Mental health care has improved since the days when a teenager diagnosed with psychosis was told she would never complete her education, obtain a job or live a normal life.
Robert Drake, Ph.D., a professor of psychiatry at Dartmouth's Geisel School of Medicine, speaks about the social needs of mental health patients at a recent forum.
But changes in the field have include stumbling blocks as well as successes, said a panel of experts that discussed behavioral health in an era of reform at a forum hosted by Health Affairs(www.healthaffairs.org) on June 7. The panelists included Larry Davidson, Ph.D., director of the Yale Program for Recovery and Community Health. He shared the story Patricia Deegan, Ph.D., the teenager who received the grim diagnosis, but who went on to become an adjunct professor of community and family medicine at Dartmouth College's Geisel School of Medicine.
Armed with a diverse set of data, health observers are unsure how to measure progress in the field.
"Are we there yet or are we going in the wrong direction?" asked Alan Weill, editor-in-chief of Health Affairs.
- Panelists at a recent discussion of behavioral health in an era of reform noted stumbling blocks and successes in the treatment of mental illness.
- Forty percent of adults with severe mental illness are not receiving treatment at all despite changes in insurance coverage.
- Better support for integrating behavioral health into primary care may help.
There have been major changes to insurance policies, for instance, but the number of adults who received mental health treatment increased only slightly from 12.6 percent in 2003 to 14.6 percent in 2014, an increase that is largely attributed to psychiatric medications. Forty percent of adults with severe mental illness are not receiving treatment. Only 15 percent of people with mental illness are employed although 70 percent of them would like to be.
There is a shortage of access to mental health care, especially in rural and low-income urban areas, panelists noted. Local and state resources to provide financial support are limited.
The AAFP is pressing Congress for a solution on the federal level through better support for integrating behavioral health into primary care, where the majority of mental health services are provided in the United States. The Health is Primary(healthisprimary.org) campaign from Family Medicine for America's Health(fmahealth.org) recently devoted a month to promoting such integration.
Helpfully, awareness of mental health needs is much greater today than in the past, panelists said. Early intervention for patients is growing, public acceptance of medication for mental illness has increased, and patients are receiving evidence-based treatment. Legislation, including the Patient Protection and Affordable Care Act, has improved coverage and payment.
Still, Mark Olfson, M.D., a psychiatry professor at Columbia University, said policy changes are needed. He called for integrating mental health professionals into primary care teams, offering more loan repayment programs to encourage mental health professionals to work in underserved areas, and including social workers in psychiatric treatment. Creating more psychiatry training slots would be too expensive and time-consuming given immediate needs, he said.
Robert Drake, Ph.D., a professor of psychiatry at Dartmouth's Geisel School of Medicine, said addressing the social needs of mental health patients remains a difficult but important task. He recalled a patient with schizophrenia who had no friends and limited social skills, but who was good with animals. Clinic staff worked with local social service agencies to find him a job at a kennel that bolstered his confidence and helped him make friends.
"We've been working on this for 20 years," Drake said. "The main problem is there is no clear way to fund these services."
Treatment protocols have changed significantly to patients' advantage. Michael Hogan, Ph.D., principal of Hogan Health Solutions, said health professionals previously cared for the brain much as they cared for the kidney -- providing treatment only during a breakdown and then making a referral to a specialist. Now mental health needs are addressed before a crisis occurs.
"We want people to go through the same door for their brain as they do for their heart," he said.
But out-of-pocket costs for mental health care is rising along with those for other health care.
"Even if we make progress with (mental health) parity, if you have a $2,000 deductible it doesn't do much good," said Tami Mark, Ph.D., M.B.A., vice president and research director for behavioral health and quality at Truven Health.
While there is less social stigma attached to mental illness, popular media casts it as a potential threat and largely ignores advancements in the field.
"There has been a lot of movement in integration of care, but it is not showing up in the media," said Emma McGinty, Ph.D., an assistant professor at the Johns Hopkins Bloomberg School Public Health who has analyzed media coverage of mental illness.
Related AAFP News Coverage
Alliance for Health Reform/Commonwealth Fund Briefing
Integration of Primary Care, Mental Health Sorely Needed, Says Panel