Historic Day or a Missed Opportunity in Mental Health Care?

Jeffrey A. Lieberman, MD


July 27, 2016

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Hello. This is Dr Jeffrey Lieberman of Columbia University and New York Presbyterian Hospital in New York City, speaking to you today for Medscape. On July 6, the House of Representatives passed what could be historic legislation in mental health care, possibly the most historic since the Mental Health Parity and Addiction Equity Act of 2008 and the Community Mental Health Act of 1963.

This legislation is called the Helping Familes in Mental Health Crisis Act, HR 2646. It was authored and sponsored by Republican Congressman Tim Murphy from Pennsylvania and Democratic Congresswoman Eddie Bernice Johnson from Texas. HR 2646 had a long and difficult history before reaching this historic moment when the House voted its approval nearly unanimously.

The story begins on December 14, 2012, when a strange and solitary 20-year-old man named Adam Lanza killed his mother and proceeded to the Sandy Hook Elementary School in Newtown, Connecticut, where he murdered 20 children and [six] teachers before taking his own life. This heinous crime shocked everyone. A series of mass violent incidents happened before and after it, but this one provoked outrage and calls for action.

At that time, Congressman Murphy began to draft legislation. The bill took a year before it was initially presented to the House of Representatives, in December 2013. In this first attempt, it was not modified in a way that engendered sufficient bipartisan support to move it out of committee and bring it to the House floor for a vote. Thus, when the session ended that year, the bill was dead.

But Representatives Murphy and Johnson were not deterred. They knew how important it was. There was so much support within Congress and within stakeholder groups across the country that they introduced it again the following year and went through a lengthy process within the House Energy and Commerce Committee to address the concerns of stakeholder groups and representatives on both sides of the aisle. Finally, on June 15, 2016, with a 53 to 0 vote, HR 2646 was approved to be moved from the House Energy and Commerce Committee to the floor of the House, where it was passed 2 weeks later.

A Game Changer

HR 2646 will be game changing if it comes to pass. The bill contains a number of consequential elements that would affect the way mental health care research and services are delivered, and would improve coordination between the National Institutes of Health (NIH), the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institute of Mental Health (NIMH), and other agencies of the federal government that play a role in mental health care services. HR 2646 would also provide a mechanism for creating more standardized and uniform evidence-based treatments across the United States by virtue of the leverage that federal funding offers, largely through SAMHSA.

This bill provides for the creation of an assistant secretary of mental health within the Department of Health and Human Services. This person would be the senior-most government official coordinating efforts to address the issue of mental illness and would effectively have administrative authority over SAMHSA, a federal agency with a $3.6 billion budget to support services in the 50 United States.

HR 2646 would help to coordinate SAMHSA programs and the research being generated by the NIH, particularly the NIMH. It would provide encouragement to states to adopt such mechanisms as assisted outpatient treatment, which would require individuals with psychotic disorders—people who may not have the insight to participate in treatment—to receive treatment even over their objections. It would also provide educational help. It would allow physicians to communicate with each other and with family members about a mentally ill individual even when the individual has not given direct permission for this.

A Plea for Nonpartisan Reconciliation

A whole host of measures in HR 2646 would be quite valuable and have a significant impact if they are applied. I say "if" because, even though the bill has been approved almost unanimously by the House, it still has to be reconciled with a Senate version, titled the Mental Health Reform Act, S 2680. This legislation was drafted and sponsored by Senator Lamar Alexander of Tennessee and Senator Chris Murphy of Connecticut. For reasons that I am not going to go into, this Senate version of the bill is a far cry from the House version and includes much less substantive elements that would have a meaningful effect on mental healthcare services and research.

Nevertheless, the way our government is organized requires a reconciliation of these two versions of the bill. First, the Senate has to approve S 2680 and then it goes to a committee for reconciliation with HR 2646. It is my hope and my plea that this process can occur efficiently and expeditiously, without eviscerating the important and substantive elements that are in the House bill. I hope this process will not be subject to partisan politics or parochial concerns of stakeholder groups, even when they tackle issues that could be considered controversial.

After each of these incidents occurs, people in their outrage call for action but then nothing is done to make any real change. This legislation would bring significant change.

This bill has been in gestation since the horrific Sandy Hook tragedy and it addresses a recurring situation in our society: mass violent incidents perpetrated by people with untreated mental illnesses and affecting innocent bystanders who usually have nothing to do with the perpetrator. It is discouraging that after each of these incidents occurs, people in their outrage call for action but then nothing is done to make any real change. This legislation would bring significant change.

I encourage you to follow this process. Reach out and ask your representatives, senators, any organizations, media, and advocacy groups to support an efficient and bipartisan reconciliation of these bills and to preserve—intact—the elements that are in HR 2646, which are the most important, most valuable, and most consequential to people like ourselves who provide mental health care and to individuals who would be the recipients: patients, their families, and also society as a whole.

Thank you very much for listening. I am Dr Jeffrey Lieberman from Columbia University and New York Presbyterian Hospital, speaking to you today for Medscape.


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