Healing the Broken Mind: Transforming America's Failed Mental Health System

I had hoped for more from this book, with its evocative and expansive titles. Timothy Kelly, a psychologist by training, was Commissioner of Virginia's Department of Mental Health, Mental Retardation and Substance Abuse Services for several years in the mid-1990s and then went on to different leadership roles in mental health in this country.

In this short book, Kelly's proposition is that the mental health system is broken (with proper attribution to the President's New Freedom Commission), that incremental change will only sustain what we have (maybe better to say what we don't have), and that transformation driven by a "perfect storm" of economic necessity and public outcry is what we must hope for. He calls for evidence-based practices, measuring performance, competition, consumerism, and leadership. He is clear in his overarching analysis and goals but does not take us far enough into the mess of it all where transformative solutions must be found, supported, and brought to scale.

What would it take to transform our failed system? This is a question I began to try to answer recently in a commentary for another journal (1). Perhaps the answer is best understood, especially by clinicians and policy makers, as the gap between what we know and what we do—a gap so wide it continues to astound. But I believe that a fine model for closing the gap is a public health one: identify the populations and diseases where prevalence and burden are great, where solutions (often good if imperfect) exist, and where those solutions (treatments and social interventions) are known but not being sufficiently employed, and then systematically proceed to implement those solutions—person by person, disorder by disorder, community by community, and population by population until we can be assured, by reliable and valid measures, that the gap is closing.

The means to close the quality gap, it seems to me, align along three complementary lines. These are the tools needed to close the gap, the actions needed, and the people or actors who will do so. The field of mental health (including substance abuse) can take pride in the array of tools we have developed. These now include clinical decision trees built from accumulated evidence (also called evidence-based and consensus practices); standards of care; drug utilization review that is truly directed to safety and effectiveness, not solely cost control; professional learning and quality improvement communities; professional distance learning (if you can get a master's in business administration online, you can sharpen your clinical skills online); and peer coaches and supports along with "shared decision making" between clinicians and recipients.

The actions are how these tools are used. Here are some ways: contracting by buyers (government and industry) that specifies the results expected of what is bought; performance monitoring where what is bought is measured and monitored; financing of services increasingly on the basis of what works and how good the delivery is; accreditation and licensing of services (clinics and hospitals) dependent on clinical performance, not exit signs, square feet, and door hinges; and regulatory relief as well as regulatory change consistent with the clinical objectives needed.

But nothing happens unless we humans drive it. The actors are government—progressive government, which needs to lead—especially at the state level, where Medicaid drives health care practices and policy. At the federal level, we have a unique moment for interagency collaboration among the Centers for Medicare and Medicaid Services, Veterans Affairs, and Housing and Urban Development, and perhaps Substance Abuse and Mental Health Services Administration will have a voice, not just a seat at the table. The clinical community, providers, needs to examine itself and be dissatisfied with what it's doing since our results are so far from what they need to be. This is not to blame providers since they are at the mercy of the "non-system" we have grown and the peculiarities of financing—but clinicians and clinical administrators need to be restive about what we are not doing. Perhaps the most important actors will be consumers and their families who organize to assert their will and refuse to allow the status quo to persist since hope and a life of contribution in the community is possible for people with serious mental illness, if we do the right things.

That's a lot of tumblers that would need to fall into place to open the lock(s) keeping us from transformation. Yet it was not long ago that schizophrenia was considered a hopeless condition. Why should we have the same dismal regard for transformation? Problems are there for solving, not for acceding to. Like John F. Kennedy said, we do it because it is hard, not because it is easy.