Federal Agencies Must Partner to Overhaul Care For People With SMI

Few individuals with serious mental illness (SMI) receive effective treatment as a result of fragmented federal systems that are providing inadequate services, according to the first report from a committee working to improve care for this population.

David Hathcox

The report comes from the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC), created by the 21st Century Cures Act to bring together federal agencies along with researchers, advocates, and providers. Its aim is to enhance coordination across the federal government to improve the lives of people with SMI.

Individuals with SMI lack access to evidence-based treatments, so they experience high rates of homelessness, joblessness, disability, involvement with the criminal justice system, premature death, and other negative outcomes, said ISMICC Chair Elinore F. McCance-Katz, M.D., Ph.D., at a press conference last month following the committee’s presentation to Congress. “Our health care system can do better and the federal government can marshal its resources to help make that happen,” said McCance-Katz, the assistant secretary for mental health and substance use at the Department of Health and Human Services (HHS) and head of the Substance Abuse and Mental Health Services Administration (SAMHSA).

Most recommendations from the 2003 President’s New Freedom Commission on Mental Health were not implemented or only partially realized, ISMICC’s first report noted.

There were 10.4 million adult Americans in 2016 with an SMI that causes functional impairment that substantially interferes with at least one major life activity. More than one-third received no treatment. Two million people with SMI are incarcerated each year.

There were 7.4 million children and youth under the age of 18 who experienced a serious emotional disturbance (SED), defined as having at least one diagnosable mental, behavioral, or emotional disorder that substantially impairs life functioning. Individuals with SMI or SED face a greater risk of suicide, higher rates of physical illness, and a life expectancy 10 years shorter than that of the general population.

“This committee must take an unflinching and unsparing look at our current systems and services and then move forward with hope and the knowledge that our efforts can improve the lives of millions of Americans,” said Eric D. Hargan, acting secretary of HHS, at the public meeting following the press conference.

The report, which Hargan called the “first of its kind,” offers five basic recommendations on improving care and outcomes for people with SMI or SED:

• Strengthen federal coordination of services: This includes an evaluation of the federal approach to services and using data to improve quality of care.

• Boost access and engagement: Make it easier for individuals to get high-quality care, particularly crisis care and early intervention for youth, as well as community-based alternatives to hospitalization.

• Advance evidence-based treatments: Focus on specialty care for first-episode psychosis and suicide prevention strategies. Make recovery services and housing more available.

• Divert from criminal justice systems: Train first responders on how to work with people with SMI and SED and create therapeutic dockets in court. Also, provide universal screening and treatment for people who are incarcerated.

• Develop finance strategies: Make care more available and affordable, such as eliminating discriminatory financing practices and enforcing parity laws.

Role for Psychiatrists Emerges

McCance-Katz told Psychiatric News that she believes the committee’s work will ultimately reform the national mental health system and that psychiatrists can be valuable leaders in this effort. Psychiatrists play a critical role as team leaders in patient care, and their knowledge and experience will help shape the future of mental health care, she added. “They will be playing a huge role in determining how the next generation will be trained, too.”

McCance-Katz said she hopes to see a system in which psychiatrists partner more closely with treatment and recovery providers and case managers. “It’s time for the community to come together, determine what services people with SMI need, and bring them into one setting,” she explained. This will allow individuals to “get medication, case management, therapy, peer-led counseling treatment, and integrated recovery services all in one place.”

How will the ISMICC’s recommended changes be funded? The committee will be looking closely at the eight states now piloting comprehensive care models known as Certified Community Behavioral Health Clinics to help determine the costs of providing enhanced services, factoring in the increased Medicaid reimbursement rate these providers receive, McCance-Katz said. “We hope the data show there are savings to be had in integrated care,” she said, such as reductions in hospital stays and incarcerations.

Team Approach Effective

Pete Earley, a journalist and author of Crazy: A Father’s Search Through America’s Mental Health Madness, said at the press conference that the future looked bleak after his son Kevin became psychotic and was diagnosed with bipolar disorder at age 22. He was told that there was no cure for the disabling disorder, and it was very unlikely that his son would work full time or live independently and might become addicted to drugs and alcohol.

For six years, Kevin, a college graduate, cycled in and out of hospitals and was arrested for breaking and entering a home. He was tasered on two occasions by police. But the cycle was broken when a mental health crisis team was able to coax Kevin into treatment. Recovery care helped him obtain supportive housing, leading eventually to a job picking up carts at a big box store.

Now, Kevin takes daily medication, lives independently, pays his own bills and taxes, and has been stable for seven years. He is pursuing a master’s degree and works full time in a job that gives him purpose: helping others overcome mental illness as a peer counselor.

“He’s living proof that people with mental illness are entitled to lives with respect, hope, and dignity,” Earley said. “The key was getting him engaged in his own treatment. If you approach him with a peer, approach him with hope and with personal experience he can relate to, it works better than if you strong-arm him into treatment.”

ISMICC to Focus on Engagement, Access

A major focus of the ISMICC will be improving patient engagement and access, explained Anita Everett, M.D., chief medical officer of SAMHSA, who will be leading ISMICC’s efforts. A particular emphasis will be on individuals with first-episode psychosis and for transitional youth aged 15 to 25. These youth might better be reached with electronic tools such as texting or Skypeing, she told Psychiatric News.

While there is much variability in patient follow-up practices among the states, too often patients who refuse to take their medications just drop off the radar. To keep people in treatment, she would like to see a move toward more accountable services in which a caseworker would be responsible for following a group of patients with a recent onset of psychosis. The caseworker would use crisis treatment services and proactive outreach tools to keep these patients in treatment. For such an effort to work, clinicians need better ways to determine who would benefit from a higher level of care, she added.

APA welcomed the ISMICC’s recommendations and is looking forward to seeing the responses of federal agencies. “Our members are ready to work with the administration and Congress to implement the recommendations made today,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., in a press statement. “Our patients deserve the best care possible, and [the ISMICC] report is a step in the right direction. APA thanks the assistant secretary of mental health and substance use for leading this effort.”

“Stay tuned,” Everett told Psychiatric News. “The report is not the end. It’s the beginning of a five-year process oriented toward expansion of access and engagement for this group.”

The ISMICC is now prioritizing the recommendations in the report. It will continue to meet and by December 2022 will present its final report to Congress outlining its accomplishments and identifying future opportunities for improvement. ■