed without a psychiatric diagnosis is growing. Health Aff (Millwood). 2011;30(8): 1434–42. Wiechers IR, Leslie DL, Rosenheck RA. Prescribing of psychotropic medications to patients without a psychiatric diagnosis. Psychiatr Serv. 2013;64(12):1243–8. Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA. 2010;303(1):47–53.
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18 Kirsch I. The emperor’s new drugs: exploding the antidepressant myth. New York (NY): Basic Books; 2010. 19 González HM, Vega WA, Williams DR, Tarraf W, West BT, Neighbors HW. Depression care in the United States: too little for too few. Arch Gen Psychiatry. 2010;67(1):37–46. 20 Mechanic D. Physician discontent: challenges and opportunities. JAMA. 2003;290(7):941–6. 21 Mechanic D, McAlpine DD. Mission unfulfilled: potholes on the road to mental health parity. Health Aff (Millwood). 1999;18(5):7–21. 22 Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO, et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med. 2005;353(12):1209–23. 23 Rosenheck RA. Outcomes, costs, and policy caution. A commentary on: the Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS 1). Arch Gen Psychiatry. 2006;63(10):1074–6. 24 Glover RW, Miller JE, Sadowski SR. Proceedings on the state budget crisis and the behavioral health treatment gap: the impact on public substance abuse and mental health treatment systems [Internet]. Washington (DC): National Association of State Mental Health Program Directors; [cited 2014 Jun 27]. Available from: http://www.nasmhpd .org/docs/policy/summary congressional%20briefing_ 2012.pdf 25 McFarlane WR, Lukens E, Link B, Dushay R, Deakins SA, Newmark M, et al. Multiple-family groups and psychoeducation in the treatment of schizophrenia. Arch Gen Psychiatry. 1995;52(8):679–87. 26 Drake RE, Skinner JS, Bond GR, Goldman HH. Social security and mental illness: reducing disability with supported employment. Health Aff (Millwood). 2009;28(3):761–70.
27 Marshall T, Goldberg RW, Braude L, Dougherty RH, Daniels AS, Ghose SS, et al. Supported employment: assessing the evidence. Psychiatr Serv. 2014;65(1):16–23. 28 McGinty EE, Webster DW, Barry CL. Gun policy and serious mental illness: priorities for future research and policy. Psychiatr Serv. 2014; 65(1):50–8. 29 Mechanic D. Seizing opportunities under the Affordable Care Act for transforming the mental and behavioral health system. Health Aff (Millwood). 2012;31(2):376–82. 30 SAMHSA-HRSA Center for Integrated Health Solutions. Behavioral health homes for people with mental health and substance use conditions: the core clinical features [Internet]. Washington (DC): Department of Health and Human Services; 2012 [cited 2014 Jun 27]. Available from: http://www.integration.samhsa .gov/clinical-practice/CIHS_ Health_Homes_Core_Clinical_ Features.pdf 31 Centers for Medicare and Medicaid Services. State health home CMS proposal status (effective June 2014) [Internet]. Baltimore (MD): CMS; 2014 [cited 2014 Jun 27]. Available from: http://www.medicaid.gov/ State-Resource-Center/MedicaidState-Technical-Assistance/HealthHomes-Technical-Assistance/ Downloads/HH-MAP_v32.pdf 32 Bishop TF, Press MJ, Keyhani S, Pincus HA. Acceptance of insurance by psychiatrists and the implications for access to mental health care. JAMA Psychiatry. 2014;71(2): 176–81. 33 Weissman MM, Verdeli H, Gameroff MJ, Bledsoe SE, Betts K, Mufson L, et al. National survey of psychotherapy training in psychiatry, psychology, and social work. Arch Gen Psychiatry. 2006;63(8):925–34.
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Mental Health By David Mechanic 10.1377/hlthaff.2014.0504 HEALTH AFFAIRS 33, NO. 8 (2014): 1416–1424 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
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David Mechanic (mechanic@ rci.rutgers.edu) is the René Dubos University Professor at the Institute for Health, Health Care Policy, and Aging Research at Rutgers University, in New Brunswick, New Jersey.
