Our Short-Sighted Mental Health Policies

Jeffrey A. Lieberman, MD


November 23, 2016

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Hello. This is Dr Jeffrey Lieberman of Columbia University in New York City, speaking to you today for Medscape. Lately I have been feeling as though I am becoming more of a curmudgeon. I have been irritable and intolerant, and things get me more upset than they used to. But maybe it is for good reason.

I owe my current distress to several events that underscore the continued neglect, inattention to, and prioritization of issues of clear need and benefit to the American people that we have not acted upon. When I say "we," I am referring to our government, the media, the healthcare system, and even the population at large, which should demand its rightful due in the way of services, policy, legislation, and funding.

I am specifically talking about mental health care and mental illness. Mental illness has always been neglected and given short shrift. Psychiatry and mental health care are what I call the Rodney Dangerfield of medicine—they do not get the respect they deserve. As we become more and more aware of the deleterious consequences of this, one would think corrective actions would be taken, but they are not or they are happening much too slowly. Several recent occurrences dramatically highlighted this and, frankly, ticked me off.

Missed Legislative Opportunity

This summer, a piece of legislation that could be transformative for mental health care in the United States was finally passed by the House of Representatives. I have talked about this in previous blogs. The Helping Families in Mental Health Crisis Act, HR 2646, was initiated by Congressman Tim Murphy and Congresswoman Eddie Bernice Johnson in the aftermath of the massacre of children by Adam Lanza in Sandy Hook, Connecticut. It was meant to bring about sweeping changes in the way that mental health services are coordinated and financed by the federal government.

This bill slogged its way through the political process for 3 years; in July it was finally approved by a nearly unanimous vote of 533 to 2. The Senate version, the Mental Health Reform Act, S 2680 (formerly S 1945), is a far cry from the House bill, and if passed, it would need to be reconciled with the House bill. Unless some measures of the House bill are incorporated into the reconciled bill, the whole exercise will not be nearly as effective as it could be.

The opportunity to pass this meaningful legislation is running out of time, and the political challenges are particularly concerning to me, not least because Congress adjourned for the election and will return afterwards only for a lame duck session. If nothing is done before the end of this Congress, then the process has to start all over again the next year. This is a missed opportunity—big time.

Agenda for Mental Health Care Ignored

On August 29, 2016, in the midst of the presidential campaign, Secretary Clinton released an agenda for mental health care. When was the last time a presidential candidate—not a president but a presidential candidate—ever released a thoughtful, potentially comprehensive position statement on mental health care? I cannot think of any. There have been presidential commissions, but not a position statement by a candidate in advance of an election. That is noteworthy.

The Clinton campaign released this agenda on a Monday, the beginning of the week, clearly hoping for continuing media attention during the rest of the week (in contrast to releasing something at the end of the day on a Friday before a holiday weekend, which would be buried). But what really got my dander up is that it got no attention. An August 31, 2016, editorial[1] in the Washington Post took note, saying essentially that the Clinton agenda was released and no one was talking about it. It got next to no play in the media, which tells you how much interest the media believes the public has in this topic. Shameful.

Psychiatrists Overlooked After Hinckley Released

Ten days later, on September 10, news came that John Hinckley Jr, the would-be assassin of President Ronald Reagan, was being released from St Elizabeth's Hospital in Washington, DC. After he tried to murder President Reagan, a court found him not guilty by reason of insanity and he was remanded to St Elizabeth's, and presumably has been getting better for 35 years. He does seem fit to be released back into society, meaning that he is better and out of danger, and whatever punitive action was intended by his mandated residence at St Elizabeth's has been accomplished.

The real issue is whether he really is better and is not a danger. I have no opinion about that because I do not know his mental status, his diagnosis, the treatment, and aftercare. In the wake of that announcement with all of the media coverage that attended it, there was commentary by lawyers, police, and criminal justice experts. No commentary by psychiatrists was included among those opinions. Psychiatrists presumably would be an integral, if not essential part, of any consideration of how such a case should be handled given the primary question: Is he better? Does he possibly continue to be a danger? How do we ensure that he is not a danger by providing the necessary treatment? No commentary by psychiatrists. What does that say about the way the media views this and the credibility of input from psychiatrists? Not much.

The Displaced With Mental Illness

A week later, on September 18, the New York Times published a very interesting article,[2] written by a journalist who had been stationed in Asia for the past 25 years. He and his family had finally returned to the United States and he was assigned to cover a beat in northern California. The article was about returning to his home country and his impressions after having been away for more than a quarter of a century.

Among a number of very interesting reactions, the author's dominant impression was of walking through the middle of San Francisco and seeing the homeless on the street, including large numbers who were displaced persons with mental illnesses. He commented that, despite the poverty and the much lower level of development in the many Southeast Asian countries he covered, he had not seen the kind of human detritus strewn through those communities that he saw in San Francisco, one of the richest metropolitan areas in the world. How could this happen in a country with the resources and the level of development of the United States?

Awareness Is Growing but Policies Remain Shortsighted

In the aggregate, these four developments, occurring within a relatively short period of time, point to a social problem that has existed historically yet has not been accorded the importance and the attention it deserves. This is how our society cares for people with mental illness, provides for them in terms of mental health care, and finances the social policies that govern how mental health care is provided and made accessible to people. Although awareness of the scope of the problem is growing in terms of the statistics, costs, epidemiology, and awareness of the consequences, particularly the burden of illness, our government does not act. This burden includes the monetary costs to society and the egregious social pathologies that crystallize in our society as a result of this neglect—homelessness, prisons crowded with persons with mental illness, rising rates of addiction, increasing demographic groups with suicidal behavior, and the mass violent incidents, some of which are perpetrated by individuals with untreated mental illness.

It is infuriating. I hate to believe that I am becoming less tolerant and that my emotional response is disproportionate to the perceived problem. I do not believe that is so in this case. I simply have an acute awareness that appreciates how self-defeating and shortsighted our policies are. Rather than be discouraged and walk away from this, throwing up our hands, becoming angry and having a tantrum, I encourage you, as myself, to stay the course, redouble our efforts, and continue to try to make people appreciate the scientific, clinical, and social reality of mental illness. We must underscore our ability to provide evidence-based care that is effective and will reduce the burden of illness and the consequences and costs to our society. And we must press for change.

Change will come. We will be using our ability full force to provide mental health care. The rate-limiting factor will be how quickly legislation, financing, and social policies will change. That will happen; the question is, when?

Thank you for listening. This is Dr Jeffrey Lieberman of Columbia University, speaking to you today for Medscape.


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