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The Issue

Problem Defined

Affecting all segments of society, mental illness does not discriminate based on age, class or ethnicity. Millions of Americans have serious mental illness, including schizophrenia, bipolar disorder, and major depression. 

However, many are going without treatment. To make psychiatric, psychological, and supportive services for individuals with mental illness more readily available, federal attention should be directed at increasing interagency coordination, research funding, and early intervention programs; reducing stigmas; leveraging technology; and reforming the criminal justice system to lower the number of patients ending up in prison. 

Background
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1.
1. Mental health statistics: prevalence and treatment

A mental illness is a condition that impacts a person's thinking, feeling or mood and may affect his or her ability to relate to others and function on a daily basis. 

Approximately 1 in 25 adults in the U.S., or 10 million, experiences a serious mental illness (e.g. schizophrenia, bipolar disorders, post-traumatic disorders) in a given year that substantially interferes with or limits one or more major life activities.

Only 41% of adults in the U.S. with a mental health condition received mental health services in 2014. Among adults with a serious mental illness, 63% received mental health services in 2014.

2.
2. The many deficits of the current mental health system

The federal government currently spends $130 billion annually across 8 departments and 112 programs on mental health. The Government Accountability Office (GAO) found that sufficient “coordination for programs supporting individuals with serious mental illness is lacking.”

Likewise, agencies do not collect data on how mental health dollars are spent or whether they are being spent effectively. GAO found that only 20 percent of federal grants “required its grantees to state that they will use evidence-based practices to treat individuals with mental illness.” 

Deficits of the mental health system include: 

  • The leading federal mental health agency does not employ a psychiatrist.
  • There is only 1 child psychiatrist available for every 2,000 children with a mental health disorder. 
  • There is a nationwide shortage of about 100,000 psychiatric beds.
  • 3 of the largest mental health hospitals (LA County, Cook County, and Rikers Island) are criminal incarceration facilities.
  • Nearly 8,000 annual official complaints arise from privacy rules that irritate both physicians and family members.   
3.
3. Prevailing social stigmas

Mental illness has a wide range of effects on a person's education, employment, physical health, and relationship status. Culture and social networks (family and friends) play influential roles in the relationship between stigma (e.g. shame or secrecy) and access to treatment.

From a public standpoint, stereotypes depict people with mental illness as being unpredictable, a danger to society, incompetent, or ultimately responsible for their illness. These can lead to discriminatory practices, such as excluding people with these conditions from economic and social opportunities.

4.
4. The benefits of treatment

If treatment is started early, recovery, including meaningful roles in social life, school and work, is possible. 

  • Early intervention and prevention are critical given the age of onset. 50% of serious psychiatric illness occurs before the age of 14, and 75% before the age of 24 (National Institute of Mental Health - NIMH). 

As Director of the National Institute for Mental Health (NIMH) at the National Institutes of Health (NIH), Dr. Thomas Insel informed the Subcommittee on Oversight and Investigations that treatment can lower the risk of violence 15-fold in persons with a Severe Mental Illness (SMI). 

There are also benefits if treatment is started during adulthood. A study published in the journal The Lancet in May 2014 examined over 80,000 subjects (40,937 men and 41,710 women) whom were prescribed antipsychotics and mood stabilizers over the course of three years (2006 - 2009). A fraction of these (6.5% of men and 1.4% of women) were convicted of a violent crime during the study period. Intragroup findings showed that “[c]ompared with periods when participants were not on medication, violent crime fell by 45% in patients receiving antipsychotics and by 24% in patients prescribed mood stabilizers.”

Go deeper
Expert Authors

MPU, Inc. 

Giovanni Bruna
Junior Analyst - TheChisel by More Perfect Union

The Solution

Proposed Recommendations
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1.
1. Establish the role of an Assistant Secretary for Mental Health and Substance Use Disorders

Appointing an Assistant Secretary for Mental Health and Substance Use Disorders, whom would be required to be a licensed psychiatrist or clinical psychologist with mental illness research experience would raise the importance of mental health in the nation’s leading health agency. 

Duties would include:

  • promote, evaluate, merge, and coordinate research, treatment, and services across departments, agencies, organizations, and individuals with respect to the problems faced by individuals suffering from mental illness or substance use disorders.
  • ensure access to effective, evidence-based* treatment for individuals with mental illnesses and/or substance use disorders.
  • make public all federal investigations in compliance with the Mental Health Parity and Addiction Equity Act of 2008, so that families and consumers know what treatment they have rights to access. 
2.
2. Reform the Substance Abuse & Mental Health Services Administration for federal coordination
  • Replace Substance Abuse & Mental Health Services Administration (SAMHSA) with the Office of the Assistant Secretary for Mental Health and Substance Use Treatment and transfer all authority to the Assistant Secretary. 
  • To bring accountability to how mental health dollars are spent, require grant recipients to follow evidence-based standards, eliminate unauthorized programs, and mandate congressional oversight of all federal behavioral health grants. 
  • Federal interagency coordination can more effectively promote evidence-based programs through the establishment of an Interagency Serious Mental Illness Coordinating Committee. This entity would organize, merge, and synchronize the research, treatment, housing and services for individuals with mental illness and substance use disorders.  
  • Also, prohibit taxpayer dollars from going to legal advocates and antipsychiatry activists working to stop medical care. 
3.
3. Reform HIPAA and FERPA to empower caregivers

Clarify the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations and the Family Educational Rights and Privacy Act (FERPA). 

