Tensions Complicate Efforts to Transform MH Systems

State health planners have encountered numerous obstacles during the early stages of mental health system transformation efforts, including funding shortfalls and resistance from some consumer-advocacy groups.

Mental health transformation—the top-to-bottom reform of the nation's service delivery system called for by the President's New Freedom Commission on Mental Health four years ago—is in the early stages of a multiyear effort to create pilot plans in several states to overhaul their public and private mental health systems. The effort aims to replace the nation's patchwork mental health system with a cohesive approach that emphasizes the possibility of recovery.

Officials from some of the nine states that have received five-year federal Mental Health Transformation grants reported their progress at APA's annual meeting in May in San Diego.

Consumer health groups have voiced opposition to some of the mental health transformation plans under development, in part, because the plans attempt to refocus state resources across the spectrum of mental illnesses. The approach, which follows commission recommendations, is required for grant recipients. Some groups that represent patients with serious mental illnesses and their families have long pushed to get states to focus more resources specifically on those conditions, panelists reported.

Complaints from groups representing patients with severe mental illness and their families, for example, recently led the new Maryland governor to replace the state official leading the transformation-planning effort over concerns that this individual had insufficient expertise in programs and services for those with serious mental illness.

Maryland sought to overcome tension with some consumer groups by including them from the early stages of mental health transformation planning, which is in its second year, according to Brian Hepburn, M.D., executive director of the Maryland Mental Hygiene Administration.

“They're not there to give you after-thoughts but to help from the beginning,” Hepburn said of the advocates.

L. Mark Russakoff, M.D., chair of APA's Committee on Psychiatric Administration and Management, said state officials in New York provided opportunities for patient groups who were not involved from the beginning of the planning process to ask questions and provide comments later.

Consumer groups are also frustrated by the five-year time frame for mental health transformation efforts, maintaining that the long development time ensures that systemic changes will not be implemented, even in the first states to attempt this, for several additional years.

Recovery or Evidence-Based Model?

Planners also have had to address concerns of some consumer groups that all of the state initiatives plan to devote equal funding and resources to recovery models and to evidence-based practices. The New Freedom Commission placed equal emphasis on the two approaches, although they are very different and diverge in some areas. Some patient groups regard evidence-based practices as almost a “right-wing conspiracy” because they run counter to the recovery model's emphasis on phenomenological ex periences and t he autonomous rights of those in recovery, according to Sy Saeed, M.D., chair of the Department of Psychiatric Medicine at the Brody School of Medicine of East Carolina University.

He traced the reduced emphasis on only using therapeutic approaches based on placebo-cont rolled, double-blind, prospective research to federal reports that have illustrated the “huge gaps in what we know about these [mental] illnesses and how to treat them.” He emphasized increased dialogue with patients to make them aware of the available treatment choices.

Systemic Change Required

Conversely, the other challenge for transformation planners is how to get health care clinicians to implement practice guidelines as part of their everyday work, Saeed said. Systemic change is required, he said, to overcome pervasive reluctance among clinicians to use guidelines and new research.

Health care planners also have encountered resistance to the transformation plans from some clinicians, who are concerned that the model's emphasis on consumer-directed care will result in patients and their families telling trained professionals how to provide care.

“There is a certain amount of resistance, but we're working through that,” Hepburn said, about health care providers in Maryland.

Some health professionals also have criticized the lack of changes in distributing state and federal funding more evenly to support research on all types of mental illness and not focusing in particular on serious mental illnesses.

Yet another concern state officials have grappled with is how to move low-income patients into a recovery model of care, which can result in a loss of their entitlement benefits.

Hepburn explained that the planning efforts in Maryland have focused on ways to overcome the impact of the lack of health insurance on access to mental health services. That lack of access has led to a situation in which 28 percent of patients who come to emergency rooms need mental health care.

The hard reality of financial limits arise in every health care system undertaking transformation planning.

The process's emphasis on community rather than institutional care is a laudable goal, but it doesn't work without a spectrum of supports, including housing and employment, said Lydia Weisser, D.O., clinical director of Mississippi State Hospital, who until recently participated in Georgia's transformation planning.

Limited resources have affected Georgia's effort most recently by causing transformation planning efforts to be suspended while all seven of the state's psychiatric hospitals prepare for an unscheduled Joint Commission audit.

State officials in Maryland worry that once planning has been completed the legislature may not fund the range of initiatives identified, Hepburn said. That concern was reinforced by the loss of recent savings at psychiatric hospitals. State officials had planned to shift those savings to community-based programs but the legislature required a 2 percent across-the-board cut that wiped out those transferable funds.

The ongoing f unding shortfalls in every state are exacerbated by the increased expectations of patients and the public that mental health systems will provide comprehensive and timely care. Criminal-justice officials add to these demands by describing ever-larger proportions of their populations as mentally ill and demanding that already underfunded mental health programs assume responsibility for care of prisoners. ▪