Mental Health Policy

May 10, 2013 – Volume 23, Issue 18
Can access to mental health services be improved? By Barbara Mantel

Introduction

Demonstrators support a decision to charge police officers (Getty Images/Kevork Djansezian)  
Demonstrators support a decision to charge police officers in Fullerton, Calif., in the beating death of a schizophrenic homeless man, 37-year-old Kelly Thomas. In January 2013 a judge declined to drop charges against the three officers, who have pleaded not guilty. Last year the city paid $1 million to Thomas' mother to settle her wrongful death civil suit. (Getty Images/Kevork Djansezian)

An estimated 58 million American adults, or one in four, suffer from a diagnosable mental disorder. Eleven million live with a serious mental illness, such as schizophrenia, bipolar disorder or major depression. Yet it can take years for some individuals to see a mental health professional. Some don't want help, but the majority say treatment is often unaffordable. Others don't know where to go for treatment or say that insurance coverage isn't adequate. The contentious debate over gun control since the December massacre at Sandy Hook Elementary School has been accompanied by a less polarizing discussion about improving access to mental health care. Still, some proposals have split mental health advocates, including encouraging states to make court-ordered outpatient treatment easier to obtain. In addition, critics say new definitions of mental illnesses will lead to over-diagnosis. Meanwhile, insurers and patient advocates struggle to interpret federal laws requiring equal treatment of mental and physical illnesses.

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Overview

Four months after the massacre of six adults and 20 first-graders in Newtown, Conn., Senate Majority Leader Harry Reid, D-Nev., took to the floor of the chamber in early April to make a deeply personal plea for gun control legislation.

“Sometimes people in a fit of passion will purchase a handgun to do bad things with it … even as my dad did — killed himself,” said Reid.1

More than 38,000 people committed suicide in 2010, the latest year of available data, nearly half with guns. Nine in 10 who take their lives have a diagnosable mental illness, most often depression or a substance abuse disorder, according to the National Institute of Mental Health (NIMH), a government research institute in Bethesda, Md.2

After Newtown, Congress swiftly held hearings on gun control and on mental health care, despite the fact that the mentally ill account for a tiny fraction of gun crimes. While mental health advocates, researchers and scientists were wary about tying discussions about the fragmented mental health care system to the gun control debate, they welcomed the chance to advocate for better access to diagnosis, treatment and support services.

“The burden of mental illness is enormous,” Thomas Insel, director of the NIMH, told lawmakers a month after Newtown. An estimated 58 million American adults, or one in four, suffer from a diagnosable mental disorder in any given year, and it takes a decade, on average, for them to make contact with a mental health professional, said Insel. More than 11 million of those adults suffer from serious mental illness, including schizophrenia, bipolar disorder and major depression, and for them the average delay in treatment is five years. “That is five years of increased risk for using potentially life-threatening, self-administered treatments, such as legal or illicit substances, and even death,” said Insel.3

Janett Massolo (Getty Images/Prime for The Washington Post/Max Whittaker)  
Janett Massolo of Reno, Nev., holds a photo of her daughter Shannon on March 22, 2013. Using her father's handgun, Shannon committed suicide when she was 15 years old. Nine out of 10 people who take their own lives have a diagnosable mental illness, most often depression or a substance-abuse disorder. More than 38,000 people committed suicide in 2010, nearly half with guns. (Getty Images/Prime for The Washington Post/Max Whittaker)

Experts disagree on how to fix the country's broken mental health system. Proposed legislation to improve access by pumping more federal Medicaid money into community mental health centers, which treat more than 8 million low-income people a year, has some bipartisan support in Congress. But calls by families for states to make it easier to force the mentally ill into treatment are generating spirited opposition from civil liberties groups. Meanwhile critics complain that the American Psychiatric Association's latest manual of psychiatric disorders, released this month, will do nothing to stop over-diagnosis of mental illness.

The bipartisan Excellence in Mental Health Act would set new standards of care at community mental health centers. It includes a list of mandated services and requires better integration of treatment for mental illness and substance abuse; provides more Medicaid dollars for centers meeting those standards and funds the modernization of existing centers and construction of new ones.

Sen. Debbie Stabenow, D-Mich., author of the Senate version of the bill, estimated that it would allow community mental health centers to treat an additional 1.5 million people each year.4

“As we've listened to people on all sides of the gun debate, they've all talked about the fact that we need to address mental health treatment, and that's what this does,” Stabenow said in mid-April as the Senate prepared to vote on the bill as an amendment to gun control legislation.5 But gun control legislation failed, and the vote on the Excellence in Mental Health Act was shelved.

“Today, our nation's community mental health centers are simply stretched too thin and struggling to provide essential services,” said Linda Rosenberg, president and CEO of the Washington-based National Council for Community Behavioral Healthcare, a nonprofit association of 2,000 providers that supports the bill.

But Rosenberg criticized President Obama, whose fiscal 2014 budget, submitted to Congress in April, did not include funding for the proposed legislation. “I am extremely disappointed that the White House has not embraced the Excellence Act, which would increase access and early intervention in communities around the country,” said Rosenberg.6

The White House budget does call for $130 million in funding for other mental health proposals, including $55 million to train teachers and other adults to recognize the signs of mental illness in students and to help them refer students, when necessary, for services. The proposed budget also includes $50 million in tuition support to help train an additional 5,000 social workers, counselors and other mental health professionals to address critical shortages in many parts of the country.7

Some professional groups said the money was welcome but far too little. “While we applaud President Obama's budget proposal, it doesn't come close to restoring the drastic cuts in funds for mental health services that have been imposed over the last several years,” said Robert Cabaj, chair of the Council on Advocacy and Government Relations at the American Psychiatric Association, a medical society in Arlington, Va.8

Government Funds Most Mental Health Treatment  

Spending on mental health care totaled $113 billion in 2005, before adjustment for inflation, according to the latest available data, about twice the amount spent a dozen years earlier. The money went mostly toward prescription drugs and outpatient treatment. Nevertheless mental health spending as a share of total health care outlays has been slipping; it was 6.1 percent in 2005, down from 7.2 percent in 1986.

Private insurance has picked up an increasing portion of mental health expenditures, accounting for 27 percent in 2005, up about 6 percentage points from a dozen years earlier. Patients' out-of-pocket expenditures remained at roughly 12 percent, and the federal government's share was not much changed either, at about 28 percent. States' share of mental health spending, however, dropped from 35 percent in 1993 to 30 percent in 2005 and is likely to have dipped further since.9

The deep recession that officially began in December 2007 and ended in June 2009 took a huge toll on state finances, and states cut approximately $5 billion in public mental health spending from 2009 through 2013, according to the National Association of State Mental Health Program Directors in Alexandria, Va. Over the same period, demand for publicly financed inpatient and outpatient mental health services rose 10 percent.

“Those cuts have had a devastating impact on access to services for people,” says Ronald Honberg, national director for policy and legal affairs at the National Alliance on Mental Illness (NAMI), an advocacy group in Arlington, Va. “It's helped to further precipitate a system that is responding to emergencies rather than doing ongoing care and prevention.”

The number of state psychiatric hospital beds fell by about 4,500 — 9 percent of total capacity — between 2009 and 2012. Outpatient services have suffered as well. “In my own state of Arizona, virtually all state-only funded behavioral health servicesFootnote * have been dramatically reduced or eliminated over the last few years,” Laura Nelson, chief medical officer of the Arizona Department of Health, told Congress last year. “Over 4,600 children have lost behavioral health services. Nearly 6,300 adults lost access to substance abuse treatment services.10

“Due to mental health cuts, we are simply increasing emergency department costs, increasing acute care costs and adding to the caseloads in our criminal and juvenile justice systems and correction systems,” said Nelson. For example, in a survey of more than 6,000 hospital emergency departments, 70 percent reported boarding psychiatric patients for hours or days, and 10 percent reported boarding such patients for weeks while staff looked for psychiatric beds.11 And according to a recent report, the percentage of inmates in New York City jails with mental health problems rose from 24 percent in 2005 to 33 percent in 2011.12

Sheriff Brian Gootkin, who supervises 48 deputies in Gallatin County, Mont. — an area twice the size of Rhode Island — blamed reductions in community mental health funding for a significant jump in psychiatric emergencies that his force must handle. “Every deputy that is diverted to the Montana State Hospital or even to a local hospital is not on patrol maintaining public order and deterring crime,” Gootkin complained.13

The 2010 Patient Protection and Affordable Care Act — the sweeping health care system overhaul championed by Obama — will add to the demand for mental health services as it extends health coverage to more than 30 million Americans, including an estimated 6 million to 10 million with mental illness.

Against that backdrop, here are some of the issues that lawmakers, advocates, mental health professionals and people with mental illness and their families are debating:

Should states make it easier to force the mentally ill into treatment?

On March 19, 2005, Roger Scanlan of Allentown, Pa., diagnosed with schizophrenia and off his medications, killed his parents with a knife and then took his own life by cutting his throat. Five years later, his brother, Michael, testified on behalf of proposed legislation in Pennsylvania to make it easier for courts to order outpatient treatment of the mentally ill.

“I always knew when he wasn't taking his meds,” Scanlan said of his brother. “He would become very passionate about government, religion, and then he would believe that he was the second coming of Christ or Moses or some other biblical figure.”

“Everyone from crisis, the Allentown Police Department, his doctors, they all knew the pattern. We, as a family, we couldn't intervene to help him. We couldn't get him off the street. We were told that Roger had rights,” said Scanlan. “What rights did my mother and father have?”14

The legislation died in committee in 2010. But since the Newtown massacre, families and a prominent advocacy group favoring easing rules for court-ordered treatment have renewed their campaign, testifying before Congress and at state forums. Civil liberties groups and other mental health advocates are strongly opposed, saying patients should not be forced into treatment.

Forty-four states allow courts to order outpatient treatment of mentally ill people who have a history of not complying with treatment, which is sometimes referred to as assisted outpatient treatment or AOT. Most states require the person to be an imminent danger to self or others. For example, in Pennsylvania, a court can't order treatment unless the person committed or tried to commit serious harm to self or others within the past 30 days.15

But 10 states have less stringent criteria. For example, New York's Kendra's Law, named for a young woman pushed to her death in front of a subway train in 1999 by a schizophrenic man off his medications, does not require evidence of recent harm. A New York court can order outpatient treatment for someone who is not complying with mental health treatment if non-compliance led to hospitalization or confinement in a mental health unit in a jail or prison at least twice in the last three years or to serious or attempted serious violent behavior in the past four years.16

Doris Fuller, executive director of the Treatment Advocacy Center, a nonprofit based in Arlington, Va., wants states to model their laws on New York's. Making it easier for courts to order outpatient treatment would help the small subset of people known in the mental health world as “frequent flyers,” says Fuller. “Many of them don't acknowledge that they are ill or they don't know that they are ill,” she says. Court-ordered treatment, which is monitored and carries penalties for failing to take required medication, is needed to stabilize people until they voluntarily comply with treatment, she says.

