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Serious Mental Illness Committee Has Its Work Cut Out

<ѻý class="mpt-content-deck">— Challenges in collecting data, improving diagnosis highlighted
Last Updated December 4, 2017
MedpageToday

WASHINGTON -- The federal government's new committee on serious mental illness certainly has no shortage of issues to sort through, if its first meeting is any indication.

The group, officially known as the Interdepartmental Serious Mental Illness Coordinating Committee, met on Thursday for the first time. In welcoming members, Health and Human Services Secretary Tom Price, MD, called the committee "historic" and its purpose "significant".

"There is no time like now for work of this committee to begin. We are badly in need of a fresh examination of how we treat serious mental illness in America," he said. "Each of our priorities presents a complicated challenge, one where our policies are coming up short, and one where real progress would be a truly meaningful victory for the health and well-being of Americans."

Price also shared the story of a family friend named Charles. "He got to be 18, 19, 20 and struggled with schizophrenia, was in and out of institutions, in prison, and he lived homeless for a long period of time. Charles woke up one morning and decided he needed to kill his father and himself, and he did ... We are deeply committed to understanding why we failed Charles and his family."

Members Tell Personal Stories

The 24-member committee also heard from Ben Carson, MD, Secretary of Housing and Urban Development. "As we help people find housing, we must be aware of additional mental health issues. We must look for places of intersection, places for intervention. Homelessness, for instance," said Carson. "One estimate is that 26% of all sheltered homeless persons have a severe mental illness. So the shelter is an important point of contact. Staff must be trained to recognize mental health issues and mental disabilities."

"At HUD, I can assure you we'll be strong advocates for mental health [diagnosis] and treatment," he said.

Committee members each gave their own brief introductions; many of them either struggled with mental illness or substance abuse themselves, or had family members who did. "I have a brother who never survived his addiction," said Ralph Gaines, Principal Deputy Assistant Secretary for Community Planning and Development at HUD.

"The only people that recognized my mental illness were my children," said Elena Kravitz, a peer support provider and manager with Collaborative Support Programs of New Jersey.

"I have schizophrenia; I have been ill since 1977," said Elyn Saks, JD, PhD, law professor and legal scholar at the University of Southern California.

A Host of Challenges

Committee chair Eleanor McCance-Katz, MD, PhD, assistant secretary for mental health and substance use at the Substance Abuse and Mental Health Services Administration (SAMHSA), laid out some of the committee's charges. "A major concern I have is keeping people with serious mental illness out of our prisons ... How do we move medical treatment of serious mental illness out of prisons and back to communities? I also hope to hear discussion of how we can make better use of evidence-based treatments ... and linkages with peers to support recovery."

She also said she wanted to hear "a discussion of how civil commitment laws might be appropriately used to assist a person with preventing relapse to psychosis ... I also want to know whether there are ways federal agencies can assist -- for example, by compensating physicians for their time spent in such processes."

Access to care and recovery support services are an ongoing challenge, McCance-Katz continued. "The estimates are that 35% of people with mental illness get no treatment at all. This is a terrible disservice. Emergency departments are not an appropriate place to provide needed care ... I am looking to you for suggestions around issues like hospital beds and acute care versus longer term needs." Other issues she mentioned included:

  • Use of psychotropic medications
  • Medication effectiveness
  • Use of clozapine for resistant schizophrenia
  • Protecting privacy rights
  • Behavioral healthcare workforce including numbers of people and geographic distribution
  • Integration of behavioral and physical healthcare
  • Addressing concurrent substance use disorders

Other government members of the panel also discussed the challenges they face. "How are we defining serious mental illness itself?" said Paolo del Vecchio, director of SAMHSA's Center for Mental Health Services. "Across the federal government we're defining it differently, so the need for standardized data collection is critical."

Over at the Department of Veterans Affairs (VA), "Despite substantial VA investment ... [suicide] rates have stayed high," said John McCarthy, PhD, MPH, director of the VA's Serious Mental Illness Treatment Resource and Evaluation Center. "The VA has prioritized suicide prevention and put an emphasis on everyone being responsible, and on partnerships," but challenges remain.

Overall, "suicide rates rising across all population groups, particularly in middle-aged men and in youth," said Joshua Gordon, MD, PhD, director of the National Institute of Mental Health. "How do we predict individuals at high risk of suicide and, once we've identified them, how can we help them? That [especially] includes those not only in jail or prison but also in the year after release from prison."

More Data Needed

Then it was the non-government panelists' turn. For youths transitioning to adulthood, "there is extremely little evidence of what works in that age group," said Maryann Davis, PhD, research associate professor of psychiatry at the University of Massachusetts Medical Center. She noted that a issued in 2015 called for establishing an evidence base for mental health among young adults.

"I think a lot more emphasis could be placed on the need to develop that evidence base," said Davis. "The second aspect is the ... need for much more research on how to deliver services in a manner appealing to young people. I know SAMHSA has had a few programs on how to better support transition-age youth, and it would certainly be beneficial to see those continue and expand."

Panelists also raised the issue of social connections. "This issue of friends I think we diminish," said David Covington, MBA, president and CEO of RI International, an organization that assists mentally ill patients with housing, employment, and other needs. He mentioned a study showing that loneliness was a 30% contributor to early mortality, "and we find almost no data [on that] in the serious mental illness community." Helping mentally ill patients find jobs is also important to their well-being, he continued; until that is dealt with, "we are going to miss out on a huge opportunity."

Cognitive deficits are another problem, said Joe Parks, a practicing psychiatrist and medical director of the National Council for Behavioral Health. "The majority of these people see 15-20 different providers, they're taking 16 different medications, they have deficits in executive ability and the ability to organize information -- and we expect them to keep track of that and figure out what they need and when they need it. We shouldn't be surprised because they don't have the wherewithal to get all that straight."

"We don't require the supports to help them with cognitive deficits," he said to the federal officials on the panel. "Unfortunately, you're going to be the ones to require and regulate that it be done. This is an area where the private sector is failing and it requires more regulation, not less."

Katz noted that the committee's first report to Congress is due in December of this year, and will include sections on advances in dealing with serious mental illness, federal programs in place, as well as their outcomes, and recommendations agencies can take to better coordinate services for adults and children with serious mental illness. An outline of the report will be circulated to the committee in mid-September, followed by a first draft in mid-October and a second draft in mid-November. The committee's second report is due in 5 years, she said.