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Policy advocates who had been buoyed by introduction of legislation that would put new emphasis on mental health policy are concerned that the recent terrorist attacks in the United States may distract lawmakers and others from that effort.
"There were bills sponsored by Sen. Kennedy and others that gave us hope," Henri Treadwell, program director for health and science education at the Kellogg Foundation in Battle Creek, MI, tells State Health Watch. "It looked as though this was an issue whose time had come and that people recognized that there were unmet needs with the uninsured and underinsured.
"We’re concerned that events may overtake us and lead to ignoring the needs of those who have regular old-fashioned mental health problems in their desire to help those who have problems arising from the events of Sept. 11," he says.
Earlier this year, the Kellogg Foundation funded a study, "Forgotten Policy: An Examination of Mental Health in the U.S.," that pointed out significant gaps in mental health policy and suggested strategies for improving the current system.
Marguerite Ro, who is a professor at Columbia University in New York City, wrote the report and expresses concern with the study’s conclusion.
"In an era of technological and scientific advances, most Americans who suffer from mental health and/or substance abuse disorders go untreated," she says.
"Approximately 20% of the population is affected by mental health or substance abuse disorders during any given year. Less than one-third of those affected will receive any type of treatment. Barriers to treatment include the lack of health insurance coverage, high cost of pharmaceuticals, and stigma surrounding mental illness," Ms. Ro says.
For vulnerable populations — those with low income, the uninsured, and rural and minority populations — the barriers to care are compounded by problems with transportation and childcare and a lack of culturally competent and geographically accessible care.
Ms. Ro says the strategies and recommendations arising from the study offer ways to start improving the current system so it better addresses the mental health needs of vulnerable Americans. Highlights of the strategies and recommendations include:
• Reduce stigma as a barrier to access by providing stigma awareness training for health care providers, disseminating stigma awareness literature for consumers and providers in Medicaid contracting, increasing awareness at community-based points of entry through professional associations and institutions and employers, and training culturally competent and diverse health and social service providers.
• Eliminate financial barriers to access by expanding the federal mental health parity act to require that all limitations on coverage for mental illness equal those for medical and surgical benefits and advocating for state legislation that achieves full and comprehensive parity with protections for treatment for alcohol and substance abuse.
• Address prescription drug coverage issues by requiring drug companies to base direct-to-consumer drug costs on an average of costs negotiated with insurance companies, requiring prescription drug coverage in plans regulated by state insurance commissioners, requiring insurance companies to review and revise drug formularies routinely to ensure that newer, more effective drugs are included, and supporting prescription drug coverage for all Medicare recipients.
• Integrate services for co-occurring mental health and substance dependence disorders by coordinating funding streams to allow mental health and substance abuse treatment into integrated plans, requiring that inpatient and emergency treatment for either condition involve screening of the other along with discharge and follow-up for both conditions, and rolling out requirements and incentives for integrated mental health, general medical, and social services systems.
• Support the mental health work force by maintaining flexible use of nonphysician providers, requiring or increasing reimbursement rates for mental health services provided by mental health and primary care practitioners, standardizing mental health quality indicators across provider types, and supporting continuing education programs for primary care professionals in delivery of mental health care.
• Target the needs of vulnerable populations by requiring cultural competence for Medicaid participation, requiring managed care entities to contract with primary care physicians to provide mental health services in rural areas, supporting research into alternative delivery options in rural areas, expanding use of telemedicine and e-health, and convening a broad-based task force to study the needs of those with serious mental disabilities.
• Enhance school-based health and mental health services by training teachers to identify and respond to individuals with mental illness, maximizing use of available Medicaid funds for outreach, enrollment, and preventive services, and finding better ways for case management and reduction of administrative inefficiencies.
• Support school-based violence prevention programs by increasing availability of mental health services in schools and developing standards and mechanisms for schools to integrate violence prevention interventions into the curriculum.
• Address the needs of foster children by convening a task force to examine the special needs of those in foster care and developing state guidelines on the process and regulations for providing children in foster care with adequate general and mental health care.
• Expand insurance coverage for adults with mental disabilities through expanding Medicaid coverage.
• Address housing needs of adults with mental illness by supporting independent living arrangements and providing incentives for neighborhoods to accept supervised living arrangements.
• Tackle employment needs of adults with mental disabilities by providing incentives for vocational rehabilitation programs to address needs of adults with severe mental illness and providing supported employment, transitional employment, and psychosocial rehabilitation programs for people with mental illnesses.
• Address issues involving criminalization of adults with mental illness through supporting applied violence risk assessment research for use in law enforcement and community settings, enhancing referral and follow-up mechanisms from the criminal justice system to the mental health and substance abuse systems, and using diversion programs to channel individuals with mental illness into treatment, rather than jail.
• Promote mental health among the elderly by encouraging screening for depression in primary care, monitoring referrals and outcomes as a quality assurance process and requiring training in primary care clinician curriculums and continuing education for the recognition, diagnosis, and treatment of mental disorders in the elderly.
• Address deficiencies in nursing homes by providing incentives for development of innovative programs that increase coordination of care and geographic access to services and minimize cost, training nursing home providers to identify symptoms of mental disorders and make referrals to mental health providers, and developing quality assurance guidelines on mental health for nursing home facilities.
Ms. Ro says that many of the strategies would require new funds. "Yet it is clear that ignoring mental health problems is costly to individuals and to society. Many of these recommendations require the acknowledgment of mental health and a system of accountability toward insuring quality mental health services. Mental health impacts more than biological health; it is a component to social functioning and productivity. As such, the impact of mental health on education, employment, and well-being cannot be ignored."
Mr. Treadwell tells State Health Watch the question of linkage between mental health and substance abuse is a key issue. "We need to figure out how to give counseling that gives hope and doesn’t get people into a self-destructive cycle."
Despite the terrorist attacks, he says, "We are reaffirmed in our direction and committed to pushing the needs of everyday Americans."
[Contact Mr. Treadwell at (616) 968-1611 and Ms. Ro at (212) 305-7185.]