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Who You Gonna Call? Getting a Handle on Mental Health Care



April 9th, 2008

It’s been nearly five years since the President’s New Freedom Commission on Mental Health issued its final report. The report affirmed the possibility of recovery and the effectiveness of available treatments for many conditions. But it also warned that many patients never find their way to care and that providers are often unaware of therapies that have proved their worth.

The commission also marshaled evidence of the crucial importance of ancillary services like supported housing and employment and income-support programs for the severely ill. But it candidly acknowledged that management of these services is in most cases hopelessly fragmented among siloed government departments with no collaborative traditions.

No one was expecting miracles from the report, and none have occurred. But it’s not because no one is trying. Two years ago, for example, the National Institute of Mental Health produced its blueprint for disseminating evidence-based best practices to clinicians, The Road Ahead. The obstacles were detailed this week at a MacArthur Foundation-sponsored research conference in Washington.

Knowledge about new drugs spreads rapidly, because the pharmaceutical industry gets a handsome return on its investments in physician sales calls and direct-to-consumer advertising. But effective interpersonal treatment techniques like cognitive behavioral therapy don’t generate profits for their inventors, so there is not much of a business case for the enterprise of dissemination.

The notion that supportive housing, employment, or income programs are an integral part of care for the seriously ill was originally the vision of idealistic social reformers, said Howard Goldman, director of the MacArthur Network on Mental Health Policy Research. But since that vision was first articulated three decades ago, studies of the effectiveness of such programs have confirmed their value. “Research has turned social reform into evidence-based practice,” Goldman said.

But just as implementation of clinical best practices has lagged behind research, coordination of treatment with supportive services is typically lost in a maze of structural and administrative disconnects. Medication may temporarily stabilize a schizophrenic patient. But when that patient needs help applying for a housing voucher, a disability check, or a slot in a vocational rehab program, “Who you gonna call?” asked Mike Hogan, who was chair of the New Freedom Commission and is now mental health commissioner for the state of New York. Meanwhile, unmet needs spill out into schools, courts, welfare offices, and the streets.

The locus of responsibility for coordination of mental health services remains conspicuously indeterminate, Hogan said in summing up the problems that confront the mental health field. Medicaid is the largest single payer for care, but it spends nothing on employment or housing services. State mental health agencies historically bore the principal responsibility for organizing services but lack the authority to manage federal funds or local care delivery operations. Local government may serve as an important service provider but lacks resources to orchestrate supports. Private, for-profit managed behavioral health care organizations administer provider payments under Medicaid and private insurance but have little incentive to invest in wraparound services. Consumers and their families have the most knowledge of what is needed but the least leverage to influence the organization of care.

Hogan advanced the notion of “stewardship” as a way of thinking about how to get results at all levels of a system of such overwhelming complexity. The Washington conference marked the winding down of 30 years of investment in mental health policy by the MacArthur Foundation. In his valedictory remarks, Goldman suggested that the foundation’s role as a steward must now be taken up by the voluntary efforts of the willing. “Go forth, and connect,” he concluded.

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