Reforming HIPAA would allow a caregiver to receive protected health information when a mental health care provider reasonably believes disclosure to the caregiver is necessary to protect the health, safety or welfare of the patient or the safety of another. 

Similarly, reforms to FERPA would allow an educational agency or institution to disclose an education record to the caregiver of the student under the same circumstances as mentioned above.

This breaks down barriers to enable families to work with doctors and mental health professionals in order to be a part of the front-line care delivery team.

[ Glossary: A caregiver is an individual, including a family member, who assumes primary responsibility for providing a basic need to an individual with a serious mental illness. 

Health Insurance Portability and Accountability Act (HIPAA): 

Family Educational Rights and Privacy Act (FERPA):

4.
4. Implement alternatives to institutionalization and reform the criminal justice system

Provide incentives to states to provide community-based alternatives to institutionalization, such as Assisted Outpatient Treatment (AOT), and other assertive-care community approaches, for those with serious mental illness. 

[ Glossary: AOT is court-ordered treatment for those individuals too ill to recognize their own need for medical care. ]

  • For states and counties with AOT programs, information on rates at which the program impacted those with serious mental illness who participated in AOT programs compared with those who did not participate but would still qualify, will be reported.

The issue of AOT can become a slippery slope because opponents say it's a form of government overreach, controlling where and how a patient is treated, including by whom and with whom he or she discusses personal matters. This situation plays into patient privacy rights. 

Expand Crisis Intervention Team (CIT) training for law enforcement, so that patients are treated in the healthcare system and not in the criminal justice system. CIT is a first-responder model of police-based crisis intervention by means of community, health care, and advocacy partnerships.

5.
5. Advance early intervention and prevention programs

Reauthorize: 

  • National Child Traumatic Stress Network: established by Congress in 2000, its mission is to raise the standard of care and improve access to services for traumatized children, their families and communities throughout the US.

Authorize (for the first time in federal law):

  • Recovery After Initial Schizophrenia Episode (RAISE): an evidence-based early intervention program that shows low-dose medication and support services for a person at risk of developing full-blown schizophrenia can reduce suicide rates and help patients lead functional lives. 

Create: 

  • Anti-stigma program for students: authorizes the Assistant Secretary for Mental Health and Substance Use Disorders to organize a national awareness campaign to assist secondary and postsecondary school students in reducing the stigma associated with serious mental illness.
6.
6. Leverage technology to improve mental healthcare for the underserved

In rural areas, where patients traditionally have limited access to care, pushing forward tele-psychiatry (using technology to bring clinical care to patients) would link pediatricians and primary care doctors with psychiatrists and psychologists.  

The latter can be done by establishing a $12 million four-year grant program to assist up to ten states in developing a tele-psychiatry and physician training program for treating and referring children and young adults. 

Similarly, advancing integration between primmary and behavioral care requires extending health information technology for mental health providers. The latter then coordinate care with primary care doctors using electronic medical records.

7.
7. Create a National Mental Health Policy Laboratory and increase funding for certain research

Create a National Mental Health Policy Laboratory, made up of medical professionals and experts in research design, who will establish evidence-based and peer-review standards for grant programs. 

Funding for the National Institute of Mental Health, in the amount of $40 million for each of fiscal years 2016 through 2020, would exclusively go either towards supporting research directed at reducing the risk of self harm, suicide, and interpersonal violence, or to the Brain Initiative (Brain Research Through Advancing Innovative Neurotechnologies Initiative).

8.
8. Reform Medicare and Medicaid

By enhancing Medicaid coverage related to certain mental health services topatients would be allowed to be billed for mental health services and primary care services at the same location, on the same day.

Allow the codification of drugs used to treat mental health disorders as a protected class of medication under Medicare and Medicaid.

Also, eliminate the 190-day lifetime limit on coverage of inpatient psychiatric hospital services under Medicare.

Modify Medicare discharge planning requirements for patients with a mental health condition that includes accessing community-based services.

Expected Results
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1.
1. Earlier and broader access to treatment

Early childhood intervention programs can allow individuals with a mental illness to be routed to healthcare professionals at an earlier age, rather than prisons later in life. This will enable them to explore and obtain more effective treatment options, and in the long-term, it could potentially increase access to psychiatric beds by having more of these readily available to patients who were not able to secure early access to treatment. 

2.
2. Greater accountability and an enhanced behavioral workforce

The appointment of an Assistant Secretary for Mental Health and Substance Use Disorders with sufficient mental health credentials and monitoring the proper allocation of federal funds and the success of mental health programs is essential to improving transparency and efficiency. These actions will reduce bureaucracy, ensure more patients are treated, and bring greater accountability to the federal government's efforts at addressing mental illness.

3.
3. Lower levels of violence linked to individuals with a mental illness

Mood stabilizing prescribed medications not only tame delusions, help restore emotional order and prevent relapses, but they may also reduce risks to the communities in which these patients live. Other factors that would make communities safer include expanding AOT and CIT training for law enforcement. 

Budget
Budget Impact
Net Present Value

The Conversation

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