Many states rarely use their court-ordered outpatient treatment laws, and Fuller wants that to change as well. “California has a law similar to Kendra's Law, but there are 58 counties in California and at this point, only one county has opted in and another has a pilot program,” says Fuller. The same is true in Texas, she says, where courts in Dallas County have started using the state's outpatient treatment law more frequently. “But then you have other counties that aren't using it for whatever reason,” she continues. “The local mental health officials haven't gotten on board, [and] there are concerns about what it will cost.”

Patient-rights groups strongly object to looser criteria for or greater use of court-ordered outpatient treatment. “These laws [such as New York's Kendra's Law] are based on speculation,” says Debbie Plotnick, senior director of state policy at Mental Health America, a national advocacy group for people with mental illness based in Alexandria, Va. Mental health disorders are episodic, she says. “People could have been in the hospital within the past three years and doing very well now in the community. You cannot say they are likely to be a danger to self or others.”

The problem is not that the seriously mentally ill are refusing treatment, say Plotnick and others. “We have interventions that are effective for the people that the Treatment Advocacy Center claims cannot be reached. The problem is that those interventions are not available for those who need them,” because of a lack of insurance and funding, says Ira Burnim, legal director at the Washington-based Judge David L. Bazelon Center for Mental Health Law.

These interventions include support provided by trained peers (people living successfully with mental illness); supported housing staffed by mental health workers; and so-called assertive community treatment or ACT, in which a team consisting of a psychiatrist, nurse, social worker, employment counselor and a case worker provides highly individualized services to an individual at home.

“Another missing element of community care that is sorely lacking around the country is the presence of a crisis center that can take people in for brief periods of time, arrange hospitalization if needed and is available 24/7,” says Michael Hogan, New York state's commissioner of mental health until retiring late last year.

Caseworker Cheryl Boone talks to a client (AP Photo/Charlie Riedel)  
Caseworker Cheryl Boone talks to a client during a therapy session at the Johnson County Mental Health Center in Shawnee, Kan., on Jan. 23, 2013. Proposed legislation to improve access to mental health treatment calls for pumping more federal Medicaid money into community mental health centers. (AP Photo/Charlie Riedel)

But Fuller says making treatment and support services more widely available is not enough if people in crisis refuse to use them. “You could literally park people who are actively psychotic on the front door of the best service center in the country, and if they don't think they are sick, they are not going to [voluntarily] walk through that door and access those services.”

Plotnick rejects that argument. “I'm saying we should give people services upstream before they reach a crisis. We have to help them before they are in that stage,” she says.

The largest and latest study of the impact of Kendra's Law was published four years ago. It compared people's experience under court-ordered outpatient treatment with their prior experience, controlling for other factors.17

“Overall, under assisted outpatient treatment, people were less likely to get hospitalized, more likely to receive appropriate medications for their condition, less likely to be arrested, and generally functioned better, with no apparent effect of feeling coerced,” as long as individuals were under court order for at least six months, says Marvin Swartz, a psychiatry professor at Duke University and the study's principal investigator. The study found that these improvements were sustained once the court order expired.

“It makes sense because a Kendra's Law order pushes you to the top of the line,” says Burnim. “They got better because they got access to much better services, not because of the court order.”

In fact, unlike other states with assisted outpatient treatment, New York created a new stream of funding to administer Kendra's Law and also plowed money into expanding services for those who have a serious mental illness.

But Swartz says his study showed that the court order itself conferred benefits. In one analysis, the researchers looked at people who were receiving intensive treatment from a team of professionals without a court order and with a court order. “We found that people under court order did better,” says Swartz.

Hogan says there could be another explanation. Under court-ordered outpatient treatment, government watchers monitor the professional team delivering services, and, as a result, the quality of the treatment may have simply been better, he says.

Does the medical profession define mental illness too broadly?

No laboratory tests exist to help mental health professionals diagnose and treat mental illness. That absence is a huge disadvantage for psychiatry, according to Allen Frances, former chair of the psychiatry department at Duke University, and “it means that all of our diagnoses are now based on subjective judgments that are inherently fallible and prey to capricious change.”18 As a result, the psychiatric profession has cast the net too broadly, capturing both those with mental disorders and those without, he says.

Frances is an outspoken critic of the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), to be published this month by the American Psychiatric Association (APA). First published in 1952, the DSM classifies mental disorders, describing their symptoms and listing the number and duration of symptoms needed to make a diagnosis. The task force overseeing the newest iteration, the DSM-5, “gave their experts great freedom, and the experts have used that freedom to do what experts always do, which is try to expand their area of interest,” says Frances.

But the manual's supporters reject that view. “We developed DSM-5 by utilizing the best experts in the field and extensive reviews of the scientific literature and original research, and we have produced a manual that best represents the current science and will be useful to clinicians and the patients they serve,” said Dilip Jeste, APA president and chief of geriatric psychiatry at the University of California, San Diego.19

The diagnostic manual has drawn criticism since its origin and has become increasingly controversial as its influence has grown. It “shapes who will receive what treatment,” said Mark Olfson, a Columbia University psychiatry professor not involved in the revision. “Even seemingly subtle changes to the criteria can have substantial effects on patterns of care.”20 There have been plenty of not-so-subtle changes over the years, including an expansion of the number of diagnoses from 106 in the first edition to 297 in DSM-4. 21

Critics of the version due to be published this month come from outside and inside the profession. Frances, in fact, was the chair of the task force for DSM-4, published in 1994. He points to a new diagnosis included in the DSM-5 as just one example of what he says is wrong.

It's called Disruptive Mood Disregulation Disorder (DMDD), and it's an attempt to reduce the number of young children who increasingly are diagnosed with bipolar disorder and medicated with powerful antipsychotic drugs. DMDD is a diagnosis for irritable children who have been having “severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation.”22

“The threshold for DMDD is high and children must meet several diagnostic criteria,” David Kupfer, chair of the DSM-5 task force and head of the psychiatry department at the University of Pittsburgh, says in an email. The outbursts must occur three times a week on average and have been present for at least a year.

But “in real life, it will be kids with temper tantrums who will get the diagnosis,” says Frances. “So instead of reducing the risk of excessive medication, I think this greatly increases it. If you want to attack the excessive diagnosis of bipolar disorder in children, you should have big warnings in the bipolar section that this is being terribly over-diagnosed in kids, explain why and explain what should be done.”

Several other changes to the diagnostic manual also are raising hackles. In the DSM-4, an individual grieving the loss of a loved one could not be diagnosed with major depressive disorder (MDD) unless symptoms persist for at least two months. For all other individuals, the threshold for a diagnosis of MDD is lower. Symptoms, such as sadness, loss of interest, loss of appetite, trouble sleeping and reduced energy, need last only two weeks before a diagnosis can be made.

The DSM-5 removes the exclusion for bereavement. Its elimination “shows that psychiatry has no idea how to define what's normal, what's abnormal and how to differentiate between them,” said Allan Horowitz, author of The Loss of Sadness and a sociology professor at Rutgers University in New Jersey. “One of the essential ways we show our humanity is to grieve after the death of an intimate. Amazingly, psychiatry now sees this as a mental disorder.”23

Psychiatrist Ronald Pies said such concern is misplaced. “Grieving persons are not immune to major depressive disorder, and, indeed, bereavement is a common trigger” for it, said Pies, a professor at Tufts University School of Medicine in Boston. Many mood disorder specialists think “the risk of overlooking MDD, with its high potential for suicide, far outweighs the less serious risk of ‘over-calling’ MDD,” said Pies. Besides, most experienced clinicians can tell the difference between grief and major depression, he added.24

But often, primary care physicians and pediatricians are making the diagnosis, not specialists with years of training in mental illness, who are in short supply. “Primary care physicians look at the DSM with confusion,” says Peter Jensen, a child psychiatrist at the Mayo Clinic in Rochester, Minn. “If they use the DSM carefully, it will help them not treat someone as having Attention Deficit Disorder when they might actually have anxiety or depression.25 But if they're rushed, they can't do that, and that's why we see over-diagnosis and over-treatment.”

The DSM is not the problem, he says. “The scientists who come up with the criteria have really struggled to make them as tight as possible,” Jensen says.

Do insurers treat mental and physical health equally?

When Congress passed the Mental Health Parity and Addiction Equity Act in 2008, it required group insurance plans sponsored by employers with 50 or more workers to put coverage of mental illness and substance abuse on an equal footing with physical health.

But the Obama administration has yet to release the final rules implementing the law. “It took 12 years to pass that parity act, and four years later we still have no rules and therefore no enforcement,” said James Ramstad, a former Republican congressman from Minnesota and supporter of the bill. “It's unconscionable.”26

“A law without rules isn't worth the paper it's written on, and what that means is that insurance companies can continue to do business as usual,” said Patrick Kennedy, a former Democratic congressman from Rhode Island and another of the law's champions.27

At a congressional budget hearing in April, U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius had only this to say: “We are committed to finalizing the rule this year and are in the process of doing just that.”28

“Insurance plans have been working hard on implementation,” based on an interim final rule the administration released in 2010, says Susan Pisano, spokeswoman for the Washington-based America's Health Insurance Plans, the industry trade association. The industry supported the parity law, she says.

The law is supposed to ensure that insurance plans don't impose financial requirements — deductibles, copayments, out-of-pocket payments and co-insurance — for mental health care and substance abuse treatment that are more restrictive than for physical health benefits. Parity also applies to treatment limitations.29 For example, if an insurance plan doesn't limit the number of hospital days or out-patient visits for most physical care, it can't place such limits on mental health care.

Cost Deters Many From Treatment  

Mental health advocates say insurers have done a pretty good job of getting those numerical limits in line but are falling down when it comes to scope of services. “We still continue to see wholesale exclusion of benefits on the behavioral health side that we don't see on the medical/surgical side,” says Andrew Sperling, director of legislative advocacy for the National Alliance on Mental Illness. For example, plans will cover rehabilitation after a hospital stay for a stroke, but many won't cover intensive day-therapy after hospitalization for substance abuse, he says.

“We believe this violates the spirit of the law,” Sperling says. The Obama administration interim final rule mentions parity for scope of services but has no binding requirements. Sperling hopes the final rule will make such requirements clear.