More People Than Ever Before Are Receiving Behavioral Health Care In The United States, But Gaps And Challenges Remain ABSTRACT The high prevalence of mental illness and substance abuse disorders and their significant impact on disability, mortality, and other chronic diseases have encouraged new initiatives in mental health policy including important provisions of the Affordable Care Act and changes in Medicaid. This article examines the development and status of the behavioral health services system, gaps in access to and quality of care, and the challenges to implementing aspirations for improved behavioral and related medical services. Although many more people than ever before are receiving behavioral health services in the United States— predominantly pharmaceutical treatments—care is poorly allocated and rarely meets evidence-based standards, particularly in the primary care sector. Ideologies, finances, and pharmaceutical marketing have shaped the provision of services more than treatment advances or guidance from a growing evidence base. Among the many challenges to overcome are organizational and financial realignments and improved training of primary care physicians and the behavioral health workforce.
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ith the passage and implementation of federal mental health parity legislation in 2008 and the many supportive provisions for behavioral health in the Affordable Care Act (ACA), there appears to be a turning point in the recognition of the centrality of mental health status and function for the nation’s health. But many challenges remain in developing services responsive to the realistic needs of people with serious mental health and substance abuse disorders. Central to the challenge is timely access to services and needed referrals, appropriate organization and coordination of services, and greater commitment to providing evidence-based services of high quality. As the late John Eisenberg so appropriately challenged the field of medicine more generally: “We need to respect experience and expertise, but not accept the doctrines of those who would have physicians follow the 1416
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lead of self-proclaimed experts and authorities, whose assertions often lack the strength of scientific evidence. We need to move away from ‘eminence-based’ medicine, and toward evidence-based medicine.”1 In this article I review the damaging effects of serious behavioral disorders and the forces that shaped the evolution of the current system, including the disarray of services, the status of financing, and the essential role of Medicaid. I then examine pathways to evidence-based practice, particularly for people with the most serious and incapacitating disorders. I conclude with the challenges of reform and discussion of implementation of opportunities of the ACA and extensions of Medicaid.
The Costs Of Behavioral Disorders Behavioral health is a central aspect of health status, and serious behavioral disorders have
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devastating effects on the well-being of individuals, families, and communities. They contribute importantly to mortality not only through high risks of suicide but through deaths from the wide spectrum of causes of mortality. Studies vary in their estimates from eight to thirty years of life lost depending on populations studied and methodological approaches.2–4 The consequences of behavioral disorders extend well beyond the affected individuals: to their families, to the development of children, and to the welfare of the wider community. Behavioral disorders are a major cause of disability in the population and can be responsible for the inability to work or reduced work performance. From an economic perspective, such disorders not only have high costs of reduced productivity but have been for some time the largest contributor to Social Security disability status other than musculoskeletal disorders.5,6 Increasingly, research finds that behavioral disorders, while not a direct cause of many important disorders such as diabetes and cardiovascular disease, contribute to these conditions through lifestyles; use of substances; and, unfortunately, even treatment. Behavioral disorders also induce great pain and distress, which studies find are comparable to the most serious of physical disorders.7(p8-9)
The Social Trajectory Of Behavioral Health Any serious historical examination of the evolution of behavioral health must conclude that so-
cial forces, ideologies, finances, and more recently pharmaceutical marketing have shaped the system of services more than treatment advances or improved care. Prior to the mid-1950s most patients with serious disorders were treated in public mental hospitals, often with long lengths-of-stay. In the mid-1950s more than a half-million people were in public mental hospitals, when the population of the United States was 167 million. As the myth goes, antipsychotic drugs were introduced in the early 1950s, and the availability of these new effective treatments allowed the emptying of mental hospitals (Exhibit 1). The introduction of antipsychotic drugs did have utility in sedating patients, making them easier to manage, and it gave hospital administrators, hospital personnel, and family members confidence that patients could leave the hospital. But as Exhibit 1 shows, these drugs did not in the main empty public mental hospitals. Between 1955 and 1965 public mental hospital populations decreased by about 15 percent. These populations were reduced by an additional 65 percent during 1965–85 (Exhibit 1). This decrease primarily was made possible by Medicaid and Medicare, and other government safety-net programs such as the expansion of disability insurance, and by large incentives to the states to move patients to settings where the federal government, and not states, would assume much of the costs. During this two-decade period large numbers of patients were moved from state mental hospitals, which were the full financial responsibili-
Exhibit 1 Resident Patients In State And County Mental Hospitals: Total Population As A Percentage Of 1955 Base, 1955–2000
SOURCES For 1955–74: President’s Commission on Mental Health. Task panel reports: submitted to the President’s Commission on Mental Health, volume 2. Ann Arbor (MI): University of Michigan Library; 1978. p. 94, Appendix Table 3. For 1975–2000: Center for Mental Health Services. Mental health, United States, 2004. Rockville (MD): Substance Abuse and Mental Health Services Administration; 2006. (Report No. SMA-06-4195). p. 208, Table 19.5. NOTES The number of state hospital residents in 1955 was 558,922. SSI is Supplemental Security Income. SSDI is Social Security Disability Insurance.
