Acad Psychiatry (2014) 38:561–565 DOI 10.1007/s40596-014-0143-6


The Role of Academic Psychiatry in Leading Health Policy Reform Herbert Pardes & Jonathan E. Gordon & Joan M. Leiman

Received: 18 February 2014 / Accepted: 21 April 2014 / Published online: 17 July 2014 # Academic Psychiatry 2014

Abstract The authors discuss the current state of mental health care reform and the opportunity for academic psychiatry to emerge in a leadership role in the organization and delivery of mental health care. Keywords Mental health care reform . Affordable care act . Economics

Mental health and mental illness have always fought an uphill battle to gain appropriate attention, priority, and resources. Most people with the capacity to give money fear heart disease, Alzheimer’s disease, and cancer much more than fear psychiatric illness. The result has been a long history of giving low priority to mental illness in allocating public and private supports. Many factors prevent appropriate national attention being paid to the impact of mental illness and mental health services and research. Many people lack insurance coverage for mental health [1], and there is poor financial reimbursement as compared to medical care. The steady reduction in the number and support of mental health treatment facilities and beds—particularly state institutional facilities—has further compromised access [2]. This reduction has been exacerbated by the failure to put in place adequate numbers of mental health providers, treatments, and programs in the community to pick up the displaced need that has not disappeared. There are insufficient numbers of providers and mental health workers, and those working in the field lack diversity and are poorly distributed H. Pardes (*) : J. E. Gordon New York-Presbyterian Hospital, New York, NY, USA e-mail: [email protected] J. M. Leiman Columbia University Mailman School of Public Health, New York, NY, USA

[3]. There is also a lack of appropriate housing with supportive services for the mentally ill [4]. Add to these factors weak philanthropic support, the persistence of stigma, which often underlies the low priority assigned to mental health in health policy and services, and the paucity of the more highly reimbursed clinical diagnostic and treatment procedures that provide other medical specialties with revenue, that one realizes the serious challenges the field faces.

The Current State of Mental Health Reform There are signs, however, that the national mood may be shifting. The repeated and seemingly endless episodes or gun violence that have horrified and terrified the nation are generating new advocates for better mental health programs. The large number of veterans returning home from Iraq and Afghanistan with posttraumatic stress disorder (PTSD), depression, and substance abuse and the increasing numbers and rates of suicides among veterans and the active military are eliciting public compassion [5]. The World Health Organization has publicized the large role that mental illness plays in the Global Burden of Disease [6], and policy makers and the public are beginning to recognize the huge impact mental illness has on driving up health care costs—including both costs resulting from mental illness itself and costs resulting from psychiatric comorbidities with non-psychiatric conditions [7, 8]. The growing number of the mentally ill in prisons is becoming recognized as a major factor in the nation’s oversized and extremely costly prison population [9]. Finally, new reimbursement rules that incent hospitals to avoid readmissions are exposing the formidable difficulty in reducing readmissions for patients with psychiatric conditions [10]. In light of these and other developments, we are seeing emerge a number of encouraging policies regarding mental health. President Obama has strongly asserted the need to


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improve mental health care, and has commissioned a major research study of the brain, that could lead to new treatments for brain-related disorders [11]. Recently issued regulations effectuating the 2008 Mental Health Parity and Addiction Equity Act define and require more precise realizations of parity in the reimbursement for mental health care, and the Affordable Care Act (ACA) has eliminated preexisting conditions—including mental illness—as barriers to coverage. As a result of these and other provisions of the ACA, the potential now exists for millions more people to receive mental health coverage. We are also seeing the development of innovative approaches and models aimed at strengthening the mental health care system in terms of prevention, intervention, treatment, quality, and social and community support. These models are demonstrating that co-locating and even integrating general health and mental health care—a model known as collaborative care—can strengthen overall care and lead to better outcomes [12, 13]. Some of the notable changes that characterize the new models are team-based care delivery, care coordination, use of technologies such as telemedicine, electronic records and registries, computer-based decision support, and coordinated database management; and innovative programs to disseminate effective mental health practices and develop more skilled practitioners across multiple disciplines, including paraprofessionals and community mental health workers. Some of the notable new models include the following: The work of Jürgen Unützer and his colleagues in Washington State applies a variety of team and measurementbased efforts in a population health model to improve the care of individuals with depression across the state [14]. The Second Chance Program at the Payne Whitney Westchester Center of New York-Presbyterian Hospital is demonstrating the effectiveness of longitudinal treatment strategies to help people regardless of the seriousness of their illness. Patients who have been in state hospitals for more than 5 years are enrolled in Second Chance, where rehabilitation enables them to achieve some function as members of society [15]. A new program in Massachusetts aims to provide timely, high-quality care to children with mental illness by assembling pediatricians and other primary care providers with mental health expertise into an organized system of child mental health experts committed to rapid response [16]. A model that embeds a mental health hospitalist directly in hospital departments of medicine is achieving reductions in length of stay and costs of care through earlier identification of need and rapid initiation of effective interventions [17].

