We Need REAL Change in Mental Health Policy, Not the Illusion of Reform

By David Shern, Ph.D.

In a recent blog on the American Enterprise Institute (AEI) website entitled “Stop Ignoring the Needs of the Mentally Ill,” Drs. Sally Satel and E. Fuller Torrey outlined the reasons why they supported the Helping Families in Mental Health Crisis Act (H.R. 2646). Drs. Satel and Torrey suggest that we can fundamentally reform mental health services by introducing more coercive “treatment,” building more beds, and reorganizing the nation’s leading mental health and substance abuse authority. But these simplistic approaches ignore core elements of the problem. They are ‘quick fix’ solutions that have little promise of doing much to address our contemporary crisis.

Few people would quarrel with key features of the problem- we incarcerate intolerable numbers of people with severe mental illnesses, and we lack effective engagement strategies- not to mention the poverty and social exclusion that plague this population. A comprehensive approach to these problems, however, requires both more resources and better use of the resources that are currently available. Drs. Satel and Torrey propose more of the same – strategies that have characterized the last 50 years.

They cite a GAO report that documents the several federal programs that provide services and supports for persons with severe mental illnesses, including the Social Security Administration, HUD and others. They assert that the creation of an Assistant Secretary of Mental Health will create the organizational structure to coordinate these activities. Were it only so simple! Currently, the SAMHSA administrator, a Presidential appointee, reports directly to the Secretary of HHS, which organizationally parallels the Assistant Secretaries of HHS. There is no reason to believe that adding an Assistant Secretary title to the role will make any difference within HHS, and it would have absolutely no effect on other governmental departments critical for community life of people with mental illnesses. We’ve repeatedly learned that reorganizations are appealing but rarely accomplish the magic that the reorganizers hope to achieve.

In H.R. 2646, “Involuntary Outpatient Commitment” has euphemistically been renamed “Assisted Outpatient Treatment.” However, the marketing twist doesn’t change the basic rationale of the approach. Ostensibly, for people who are not compliant with the system’s idea of care, having a judge order an individual to comply with the treatment plan will fix the problems of an inadequate system. (An inpatient stay is the ‘punishment’ for noncompliance.) In New York State, where AOT has demonstrated some success, it was accompanied by $120 million dollars in enhanced service funding. Leaders in New York attribute the success of the program both to the enhanced services and to increased provider accountability for individuals assigned to their care. The latter could be achieved without coercion.

The approach proposed by H.R. 2646 and supported by Satel and Torrey ignores the fact that coercion and court involvement can increase stigma and drive people from the care system. What is needed are accessible, meaningful services with engagement-oriented outreach. Unfortunately, mental health budgets have been slashed in many states, and effective outreach services have been reduced and in many cases, all but eliminated. Many localities lack the resources to implement evidence-based, voluntary community treatments that reduce the need for involuntary or inpatient services. For example, trauma-specific treatments designed for people with co-occurring mental health, substance abuse and trauma histories have been shown to be effective, even with very hard-to-serve populations, but they have not been widely adopted. The current legislation does nearly nothing to improve community service capacity. Creating a legal mechanism to compel individuals into a non-existent system is a cruel fiction that creates the illusion of fixing a problem.

The third leg of the proposed “reform” involves opening a spigot of funding for inpatient services that was initially closed to keep states from shifting inpatient costs onto the federal government. That danger still exists. In addition, it is difficult to tell how many inpatient beds are needed or even how many are currently available. The numbers cited by Satel and Torrey relate to state-funded, specialty inpatient facilities (state hospitals, which comprise only a fraction of available inpatient and residential alternative beds). While the private psychiatric hospital lobby would love to have a new entitlement for their industry, and while there may be a need for more residential alternatives, any expansion should involve a systematic appraisal of the system of care available in each community and a plan for allocation of resources to ensure the range of services needed. Preferentially funding one component of the system while neglecting others isn’t a smart approach.

Perhaps an even more frightening aspect of this pendulum swing towards institutional models of care is that large psychiatric institutions historically have been breeding grounds for neglect and abuse. The exposure of horrors and atrocities in U.S. mental hospitals, in addition to their cost, was the impetus behind the move towards community mental health beginning in the 1960s.