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Mental Health ty of the states, to board-and-care facilities, which were typically privately run residential care homes providing minimal care and, commonly, low living standards. Many patients with behavioral health problems were transferred to nursing homes. Most hospital care for patients with behavioral health problems was transferred to general hospitals, either in specialized psychiatric units or scattered among medical and surgical beds, all substantially reimbursed through federal programs.8 After 1985 managed care reinforced the deinstitutionalization trend by way of stricter utilization management, but the effects were modest relative to the powerful financial incentives to the states and the federally supported safety net. As inpatient care moved to general hospitals, over time mostly to specialized psychiatric and chemical dependency units, strict managed care reduced admissions and kept lengths-of-stay short, largely to stabilize symptoms. The theory was that care would now be provided in an integrated community program in which the hospital played a coherent part—an aspiration largely unfulfilled. Patients were commonly returned to community settings without adequate follow-up or access to the range of services needed to facilitate function and allow a decent quality of life. After some fifty years this is a failure that mental health professionals, policy makers, and much of the public still aspire to correct for those with the most severe and incapacitating disorders. Advocates for the mentally ill complain that jails and prisons have become the new mental hospitals; many people arrested and incarcerated have a range of behavioral disorders. These populations also include a disproportionate number with serious mental disorders, substance abuse disorders, and comorbid mental illness and substance abuse.7(p298-300),9,10 Comorbidities—particularly substance use and abuse, both legal and illegal—greatly increase arrests and incarceration as well as homelessness, emergency department visits, unemployment, and nonadherence to treatment.11(p17),12 These disorders are inadequately treated in most correctional institutions, and people with serious mental illnesses are commonly victimized.
Anatomy Of The Behavioral Health Services System Many people at some point in their lives have behavioral problems that go beyond the common stresses of daily life and may require some treatment. At any point in time, as many as 5– 10 percent of the population has disorders that are serious and involve substantial impairment and a critical need for treatment and care.7(p79-81),13 1418
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A great deal of treatment occurs exclusively in the primary care sector even for those with very serious disorders.
Behavioral health services are provided in a variety of primary care and specialty care settings and by a range of different providers. Most problems are initially recognized in informal settings and usually first become formally identified by non-mental health specialty providers. There have been many efforts extending over the past fifty years to increase interests and capacities of primary care practitioners to manage these problems,7(p161-3) primarily referring people with more serious disorders to the mental health specialty sector. This remains a priority under the various provisions of the ACA, such as medical homes. The National Comorbidity Survey, which examined the prevalence of many major mental illnesses over the period 1990–92 to 2001–03 using comparable measures, found little change in prevalence but increases in treatment rates of about two-thirds.13 About a third of people with a measured disorder in 2001–03 received some care.13 The more serious the disorder, the greater the likelihood of treatment and referral to the mental health specialty sector.7(p79-81),13 Yet a great deal of treatment occurs exclusively in the primary care sector even for those with very serious disorders. At least a third of people with a mental disorder and serious functional impairment in the period 2009–11 received no mental health care in the prior year.11(p96) Access to services, of course, depends on insurance coverage, and about 21 percent of people with mental illnesses in the period 2010–11 did not have insurance. This group was less than half as likely as those on Medicaid or the Children’s Health Insurance Program (CHIP) to receive any mental health care.11(p37,p94) Studies find that approximately three-fifths of all psychiatric drugs are prescribed by general medical practitioners, although psychiatrists account for the majority of prescriptions for antipsychotic and antimania prescriptions.14 A study of office visits to office-based clinicians other than psychiatrists for the period 1996–2007