The patient-centered medical home model can coordinate an array of important auxiliary services to complement direct mental health care delivery. Growing numbers of these medical homes are addressing the many medical, familial, social, and environmental factors that can compromise the care of mental illness [18]. We are seeing more attention paid to patient-centric efforts focused on recovery [19], empowerment, hopefulness, building self-efficacy, and enhancement of self-management skills. There is a greater focus on early intervention programs to prevent serious illness such as “first break” programs. One example is RAISE, which concentrate attention on care immediately after a first schizophrenic episode to improve longterm outcomes [20]. The fact that prepubertal children of mothers with depression are at serious risk for depression themselves is receiving wider recognition and study [21]. On the academic front, we are seeing increased academic/public and academic/community alliances [22] and coordination within and across academic institutions through programs such as the NIH Clinical and Translational Science Awards program. On the employment front, we are seeing a more support for the employment of people with serious mental illness [23]. All this innovation is being spurred and supported by the development of centers for practice innovation in states such as Maryland and New York [24]. This work is being informed by greater recognition of the assets and resources that communities can provide the treatment and support of the mentally ill through authentic engagement with community-based leaders and organizations, as exemplified by the work of Ken Wells and his colleagues at UCLA [25].

A Leadership Role for Academic Psychiatry Never has there been a greater need, or a more opportune moment, for creativity and innovation in the organization and delivery of mental health care. In this swirl of issues and opportunities, academic psychiatry is uniquely positioned to exercise a leadership role and to transmit the values and principles of compassionate and ethical inquiry and care giving to future psychiatric and medical leadership in education, research, and care. As integral parts of academic health centers, psychiatry departments share a core societal role and mission: the pursuit of advances in care, teaching, and research in settings in which the three converge and mutually inform and enrich one another. By virtue of their home in universities, academic psychiatrists interact with multiple sectors of society—with the rest of the field of academic medicine, education, government, community, the legal and judicial systems, and the media, giving them the ability to influence many societal functions and issues. In utilizing

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these assets, there are numerous areas where academic psychiatry can play a leading role. At the same time, there is a major need for quality measures that accurately assess both processes and outcomes in mental health and that enable proper evaluation of program effectiveness. Academic psychiatry, with its integration of research, education, and clinical care, is ideally positioned to lead this development effort, which will include the increased use of data reporting and analytics. There is also a huge need for greater advocacy for the fields of mental health care and research. By mobilizing their faculty, students, trainees, mental health consumers, and family groups, academic psychiatry is perfectly positioned alongside the rest of medicine (through organizations like the American Psychiatric Association, Research!America and the Association of American Medical Colleges) to advocate aggressively for better reimbursement for mental health care and more research dollars for mental illness. Academic psychiatry can use its relationships with other academic medical departments and with medical center administrations to win support for mental health dollars by demonstrating the value of programs that integrate general and mental health care. It should also reach out to the other mental health disciplinary organizations (e.g., psychology, social work and nursing) to broaden this coalition of support. Finally, it can develop academic/public/ private partnerships with an emphasis on broad-based community engagement to catalyze a resurgence of the potent alliance between patients, families, and providers that formed in the 1980s to again become a strong societal force for attention to mental illness [26]. Academic psychiatry has a critical role to play in addressing the problems and shortages in mental health manpower. There are shortages of specialists in child psychiatry, minority psychiatry, and geriatric psychiatry, all of which are magnified by inequities in geographic distribution [27–29]. There is also an urgent need to train primary care providers and teams in the treatment and management of depression and other mental illnesses that are increasingly addressed in a primary care setting. Similarly, if the system is going to be able to meet the increasing demand for mental health treatment that the ACA will bring, new ways must be crafted to utilize and train paraprofessionals and community mental health workers to expand and enhance the capacity of the system. To accomplish all of these things, academic psychiatry needs to foster a culture of innovation, openness to ideas from diverse sources, dedication to the spread of information, and a pursuit of continuous improvement as advocated by the Institute of Medicine [30]. Students, residents, and fellows need to be encouraged to both learn from the faculty and others with experience while at the same time exploring new approaches. Academic psychiatry has the opportunity to develop clinical