The interim rule also states that insurance plans must manage utilization of benefits evenly across mental health and physical health care. For example, if a plan does not require prior authorization for medical and surgical admissions, then it can't require prior authorization for mental health admissions, advocates say.

The New York State Psychiatric Association, along with three individuals, filed a class action lawsuit in March against UnitedHealth Group, one of the country's largest health insurers, charging that the company “improperly processed and discouraged claims for mental health and substance abuse,” says New York attorney Brian Hufford, the lead lawyer in the case. At its heart is a charge that the insurer requires pre-authorization for psychotherapy sessions but not for most outpatient medical care.

“The only explanation I've seen is that for certain ancillary services, like physical therapy, they require pre-authorization, and so they say they can do it for mental health care,” says Hufford. But mental health is not an ancillary service like physical therapy, he says.

“We are committed to helping people with mental health issues reach long-term recovery,” UnitedHealth Group said in a statement. “We have received the complaint and are currently reviewing it.”30

Comparing utilization review criteria across mental and physical health sounds straightforward, but it's not as simple as comparing copays, says Pamela Greenberg, president and CEO of the Washington-based Association for Behavioral Health and Wellness, the trade association for the specialized companies that insurers often hire — or own — to manage mental health benefits. “It's a little bit like comparing apples and oranges,” she says.

In addition, her members often cannot get the information they need from insurance plans to make these comparisons, says Greenberg. “We're being asked to find out when does the medical plan require prior authorization and under what circumstances, but there is no requirement [in the parity law] that [insurers] share it with us.”

That lack of information also makes it difficult for consumers to know if their insurer is treating mental health benefits equitably. “The consumer is at a complete loss,” said Julie Clements, deputy director of regulatory affairs at the American Psychiatric Association.31

Advocates hope the final rule better clarifies what information insurers must share. “The delay really does reflect the complexity of these issues and the need to get extensive input. People really had a lot to say about this,” says Gary Blau, chief of the Child, Adolescent and Family Branch of the federal Substance Abuse and Mental Health Services Administration.

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*Behavioral health services refers to mental health as well as substance abuse services.

Background

Rise of State Hospitals

Before 1800, mentally ill people in America were cared for at home or in their communities though charity. But after 1800, rapid population growth, immigration, urbanization and growing geographic mobility upset those traditions, and an increasing number ended up in jail, in poorhouses, or in the few existing — and often overcrowded — mental hospitals, inspiring one woman's crusade for better care.

Dorothea Dix, a retired Boston teacher, visited a jail in 1841 to teach women prisoners and was horrified by the number of mentally ill and the conditions in which they were kept. Galvanized by the experience, she visited jails and poor houses across Massachusetts and addressed the legislature in 1843, denouncing “the present state of Insane Persons confined within this Commonwealth, in cages, closets, cellars, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience!”32

Dix helped convince lawmakers to expand the Worcester State Lunatic Asylum and, in the 1850s, build two new mental hospitals. Dix's success in Massachusetts “launched her on a lifetime career as an apostle for asylums,” wrote psychiatrist E. Fuller Torrey and his research assistant Judy Miller in The Invisible Plague. 33

During the 1840s and '50s, a total of 23 public mental hospitals were built in 19 states, almost three times more than had been built in the previous 20 years. Public officials and legislators supported the expansion of public mental hospitals in part because proponents promised the institutions “could cure insane individuals and therefore would ultimately save money,” wrote Torrey and Miller.34

But most mental hospitals had more patients than they could handle effectively, making it difficult to pursue time-consuming individualistic therapy. By the early 1900s, “public facilities persisted as large and impersonal institutions characterized by a custodial attitude, meager allowances for active psychiatric treatment, limited professional staff, and a dependence on untrained and unskilled personnel,” according to health policy experts David Mechanic, Donna McAlpine and David Rochefort in Mental Health and Social Policy. 35

Shift to Community Care

During the 1940s, several journalists published exposés of conditions in state mental hospitals. Life magazine published the lengthy article “Bedlam 1946” accompanied by “dramatic and horrifying photographs” that “only added to its emotional impact,” wrote historians Gerald Grob and Howard Goldman in The Dilemma of Federal Mental Health Policy.

At the same time, demoralized psychiatrists were abandoning mental institutions for private or community practice, replaced by “foreign medical graduates with little or no training in psychiatry.”36 Advocates for the mentally ill as well as lawmakers looking for cost savings began to embrace the idea of treating the seriously mentally ill as outpatients in their communities. In the 1950s, New York and California passed laws establishing community mental health clinics.

“The advent of the first generation of antipsychotic drugs was one of several factors contributing to the release of patients from state mental hospitals,” wrote health economists Richard Frank and Sherry Glied in Better But Not Well. “Chlorpromazine was the first medication to take the psychiatric world by storm, heralding the modern era of biological psychiatry.” It was first marketed in the United States in 1954 under the brand name Thorazine as a treatment for schizophrenia. Considered widely effective, it came, however, with serious neurologic side effects, including rigidity and tremors.37

In 1963, President John F. Kennedy signed into law the Mental Retardation Facilities and Community Mental Health Centers Construction Act. States could apply for federal grants to establish a system of community mental health centers. The new centers were required to provide five essential services: inpatient hospitalization; partial hospitalization (in which patients live at home but come to the center up to seven days a week); outpatient care; round-the-clock emergency care; and education and consultation services.

The resident population in state and county mental hospitals fell from more than 500,000 in the 1950s to fewer than 40,000 by 2005.38 Many patients were released back to families, group homes or single-occupancy residences to receive treatment locally, but others were simply shifted to nursing homes or general hospitals.

“Federal programs offered an irresistible bargain to state administrators,” wrote Mechanic and colleagues. Medicare, created in 1965, covered mental health treatment for enrollees who entered general hospitals and private psychiatric hospitals; Medicaid, created at the same time to provide health care for the poor, paid a large share of mental health treatment costs for enrollees in general hospitals and nursing homes.

“By directing patients away from public mental hospitals, then, the state could capture huge budgetary savings,” Mechanic and colleagues said. The result was a vast expansion in private nursing homes and private mental hospitals and a boom in specialized psychiatric and substance abuse units in general hospitals, they noted. “Over time, such facilities became the main entry point for acute inpatient behavioral health care.”39

Meanwhile, the creation and construction of community mental health centers (CMHCs) proceeded slowly. A shortage of mental health professionals was one problem. Another was the Vietnam War's diversion of funding. A total of 2,000 mental health centers were supposed to be built by 1980, but the actual number was 754. “By then it had become abundantly clear that … CMHCs were not serving as replacements for traditional public mental hospitals,” according to Grob and Goldman.40

In 1968 Congress expanded the role of the centers to serve substance abusers, children and older people. Grappling with a broader mission and tight resources, centers “chose to serve a great number of less impaired and lower-cost people rather than disproportionately allocating their budget to high-cost severely ill people,” wrote Frank and Glied.41 In addition, the centers did not, and were not required to, coordinate continuing treatment and support for thousands of individuals being discharged each year from mental hospitals.

By the end of the 1970s, the mental health system was a decentralized, uncoordinated and bewildering array of institutions and practices: public and private psychiatric hospitals; nursing homes; residential care facilities; community mental health centers, funded mostly by Medicaid but also by county, state and federal programs, Medicare and private insurance; outpatient and inpatient units in general hospitals; group homes; and client-run services.42

Changing Federal Policy

In 1980, Congress passed the Mental Health Systems Act. The federal government would continue to issue grants to states, but now there would be performance contracts to ensure accountability. The role of community mental health centers was reaffirmed, with an emphasis on caring for the seriously mentally ill, and states could apply for grants to coordinate state and federal services.

But upon taking office in 1981, President Ronald Reagan reversed course and successfully persuaded Congress to repeal the act. Next, Congress significantly cut funding and then bundled the federal grants for community mental health centers and other federal funding for mental health into a single lump sum given to each state annually with few strings attached. Finally, in response to a drastic expansion in the number of people receiving federal disability payments, the Reagan administration began extensive in-person reviews in 1983 to weed from the rolls those it decided were not permanently disabled.

About 500,000 people lost their disability payments, a disproportionate number of whom were mentally ill. The purge led to a public outcry, and in response Congress passed the 1984 Disability Benefits Reform Act: The government could terminate benefits only if an individual's medical condition improved enough to allow the person to return to gainful employment. The disability rolls have been increasing ever since, with the mentally ill the fastest growing group.43

Mental Health Prescriptions Soar  

The late 1980s and '90s also saw the development of new drugs to treat mental illness. A new generation of so-called atypical antipsychotic medications — including clozapine, olanzapine, quetiapine and risperidone — have been shown in studies to be as effective as the older antipsychotic drugs in treating schizophrenia but with a reduction in the tremors and rigidity that made many people reluctant to stick with their drug regimen. However, the new drugs are more costly and have been associated with weight gain and diabetes.

Tricyclic antidepressants were introduced in the 1950s and '60s to treat major depression, but they had a long list of side effects, including drowsiness, dizziness, constipation, weight gain, headache and increased heart rate. The development of selective serotonin reuptake inhibitors, or SSRIs, beginning with Prozac in 1988, “transformed the treatment of depression,” according to Frank and Glied. SSRIs are of equal efficacy as tricyclic antidepressants but are safer, better tolerated by patients and pose less danger from overdose, according to researchers. “These drugs entered both the medical mainstream, through their widespread use by primary care providers, and the popular culture, with Peter Kramer's best-selling book in 1993, Listening to Prozac,” wrote Frank and Glied.44

Equal Treatment

As the cost of health care rose due to an aging population, expensive new drugs and costly technological advances, such as the development of sophisticated imaging machines, managed care emerged in the 1990s as a way to try to subdue the rising costs.

Previously, an employer signed a contract with a single health insurance company to provide employees with a traditional indemnity plan — also known as a fee-for-service plan — that allowed individuals to use any doctor they chose and submit their bills to the insurer for partial reimbursement, typically 80 percent. Under managed care, employers often give employees a choice of plans. A health maintenance organization, or HMO, the oldest form of managed care, puts doctors on staff or signs contracts with medical practices to provide care for enrollees, who must use the physicians in the plan. A preferred provider organization (PPO), another form of managed care, is closer to a traditional fee-for-service plan. But enrollees are reimbursed at a lower rate if they use doctors outside of the PPO network. In-network doctors have agreed to provide medical care at a discount.

