COMMENTARY

A New 'Champion of Mental Health Care'

Jeffrey A. Lieberman, MD

Disclosures

April 04, 2014

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Hello. This is Dr. Jeffrey Lieberman of Columbia University, speaking to you today for Medscape. I want to take this opportunity to comment on a recent legislative development that is potentially of great significance.

It comes through the efforts of a newly emergent champion of mental health care in Congress, Representative Tim Murphy, a Republican Congressman from Pennsylvania. Congressman Murphy, who himself is a trained psychologist, has seen fit to take on as a primary interest the plight of the mentally ill and our badly needed improvement in mental health care services. In all candor, this interest is in part prompted by the recent spate of mass violence incidents and particularly the incident in Newtown, Connecticut. The introduction of this proposed legislation occurred on the first anniversary of that tragic event.

Congressman Murphy has proposed the Helping Families in Mental Health Crisis Act, and in doing so he has followed in the footsteps of a number of other previous Congressional leaders who have advocated for mental health care legislation to improve the treatment of the mentally ill. In recent years, many if not most of these leaders have retired or are not active in this area for other reasons. I am speaking of people such as Senators Pete Domenici and [the late] Arlen Specter, the late Senator Paul Wellstone, and Congressmen John Porter, Gordon Smith, and Patrick Kennedy. They were major figures in the efforts to advance the cause of mental health care. In the current Congress, however, there are not many of these leaders, and that is why Congressman Murphy's entry into this arena is so welcome.

This proposed legislation includes a number of very interesting elements. Most of these are welcome efforts that you would support without qualification. Others require some thought and discussion in terms of refining or considering how they should be shaped. On balance, this is a very important piece of legislation and would no doubt advance our field and serve our patients very well.

Right now, the Bill is wending its way through the legislative process, seeking sponsors, and trying to enlist support from various stakeholder groups, professional groups such as the American Psychiatric Association, the American Psychological Association, nurses, family practitioners, and patient groups such as NAMI (National Alliance on Mental Illness), and provider organizations such as hospitals. Hopefully, a consensus will develop to support this legislation.

What Are the Specifics?

Among the elements that are the most exciting are that this legislation calls for the creation of an interagency coordinating committee on serious mental illness, which would comprise representation at the highest levels of government. This would include people from the Department of Health and Human Services (DHHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institutes of Health (NIH), the National Institute of Mental Health (NIMH), the Department of Justice, and the Centers for Disease Control and Prevention. These delegates would form an interagency committee to ensure coordination of policies and strategies to support legislation and funding of mental health care services and research.

The bill also includes the proposal that a position be created within DHHS for Assistant Secretary of Mental Health, which would either be a psychiatrist or a psychologist. Now, this is a very laudable element of the bill and would highlight the importance of mental health care. It is not clear how politically viable this would be, but having leadership at this level of government who would have the responsibility to oversee and coordinate mental health policy would be very desirable.

Another element involves establishing a national mental health policy laboratory. This is a committee that would be formed under the interagency mental illness coordinating committee or under their auspices of the Assistant Secretary of Mental Health, if that position is created. This laboratory would monitor developments in mental health care research and implementation, and in consultation with the NIH, and particularly the NIMH, would determine when a research finding has arrived at a point where it could be applied to clinical care. Up to 5% of the block grant funds that are allocated by SAMHSA could then be used to support this new model of care or method of intervention within the states.

For example, this could support the early identification intervention model of care that the NIMH has been pioneering in the context of its RAISE programs. (RAISE means Recovery After an Initial Schizophrenic Episode.) These clinical programs are staffed and trained specifically to engage people who are showing the beginning signs of a psychotic disorder. These programs would provide wraparound, team-based, multielement treatment, which would be geared to stave off the progressive nature of the illness and prevent cumulative morbidity and disability.

But there could be other programs, such as suicide prevention programs or programs to treat substance abuse and mental illness comorbidities, as soon as research provides enough evidence to indicate that such programs are "ready for primetime."

In addition, an element in the bill prevents the tiering of formularies or the exclusion of new drugs from Medicaid and Medicare formularies, so that treatment of mental illness would not be limited in a way that is not equitable or evidence-based. Another element in the bill would provide for diversion of funds potentially from SAMHSA to the NIMH to support research that would translate into clinical care. These are some of the positive elements of this very significant piece of legislation.

Some Elements Will Require More Debate

The elements that are more complicated and require further discussion include the need to create a position at the Assistant Secretary level in DHHS, to be Assistant Secretary for Mental Health. That has political ramifications that are above my pay grade, but I have been advised that creating such a position is not clearly viable from a political standpoint.

Another, more complicated element involves the requirement that each state that receives SAMHSA block grants have assisted outpatient treatment -- a mandatory treatment mechanism -- that is operative in the state. Assisted outpatient treatment has been an effective mode of service provision, particularly with individuals who have histories of nonadherence to treatment and the potential for relapse and readmission to hospital or violence; however, we do not have a unanimity of opinion about whether this policy or mechanism should be uniformly used by states and imposed on people, overriding their right to refuse treatment. This is something that requires further discussion to look for agreement on whether or not it should be included.

All of this notwithstanding, there is much more that is good than that is problematic in this bill, and with further refinement of these points, I hope it will generate the support it needs, both from stakeholder groups as well as within Congress.

Whatever the outcome, it is welcome and great news that Congressman Murphy has taken this on as an issue that is worthy of his priority attention. Goodness knows our field needs champions in Congress, and Congressman Murphy has emerged as one of them. At no time has the need for comprehensive mental health care been clearer than now, as we have seen with some of the regrettable and tragic consequences of the lack of a coherent mental health care policy and an effective public mental health care system.

Please take a look at this bill as news reports about its progress through the legislative process continue, and express your opinions about it as well, directly to Congressman Murphy and to your own representatives and senators.

Thank you for your attention. This is Dr. Jeffrey Lieberman from Columbia University, speaking to you today for Medscape.

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