laboratories where innovative models that coordinate and integrate medical and mental health care can be designed and tested. Finally, and most critically, academic psychiatry can encourage people who live with mental illness either themselves or in their family to fight the scourge of stigma. Stigma still represents a severe and destructive force on the resources available for the support of mental health care and research. Many other fields, such as cancer, AIDS, and heart disease not only enjoy higher priority in public resource allocation but also substantial amounts of philanthropy. The minute number of foundations nationwide that include mental illness in their priorities is an embarrassment. Yet we are beginning to witness a trend in which people are becoming more open to providing philanthropy for mental illness programs. The Brain and Behavior Research Foundation (previously called NARS AD) and the Lieber Institute affiliated with Johns Hopkins represent stellar examples of how to develop and sustain philanthropy for efforts to address mental illness [31]. The time is ripe to generate more such efforts given the tens of millions of people who suffer, or who have family members who suffer, from mental illness.

Conclusion Although there are serious impediments to improving our mental health care system, the challenges are not insurmountable. When we think back to the array of unthinkable approaches that have characterized the care of mental illness over decades, we recognize that we have seen, and are seeing, considerable improvement and progress. There is an increasing national awareness of the problems caused by mental illness and mental health care that is driving growing interest in addressing these issues. Academic psychiatry must help to harness the emerging interest on the part of those who are or have been directly or indirectly affected by mental illness to catalyze a turnaround of the shockingly low priority that mental illness has endured for so long. Psychiatry has come a long way. The introduction of new medications, along with new attention through evidencebased care to older medications such as lithium and clozapine, and the development of a variety of psychological therapies, such as short-term therapy, cognitive behavioral therapy, and interpersonal therapy, is having a substantial, positive impact on mental health care and patient outcomes. There are a growing number of new approaches to treatment, such as personalized genomic medicine, as well as other new ways of providing and organizing treatment and care, such as a focus on recovery and a movement to integrate mental health and primary care. Within the medical field, psychiatry has gained greater respectability—the number of deans of medical schools and heads of teaching hospitals that come from the psychiatric


discipline has increased dramatically. The amount of research being done in medical schools by psychiatry departments has increased greatly. Some years ago, there were few departments that had a substantial research program [32]; today, psychiatry receives the second-most NIH funding of any discipline [33]. Despite the many stops and starts, the increased attention over decades to mental health research and related research in brain and behavior is bearing fruit. But, we still need a concerted and widespread boost of creativity and innovation. We need broad involvement of concerned people. Academic departments, which draw faculty, students, scientists, clinicians, and others who are interested and trained in leadership and who are motivated to push the frontiers of knowledge and practice, are logical settings out of which to generate this energy. It is incumbent on academic psychiatry by virtue of its principles, its values, and its sense of responsibility to patients and their families, and to society as a whole to join and spur others to action. Academic psychiatry alone does not have all the answers, but it certainly has a critical role to play in generating coalitions and addressing the nation’s critical need for an improved mental health system.

Disclosures On behalf of all the authors, the corresponding author reports no conflicts of interest related to this commentary.

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The role of academic psychiatry in leading health policy reform.

The authors discuss the current state of mental health care reform and the opportunity for academic psychiatry to emerge in a leadership role in the o...
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