From the beginning, employers and general health plans chose to carve out coverage of mental health care and assign it to specialized behavioral health care companies. These companies saved money by limiting the number of days allowed for inpatient care, reducing prices paid to their network of mental health providers, limiting the number of outpatient visits and requiring preauthorization for treatment. The reliance on behavioral health care companies eventually spread from the private sector to Medicaid.

Mental health advocates argued that the behavioral health care companies' cost controls were discriminatory because they were stricter than those for physical care. They lobbied Congress for parity, or equal treatment.

Congress passed the Mental Health Parity Act of 1996, but its scope was limited. The act restricted the ability of group health insurance plans to place lower annual or lifetime dollar caps on mental health benefits than on medical and surgical benefits. But the act did not stop group plans from having higher copayments for mental health care or from limiting the number of inpatient days or outpatient visits even when no such limits existed for medical or surgical care. The act also did not prevent group plans from dropping mental health coverage. It applied only to health plans sponsored by employers with 51 or more workers, and it did not apply to health insurance coverage purchased by individuals. It also did not apply to treatment for substance abuse.45

The percentage of workers with dollar caps on mental health coverage fell substantially as a result of the law, according to researchers. But, contrary to advocates' hopes, restrictions on inpatient days and outpatient visits for mental health care increased.46

In 1999, President Bill Clinton's surgeon general, David Satcher, issued Mental Health — A Report of the Surgeon General, a landmark analysis of the mental health field. It emphasized the need to understand mental illnesses as real, often disabling, health conditions and identified a range of effective treatments backed by research that often had not been put into practice.

In 2002, President George W. Bush formed the New Freedom Commission on Mental Health to study the nation's mental health system and recommend improvements that would not increase spending. After a year of study, the commission found that “recovery from mental illness is now a real possibility,” but that the mental health care system was a “patchwork relic — the result of disjointed reforms and policies.”47

The report, though not a blueprint for action, defined several goals for transformation, including integration of mental and physical health care; empowerment of consumers and families; increased early screening, assessment and referral; research-guided treatment; and improved access to and coordination of care.48

When Bush announced the formation of the commission, he identified three barriers to mental health care: stigma, the fragmented delivery system and private health insurance plans' often unfair treatment limitations and financial requirements on mental health benefits. Insurance companies “must treat serious mental illness like any other disease,” the president said.49

At the time, however, many congressional Republicans were opposed to so-called “mental health parity” for fear that it would drive up health care costs and discourage employers from offering coverage. But in 2008, after Democrats gained control of both houses of Congress, lawmakers passed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act.

Like the 1996 law, it applied only to group plans, exempted plans sponsored by small employers and allowed plans to drop mental health coverage. But it was far more ambitious than the previous law. It expanded parity by including deductibles, copayments, out-of-pocket expenses, co-insurance, covered hospital days and covered outpatient visits. It also expanded parity to substance abuse treatment.

The 2010 Patient Protection and Affordable Care Act will eventually expand parity. Starting at the end of this year, individuals and employers with fewer than 100 employees — 50 or fewer in some states — can purchase health insurance through online exchanges operating in every state. Insurance plans offered through the exchanges must provide mental health coverage and abide by federal parity rules. However, most Americans will continue to get health insurance through employer-sponsored plans that are not purchased through the exchanges.50

The health law also expands Medicaid to anyone who earns less than 133 percent of the federal poverty level (about $31,320 for a family of four), with the federal government footing most of the bill.51 That could potentially extend health insurance coverage to up to 10 million people with mental illness. However, as of early May, 12 states were leaning toward opting out of Medicaid expansion and another 13 were undecided.52

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Current Situation

Integrating Care

A number of Democrats and Republicans in Congress are backing legislation they say will address the problems plaguing the nation's mental health system. The Excellence in Mental Health Act would:

  • Increase funding for qualified community mental health centers;

  • Increase access to an array of treatments and services that research has shown to be effective, including peer support, cognitive behavioral therapy, supported employment and supported housing;

  • Require community mental health centers to screen for physical health problems and collaborate with primary care providers to give people with mental and addiction disorders medical treatment and preventive care.

“Integrating care is critically important,” says Honberg of the National Alliance on Mental Illness. “We've had these two systems — mental health care and physical health care — operating far apart without talking to each other, and there have been huge consequences.”

Honberg is referring to a 2006 report from the National Association of State Mental Health Program Directors that shocked many of those working in mental health care at the time. Analyzing state data, researchers found that people with serious mental illness die, on average, 25 years earlier than the general population.

While suicide and injury accounted for about one-third of those premature deaths, most were due to what the report called preventable medical conditions, such as cardiovascular, pulmonary and infectious diseases as well as diabetes. Higher rates of smoking, alcohol and intravenous drug use and poor nutrition put those with serious mental illness at greater risk for developing those diseases than the general population. Homelessness, unemployment, poverty, incarceration and social isolation also contribute to poor physical health.

Serious Mental Illness in Adults Most Prevalent in Young  

The new generation of antipsychotic drugs also plays a significant role. While they have far fewer neurologic side effects than older drugs, they are highly associated with weight gain, diabetes, insulin resistance and other metabolic disorders.

But equally important is the lack of access to primary care.53 In response, four years ago the Substance Abuse and Mental Health Services Administration (SAMHSA) began issuing grants to communities that wanted to add primary care to services available at community mental health centers. SAMHSA currently funds 93 such projects.

“Just from being on medication for mental illness, I gained about 60 pounds,” said Gary Ward, who participates in a Washington County, Maine, program that provides primary and mental health care in one location. In two years, Ward has lost 38 pounds. “It's given me my life back, it really has.”54

Integrating care seems like a simple idea, but Kathleen Reynolds, vice president for health integration and wellness promotion at the National Council for Community Behavioral Healthcare, says there are several challenges.

“One is financing,” says Reynolds. Complicated Medicaid and Medicare billing rules don't make it easy to bill for both primary and mental health care from one location. Another challenge is confidentiality. Federal and state confidentiality rules and regulations can make it difficult for a mental health provider and a primary care provider working together onsite to share information if they are from different agencies. “Yes, you can do it by getting every person to sign a release, but it is a burden to make sure those releases are up to date and cover all the information,” says Reynolds.

Yet another challenge is cultural and organizational, she says. Mental health professionals typically spend long periods with individuals and get paid to do so. Primary care providers get paid per encounter, no matter how long the visit, so “the pace of the work in primary care is much faster,” says Reynolds. Combining the two types of care in one visit can be a challenge. “You don't want to have a person come in and spend two or three hours,” says Reynolds. “In most cases, it's the behavioral health side that modifies its practices, coming up with shorter interventions.”

Mental Health in Schools

President Obama has called for spending $55 million in fiscal 2014 to reach 750,000 young people through programs to identify mental illness in schools and refer them to treatment when needed. “If you think about adult mental illness, about 50 percent of all those illnesses can be traced and manifest by the age of 14, and three-quarters manifest by the age of 24,” says Blau of SAMHSA, which would fund the effort if it survives congressional budget negotiations. “That's why we need to emphasize prevention in early childhood.”

But schools do not have enough qualified staff members to work as part of mental health teams, according to groups representing such professionals. Jill Cook, assistant director of the Alexandria, Va.-based American School Counselor Association, says there currently are 471 students per school counselor nationwide — far too many. “Even though there has been improvement over the past several decades, our association's recommendation is one school counselor for every 250 students,” she says.

Grace Freund (Getty Images/The Baltimore Sun/MCT/Kevin Rector)  
University of Maryland junior Grace Freund studies to become a volunteer at the school's student-run Help Center, which works with students dealing with mental health crises. Of the estimated 58 million American adults with a diagnosable mental disorder, more than 11 million have a serious mental illness, such as schizophrenia, bipolar disorder or major depression. (Getty Images/The Baltimore Sun/MCT/Kevin Rector)

In addition, many states don't require school nurses. As a result, the coverage varies widely, from a high of 4,411 students per school nurse in Michigan in 2011 to a low of 396 in Vermont.55 “In the Northeast the ratios are more realistic and safe for kids, but as you go further South and West, there often is no requirement for school nursing, and the ratios get larger,” says Linda Davis-Alldritt, president of the National Association of School Nurses, based in Silver Spring, Md.

Obama's plan calls for bringing a program called Mental Health First Aid into schools to train teachers, school security officers and even front-desk personnel to recognize the signs of mental illness in youngsters.

Introduced in the United States in 2008 and modeled after a program in Australia, Mental Health First Aid is a 12-hour interactive training course designed to help the public identify, understand and respond appropriately to signs of mental illness and substance use disorders. More than 120,000 people have been trained since its inception in the United States.

“It has the potential to normalize mental illness in the public eye, not unlike physical illness,” says Wayne Lindstrom, president and CEO of Mental Health America.

Mental Health First Aid recently modified its program for use in schools, reducing it to eight hours and altering the content to better reflect signs and symptoms in young people. Two school districts — in McAllen, Texas, and Tulare County, Calif. — have signed on so far. “We don't teach people how to diagnose or treat mental illness,” says Bryan Gibb, director of public education at the National Council for Community Behavioral Healthcare, which helps run the program. Nor do Mental Health First Aid instructors simply give teachers a list of warning signs with instructions: “If you see these, pick up the phone,” says Gibb. “There would be so many false alarms.”

Instead, instructors show teachers how to de-escalate a crisis, such as when someone threatens suicide or hallucinates. But instructors spend the most time teaching adults how to have a nonjudgmental conversation with students and “refer them to professional help if necessary,” says Gibb.

That referral doesn't happen without permission from a parent or guardian, he adds.

Gibb says the organizers also recognize the risk that teachers might see signs and symptoms of mental disorders, such as depression, anxiety or an eating disorder, where there are none. “We tell teachers … we really want you to be aware of that bias,” says Gibb.

So far, there have been no studies of Mental Health First Aid's effectiveness in schools, but Gibb says studies are planned. SAMHSA says it will monitor the program's impact on teachers and students if Congress authorizes funding.

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Outlook

Legislation in Limbo

Senators sponsoring mental health legislation planned to piggy-back on the gun control bill that was up for a vote in the Senate last month, offering their proposals as amendments. During two days of tense voting on the gun bill, the Senate overwhelmingly passed the Mental Health Awareness and Improvement Act, which would reauthorize several federal programs, such as suicide prevention, and fund a new initiative to bring Mental Health First Aid into schools. But when the gun bill died, so did the Mental Health Awareness law, at least for now.

The gun bill's death in the Senate also has left the more heavily lobbied Excellence in Mental Health Act in limbo. It never even came up for a vote as an amendment. Now its Senate sponsors and mental health advocates must adjust their strategy.

