Better but not well—that's the verdict that economist Richard Frank,
Ph.D., rendered for the U.S. mental health system in a lecture at APA's 2009
annual meeting in San Francisco in May in which he provided an overview of
recent trends in organization and financing of mental health services.
Harvard economist Richard Frank, Ph.D., describes large system changes
that have expanded access to mental health treatment, but have overemphasized
pharmacotherapy in primary care settings at the expense of specialty care and
Credit: David Hathcox
Though access has been expanded significantly, and treatment effectiveness
has improved markedly, the financial incentives in place since the 1990s have
served to "overcorrect" the system toward an overemphasis on
pharmacotherapy, as opposed to psychosocial treatments, and toward primary
care as opposed to specialty
These are the trends, Frank said, that account for most
stakeholders—especially clinicians—seeing a broken and
dysfunctional system even though enormous strides have been made in breaking
down stigma and improving access to care.
Better But Not Well is the title of a 2006 book by Frank,
published by Johns Hopkins University Press, about the evolution of the mental
health system since the 1950s.
"We treat a higher percentage of people with mental disorders than at
any time in U.S. history," Frank said. "Multiple effective
treatments are available for most major mental disorders. And we have managed
to increase access to effective offerings while claiming roughly the same
share of the national income as we did in 1975. So on the face of it, there
are reasons to be proud of the successes that have occurred."
But Frank presented evidence that the expansion of access to mental health
care was driven by large system changes in organization and financing during
the last 20 years, with strong incentives pushing care toward pharmacotherapy
in the primary care setting. Reforming these imbalances will require similarly
major changes; he highlighted the need to revisit the carveout model and to
rethink the financial separation of specialty mental health care from the
He also called for a new emphasis in training and continuing medical
education on evidence-based psychosocial treatments.
"The economic incentives in place since 1990 directed care in new
directions, and the system responded," Frank told psychiatrists at the
meeting. "There is now evidence emerging that care may be
underemphasizing psychosocial care. Correcting the imbalance in a
cost-effective way will require important and difficult institutional changes.
All of them will inflict some pain, and the pain will be widely
Frank outlined the evolution of the American mental health system from its
reliance in the 1960s on inpatient care and long-term psychotherapy in the
outpatient setting. By the 1990s, he said, mental health financing looked more
similar to that of general medical care: Medicaid and private insurance became
dominant and state funds became less so, and insurance coverage for
prescription drugs expanded enormously.
Especially important, managed behavioral health care companies became a
dominant force in allocating scarce resources. This had the effect of reducing
out-of-pocket costs for patients and dramatically reducing inpatient care.
But because behavioral health carveout companies have an incentive to move
care off of their budgets and into general medical care budgets, the
predominance of these companies has also pushed much mental health care into
the primary care setting where pharmacotherapy—rather than psychosocial
treatments—is the major form of therapy.
Moreover, the very low rates of reimbursement in state Medicaid programs
have discouraged the participation of specialists, while those who do
participate tend to practice only pharmacotherapy rather than more
time-intensive psychosocial treatments.
Frank presented data showing the changes between 1990-1992 and 2000-2003 in
the distribution of mental health care users by setting: while 27 percent of
patients received their mental health care from a primary care physician in
1990, by 2000-2003 almost 41 percent did so. Interestingly, the distribution
of people seeking care from psychiatrists also increased in that time period,
from 19.6 percent to 25.8 percent.
"But there was no increase in the percentage of people treated by
psychiatrists with psychotherapy," Frank emphasized. "It's all
pharmacotherapy and very often pharmacotherapy alone."
Even more problematic was evidence Frank presented suggesting that early
gains in quality have leveled off or dropped. Percentages of people receiving
appropriate treatments for depression, schizophrenia, and bipolar disorder
increased dramatically between 1975 and 1997.
But more recent quality data suggest that for depression, schizophrenia,
and attention-deficit/hyperactivity disorder (ADHD), recommended psychosocial
treatments have remained consistently low or have dipped somewhat. For
instance, Florida Medicaid data show that the numbers of children identified
as having ADHD but receiving no treatment has risen sharply.
"Quality of care is no longer increasing, and in some cases we may be
giving up past gains," Frank said. "Psychosocial treatments have
declined or remained flat at a very low level for most of the last 10 years.
And this is true whether you look at psychosocial treatment as stand-alone
psychotherapy, psychotherapy in combination with medications, or the
psychosocial component of managing the pharmacotherapy."
So, what can be done to address the imbalances in the system?
First, Frank said the passage of the parity law is an important step.
"Implementation of parity creates new opportunities to rebalance care
toward psychosocial treatments," he said. "Suddenly outpatient
cost-sharing will be put in line with general medical cost-sharing and with
medication management and pharmacotherapy, so the consumer is going to get a
price decrease for psychosocial care that will tend to drive people back in
"We eliminate the limits for outpatient care so providers have more
flexibility in dealing with particular cases," Frank said.
Frank said the relegation of specialists to doing only pharmacotherapy
needs to be reconsidered. "To take the people who are most focused in
our system on mental health care and say 'You are only supposed to do this one
little piece' makes no sense. We need to reengineer the financial incentives
so we put that expertise to work improving mental health and managing the
balance between psychosocial and pharmacotherapy."
But clinicians have changes to make too. In this regard Frank strongly
emphasized the movement toward evidence-based care. "We need to focus on
education of providers on treatments that work," he said."
Licensure and certification need to be tied to training and skill, and
continuing education must be aligned with emerging evidence on what works. And
clinical research needs to be focused on evidence-based psychosocial
treatments that are user friendly, cost-effective, and practical to