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found that an increasing proportion of visits involving an antidepressant medication documented no psychiatric diagnosis, and by 2007 this characterized a large majority of such visits.15 In another study, using MarketScan claims data, 58 percent of patients receiving a psychotropic medication had no documented psychiatric diagnosis, but this was largely among non–mental health specialty providers.16 These patterns of use of antidepressants among nonpsychiatrists are not fully understood but raise concerns about appropriate use in accord with evidence-based practice. Many patients in primary care have mild or moderate symptoms of depression, and the research literature suggests little efficacy of antidepressants for these populations.17,18 Nevertheless, psychotherapeutic treatments, which in many instances may be useful and appropriate, have declined. Moreover, the care of patients who meet clinical criteria for depression typically complies poorly with American Psychiatric Association (APA) Practice Guidelines. An epidemiological analysis of some 15,762 patients reporting on their treatment for depression found guideline-concordant therapy varying from a high of 12 percent among non-Latino white patients to less than 1 percent among Caribbean black patients.19 Even allowing for disagreement about the appropriateness of APA guidelines for primary care practice and possible reporting errors, performance is far off the mark. As the nation embarks on many new ventures to provide improved care through medical homes and accountable care organizations (ACOs) depending greatly on primary care providers, the experience over the past several decades should suggest caution in making assumptions and preparations. Primary care providers face increasing expectations within a context of increasing financial and time pressures.20 Many patients with behavioral disorders are difficult to
manage quickly, requiring careful evaluation, listening, and support; and they pose uncertainties for primary care clinicians because of limited training and knowledge of behavioral issues. Thus, it is hardly surprising that patients with behavioral problems are given medications without a thorough evaluation or follow-up. The expectation is that a well-organized and integrated team practice can manage these challenges, but experience makes clear that doing so requires strong commitment and excellent management.
Economic Realities Of Behavioral Health Care Given increased attention to behavioral health issues in recent decades, and more people seeking behavioral health assistance, many assume that behavioral health accounts for an increasing proportion of health expenditures over time or at the very least not losing ground. As Exhibit 2 indicates, however, in the past twenty-five years behavioral health has lost ground relative to other types of health expenditures, falling from 9.3 percent of US health expenditures in 1986 to 7.3 percent in 2009. Perhaps this should not be a surprise. Behavioral health is a low-technology enterprise. In other areas of care, such as cancer and cardiovascular disease, there have been dramatic and expensive advances in imaging and treatment technologies and strong interest groups supporting their dissemination. Behavioral health therapies have not advanced dramatically, and behavioral health care proponents, other than the pharmaceutical industry, mainly focused on the promotion of drugs, have a relatively weak political voice. There have been large changes, however, in the distribution of behavioral health expenditures, allowing more people to obtain some services. Traditionally, mental health was a state responsibility, and most funding was devoted to state mental hospitals and the most severely
7.3
◀ %
Of US spending
Behavioral health accounted for 7.3% of US health spending in 2009– down from 9.3% in 1986.
Exhibit 2 Mental Health And Substance Abuse Expenditures As A Proportion Of Health Expenditures, United States, Selected Years 1986–2009 Mental health as a proportion of health expenditures Mental health share Substance abuse share Medicaid share of mental health spending
1986 9.3% 7.2 2.1 17
1992 8.1% 6.4 1.7 21
1998 7.3% 6.0 1.3 25
2002 7.5% 6.2 1.3 27
2005 7.3% 6.1 1.2 28
2009 7.3% 6.3 1.0 30
SOURCE Adapted from the following sources: Mark TL, Levit KR, Vandivort-Warren R, Buck JA, Coffey RM. Changes in US spending on mental health and substance abuse treatment, 1986–2005, and implications for policy. Health Aff (Millwood). 2011;30(2):284–92. Mark TL, Levit KR, Buck JA, Coffey RM, Vandivort-Warren R. Mental health treatment expenditure trends, 1986–2003. Psychiatr Serv. 2007;58(8):1041–8. Substance Abuse and Mental Health Services Administration. Behavioral health, United States, 2012 (Note 11 in text), p. 3 and Tables 123 and 124.
