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Reforming the Mental Healthcare System

Mental health has been in the news a lot recently, mostly for the wrong reasons. What is most disturbing is how some commentators are using the recent mass shootings as evidence to further stigmatize mental illness. While they talk about reforming a broken mental health care system, what they are actually promoting is institutionalization for individuals with severe and persistent mental illness. This is unacceptable and distracts policy-makers from the fundamental issue; our current mental health care system is broken, underfunded and often criminalizes mental illness.

Why do we allow society to blame those who suffer from these devastating illnesses when they are the victims? It is no secret that even the best evidence-based treatments are still not good enough. Yet, they represent the latest research and should be widely available to patients. Sadly this is not the case. Community mental health centers are underfunded and lack the resources to offer such treatments. Training is expensive and access is limited. Insurance companies frequently balk at paying for treatment that they argue is questionable from an efficacy standpoint. The complexity of the mental health system, divergent opinions about treatment, and limited access to care often leaves family and patients confused, frustrated and marginalized. It is not exaggerating when people say the mental health system is broken and in crisis.

So what can be done? To start, our leaders need to stop using these isolated incidents of violence as evidence to support changes in the mental health system. However well meaning, it sends the wrong message and ultimately does more harm that good. Secondly, the government needs to get out of the way and let those who understand mental health care take the lead. There is far too much bureaucracy and inefficiency in the system (the current government shutdown an outstanding example). We need congress to appropriate funding at a level that meets the current needs of the system, without any stipulations or interference from special interest groups. Appoint a director to oversee a complete reformation of the system who is given the authority to implement the necessary changes (versus the usual congressional route of asking for a report that never goes anywhere). The director should bring together the National Institute of Mental Health, the Veterans Administration, the Substance Abuse and Mental Health Services Administration, the National Alliance on Mental Illness, the Center for Medicare and Medicaid Services, as well as various research and provider stakeholders to develop a comprehensive plan that aligns research, training, advocacy and treatment objectives on a national level. Simplify the process for accessing care and reduce the administrative burdens associated with providing mental health care. Stop kowtowing to special interest groups and make mental health parity a reality. Create a national standard for reducing the criminalization of mental illness through the use of mental health courts and mandated treatment for those most at risk for violence. Ensure that there is adequate access to various levels of care nation-wide. Prioritize the implementation of electronic medical records that allow for seamless communication between providers. Provide funding for training providers that includes national standards for graduate programs and licensing. Revamp psychiatric training programs to ensure that psychiatrists are thoroughly trained in psychotherapy as well as psychopharmacology. Mandate that insurance companies reimburse for psychiatrists who provide psychotherapy. Provide incentives for the development of novel treatments, including medications.

This is a daunting list and incomplete. Critics may call such a proposal idealistic, too expensive and unworkable. However, what other options do we have? The patchwork approach has not proven effective and there is little evidence that leaving the process in the hands of a partisan congress will produce acceptable results. Overhauling the mental health care system can only be effective if there is a comprehensive, long-term vision that aligns research, treatment, training and advocacy objectives. It will be difficult and expensive, but those who suffer from severe and persistent mental illness deserve our best effort.

Latest NIMH Research News

There are three recent and exciting research study reports from NIMH I want to share. The first discusses the potential of modifying gene expressions to treat schizophrenia. While a major limitation of the study is that it was looking at the brains of mice, it still holds much promise for understanding the mechanisms associated with schizophrenia and developing novel treatments. The second study examined the relationship between bipolar affective disorder and influenza. Researchers have long suspected that prenatal exposure to the flu virus may be a risk factor in developing bipolar disorder and schizophrenia. This current study suggests there is a fourfold increased risk. Finally, over the past several years I have been watching with interest the research on ketamine as an antidepressant agent. Research has been taking place on the use of ketamine as a rapid antidepressant. One of the challenges with ketamine is that it has many unwanted side effects and is a drug of abuse. Researchers have now developed a molecular cousin to ketamine that seems to have similar antidepressant effects without these side effects. Such a medication could revolutionize the treatment of depression like Prozac did when it first came onto the market. One of the drawbacks to current generation antidepressants is that they can takes weeks to reach full effect. Imagine the benefit of a medication that achieved the same or better results in minutes or hours? It could lead to lower rates of inpatient treatment, decrease the risk of suicide, reduce time waiting for services and service utilization. There is still a long way to go before such a medication may be available, but it gives hope to all those affected by mental illness.