“We're pushing for co-sponsors, and the more co-sponsors we get the more likely it is that Senate Majority Leader Harry Reid will give us a vote,” says Sperling of the National Alliance on Mental Illness. Sperling says NAMI is preparing for two possibilities: that the Senate gets a second crack at voting on gun legislation or that the mental health act's sponsors will offer it as amendment to some other bill. “We have our members and affiliates calling senators, writing in, emailing, you name it,” he says.

The lead sponsors of the Excellence in Mental Health Act will decide the ultimate strategy. “I think there's a really good opportunity we can still get this done. It should not be dependent on gun legislation,” Sen. Roy Blunt, R-Mo., told Politico after the gun bill was pulled from the Senate floor. “I feel very confident we will get a vote at some point,” added Michigan Democrat Debbie Stabenow.56

Without a federal law, action on mental health is left to the states. Some states — such as Pennsylvania and Wisconsin — are considering restoring some of the money cut from mental health budgets. But Joel Miller, senior director of policy and healthcare reform at the National Association of State Mental Health Program Directors, says he doesn't think most states will restore mental health money. “There are Midwestern industrial states like Illinois and Michigan that have not funded their public pensions properly, so they're going to take it out on the health care side.”

The most important action states can take right now, says Miller, is to sign on to the Affordable Care Act's Medicaid expansion program, which could extend health care coverage to as many as 10 million additional people living with mental illness. “That will bring new federal monies into state budgets for treating people with mental illness,” he says. In the first three years of the expansion, beginning in 2014, the federal government will cover 100 percent of the costs for expanded enrollees and then 90 percent after that. But as of early May, only 20 states had committed to Medicaid expansion, with another six leaning toward it.57

Several Republican governors have spoken out against expanding Medicaid, including Gov. Rick Perry of Texas. “Texas will not be held hostage by the Obama administration's attempt to force us into the fool's errand of adding more than a million Texans to a broken system,” Perry said in early April.58 The Southern-most states from Texas to North Carolina, with the exception of Florida, are leaning toward opting out of Medicaid expansion. So are Idaho, Missouri, Oklahoma, Montana and Alaska.59

Advocates are working hard to convince legislatures and governors in those states to change their minds. “There are so many people who have no access whatsoever to health care and who have extreme needs,” says Plotnick of Mental Health America. “The Medicaid expansion would reach those folks who have nothing.”

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Pro/Con

Will the new mental-disorders manual lead to over-diagnosis?

Pro

DR. Allen Frances
Professor emeritus of psychiatry, Duke University School of Medicine; former chair of the DSM-4 Task Force; author of Saving Normal. Written for CQ Researcher, May 2013

We already are in the midst of a troublesome diagnostic inflation, and the revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) threatens to expand it into an even more harmful hyperinflation.

The numbers are startling and scary. In any given year, 25 percent of the general population qualifies for a mental disorder; 50 percent will over their lifetime; and 20 percent take a psychotropic medicine. More people now die from overdoses caused by medicines prescribed by doctors than by street drugs sold by the cartels. In the last 20 years, rates of adult bipolar disorder have doubled, attention deficit disorder (ADD) has tripled, and autism and childhood bipolar disorder have grown a remarkable 40-fold.

People don't change quickly, but labels do. Small changes in how disorders are defined can result in large changes in who gets labeled. Diagnostic fashions are heavily influenced by drug-company marketing, which in the United States is fueled by enormous budgets and conducted with unprecedented freedom from regulation. The ubiquitous advertising has successfully sold the misleading message that expectable problems of living are mental disorders that are caused by a chemical imbalance and require a pill solution. Illegal drug company marketing has led to multiple billion-dollar fines that are not much of a deterrent given the enormous revenues generated by artificially created demand.

The other major driver of diagnostic inflation is the fact that DSM diagnosis has become too important in decisions that determine eligibility for mental health care, school services and disability benefits.

Except for autism, all the changes in DSM-5 will increase the rates of diagnosis — either by adding new disorders or reducing thresholds for existing ones. Expectable grief becomes major depressive disorder; the normal forgetting of old age is mild neurocognitive disorder; worrying about a medical illness is somatic symptom disorder; overeating is binge eating disorder; temper tantrums are disruptive mood dysregulation disorder; and adult ADD will be so easy to diagnose that the already large illegal market of diverted stimulant drugs will be even harder to control.

We should be tightening diagnostic standards, not loosening them. When we increase the resources devoted to the worried well who don't need them, we deprive the really sick who desperately do.

Con

DR. Michael B. First
Professor of clinical psychiatry, Columbia University. Written for CQ Researcher, May 2013

No one can say for sure what impact the new revision of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-5) will have on diagnosis — the book isn't out until this month, and its impact will slowly unfold over months, if not years. But it probably won't lead to over-diagnosis. Anomalous rises in diagnostic rates are, frankly, much more likely to be rooted in factors other than the diagnostic system. These include external pressures on clinicians to make diagnoses in a limited period of time; pressure from patients and families for quick fixes to complex problems, and pharmaceutical marketing influences.

Psychiatric diagnosis is a complex process in which a trained clinician interacts with a patient to collect a psychiatric history, gathers corroborating information from family members, reviews medical records and laboratory findings and then determines the diagnosis by synthesizing this information and applying clinical judgment to the technical rules laid out in the American Psychiatric Association's classification of mental disorders. When shortcuts are taken by not conducting a thorough evaluation or by ignoring the manual's diagnostic rules, over-diagnosis and misdiagnosis, with its consequent overtreatment and mistreatment, can occur.

The marked rise in the attention-deficit/hyperactivity disorder (ADHD) diagnosis over the past 20 years and the consequent escalation in stimulant prescriptions is a perfect illustration of the complex nature of this phenomenon. Under pressure from some parents, school systems and patients for a quick fix to improve attention and concentration or to get an edge over the competition, combined with heavy promotion by the pharmaceutical industry of new drug formulations, many clinicians applied the ADHD label inappropriately. They did so to justify their decision to write a prescription for stimulants without having conducted a proper symptomatic or functional assessment or having determined that the requirements for the diagnosis, as laid out in the DSM, were met. For example, there should be clear evidence of clinically significant impairment in social, academic or occupational functioning.

The best hope to combat misdiagnosis of any kind would be an intensive educational campaign promoting comprehensive diagnostic evaluation using accepted scientific methods. Suggesting that the DSM classification itself is the main reason for over-diagnosis ignores the fact that psychiatric diagnoses do not simply exist in the abstract. They are tools used by clinicians to foster communication and to improve clinical care. Diagnoses are only as good as the people making them.

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Chronology

 
1840s–1950sStates build public mental hospitals; drugs for mental illness are developed.
1843Activist Dorothea Dix denounces condition of the mentally ill confined in jails and poorhouses.
1860Twenty-three public mental hospitals are built between 1840–1860.
1946 Life magazine publishes an exposé of deplorable conditions in many state mental hospitals.
1950sNew York state and California pass laws establishing community mental health clinics as alternatives to hospitalization.
1954Thorazine is marketed in U.S. to treat schizophrenia, heralding the modern era of biological psychiatry; considered widely effective, thorazine has serious neurologic side effects.
1956The first tricyclic antidepressant to treat clinical depression is introduced…. More than 500,000 people reside in state and county mental hospitals.
1960s–1980sFederal laws empty public mental hospitals, as new drugs revolutionize treatment.
1963Congress provides federal grants to states to establish community mental health centers to serve the deinstitutionalized mentally ill.
1965Newly created Medicare and Medicaid pay for treating acutely mentally ill in general hospitals, private psychiatric hospitals and nursing homes; states shift many patients out of public mental hospitals into these facilities instead of into communities.
1968Congress expands role of community mental health centers to serve children and the elderly.
1980Only 754 community mental health centers have been built since 1963, far short of the projected 2,000…. Congress passes the Mental Health Systems Act.
1981At President Ronald Reagan's urging, Congress repeals the Mental Health Systems Act and reduces federal funding to states for mental health care.
1983Reagan administration purges 500,000 people from federal disability rolls, a disproportionate number mentally ill.
1984The Disability Benefits Reform Act prevents the government from terminating an individual's disability benefits unless there is enough medical improvement to allow gainful employment.
1988Prozac, the first selective serotonin reuptake inhibitor, or SSRI, is introduced for depression treatment.
1989The first so-called atypical antipsychotic medication is introduced, followed by three more such drugs in the 1990s.
1990s-PresentInsurance plans shift to managed care; government requires parity.
1990sManaged care plans adopted in effort to control rising health care costs.
1996Mental Health Parity Act restricts large group health insurance plans from placing lower dollar caps on mental health benefits than on physical care.
2005Resident population of state and county mental hospitals has fallen to 40,000.
2008The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act significantly extends parity to insurance coverage of mental health and coverage of physical health in large group plans.
2010Patient Protection and Affordable Care Act extends parity to individual and small group plans purchased through newly created state insurance exchanges.
April 2013Mental health legislation tied to gun control dies in the Senate when gun control bills fail to muster enough votes for passage; sponsors say they hope to reintroduce mental health legislation later in the year.
  

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Short Features

“It's a huge problem, starting with the child mental health system.”

Tens of millions of Americans are living with mental illness, but many are going without care, in part because of a shortage of qualified mental health professionals.

The 2010 Affordable Care Act — the sweeping health care law championed by President Obama — will extend health coverage to an estimated six to 10 million individuals living with mental illness.1 But experts cite a shortage of psychiatrists, clinical psychologists, psychiatric nurses and specialized social workers to handle current demand, let alone any expansion.

“It's a huge problem, starting with the child mental health system,” says Ronald Honberg, national director for policy and legal affairs at the National Alliance on Mental Illness (NAMI), an advocacy group in Arlington, Va. “There is a severe shortage of child psychologists and psychiatrists around the country, especially in rural areas.” (Child psychiatrists are medical doctors with special training in treating psychiatric problems in children and adolescents.)

Dividing the number of children estimated to be suffering from serious emotional disturbance by the hours worked by practicing child psychiatrists yields, on average, one hour a year of attention per child. “You can't even do an evaluation in an hour,” says Peter Jensen, a child psychiatrist at the Mayo Clinic in Rochester, Minn. “You can't manage complex medications. You can't do followup.”

“The largest factor behind the shortage is the longer period of education [required] to be a child psychiatrist,” says Kristin Kroeger Ptakowski, director of government affairs and clinical practice at the American Academy of Child & Adolescent Psychiatry, a professional medical association in Washington, D.C. (It takes six years of training after medical school to become a licensed child psychiatrist.)

