A Policymaker's Guide to Mental Illness
by Timothy A. Kelly, Ph.D.
Executive Summary #1522
March 7, 2002
http://www.heritage.org/Research/HealthCare/BG1522ES.cfm Tens of millions of Americans will experience depression, panic attacks, or some other form of mental illness this year. Of these, 6.8 million will suffer from the most severe forms such as schizophrenia and bipolar (manic-depressive) disorder. Countless jobs will be lost and lives will be put on hold as individuals and their families struggle to cope with the chaos and heartbreak of mental illness. Some of those with mental illness will attempt suicide, and many will be successful. In 1996, 500,000 Americans visited emergency rooms as a result of suicide attempts; 31,000 of those who attempted suicide died.
Many legislators and policymakers are seeking a way to address these critical problems. To do so effectively, however, they must better understand the nature of mental illness, as well as strategies for making mental health services more effective.
What is Mental Illness? Mental illness is defined as "a biopsychosocial brain disorder characterized by dysfunctional thoughts, feelings, and/or behaviors that meet diagnostic criteria." Policymakers should differentiate between serious mental illness such as schizophrenia that requires treatment on a priority basis and less severe problems such as caffeine intoxication that can best be addressed with indigenous community resources.
Serious mental illness (SMI) is defined as (1) all cases of schizophrenia; (2) severe cases of major depression and bipolar disorder; (3) severe cases of panic disorder, obsessive-compulsive disorder, and post-traumatic stress disorder; (4) severe cases of attention deficit/hyperactivity disorder; and (5) severe cases of anorexia nervosa. Clinical symptoms and standard treatments for each of these eight serious mental illnesses are presented, as well as estimates of the number of Americans who currently suffer from each.
Making Mental Health Services More Effective A person struggling with serious mental illness deserves effective care, whether provided through private insurance or public funds. Although many people receive the care they need, many others receive care that is far from effective and cycle endlessly in and out of mental health services that miss their mark. Policymakers seeking to reform and improve the nation's mental health services should consider the following issue areas.
Little information is gathered as to how well a given treatment works for a given person receiving care. Most mental health management information systems in the public and private sectors simply list demographics and services provided. Instead, providers should measure and document the actual outcomes of care provided. Regular use of standardized outcome measures would help transform mental health services into an evidence-based practice, improve the overall quality of care, and ensure that ever greater numbers of people with SMI can function productively in their home communities.
Providing Parity in Coverage.
Coverage and access to services for serious mental illness should be on a par with coverage and service access for physical illnesses. A challenge in providing parity will be to determine which of the mental illnesses should be designated for full coverage.
Establishing Safeguarded Outpatient Commitment.
Inpatient commitment occurs when a court determines (through evaluation) that a person with SMI is at risk to hurt himself or others, and therefore needs psychiatric hospitalization. Currently, once a person has been successfully treated and is discharged from a psychiatric hospital, the court has no say over whether that person remains in treatment. Cessation of treatment, especially of medications, is the primary cause of relapse after discharge, and outpatient commitment was conceived to address this problem. The basic concept is that hospitalized persons with SMI could be given an opportunity for early discharge, contingent on their agreement to remain in treatment in their home community. Those who did not abide by this agreement could be re-hospitalized, or perhaps required to attend a day treatment program, for treatment stabilization without new commitment hearings. Such authority should be used only when absolutely necessary and only when it is clearly in the best interest of the person receiving care. Safeguards such as review and appeals options, and adequate community services, must be in place for this policy to succeed. Consideration should also be given to related concepts, such as "advance directives" stipulating preferred care.
Requiring Parental Approval for Children's Treatment.
Parents and local authorities do not always agree on how to respond to the mental health needs of children and adolescents. A way must be found to safeguard parental rights and authority while ensuring that the needs of children and adolescents who are suffering from serious mental illness are met. This balance has proven to be difficult to achieve.
Engaging Those Who Use Mental Health Services in the Process of Reform.
Over the past two decades, increasing numbers of people with serious mental illness have begun to speak out against the "broken" mental health system. There are no more passionate advocates for reform than those who have suffered from ineffective care. Any effort at results-oriented reform must include substantial, ongoing input from those who will benefit the most--the "consumers" of mental health services.
