Five Key Steps Need to Be Taken Now to Improve MH Access

It was one of those D.C. spring mornings, jam-packed with sunshine and steamy. We sped past the Capitol dome encased in scaffolding, toward the Senate Hart Building. In the cab, we discussed the Mental Health Reform Act (MHRA) of 2016 (S 2680) and how many more iterations we might yet see. We were headed to the Senate Summit on Mental Health, organized by the bill’s sponsors, Sens. Bill Cassidy and Chris Murphy. As APA president, I was to give a provider’s viewpoint about the bipartisan legislation, sponsored also by Sens. Lamar Alexander and Patty Murray. I wanted to be supportive yet forceful about what was needed, and the senators had given me excellent material with which to work.

Entering the room, I saw representatives of many different organizations: the National Alliance for the Mentally Ill, foundations focused on mental health, National Institutes of Health, and, of course, APA. About 200 people filled the room, listening attentively. Called to the podium by Sen. Cassidy, I thanked him and Sen. Murphy for their excellent work and talked about five key issues that require attention to resolve the mental health crisis in this country.

I began by talking about the wide prevalence of mental illness in this country, with over 68 million people experiencing a psychiatric (including substance use) disorder in the past year. That number represents more than 21 percent of the total U.S. population, and lifetime rates are much higher, with estimates approaching 50 percent. More striking, the latest data, from 2013, show that more than 41,000 people died by suicide, 20 percent more than by motor vehicle accidents—this despite promising gains in medical research and public awareness. As a nation, we continue to fail people with mental illness every day.

There are several contributors to this failure. Fragmented delivery and reimbursement systems, limited funding for research, a lack of coordination in both Washington, D.C., and state capitals, obsolete regulations, workforce shortages, and the enduring stigma surrounding mental illness all pose barriers to appropriate, effective treatment. Of course, we can do better, but we need to act on several fronts.

First, federal mental health initiatives must be overseen by a psychiatrist. Because psychiatric/substance use disorders are fundamentally brain disorders, leadership with biological training is key. This medical leadership must ensure greater coordination between federal departments and agencies that oversee mental health initiatives, spanning research, mental health care delivery, and workforce training.

Second, we must increase support for the National Institute of Mental Health, National Institute on Drug Abuse, and National Institute on Alcohol Abuse and Alcoholism. The only way to gain traction in the prevention and treatment of psychiatric/substance use disorders is through research into their neurobiological causes and identification and testing of treatments that work. As precision medicine marches forward, so must psychiatric science, such that we might identify interventions tailored to the needs of the individual patient.

Third, we must train more mental health professionals, especially psychiatrists. The Organisation for Economic Cooperation and Development has determined that, in terms of psychiatrist availability, the United States is below the mean for developed countries, at 14.5/100,000, and shrinking. Some counties have only 3.5 psychiatrists per 100,000. Given that 21 percent of the population had a psychiatric disorder in the last year, let’s do a thought experiment. Consider that out of 100,000 persons, 21,000 need psychiatric care each year,and 4,200 have serious mental illness. Can you imagine that three or four psychiatrists could serve such a patient base, even with collaborative care models and use of physician extenders?

Fourth, we must enforce the Mental Health Parity and Addiction Equity Act. Much time has elapsed since this landmark legislation became law and regulations were put in place, yet insurers creatively continue to discriminate against patients with mental illness, especially by failing to maintain adequate provider networks and using multiple strategies including more onerous preapprovals for psychiatric care than for other types of medical care. We simply must expand federal efforts to enforce compliance with parity regulations.

Finally: prevention. We need not wait until disease and suffering unfold. We can develop tools to identify those at risk before any symptoms emerge through the use of genetic, molecular, and other markers. Research is essential to developing such tools. We can develop strategies to prevent untoward environmental risk factors such as child abuse or maternal depression, known to increase risk for behavioral problems, including suicide, later in life. In fact, preventing mental illness should be the fundamental goal driving research and treatment and be at the core of all federal mental health initiatives.

As APA members, we should be encouraged that these five components of meaningful mental health reform are addressed in the bill being moved through the Senate. I look forward to Congress’s enactment of this legislation during this session. ■