Moreover, practitioners say that once they are out of training, the hours are long and the pay is relatively modest compared to other specialties. To accommodate children's schedules, child psychiatrists often work afternoons and evenings, says Harold Koplewicz, himself a child psychiatrist and president of the Child Mind Institute in New York, which conducts research and offers clinical services. “And if you are accepting insurance, you are paid for seeing the child. You are not paid for talking to school teachers or for counseling parents,” says Koplewicz.

Students finishing a Ph.D. in psychology face their own hurdles. “There is a shortage of internship positions,” which is the capstone of clinical training and a requirement for a degree, says Cynthia Belar, executive director for education at the Washington-based American Psychological Association. Nearly 800 students out of roughly 4,500 could not find an internship in 2013, according the Association of Psychology Postdoctoral and Internship Centers.2

The Obama administration has proposed spending $50 million in fiscal 2014 to help train 5,000 new social workers, counselors, psychologists and peer professionals (individuals with mental illness who have successfully navigated the mental health system and can advise others). “It's a step in the right direction,” says Honberg.

But some experts expressed concern when they learned that the money would be spent to train only master's degree-level psychologists, social workers and counselors and not doctorate-level psychologists or psychiatrists as well. An administration official told The Washington Post that the aim is to help alleviate the current demand for services. “We can't take 12 years training doctors and post-docs to meet the need in 2014,” the official said.3

But Kroeger Ptakowski says the administration's strategy is short-sighted. “It's unfortunate that it doesn't include all mental health professionals,” she says. “If these funds were available now, I'm sure there would be many medical students who would be interested in going into child psychiatry.”

Adds Belar: “An investment in one year of training [for psychology internships] for already-prepared doctoral students would seem as practical as supporting three-year programs.”

Koplewicz advocates increased spending to encourage pediatricians and family physicians to pursue advanced education in mental health because they do most of the diagnosing and treating of children with mental illness. “They must be better trained,” he says.

Koplewicz proposes that primary care physicians who take an approved course in diagnosing and treating ADHD, adolescent depression, anxiety disorders and autism receive higher reimbursement from Medicaid and possibly from private insurance as well.

Jensen founded the 5-year-old Reach Institute in New York, which trains pediatricians and family doctors around the country in child mental health during an intensive three-day interactive program followed by six months of consultations with national experts.

“We teach them pediatric psychopharmacology, but a little more than 50 percent focuses on assessment, diagnosis, forming a relationship with the family and how they can do this in 15 minutes every week or every other week until the family is stabilized,” says Jensen. “And we teach them when they should refer to a specialist,” mostly if they see signs of bipolar disorder or schizophrenia.

Physicians also learn about cognitive behavioral therapy and other so-called evidence-based psychotherapy techniques so they can knowledgeably refer patients to counselors or psychologists.4

Experts say better mental health care often requires a collaborative approach in which a primary-care practice hires a social worker, counselor or psychologist on staff or as a consultant or contracts with a mental health group to treat adults or children.

But there are barriers to making collaborative care work. One is financial. “The time that a pediatrician spends on the phone with a child psychiatrist discussing a case is not necessarily time that can be reimbursed by insurance,” says Darcy Gruttadaro, director of the child and adolescent action center at NAMI. Massachusetts legislators are working on a state law that would require insurers to pay for that time, she says.

In addition, “The primary care physician may have a contract with one insurer and the mental health provider with another,” says Wayne Lindstrom, president and CEO of Mental Health America, an advocacy group in Alexandria, Va. Another barrier may be something as mundane as office space. “It may not be available, and the primary care practice may be bound by a long-term lease” that would prevent the practice from moving into joint space with the mental health professionals, says Lindstrom.

Some of these challenges may be eased as the 2010 Affordable Care Act is phased in. Through a variety of pilot programs and other enticements, the law encourages collaborative care and will experiment with paying integrated group practices a lump sum for bundled services or for the annual care of each patient. However, many programs and incentives sanctioned under the new law have not been funded because of federal budget problems.

— Barbara Mantel

[1] For background, see the following CQ Researchers by Marcia Clemmitt, “Assessing the New Health Care Law,” Sept. 21, 2012, pp. 789–812; “Health Care Reform,” June 11, 2010, pp. 505–528, updated May 24, 2011; and “Treating ADHD,” Aug. 3, 2012, pp. 669–692.

[2] “2013 APPIC Match Statistics Combined Results: Phase I and Phase II,” Association of Psychology Postdoctoral and Internship Centers, March 25, 2013, www.appic.org/Match/MatchStatistics/MatchStatistics2013Combined.aspx.

[3] Sarah Kliff, “Obama's proposed budget to seek $235 million for new mental health programs,” The Washington Post, April 9, 2013, http://articles.washingtonpost.com/2013-04-09/national/38403598_1_mental-health-services-gun-violence-health-insurance-coverage.

[4] For background, see Sarah Glazer, “Treating Anxiety,” CQ Researcher, Feb. 8, 2002, pp. 97–120.

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More than 2,700 crisis teams exist nationwide.

When the U.S. Justice Department cited the Portland, Ore., police department last September for a history of excessive force against the mentally ill, city officials agreed to join a nationwide movement aimed at helping police better deal with people experiencing psychiatric problems.5

As part of a settlement with the Justice Department, Portland formed a crisis intervention team within its police department to train law-enforcement personnel in how to respond to calls involving the mentally ill. “We all agree we can do better as a police bureau and as a community,” said Portland Police Chief Mike Reese. “This agreement will provide us a road map as we move forward.”6

The first 50 police officers were selected for the specialized training in April.

More than 2,700 crisis intervention teams exist within law enforcement departments nationwide. The program originated in Memphis, Tenn., in 1988 and has spread to every state except Alabama, Arkansas and West Virginia.7

“At least 10 percent of all police encounters involve someone with a serious mental illness,” says psychiatrist Michael Compton, a professor of prevention and community health at George Washington University in Washington, D.C. The vast majority of these interactions don't involve a high risk to public safety, he says. “They are minor infractions and misdemeanors, like loitering, subway fare evasions, things like that.”

Crisis intervention teams are dispatched when police encounter mentally ill individuals experiencing a psychiatric crisis. The teams aim to defuse the situation, prevent injury to the individual or police officers and decide whether the best course is arrest or mental health care.

Police officers volunteer for the training. “A significant percentage volunteer because someone they know and love suffers from mental illness,” says Jeffry Murphy, a 37-year veteran of the Chicago Police Department who supervised the creation of Chicago's training program for crisis intervention teams, which the city launched in 2004. Murphy has a son living with mental illness.

During the 40-hour course, officers receive intensive instruction on how to de-escalate a crisis situation, visit mental health facilities, speak with mental health professionals, interact with individuals with mental illness, role-play and ride along with experienced team officers. Police dispatchers also receive special training.

Police departments also are encouraged to forge relationships with mental health providers and advocacy groups in the community.

Studies have shown that crisis intervention teams have a noticeable impact on police officers. They are less inclined to stigmatize people with mental illness, know more about mental illness, display better de-escalation skills and are better able to refer people to mental health services, says Compton, who has studied crisis intervention teams. “And we know that these improvements last beyond the training period.”

But the ultimate goal of the teams is to reduce arrests and find help for those suffering from mental illness. Here the research is much thinner. “There have only been a couple of studies that I know of pertaining to arrest and referral decisions,” says Compton. “In my own study, we did find evidence that [crisis intervention team] officers were less likely to make an arrest.”

But training is only one of several factors driving arrest decisions, says Compton, “the big ones being the level of resistance of the subject and the level of violence potential.”

No completed studies have examined the longer-term outcomes for individuals with mental health problems who encounter the intervention teams. Do most get appropriate care or end up in jail? Can they successfully live in the community, or do they have repeat encounters with police? A large, five-year study in Chicago designed to answer these questions is underway.

Much depends on the availability and quality of mental health care providers and their relationships with the crisis intervention teams. Key, say researchers, is having a mental health facility nearby with a no-refusal policy. But a study of intervention teams across the country found that few programs had access to such a site and only about a third held “any type of formal agreement with mental health receiving facilities.”8

State and city budget cuts have put pressure on crisis intervention teams. For example, Chicago has closed six of its 12 community mental health clinics, promising that access to services wouldn't be affected. But Murphy says that hasn't happened.

“We're responding to more crisis calls because we have more people not linked to services,” he says.

— Barbara Mantel

[5] For background, see Kenneth Jost, “Police Misconduct,” CQ Researcher, April 6, 2012, pp. 301–324.

[6] Maxine Bernstein, “Portland mayor, chief, and Oregon U.S. Attorney announce settlement on Portland police reforms,” The Oregonian, Oct. 26, 2012, www.oregonlive.com/portland/index.ssf/2012/10/portland_mayor_chief_and_orego.html.

[7] CIT Center, The University of Memphis, http://cit.memphis.edu.

[8] Michael T. Compton, et al., “The Crisis Intervention Team (CIT) Model of Collaboration Between Law Enforcement and Mental Health,” Advances in Sociology Research, Volume 9, 2011.

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Bibliography

Books

Frances, Allen , Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life , William Morrow, 2013. A prominent psychiatrist analyzes the factors behind what he says is the casting of normal behavior as mental illness.

Grob, Gerald N., and Howard H. Goldman , The Dilemma of Federal Mental Health Policy: Radical Reform or Incremental Change? , Rutgers University Press, 2006. A historian of psychiatry (Grob) and a mental health policy expert trace changes in government mental health policy since the 19th century.

Mechanic, David, et al., Mental Health and Social Policy: Beyond Managed Care , Pearson Education, 2013. Health policy experts examine current social policy debates in mental health care.

Articles

Appleby, Julie , “A Guide To Health Insurance Exchanges,” Kaiser Health News, Jan. 10, 2013, www.kaiserhealthnews.org/stories/2011/march/30/exchange-faq.aspx. State insurance exchanges will allow individuals and small businesses to purchase health insurance, which must cover mental health care.

Kliff, Sarah , “Obama's proposed budget to seek $235 million for new mental health programs,” The Washington Post, April 9, 2013, http://articles.washingtonpost.com/2013-04-09/national/38403598_1_mental-health-services-gun-violence-health-insurance-coverage. President Obama includes more money for mental health programs in his proposed fiscal 2014 budget; advocates call it a small step.

Goodman, Brenda , “Study: Newer Antipsychotic Drugs Are Overused,” WebMD, Jan. 7, 2011, www.webmd.com/mental-health/news/20110107/study-newer-antipsychotic-drugs-are-overused. Researchers have found that doctors are overprescribing the latest generation of antipsychotic drugs.