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Mental Health ill patients. With deinstitutionalization and the growth of the Medicaid program, funding has substantially moved to outpatient and community care and dispersed among a broader range of clients. As late as 1990 two-fifths of mental health expenditures went to hospital care, but as of 2009 hospital care accounted for only a quarter of mental health expenditures.11(p263) Studies suggest that managed care, while providing services to a larger proportion of clients, achieves this in part by decreasing the intensity of care for those most severely disabled.21 A large transformation came in the increase in use of pharmaceuticals, for which expenditures increased from 8.6 percent of mental health expenditures in 1990 to 28.5 percent in 2009. Selective serotonin reuptake inhibitors (SSRIs) and the new generation of antipsychotic drugs were aggressively and successfully marketed to physicians and the general public. While welcomed for their seemingly less aversive side effects than earlier medications, they have been no more effective and, especially in the case of many of the new antipsychotic drugs, associated with unanticipated metabolic side effects.22,23 Nevertheless, persistent and often misleading marketing and a supposedly more positive profile of side effects persuaded general physicians to use them more readily and often excessively, encouraging the use of multiple medications for the same patient that may be unnecessary and inappropriate. Ironically, expenditures for the range of other sources of care, including psychiatrists and other professionals and psychotherapeutic interventions, decreased.
The behavioral health system is one increasingly dominated by dependence on pharmaceuticals.
The Ascendency Of Medicaid
The behavioral health system is one increasingly dominated by dependence on pharmaceuticals. Studies of services repeatedly find a decrease in alternative or complementary services, such as established psychotherapies, and little increase if any in the array of evidence-based treatments that facilitate function and quality of life and help contain many of the impairments associated with serious mental illness through psychoeducation, self-management, and coping strategies. The neglect of these services, among other limitations, undermines hope—an essential aspect of the recovery movement. Yet pharmaceuticals should not be denigrated. They are vitally important to improvements in behavioral health. It is necessary to develop a better understanding of the brain and opportunities for developing more effective and less aversive drugs. But hype does not substitute for reality, and the advances in medications have been less impressive than pharmaceutical advertising and marketing suggest. Problems are exacerbat-
The federal safety net, and the incentives embodied in Medicaid, substantially transformed the system of mental health services. By 2009 Medicaid was the single largest source of expenditures for mental health services, accounting for 30 percent of all mental health expenditures and likely to increase appreciably with the implementation of the expansions and innovative opportunities of the ACA. Even more important, Medicaid became the mental health safety net for the most disadvantaged and most impaired people in the population. In many states optional services under Medicaid provide a broader and more appropriate set of care opportunities for those with severe and persistent mental illnesses than is available in other public and private insurance programs. The challenge with the federal-state partnership that defines Medicaid is the large differences among states in support of the Medicaid program, the willingness to fund many important 1420
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optional services that are central to behavioral health, and the tendency in many states to reduce behavioral health expenditures more readily than other services during fiscal crises. It is estimated that states reduced their mental health spending by $4.35 billion between 2009 and 2012.24 This challenge is further evident in the unwillingness of many states to accept expansion of Medicaid despite the large incentives to do so or to take advantage of the incentives in the ACA to improve provision of mental health care such as health homes (a longitudinal delivery model, integrating interdisciplinary services for clients with serious mental illnesses and others with multiple chronic disease conditions).
The Challenge Of Building An Evidence-Based Behavioral Health System
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ed by widespread dispensing without careful evaluation and follow-up and the neglect of the array of services repeatedly found to improve function and client-preferred outcomes. A major principle of medical care is that priority be given to people with a more serious illness and greater need. Epidemiological studies find that approximately half of all services used are for those who do not meet criteria for the disorders measured.13 While it would be inappropriate to jump to the conclusion that these people have no need for care and cannot benefit, their needs for treatment should be balanced against the one-third of people with mental disorders and most serious functional impairments who receive little care. Moreover, those with mild and moderate disorders who commonly receive antidepressant drugs, typically no more effective than placebos for this population,17,18 would probably benefit more from psychosocial interventions such as cognitive behavioral therapy.
