It’s Time for Mental Health Policy Sanity in a Crazy World-and PS, Fund It Too!

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Editor in Chief

Every American psychiatrist alive today has lived through working in what the 1999 Surgeon General’s report called a fragmented and sorely underfunded system of mental health care in the US. Unfortunately, this report came during the midst of some of the worst managed-care abuses of reimbursement for psychiatric services. And 9/11 came 2 years later, which refocused national attention to external threats rather than internal needs.

Then came the financial crisis, followed by increasing numbers of mass murders of civilians in the US and around the world, and the rise of ISIS. So, for the past decade, in spite of the passage of federal legislation guaranteeing parity for mental health treatment, the crying need for funding adequate access and treatment of those with psychiatric disorders has gone unattended. Oh, except, that is, for the regular pontification about how everyone who is a mass murderer is psychiatrically ill, and the most important thing we need to do is get them diagnosed so that they won’t be able to buy a gun. How politicians can say that with a straight face is beyond me.

On the other hand, though, the focus on mass murderers all being psychiatrically ill did seem to have some positive impact on Congress (though I hesitate to say there is anything good about such harmful distortions of reality), when legislators were finally driven to enact some important mental health legislation in the waning days of the Obama administration.

Thankfully, the 21st Century Cures Act, a hopeful name if ever I’ve heard one, was passed in December 2016. This legislation incorporated many provisions of bills that had been proposed to improve access and reimbursement for needed psychiatric treatment, and to improve federal coordination of government supported mental health programs.

The need for better coordination and focus has been known for years. The commentary by Ellie McCance-Katz¹ in our April 2016 issue highlighted some of the concerns in this regard about the function and focus of SAMHSA (Substance Abuse and Mental Health Services Administration), a component of the Department of Health and Human Services. Her article stimulated many responses, highlighting some of the concerns and various perspectives about current federal policies. In spite of the differing points of view, none of the comments dismissed the core concerns about the need to substantially increase access to care, support more training opportunities, and incorporate state-of-the-art knowledge in designing federal programs.

Soon after the 21st Century law’s passage, the American Psychiatric Association (APA) sent an email blast highlighting some of the important provisions of the law. I want to single out several of the many important components of the new legislation that were discussed in the APA email.

There are many aspects of the law that focus on psychiatric practice and the treatment of those with serious psychiatric illnesses. Other components are related to evidence-based care access. These include:

1 Establish a new position of Assistant Secretary for Mental Health and Substance Abuse who will take over the role now played by the Administrator of SAMSHA. As best as I can tell, this upgrade is intended to enhance the presence, and perhaps the clout, of mental health program advocates within the Department of Health and Human Services of which SAMHSA is a part.

2 The role of Chief Medical officer, the position held by Dr. McCance-Katz, now has new responsibilities to serve as liaison from SAMHSA to organizations like the APA, but more importantly, to be a part of SAMHSA strategic planning work.

3 Support for a variety of grant programs to encourage development of integrated care programs, expand training opportunities for psychiatric practice in underserved settings for not only psychiatry trainees, but also other mental health clinicians, establish innovative care delivery pilot projects, and dissemination of state of the art, evidence-based treatment information.

4 New policies and procedures to strengthen the enforcement of federal parity legislation. I’ve written in a previous editorial about the unconscionably long time it took for the final rules to be published implementing that legislation, and now I hope these new requirements will actually lead to their implementation to a greater degree than has been the case.²

5 Provide for $1.5 billion over 10 years to fund the BRAIN initiative (Brain Research Through Advancing Neurotechnologies) that focuses research efforts on finding cures for serious illnesses, including schizophrenia, autism, and dementia.

6 $1 billion to improve prescription drug monitoring programs in states, with an emphasis on opiates.

7 A variety of changes to various SAMHSA advisory councils and liaisons increase the role of physicians and other mental health professionals and strengthen attention to evidence-based treatment approaches based in part on findings from federally funded research. These changes appear to address several of the criticisms from those who share Dr. McCance-Katz’s views regarding the “non-medicalization” in recent years of SAMHSA’s approach.

8 A variety of programs including enhanced training for law enforcement personnel, improving mental health care to incarcerated individuals, and support for mental health courts. A more controversial aspect of these provisions, due to concerns about potentially adverse effects of coerced treatment, is allowing the use of federal funds for establishing mental health courts to develop court-mandated outpatient treatment programs.

9 Address a wide range of regulatory issues that affect a broad group of programs throughout the health care sector, many of which would have a positive impact on delivery of mental health services to broad sectors of the underserved population, including children, the elderly, and members of some minority groups.

A more in-depth discussion than there is room for in this editorial can be found by searching for “21st Century Cures Act Mental Health provisions.”

There are just a few, not so minor, problems with implementing what is certainly the broadest and most important mental illness treatment, research, and mental health promotion legislation since the parity act was passed. One likely roadblock is the clear goal of the Republicans, including the President, to repeal the Affordable Care Act with no clear picture of how to implement a replacement. (See the cover article in this issue by Chris Koppen and Lena O’Rourke on the possible trajectory of this aspect of legislative decision-making.) These steps are likely to preoccupy policy makers so that attention to funding the new law’s mandates goes not just to the back burner, but to the back woods. And that leads to the most treacherous aspect of the situation, which is the appropriations process.

We learned a very hard lesson about the reality of congressional processes when the Affordable Care Act was passed. Due to the leadership of Senator Debbie Stabenow of Michigan, Dr. John Greden at the University of Michigan’s psychiatry department, founding president of the National Network of Depression Centers, and many others, the enhanced ACT was incorporated into the ACA legislation. This component authorized between $50 and $100 million to provide 10 years of support for the establishment of up to 30 federally funded comprehensive depression centers. Unfortunately, although the bill authorized the spending, the money was not included during the appropriations process, so nothing happened on the federal front.

The take-home lesson here: don’t spend the money before it is appropriated in a separate congressional process and signed into law. Whatever side you were on in the election, I think everyone will agree that the new administration’s mental health policy views remain murky. And, when the horse trading begins in the appropriations process, it is essential to have the support of both the President and congressional leaders. So, it’s really time to be vigilant and be active in the advocacy efforts to fund all the terrific new opportunities the 21st Century Cures Act offers. The heart-rending second cover story in this issue, from Kirk Brower, MD, puts a human face on why the funding is needed. As President Obama said in his farewell speech,

Show up, dive in, stay at it. Sometimes you’ll win, sometimes you’ll lose. Presuming a reservoir in goodness, that can be a risk. And there will be times when the process will disappoint you. But for those of us fortunate enough to have been part of this one and to see it up close, let me tell you, it can energize and inspire. And more often than not, your faith in America and in Americans will be confirmed.

References:

1. McCance-Katz EF. The federal government ignores the treatment needs of Americans with serious mental illness. Psychiatric Times. 2016; 33(4):12,16. goo.gl/h1Mrm3.

2. Tasman A. Frankly, my dear, they don't give a damn. Psychiatric Times. 2016;33(10):4-5.