The $201,000,000,000 Lottery; How Much of It Does Psychology Deserve?


The Senate Summit on Mental Health

Recently, I attended the Senate Summit on Mental Health hosted by Sens. Chris Murphy of Connecticut and Bill Cassidy of Louisiana. The purpose of the event was to advocate for the comprehensive mental health reform act that the two senators are currently championing. First let me say that the legislation is a very good, bipartisan bill. While not yet reconciled with a similar bill in the House, it promises to provide expanded training of healthcare providers and increase funding and access to mental health services. according to Sen. Lamar Alexander, the Chair of the Senate Health, Education, Labor, and Pensions Committee, the bill “has as good a chance as any” of making it to the President’s desk in this election year.

Dr. Ben Miller, the only psychologist in a lineup dominated by psychiatry and a longtime champion of psychologists in integrated care settings, gave an extremely compelling brief that put in stark terms the economic and human consequences of our fragmented health care delivery system. Ben emphasized the extraordinary human costs of working in an unintegrated setting by reporting statistics that the majority of people who commit suicide have had a primary care visit within the past month, but, due to stigma, unavailability of resources, or other factors, did not have their mental health needs adequately addressed. As Ben noted “…in our [mental healthcare] system, if you get sick you tend to stay sick.” Another speaker, the head of an Emergency Medicine Department in Waterbury, CT, provided statistics that illustrated this ugly reality. One week prior, 21 out of 31 beds in his large emergency room were occupied by “boarded” mental health patients – that is, long-term patients who waiting placement in an appropriate mental health facility. Some had been in the ED for 4-6 weeks. A high proportion of these patients were adolescents, for whom treatment options are particularly scarce.

Among other compelling panelists was the sheriff of St. Charles Parish, LA, who noted that county sheriffs had become, without training or intent, the de facto facility managers of the largest mental health systems in the country—the county jail system. He pointed out that of the extremely limited “treatment” resources available in county jails, it is mostly medication, “…not the type of therapy these people need.” Inmates with mental illness are, he reported, at very high risk of recidivism, which underscores the argument that mental health funding can be an effective crime reduction strategy. As the sheriff remarked, at the birth of our nation, we put people with mental illness in jail. After almost 250 years of democracy, due to successive failures in our mental health system, we have again returned to a system where we treat mental illness with incarceration.

You can watch the entire summit here: Dr. Miller begins his remarks in the 36th minute.

Healthcare Costs: Bradley vs. Roehrig

So how much are we paying for this inefficient, ineffective, and often cruel system? Far more than we pay for any other medical condition, it turns out. According to a recent report in the journal Health Affairs, $201 billion dollars annually. Charles Roehrig (Mental disorders top the list of the most costly conditions in the US: $201 Billion; Health Affairs, June, 2016) analyzed 2013 National Health Expenditure Account data and discovered that spending for mental disorders, at $201 billion, exceeded by a large margin the next most costly category, heart conditions, at $147 billion. The Roehrig report got quite a bit of well-deserved mention at the mental health summit. It is quite appalling that we spend this much with so little to show for it.

But what went unmentioned at the Senate summit was yet another report in Health Affairs, which to me may contain even more important data suggesting possible avenues for reining in high healthcare costs. In this analysis, Bradley and colleagues (Bradley, E. A., et al., Variation in Health Outcomes: The role of spending on social services, public health and health care 2000-2009; Health Affairs, May, 2016) discovered that states that spent more on those social services that had some demonstrable link to health (education, income support for low or needs-tested earners, supplemental nutritional assistance programs) vis-à-vis health care services had far better health outcomes. Regarding mental illness, states with higher ratios of social to health spending had a significantly lower mental health burden, estimated by the authors to be 989,000 fewer adults with mental health issues in the year 2009. In other words, aiming all of our dollars at treatment will not solve the problem. Without appropriate public health and social support preventive spending, we end up chasing our collective tails.

Some attendees of the Summit were disconcerted at comments made by representatives of organized psychiatry, who focused their entire presentation on increasing the number of psychiatrists and funding for psychiatric research. I hope we all agree that more mental health providers of all stripes are needed, in addition to funding effective preventive and support services. To focus on only one provider group is counterproductive. Further, since the medical model of treatment of mental illness has predominated in this country, I believe we have good evidence to suggest that alternatives to a purely medical approach may yield better and potentially less costly patient outcomes.

But we must ask: Is psychology ready to meet these challenges? Do our training programs produce enough psychologists who can challenge the inefficiencies of the current system? Are our psychologists sufficiently fluent in primary care, the de facto mental health delivery system in this country, to work effectively in that environment? Do our psychologists have sufficient knowledge of psychopharmacology, (which is, like it or not, the de facto treatment for mental illness in this country), to provide alternatives, either psychobehavioral treatments or combined modalities? Have we taken a cold hard look at the amount of time it takes to train a psychologist in order to honestly answer that we are responding to the evidence and not to academic traditions? Are we as a discipline ready to put aside our internecine bickering and short-sighted attempts to subvert our own professional organizations so we can bring more providers, fluent in integrated health but trained in a non-reductionist model, to the aid of patients in need?

These are not idle questions, and they all deserve more attention than we currently give them. The data before us also suggest that the attention we pay to these questions needs to be urgent, if we as a profession truly care about the well-being of our society and if we as clinicians truly care about the patients we serve.

The Collaborative Family Healthcare Association (CFHA), an interdisciplinary organization of physicians, nurses, psychologists, and other mental health providers has long championed the role of mental health in the primary care arena. It is increasingly clear that their advocacy is accurately focused on solving a very real need in American healthcare. It is equally obvious that psychologists in leadership positions in CFHA, like current APA President Susan McDaniel, have a vision for the future of the profession we would do well to heed. In support of this vision, the Register will be introducing later this year a series of educational videotapes aimed at providing psychologists with some basic skills needed to work in the integrated healthcare environment. But teaching licensed, doctoral level psychologists will not be enough. We need to place teaching of these skills where it appropriately belongs: firmly integrated into the graduate curriculum.

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