Care For People With The Most Serious Mental Illnesses The most challenging clients are those with serious disorders and impairments, often with other comorbidities, who require a range of integrated psychiatric and medical services linked to social and rehabilitative supports.7(p244-5) Since homelessness is common among those with such disorders, attention to stable housing and linkage with housing authorities is essential. Substance abuse exacerbates many of the problems and negative outcomes of serious mental illness; thus, substance abuse screening and treatment is an essential component of care. Most of these patients require long-term medication. Also in these patients, careful medication management and medication education are crucial. Patients with serious disorders often get into trouble when they discontinue their medications. Thus, maintaining adherence is a continuing challenge. Many of those most seriously ill have little
family support. Whenever possible, it is important to involve families meaningfully in the treatment and rehabilitation processes. Family psychosocial groups that provide illness education and help families share their experiences and coping efforts have been found to be helpful.25 Most patients aspire to meaningful activities, especially work, and many randomized trials have demonstrated the value of supported employment in facilitating usual competitive work for wages and fulfilling the important objective of meaningful activity.26,27 From a systems perspective, there are a variety of organizational challenges in coordinating and integrating the various important elements of care, many of which often fall outside the usual array of medically reimbursable services. Even bringing together mental health, substance abuse, and medical care is demanding, and studies repeatedly show large neglect of general medical care among people with serious behavioral disorders. Keeping people in the services system and providing adequate access, maintaining stable and appropriate housing, and providing opportunities for useful activities and participation are all part of the necessary complex mix. These components of service are carried out in the broader context of seeking to reduce stigma, diverting arrests and criminalization of people with mental illnesses, and managing aggressively the most challenging patients who have substance abuse comorbidities and poor treatment adherence. The effectiveness of many elements of care remain uncertain, but over recent decades considerable evidence has accumulated to document the value of particular treatment and rehabilitation interventions, especially when they follow closely the standards established in randomized controlled trials and related studies. Most of these interventions are not conventionally reimbursed through even good health insurance, although many state Medicaid programs acknowledge their importance, as shown in Exhibit 3.
Exhibit 3 Basic Evidence-Based Services For Adults In Medicaid, 2007 Service
Number of states
Supported employment Supported housing
15 9
Family psychoeducation Illness/disability self-management
13 19
Integrated mental health/substance abuse treatment Assertive community treatment
19 34
SOURCE Adapted from Substance Abuse and Mental Health Services Administration. Behavioral health, United States, 2012 (Note 11 in text), Table 118.
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Mental Health However, the fact that they are covered services in some states does not ensure access, and good information on the extent of such care is lacking. This reinforces the need for monitoring, accountability, and quality assurance and the successful implementation of information technology.
Implementation Of Health Reform The terrible school shootings in Colorado, Connecticut, and elsewhere by young males who were apparently mentally ill has led to considerable concern about mental health services. The school shootings have also led to some additional mental health funding. Much of the discussion surrounding these events has exaggerated the role of mental illness in violence and has oversimplified the complexity of identifying potential assailants and the serious problem of incorrectly intervening with people who would not cause problems, having possible adverse effects on them.28 Advocates welcome any public interest in improving the mental health services system, but the direction of the public discussion may further stigmatize people with mental illnesses, the vast majority no more dangerous or violent than the average citizen of comparable age and gender.7(p300-5) One of the ironies of many of these terrible events that grab the attention of the media and the public is that commonly people who commit these crimes do so after seeking psychiatric help and being turned away. It must be understood that there is no quick fix for improving access or providing high-quality services short of a major revision of the US behavioral health system. An earlier Health Affairs article29 discussed the opportunities made possible by Medicaid changes, passage of federal comprehensive mental health parity legislation (the Mental Health Parity and Addiction Equity Act of 2008), and especially the ACA. Although there have been unexpected problems in the implementation of the ACA, it offers a constructive framework for addressing many of the needs for a more meaningful behavioral health system that is better allied with general medical care and other important social and rehabilitative services. Central is the inclusion of mental health and substance abuse services as essential health benefits; broader access to Medicaid in states that participate; subsidies for people to acquire insurance on the exchanges up to 400 percent of the federal poverty level; and many efforts to promote improved chronic care management, services integration, and medical and health homes. The concept of health homes is closest to the types of long-term services integration that is especially 1422
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Despite advances in the neuro- and behavioral sciences, there remains a lack of fundamental understanding of the major mental illnesses.
necessary for people with severe and persistent disorders,30 and it is heartening that increasing numbers of states are seeking to take up the challenge. As of April 2014 fifteen states had health home state plan amendments approved by the Centers for Medicare and Medicaid Services, and eleven additional states and the District of Columbia have planning requests approved. Twenty-four states have not as yet submitted such proposals, but some may still be in a planning phase.31 It is too early to assess implementation, but enthusiasm for the concept in many states is heartening. With increasing entitlement to services among many people with great need, a pressing issue is the size and qualifications of the behavioral health workforce and its preparation for the demands that lie ahead. There are extraordinary disparities in the availability of well-trained behavioral health professionals among states and between urban and rural areas. In many parts of the country access to psychiatrists, and particularly child and adolescent psychiatrists, is very difficult, and with a few exceptions, it is almost impossible to gain access to informed evaluation and treatment for specialized problems such as autism. There has been little growth in the number of psychiatrists over many years, and psychiatry remains a relatively unpopular specialty among medical graduates. Between 2000 and 2008 there was a 14 percent reported decline of graduates from psychiatry training programs, and more than half of all psychiatrists are now age fifty-five or older.32 Moreover, psychiatrists are the least likely of all specialists to accept insurance of all kinds and especially Medicaid.32 Nor has psychiatric nursing prospered in recent decades given the growth of other new opportunities in nursing.