Levey, Noam N. , “A hole in mental health system; Obama orders the completion of regulations that will direct insurers to cover more services,” Los Angeles Times, Jan. 19, 2013, http://articles.latimes.com/2013/jan/19/nation/la-na-mental-health-20130119. The president directed the secretary of Health and Human Services to complete regulations directing insurers to cover mental health services more fairly.

Peters, Jeremy W. , “In Gun Debate, No Rift on Better Care for Mentally Ill,” The New York Times, April 12, 2013, www.nytimes.com/2013/04/13/us/politics/senators-make-bipartisan-push-for-mental-health-care.html?pagewanted=all&_r=0. Both Democrats and Republicans in Congress support legislation to fund mental health care, but tying it to gun control is a risky political move.

Pies, Ronald W. , “Bereavement Does Not Immunize Against Major Depression,” Medscape News, Jan. 24, 2013, www.medscape.com/viewarticle/777960. A psychiatrist argues that ordinary grief from the death of a loved one can be distinguished from depression.

Spencer, Jim , “Suit against UnitedHealth tests mental health coverage rules,” Minneapolis Star Tribune, April 6, 2013, www.startribune.com/business/201677791.html?refer=y. A class-action lawsuit alleges that a large insurer violated federal law forbidding treating mental health claims differently from medical and surgical claims.

Reports and Studies

“Improving Outcomes for People with Mental Illnesses Involved with New York City's Criminal Court and Correction Systems,” Justice Center of the Council of State Governments, December 2012, p. 1, http://consensusproject.org/jc_publications/improving-outcomes-nyc-criminal-justice-mental-health/FINAL_NYC_Report_12_22_2012.pdf. A criminal justice research organization examines the intersection of mental illness and incarceration in New York City and finds the percentage of inmates with mental illness is increasing.

“Proceedings on the State Budget Crisis and the Behavioral Health Treatment Gap: The Impact on Public Substance Abuse and Mental Health Treatment Systems,” National Association of State Mental Health Program Directors, March 22, 2012, www.nasmhpd.org/docs/Summary-Congressional%20Briefing_March%2022_Website.pdf. State mental health officials describe the detrimental impact of budget cuts on mental health and substance abuse treatment services.

Swartz, Marvin S., et al., “New York State Assisted Outpatient Treatment: Program Evaluation,” New York State Office of Mental Health, June 30, 2009, www.omh.ny.gov/omhweb/resources/publications/aot_program_evaluation/report.pdf. Academic researchers evaluate the impact of court-ordered outpatient treatment in New York state on patients and find fewer hospitalizations and better medication management.

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The Next Step

Defining Mental Health

Sostek, Anya , “Doctors Ponder Impact of Broader Addiction Definition Revision to DSM,” Pittsburgh Post-Gazette, May 18, 2012, p. A1, www.post-gazette.com/stories/news/health/doctors-consider-broader-definition-of-addiction-636427/. Medical experts say classifying addictions as “mild” or “moderate” may change eligibility requirements for mental health treatment under some insurance plans.

Wang, Shirley , “The Long Battle to Rethink Mental Illness in Children,” The Wall Street Journal, Oct. 12, 2012, online.wsj.com/article/SB10000872396390444273704577633412579112188.html. Some doctors say mental health conditions in adolescents should be classified differently from those affecting adults.

Insurance Coverage

Henry, Devin , “Jim Ramstad Calls for More Extensive Mental Health Coverage,” MinnPost (Minn.), March 15, 2012, www.minnpost.com/dc-dispatches/2012/03/jim-ramstad-calls-more-extensive-mental-health-coverage. Rep. Jim Ramstad, R-Minn., is urging health insurance companies to increase coverage for mental health treatment.

Lieber, Ron , “Walking the Tightrope on Mental Health Coverage,” The New York Times, Dec. 22, 2012, p. B1, www.nytimes.com/2012/12/22/your-money/walking-the-tightrope-on-mental-health-coverage.html?pagewanted=all&_r=0. Receiving mental health treatment has become difficult because many insurance plans don't cover it and a growing number of health facilities do not accept insurance policies that do.

Watkins, Tom , “Say Yes to Autism, But No to Mental Health Parity?” News-Herald (Mich.), May 2, 2012, p. A2, www.thenewsherald.com/articles/2012/04/27/opinion/doc4f9b173316553530790966.txt. Michigan is one of seven states that have not passed a mental health parity law that requires insurers to provide comprehensive mental health coverage.

State Initiatives

Branan, Brad , “Sacramento County Panel Backs Involuntary Treatment for Some Mental Patients,” Sacramento (Calif.) Bee, Jan. 5, 2013, p. B1, www.sacbee.com/2013/01/05/5093391/sacramento-county-panel-backs.html. The mental health board of Sacramento County, Calif., has endorsed involuntary treatment for mentally ill patients who have a history of violence, incarceration or certain other backgrounds.

Cole, Michelle , “State Explores Mental Health Treatment Options Beyond Hospital,” The Oregonian, Feb. 13, 2011, www.oregonlive.com/politics/index.ssf/2011/02/oregon_explores_options_to_exp.html. Oregon officials say the state needs to find new ways to deal with mentally ill criminals because hospital stays have become too expensive.

Florio, Gwen , “Missoula Municipal Judge Halts Referrals to Treatment Courts,” The Missoulian (Mont.), Sept. 24, 2012, missoulian.com/news/local/missoula-municipal-judge-halts-referrals-to-treatment-courts/article_315f21d6-0525-11e2-beb2-001a4bcf887a.html. A Montana municipal court judge says she will no longer refer those with drug or mental health problems to treatment programs because the programs are too expensive and bureaucratic.

O'Hagan, Maureen , “Accessing Mental-Health Treatment Requires Stiff Criteria,” Seattle Times, May 31, 2012, seattletimes.com/html/localnews/2018327693_mentalhealth01m.html. The family of a man who went on a shooting spree in Seattle says they weren't able to get mental health treatment for him through a Washington state program that offers it.

Youth Treatment

Heckel, Aimee , “Yoga Improves Mental, Social, Physical Health for Boulder Teens,” The Daily Camera (Colo.), March 5, 2012, www.dailycamera.com/features/ci_20080374. A yoga program in Boulder, Colo., has helped improve the mental health of teenagers in the area.

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Contacts

American Psychiatric Association
1000 Wilson Blvd., Suite 1825, Arlington, VA 22209
703-907-7300
www.psych.org
Medical society representing more than 33,000 psychiatric physicians from the United States and around the world.

American Psychology Association
750 First St., N.E., Washington, DC 20002
800-374-2721
www.apa.org
National association of psychologists representing more than 134,000 researchers, educators, clinicians, consultants and students.

Judge David L. Bazelon Center for Mental Health Law
1101 15th St., N.W., Suite 1212, Washington, DC 20005
202-467-5730
www.bazelon.org
National legal-advocacy organization representing people with mental disabilities.

Mental Health America
2000 N. Beauregard St., 6th Floor, Alexandria, VA 22311
703-684-7722
www.mentalhealthamerica.net
Advocacy organization with 240 affiliates in 41 states working to prevent mental illness and substance abuse conditions.

National Alliance on Mental Illness
3803 N. Fairfax Dr., Suite 100, Arlington, VA 22203
703-524-7600
www.nami.org
Grassroots organization with local affiliates nationwide advocating for access to mental health services, treatment, support and research.

National Association of State Mental Health Program Directors
66 Canal Center Plaza, Suite 302, Alexandria, VA 22314
703-739-9333
www.nasmhpd.org
National organization representing state mental health commissioners/directors and their agencies.

National Council for Community Behavioral Healthcare
1701 K St., N.W., Suite 400, Washington, DC 20006
202-684-7457
www.thenationalcouncil.org
National advocacy group representing more than 2,000 community behavioral health organizations.

National Institute for Mental Health
6001 Executive Blvd., Rockville, MD 20852
301-443-4513
www.nimh.nih.gov
Federal institute conducting and funding basic and clinical research to improve the understanding and treatment of mental illness.

Substance Abuse and Mental Health Services Administration
1 Choke Cherry Rd., Rockville, MD 20857
877-726-4727
www.samhsa.gov
Federal agency that administers grants to states and collects data on mental health disorders and substance abuse.

Treatment Advocacy Center
200 N. Glebe Rd., Suite 730, Arlington, VA 22203
703-294-6001
www.treatmentadvocacycenter.org
National nonprofit working for timely and effective treatment of severe mental illness.

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Footnotes

[1] Ginger Gibson, “Harry Reid cites father's suicide in gun debate,” Politico, April 9, 2013, www.politico.com/story/2013/04/harry-reid-gun-debate-father-suicide-89805.html.

[2] “Web-based Injury Statistics Query and Reporting System,” Centers for Disease Control and Prevention, www.cdc.gov/ncipc/wisqars; “The Numbers Count: Mental Disorders in America,” The National Institute of Mental Health, www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml.

[3] Thomas Insel, testimony before the Committee on Health, Education, Labor, and Pensions, U.S. Senate, Jan. 24, 3013, pp. 2, 4, www.help.senate.gov/imo/media/doc/Insel.pdf; “The Numbers Count: Mental Disorders in America,” op. cit.

[4] Debbie Stabenow, “Strengthening Mental Health Services,” www.stabenow.senate.gov/?p=issue&id=80.

[5] Jeremy W. Peters, “In Gun Debate, No Rift on Better Care for Mentally Ill,” The New York Times, April 12, 2013, www.nytimes.com/2013/04/13/us/politics/senators-make-bipartisan-push-for-mental-health-care.html?pagewanted=all&_r=0.

[6] “Crucial Mental Health Legislation to be Considered Next Week,” National Council for Community Behavioral Healthcare, April 11, 2013, www.thenationalcouncil.org/cs/press_releases/crucial_mental_health_legislation_to_be_considered_next_week.

[7] “Fiscal Year 2014, Budget in Brief,” Department of Health and Human Services, p. 41, www.hhs.gov/budget/fy2014/fy-2014-budget-in-brief.pdf.

[8] “Obama Includes Mental Health Funding Increase in Budget Proposal,” Psychiatric News Alert, April 10, 2013, http://alert.psychiatricnews.org/2013/04/obama-includes-mental-health-funding.html.

[9] “National Expenditures for Mental Health Services and Substance Abuse Treatment, 1986–2005,” Substance Abuse and Mental Health Services Administration, Tables 74 & 75, pp. 201–202, http://hcfgkc.org/sites/default/files/documents/MHUS_2010_part3_508.pdf.