Sadly, the days of “One Flew Over the Cuckoo’s Nest” are not in the past. A recent series of exposes in the Tampa Bay Times and Sarasota Herald-Tribune has highlighted disturbing coverups of abuses and preventable patient deaths in Florida’s state hospitals. This is not an isolated occurrence. Indeed, the Service Employees International Union (SEIU) has created a website called “Behind Closed Doors” dedicated to “bringing to light serious problems in care at Universal Health Services Inc., America’s largest provider of inpatient behavioral health care.” If H.R. 2646 passes, we can expect even more of these horrifying reports.

In short, these components of the current House bill, while superficially appealing, just don’t cut it. They are “more of the same” – an expansion of the approaches that got us into our current difficulties. Increasing institutional care and coercion sounds much like the strategy used in the state hospital era in which we warehoused people interminably in snake pit conditions. Organizational shake-ups rarely make the difference that shared vision and collaboration can achieve. Early intervention and prevention, assessable and patient-focused services with a rehabilitation orientation and increased funding for the community supports needed for successful recovery are the tickets to system improvement. The bill has some of these components (like early intervention) but neglects others (like prevention). It ignores major trends in healthcare that emphasize meaningful patient involvement. People diagnosed with severe mental illnesses and their families deserve real mental health reform. This is not it.

David Shern is Senior Associate, Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University.

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2 thoughts on “We Need REAL Change in Mental Health Policy, Not the Illusion of Reform

  1. I found an additional problem with the call made by Satel and Torrey for expanding the number of psychiatric beds. They curiously lumped schizophrenia and bipolar in with diabetes to then give a cost figure of $839 million in hospital costs for causes of 30-day Medicaid inpatient re-admissions for adults between the ages of 18 and 64. I thought it was strange to have schizophrenia and bipolar disorder lumped in with diabetes in assessing hospital re-admission costs. Following the link they provided to the H-CUP data they referenced, it seemed they took their cost figure from Table 3, which contained ten conditions with the most all-cause, 30-day re-admissions for Medicaid patients (aged 18-64).

    The first thing I saw was that diabetes costs could have been easily left out of their figure, meaning that $839 million should have been $588 million for schizophrenia and bipolar re-admissions alone. The second thing I noticed was Satal and Torrey referred to the H-CUP category of “Mood disorders” as “bipolar.” Bipolar disorders are mood disorders, but so are the depressive disorders; and anxiety. If the combined re-admission costs for all mood disorders was $588 million, what was the cost for just bipolar disorders? The NIH estimate of the prevalence of severe bipolar disorder among U.S. adults was 2.2%. The estimated prevalence for major depression among U.S. adults was 6.7%. If the ratio was evenly distributed, it would be roughly one-third of the $588 million figure—$196 million. Or do Satel and Torrey support “assisted outpatient treatment” for individuals refusing to remain on medication for major depression as well as bipolar disorder? What about the less serious mood disorders, like anxiety?

    Was the reference of the H-CUP category of “mood disorders” as “bipolar disorder” intentional or not? Traditionally, bipolar disorder is seen as the most serious mood disorder. I don’t believe they were confusing the difference between serious mental illnesses and less disabling psychiatric conditions, as they suggested of the critics of H.R. 2646 and lawmakers above. So unless it was an unintentional slip, they were intentionally referring to the general category of mood disorders by its most serious condition: bipolar disorder.

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  2. Yes Dr. Shern.

    Your essay is wonderfully written, with facts to back up assertions and a colloquial reference to bring it all together.

    Thank you for stepping out with your intellect and making the effort, to wit working hard on your writing, so that suffering people may know that they are, indeed, normal.

    It is because of people like you that people like myself may enjoy the greatest gift of psychiatry…to know that we are not the only ones who feel and think the way we do.

    Our problem – my problem – is that I talk about my thoughts and feelings rather freely, and I guess the general public may feel uncomfortable with what I say.

    Howsomever, I descend of a family that were, altogether, not afraid to stand up for that, in which, it believed.

    In the face of public censure, opposition and rebuke, my father and mother stood fast.

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