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Continuing research and practice built on the basis of evidence provides a hopeful pathway.
The professional workhorses of behavioral health care are clinical social workers, who number some 193,00011(p192) and administer and staff many programs dealing with people with the greatest impairments. The nearly 96,00011(p192) psychologists in the United States are predominantly in private practice, providing psychotherapy to nonpsychotic patients.7(p220-6) Many other groups make up the behavioral health workforce, including substance abuse counselors, other counselors of various kinds, and marriage and family therapists, among others, with varying training and experiences that lack any real standardization or evidence basis.33 It is not unusual for mental health organizations to employ case managers with no more than a bachelor of arts degree, and sometimes less, and give them responsibilities for some of the most impaired patients. If the United States is to truly move toward a safer and more effective and responsive system, it will be necessary to remake the behavioral health workforce; to train for more standardized evidence-based practices, but in a flexible way in relation to emerging evidence; and to attract more capable students to these varying professions. This article was adapted from the John Eisenberg Legacy Lecture presented at the University of California, San Francisco, in February 2014. It was sponsored by the California HealthCare
Conclusion The behavioral health landscape is on the threshold of major opportunities and potential changes that include new relationships between the medical and behavioral health sectors that potentially can bring increased access and improved services for many of the most disadvantaged citizens. But as the historical record of mental health services and policy reveals, promises are easy and realities difficult. Despite many advances in the neuro- and behavioral sciences, there remains a lack of fundamental understanding of the major mental illnesses. Caregivers in the field work with uncertain knowledge and contested theories, and they have less-than-ideal medications and other treatments. Serious mental illness can pose intractable problems despite our best efforts. Thankfully, successful strategies have been developed to manage treatment and rehabilitation to maintain function, prevent common secondary disabilities, and provide hope to patients and families in a way that improves patients’ outcomes and quality of life. There is a need to continue to seek more effective treatments, more timely and appropriate access, and improved ways of coordinating care including new promising applications of information technology allowing better self-management and patient instruction and understanding. The ACA and related reforms provide new opportunities to bring evidence-based practices to more patients who can benefit, but the course is not easy, and there will be many challenges ahead. Repeating the admonition of John Eisenberg, “We need to move away from ‘eminence-based’ medicine, and toward evidencebased medicine.”1 Continuing research and practice built on the basis of evidence provides a hopeful pathway. ▪
Foundation, the Clinical Excellence Research Center and Stanford Health Policy at Stanford University; the School of Public Health at the University of California, Berkeley; the Palo Alto
Medical Foundation Research Institute; and the Philip R. Lee Institute for Health Policy Studies at University of California, San Francisco.
Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis. 2006;3(2):1–14. 4 Bruce ML, Leaf PJ, Rozal GP, Florio L, Hoff RA. Psychiatric status and 9year mortality data in the New Haven Epidemiologic Catchment Area Study. Am J Psychiatry. 1994;151(5): 716–21. 5 Kouzis AC, Eaton WW. Psychopathology and the initiation of dis-
ability payments. Psychiatr Serv. 2000;51(7):908–13. 6 Social Security Administration. Annual statistical report on the Social Security Disability Insurance program, 2011. Washington (DC): SSA; 2012. (Publication No. 13–11826). 7 Mechanic D, McAlpine DD, Rochefort DA. Mental health and social policy: beyond managed care. 6th ed. Upper Saddle River (NJ): Pearson; 2013. 8 Mechanic D, Grob GN. Social policy
NOTES 1 Eisenberg JM. Evidence-based medicine. Expert voices. Vol. 1. Washington (DC): National Institute for Health Care Management; 2001. p. 1–2. 2 Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care. 2011;49(6): 599–604. 3 Colton CW, Manderscheid RW.
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