[10] Laura Nelson, “Opening Presentation: Impact of the State Budget Crisis and Treatment Gap on the Public Substance Abuse and Mental Health System,” National Association of State Mental Health Program Directors, March 22, 2012, pp. 6–7.

[11] Ibid., pp. 4, 7.

[12] “Improving Outcomes for People with Mental Illnesses Involved with New York City's Criminal Court and Correction Systems,” Justice Center of the Council of State Governments, December 2012, p. 1, http://consensusproject.org/jc_publications/improving-outcomes-nyc-criminal-justice-mental-health/FINAL_NYC_Report_12_22_2012.pdf.

[13] “Proceedings on the State Budget Crisis and the Behavioral Health Treatment Gap: The Impact on Public Substance Abuse and Mental Health Treatment Systems,” National Association of State Mental Health Program Directors, March 22, 2012, p. 14, www.nasmhpd.org/docs/Summary-Congressional%20Briefing_March%2022_Website.pdf.

[14] Public Hearing re: House Bill 2186, Health and Human Services Committee, Pennsylvania House of Representatives, April 8, 2010, pp. 66–68, www.legis.state.pa.us/cfdocs/legis/tr/transcripts/2010_0082T.pdf.

[15] “State Standards for Assisted Treatment: Civil Commitment Criteria for Inpatient or Outpatient Psychiatric Treatment,” Treatment Advocacy Center, January 2013, pp. 65–66, www.treatmentadvocacycenter.org/storage/documents/Standards_-_The_Text-_June_2011.pdf.

[16] Ibid., p. 56.

[17] Marvin S. Swartz, et al., “New York State Assisted Outpatient Treatment: Program Evaluation,” New York State Office of Mental Health, June 30, 2009, www.omh.ny.gov/omhweb/resources/publications/aot_program_evaluation/report.pdf.

[18] Allen Frances, Saving Normal: an insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life (2013), p. 27.

[19] “Asperger's syndrome dropped from American Psychiatric Association manual,” CBSNews.com, Dec. 3, 2012, www.cbsnews.com/8301-204_162-57556754/aspergers-syndrome-dropped-from-american-psychiatric-association-manual.

[20] Ibid.

[21] David Mechanic, Donna McAlpine, and David Rochefort, Mental Health and Social Policy: Beyond Managed Care (2014), p. 25.

[22] “Proposed criteria for DSM-5: Disruptive Mood Dysregulation Disorder,” University of Colorado at Boulder, Department of Psychology, http://psych.colorado.edu/~willcutt/pdfs/dsm5_disrupt_mood.pdf.

[23] “James Coyne, “Bereavement dropped as an exclusion in diagnosis of depression: protecting reimbursement, but hurting science,” PLAS Blogs, Jan. 10, 2013, http://blogs.plos.org/mindthebrain/2013/01/10/bereavement-dropped-as-an-exclusion-in-diagnosis-of-depression-protecting-reimbursement-but-hurting-science.

[24] Ronald W. Pies, “Bereavement Does Not Immunize Against Major Depression,” Medscape, Jan. 24, 2013, www.medscape.com/viewarticle/777960.

[25] For background, see Marcia Clemmitt, “Treating ADHD,” CQ Researcher, Aug. 3, 2012, pp. 669–692.

[26] Michael Ollove, “Parity for Behavioral Health Coverage Delayed by Lack of Federal Rules,” Stateline, Dec. 2, 2012, www.kaiserhealthnews.org/stories/2012/december/03/stateline-behavioral-health-coverage.aspx.

[27] Ibid.

[28] “Rep. Joe Pitts Holds a Hearing on the Department of Health and Human Services F.Y. 2014 Budget,” Political Transcript Wire, April 19, 2013.

[29] Fact Sheet: The Mental Health Parity and Addiction Equity Act of 2008, U.S. Department of Labor, www.dol.gov/ebsa/newsroom/fsmhpaea.html.

[30] Jim Spencer, “Suit against UnitedHealth tests mental health coverage rules,” Minneapolis Star Tribune, April 6, 2013, www.startribune.com/business/201677791.html?refer=y.

[31] Noam N. Levey, “Obama intends to fix holes in mental health coverage,” Los Angeles Times, Jan. 19, 2013, http://articles.latimes.com/2013/jan/19/nation/la-na-mental-health-20130119.

[32] E. Fuller Torrey and Judy Miller, The Invisible Plague: The Rise of Mental Illness from 1750 to the Present (2002), p. 219.

[33] Ibid., p. 220.

[34] Ibid., p. 226.

[35] Mechanic, et al., op. cit., pp. 47, 62.

[36] Gerald N. Grob and Howard H. Goldman, The Dilemma of Federal Mental Health Policy: Radical Reform or Incremental Change? (2006), p. 17.

[37] Richard G. Frank and Sherry A. Glied, Better But Not Well: Mental Health Policy in the United States since 1950 (2006), pp. 28–29.

[38] Mechanic, et al., op. cit., p. 61.

[39] Ibid., p. 62.

[40] Grob and Goldman, op. cit., p. 45.

[41] Frank and Glied, op. cit., p. 60.

[42] Grob and Goldman, op. cit., p. 52.

[43] Frank and Glied, op. cit., p. 63.

[44] Ibid., p. 35.

[45] “Mental Health Parity,” Advocacy On Call, www.advocacyoncall.org/health/mental_health_parity.

[46] Mechanic, et al., op. cit., p. 62.

[47] “Achieving the Promise: Transforming Mental Health Care in America,” New Freedom Commission on Mental Health, July 22, 2003, cover letter, http://store.samhsa.gov/shin/content//SMA03-3831/SMA03-3831.pdf.

[48] Ibid., pp. 24–25.

[49] “Bush endorses ‘mental health parity,’” CNN.com, April 29, 2002, http://archives.cnn.com/2002/ALLPOLITICS/04/29/bush.mental.illness.

[50] Julie Appleby, “A Guide To Health Insurance Exchanges,” Kaiser Health News, Jan. 10, 2013, www.kaiserhealthnews.org/stories/2011/march/30/exchange-faq.aspx.

[51] “2013 Poverty Guidelines,” U.S. Department of Health and Human Services, http://aspe.hhs.gov/poverty/13poverty.cfm#thresholds.

[52] Health Reform's Medicaid Expansion, Center on Budget and Policy Priorities, www.cbpp.org/cms/index.cfm?fa=view&id=3819.

[53] “Morbidity and Mortality in People with Serious Mental Illness,” National Association of State Mental Health Program Directors, October 2006, pp. 5–6, www.nasmhpd.org/docs/publications/MDCdocs/Mortality%20and%20Morbidity%20Final%20Report%208.18.08.pdf.

[54] Morgan Small, “Community Members Visit New Integrated Medical and Mental Health Facility in Bangor,” WABI TV5, March 28, 2013, www.wabi.tv/news/38847/community-members-visit-new-intergrated-medical-and-mental-health-facility-in-bangor.

[55] “Healthy Children Learn Better! School Nurses Make a Difference,” National Association of School Nurses, www.nasn.org/Portals/0/about/press_room_faq.pdf.

[56] Joanne Kenen and Paige Winfield Cunningham, “Mental health advocacy hits reset,” Politico, April 21, 2013, www.politico.com/story/2013/04/guns-mental-health-advocacy-sandy-hook-90407.html.

[57] Paige Winfield, “Health Reform's Medicaid Expansion,” Center on Budget and Policy Priorities, www.cbpp.org/cms/index.cfm?fa=view&id=3819.

[58] Corrie MacLaggan, “Texas governor reiterates Medicaid expansion opposition,” Reuters, April 1, 2013, www.reuters.com/article/2013/04/01/us-usa-texas-medicaid-idUSBRE9300FN20130401.

[59] Health Reform's Medicaid Expansion, op. cit.

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About the Author

Barbara Mantel, author of this week's edition of CQ Researcher  

Barbara Mantel is a freelance writer in New York City. She is a 2012 Kiplinger Fellow and has won several journalism awards, including the National Press Club's Best Consumer Journalism Award and the Front Page Award from the Newswomen's Club of New York for her Nov. 1, 2009, CQ Global Researcher report “Terrorism and the Internet.” She holds a B.A. in history and economics from the University of Virginia and an M.A. in economics from Northwestern University.

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Document APA Citation
Mantel, B. (2013, May 10). Mental health policy. CQ Researcher, 23, 425-448. Retrieved from http://library.cqpress.com/
Document ID: cqresrre2013051000
Document URL: http://library.cqpress.com/cqresearcher/cqresrre2013051000
ISSUE TRACKER for Related Reports
Mental Health
Mar. 13, 2015  Prisoners and Mental Illness
Dec. 05, 2014  Treating Schizophrenia
Sep. 12, 2014  Teen Suicide
May 10, 2013  Mental Health Policy
Aug. 03, 2012  Treating ADHD
Jun. 01, 2012  Traumatic Brain Injury
Jun. 26, 2009  Treating Depression
Feb. 13, 2004  Youth Suicide
Feb. 06, 2004  Mental Illness Medication Debate
Mar. 29, 2002  Mental Health Insurance
Feb. 08, 2002  Treating Anxiety
Jul. 16, 1999  Childhood Depression
Jun. 18, 1999  Boys' Emotional Needs
Sep. 12, 1997  Mental Health Policy
Aug. 19, 1994  Prozac
Aug. 06, 1993  Mental Illness
Oct. 09, 1992  Depression
Jun. 14, 1991  Teenage Suicide
Jul. 08, 1988  Biology Invades Psychology
Feb. 13, 1987  The Mentally Ill
Aug. 20, 1982  Mental Health Care Reappraisal
Jun. 12, 1981  Youth Suicide
Sep. 21, 1979  Mental Health Care
Sep. 15, 1978  Brain Research
Jul. 05, 1974  Psychomedicine
Aug. 08, 1973  Emotionally Disturbed Children
Dec. 27, 1972  Mental Depression
Mar. 24, 1972  Schizophrenia: Medical Enigma
Apr. 21, 1971  Approaches to Death
Mar. 03, 1971  Encounter Groups
Nov. 25, 1970  Psychological Counseling of Students
Feb. 19, 1969  Future of Psychiatry
Feb. 02, 1966  New Approaches to Mental Illness
Jan. 22, 1964  Insanity as a Defense
Sep. 25, 1963  Anatomy of Suicide
Nov. 20, 1957  Drugs and Mental Health
Apr. 23, 1954  Mental Health Programs
Jul. 09, 1948  Mental Health
BROWSE RELATED TOPICS:
Medicaid and Medicare
Mental Health
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