Serious Mental Illness: Federal Panel Urges Better Care

Alicia Ault

December 15, 2017

The United States needs to place a greater focus early identification and more timely treatment of serious mental illness (SMI). Moreover, health insurance benefits and reimbursement for the treatment of psychiatric illness should be on par with those for physical illness, says a new federal panel in its first-ever report.

In addition, the committee called for increased payments through Medicaid, Medicare, and other public health programs for mental health and behavioral services, as well as reimbursement for outreach services, care coordination, family and peer support, and other ancillary but necessary services that are often not reimbursed.

A major focus "is on early identification and interventions for youth," said Elinore McCance-Katz, MD, PhD, assistant secretary for mental health and substance use, who was a member of the panel, at a briefing to release the 121-page report, which includes 45 recommendations in five key areas.

"If you have a psychotic disorder, on average it takes about 2 years before you're going to come to medical attention," she said. "The longer it takes you to get to that medical attention, the more likely it is that you're going to develop a disorder that could be refractory to current ability to intervene," said Dr McCance-Katz.

The Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) was created by the 21st Century Cures Act. It has 5 years to complete its mission of enhancing coordination across federal agencies to improve service access and delivery of care for people with SMI and serious emotional disturbance (SED) and their families.

"It's not just a request, it's a congressional mandate," said Dr McCance-Katz. "That brings a focus that I don't think has been there before," she said. "Too many times, these sorts of committee have been put in place, reports have been made, and not a lot has followed," Dr McCance-Katz said.

The outlook for patients with SMI has not improved since the last major federal report in 2003. About 4% of adults older than 18 years ― 10.4 million people ― have SMI. They are 25 times more likely to take their own life than the general population, and a quarter live below the poverty line. Two million people with SMI are incarcerated each year. More than 6 million children experience serious mental disturbances every year.

Inadequate Policies, Systems

"They aren't just numbers," said Eric Hargan, acting secretary of the US Department of Health and Human Services. "They represent Americans and their families who are suffering because of inadequate policies and inadequate systems," he said.

Improving those systems will require not just dedicated people but also better interagency coordination. The ISMICC urged a complete accounting of all federal programs that affect services for those with SMI or SED.

The panel also urged a review of current federal data to ensure that SMI and SED outcomes are tracked. Findings could be used to develop core recovery measures, which can be used as benchmarks in a "national dashboard." Results should be regularly published for all federal health programs for children and youth experiencing SED and for adults experiencing SMI, says the report.

The effort will also mean more efficient use of resources and will require dedicated funding, said Dr McCance-Katz.

The National Council for Behavioral Health, which represents community and nonprofit mental health and addiction care providers, is concerned that progress will be tough without funding, said Charles Ingoglia, MSW, senior vice president of public policy and practice improvement.

"We want to see the various federal agencies actually implement the recommendations that pertain to their agency. We'd like to see the president's budget reflect these priorities," he told Medscape Medical News.

The American Psychiatric Association (APA) said it welcomed the report.

"We congratulate Assistant Secretary McCance-Katz on the release of the first ISMICC report and its focus on prevention, care, and early intervention for those with serious mental illness. Our patients deserve the best care possible, and today's report is a step in the right direction," said APA CEO and Medical Director Saul Levin, MD, MPA, in a statement.

Alternatives to Jail, Emergency Department Care

Many people with SMI are falling through the cracks in emergency departments and in prisons and jails, said Dr McCance-Katz.

"The emergency department is not a place for people who are experiencing exacerbations of mental health conditions," she said. The ICMICC panel is recommending development of alternative crisis centers and also an increase in inpatient psychiatric beds.

One way to increase both treatment access and better payment models for clinicians and care providers would be to expand the Certified Community Behavioral Health Clinic program, which is operational in only eight states, said Dr McCance-Katz. It is similar to federally qualified health centers, which provide a wide range of physical health services and are subsidized by the federal government.

The ICMICC panel also urged better training for law enforcement personnel and first responders in working with people with SMI and SED, and it recommended that screening for mental disorders and substance use disorders be required for all of those who are incarcerated in jails. Treatment for those disorders, as well as crisis intervention, should also be provided.

Overall, the committee urged a continuum of care that includes early intervention and the providing of housing, employment, and other services for those receiving treatment. It also recommended diversion for those who enter the criminal justice system and continued support for those who are released from incarceration, as well as treatment to enhance recovery.

"The goal of what we're undertaking is not just to provide more services," said Dr McCance-Katz. "What we want is a holistic approach that provides a continuum of care that meets individual needs," she said.

ICMICC panel member Mary Giliberti, CEO of the National Alliance on Mental Illness, said she was hopeful the report will have an impact that previous reports have not had, because the current system is failing.

"The inability of people with mental illness to access needed care has shattered lives and devastated families," she said.

"The health and mental health system today continues to ignore these conditions until they reach crisis. At that point, if you get care ― if at all you get care ― it's just until the crisis resolves," she said.


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