Improving the Mental Health System: Who Is Responsible?

In considering how to improve the mental illness treatment system, the first question to ask is, who should be responsible? If no one is responsible, no one can be blamed; consequent­ly there is no leverage to improve the system. Before 1963, the responsibility for the treatment of persons with serious mental illness was a state responsibility; thus, the governor and state legislature could be held accountable.

With the passage of the 1963 Community Mental Health Act, followed by federal funding through Medicaid, Medicare, Supplemental Security Income, and Social Security Disability Insurance, the funding of the mental illness treatment system effectively shifted from the states to the federal government. But who is ultimately re­sponsible? Medicaid funds are essentially driving the system, but we don’t hold the head of the Medicaid program responsible. In fact, no one is responsible. States and counties deliver the services, but their decisions are constrained by federal guidelines regarding what can and cannot be funded. The funding of mental illness services in the US is more thought-disordered than any of the thought-disordered patients it is meant to serve.

The logical answer is to give the responsibility-and the federal funds currently supporting mental illness services-back to the states and hold them accountable. The experiment in federalizing these services, begun in 1963, has been a clear and continuing failure. We tried it and it did not work. State governors and state legislatures should assume responsibility for all mental illness and substance abuse services and then be held accountable.

How can they be held accountable? How will the residents of any state know how their state is doing in the delivery of mental illness services compared with other states? This could be accomplished by having the US Government Accountability Office issue a state report card every 2 or 3 years. The report card would use data that states would be required to collect and resources from the Institute of Medicine and the NIMH. The quality of mental illness services, like the quality of public education, should be a public issue that is considered whenever governors and members of the state legislature are being elected.

Since the federal government will be getting out of the mental illness treatment business, the $3.5 billion Substance Abuse and Mental Health Services Administration (SAMHSA), a component of the Department of Health and Human Services, can also be abolished. Although SAMHSA’s official mission is to reduce “the impact of substance abuse and mental illness on America’s communities,” SAMHSA has distinguished itself as the government agency that not only fails to improve things, but actually makes things worse. It does this by funding antipsychiatry groups, which, in several states, have blocked attempts to improve the mental illness treatment system. SAMHSA sponsors conferences at which speakers have made claims such as “mental illnesses are not ‘disorders or dis­eases,’ but ‘extreme states of consciousness that are mad gifts to be nurtured and cultivated.”¹ It is extraordinary that we have allowed a federal agency to continue to waste taxpayers’ money on such nonsense.

The next thing that is needed to improve the mental illness treatment system is to fix the Health Insurance Portability and Accountability Act (HIPAA). This is another example of federal legislation that was passed with the best of intentions-to protect the privacy of patients-but which has been widely abused. HIPAA regulations make it very difficult for fam­ilies to get information on the clinical status and treatment of family members who are mentally ill, even though a family member usually ends up being the primary caregiver. HIPAA regulations are widely used by public officials as an excuse for not discussing cases in which mental health professionals or the police have made major mistakes. Indeed, HIPAA has been used as a screen to protect public officials more often than it has been used to protect patient privacy. Rep Tim Murphy’s (R, Pennsylvania) proposed legislation-the Helping Families in Men-tal Health Crisis Act (H.R. 3717)-includes some excellent suggestions for fixing HIPAA legislation.

Another problem that needs fixing is the shortage of mental health professionals, especially in rural and low-income areas. This could be solved if the states or federal government set up a training program for psychiatrists, psychologists, psychiatric nurses, and psychiatric physician assistants. Under such programs, the individuals so trained would be obligated to work in an underserved area of that state for a specified pe­riod in exchange for the training.

Three things can improve the men­tal illness treatment system within individual states. The first is to modi­fy the state’s involuntary commitment laws so that individuals with serious mental illness-especially those who are unaware of their own illness-can be treated before they end up homeless or incarcerated. Multiple studies have demonstrated that programs such as assisted outpatient treatment (AOT) and conditional release effectively decrease re-hospitalizations, incarceration, and victimization of individuals with serious mental illness, yet such programs are markedly underutilized.^2-8 Indeed, Massachusetts, Connecticut, Maryland, Tennessee, and New Mexico, do not even have legislation allowing AOT.

Another thing the states can do is to set up state commissions to oversee the quality of care of persons with mental illness and substance abuse. An excellent model for such a commission was New York’s Commission on Quality of Care for the Mentally Disabled, which operated in the 1980s and 1990s. It reported directly to the governor and thus was independent of the state Office of Mental Health. Commission members were authorized to make unannounced visits to clinics, residential housing, and nursing homes and to issue public reports on the quality of care.

A third thing that states can do is to direct all state funding for mental illness and substance abuse services to services sponsored by the state or by non-profit entities. For-profit entities should not be eligible to receive state funds because they have a strong record of providing care to the easy patients but neglecting the more difficult, and thus more expensive, patients.⁹

Last, but certainly not least, more research on the treatment of mental illness and substance abuse is needed. If we are going to truly improve the mental illness treatment system, we are going to need better treatments than we now have. Although providing services is not appropriate for the federal government, research is appropriate. Increased funding for the NIMH, the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) would be an important component of any comprehensive plan to improve the mental illness treatment system.

Disclosures:

Dr Torrey is a research psychiatrist who specializes in schizophrenia and bipolar disorder. He is founder of the Treatment Advocacy Center and Associate Director of the Stanley Medical Research Institute, which supports research on schizophrenia and bipolar disorders, and he is Professor of Psychiatry at the Uniformed Services University of the Health Sciences in Bethesda, Md. He is the author of American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System. He reports no conflicts of interest concerning the subject matter of this article.

References:

1. Earley P. An alternative voice-courtesy of you. October 3, 2010. http://www.peteearley.com/2010/10/04/an-alternative-voice/#more-818. Accessed November 17, 2014.

2. New York State Office of Mental Health. Kendra’s Law: Final Report on the Status of Assisted Out­patient Treatment. March 2005. https://www.omh.ny.gov/omhweb/kendra_web/finalreport. Accessed November 17, 2014.

3. Zanni G, deVeau L. Inpatient stays before and after outpatient commitment. Hosp Community Psychiatry. 1986;37:941-942.

4. Fernandez GA, Nygard S. Impact of involuntary outpatient commitment on the revolving-door syndrome in North Carolina. Hosp Community Psychiatry. 1990;41:1001-1004.

5. Munetz MR, Grande T, Kleist J, Peterson GA. The effectiveness of outpatient civil commitment. Psychiatr Serv. 1996;47:1251-1253.

6. Swartz MS, Swanson JW, Wagner HR, et al. Can involuntary outpatient commitment reduce hospital recidivism?: findings from a randomized trial with severely mentally ill individuals. Am J Psychiatry. 1999;156:1968-1975.

7. Hiday VA, Swartz MS, Swanson JW, et al. Impact of outpatient commitment on victimization of people with severe mental illness. Am J Psychiatry. 2002;159:1403-1411.

8. Swanson JW, Borum R, Swartz MS, et al. Can involuntary outpatient commitment reduce arrests among persons with severe mental illness? Criminal Justice Behav. 2001;28:156-189.

9. Torrey EF. Is for-profit managed care an oxy­moron? Psychiatr Serv. 1998;49:415.