Conclusion To meet the mental health care needs of Americans, policymakers should have a basic understanding of the range of mental illnesses, their treatments, and policy implications, as well as a means to identify the most serious mental illnesses for priority care. They also need to become informed on strategies for improving inadequate care. Such knowledge may then spark a much-needed national dialogue on reforming mental health services, so that persons with serious mental illness may live and work successfully in their home communities. These are the critical first steps in an ongoing effort to ensure that effective treatment is provided for all persons with serious mental illness and to promote the well-being of these individuals, their communities, and the nation.
Timothy A. Kelly, Ph.D., a licensed clinical psychologist, is a Visiting Research Fellow at the George Mason University Institute of Public Policy and formerly served as the Commissioner of Virginia's Department of Mental Health, Mental Retardation, and Substance Abuse Services.
http://www.heritage.org/Research/HealthCare/BG1522.cfm Mental illness is one of the most complex and frustrating health care issues facing policymakers today, and its toll is widespread. Tens of millions of Americans will experience depression, panic attacks, or some other form of mental illness this year. Of these, 5.6 million adults and 1.2 million children and adolescents will suffer from the most severe forms such as schizophrenia and bipolar (manic-depressive) disorder.1
Countless jobs will be lost and lives will be put on hold as individuals and their families struggle to cope with the chaos and heartbreak of mental illness. Some of those with mental illness will attempt suicide and, tragically, many of those attempts will be successful. In 1996, 500,000 Americans visited emergency rooms as a result of suicide attempts; 31,000 of those who attempted suicide died.2
America enjoys prosperity and power, but these have not provided a buffer from the plagues of mental illness and suicide. How did this come about? What can be done to address this critical problem? These are questions that many legislators and policymakers seek to answer in their roles of service to the American people.
A BRIEF HISTORY Historically, mental illness has been feared and misunderstood, and those suffering from it have been stigmatized. In colonial America, people with mental illness were called "lunaticks" and were usually cared for at home by their families. Often, this meant consigning the suffering individual to a basement or attic for long periods of time. Treatment consisted of humane custodial care at best, quackery or cruelty at worst.
By the 19th century, asylums were built so that people with mental illness could be cared for away from their home community. The various treatments that were provided were largely ineffective. In some cases, they were administered by well-meaning staff who at least treated their patients with dignity; too often, however, they were dispensed by inappropriate staff who cruelly mistreated their patients.
In the early 20th century, asylums became "mental hospitals," and the numbers of Americans committed within their walls grew substantially, reaching a high of nearly 560,000 in 1955. This rise was driven, in part, by the large number of World War I and World War II veterans whose combat experiences triggered chronic mental illness. Approximately 90 percent of those hospitalized suffered from a psychotic disorder; they had lost touch with reality and, in many cases, experienced delusions and/or hallucinations.
In the mid-1950s, the discovery of antipsychotic medications such as chlorpromazine sparked a revolution in mental hospitals. These new medications controlled psychotic symptoms, and for the first time, people with schizophrenia and other psychotic disorders could be discharged and returned to their home communities. The census of mental hospitals began a dramatic drop in their rolls, which now stand at just over 55,000.
This movement away from hospital care became known as "deinstitutionalization," as hundreds of thousands of people who would otherwise have lived much of their lives in institutions were able to go home. The initial hope was that antipsychotic medication would do for mental illness what penicillin did for infections--provide a cure for most cases. Instead, the process of drug treatment and deinstitutionalization brought about new problems. The medications themselves turned out to be problematic because they sometimes triggered severe side effects, and deinstitutionalization gave rise to a critical need for treatment and support services in the home community.
In response to this dilemma, a complementary revolution in mental health care soon developed--the community mental health movement. The goal was to provide outpatient services so that people with mental illness could receive needed care in their home communities. Community mental health centers (CMHCs) were launched with federal funding in the 1960s, and there are many dedicated and talented providers offering excellent care in today's CMHCs. Unfortunately, however, the CMHC system is now functioning largely without evidence of treatment effectiveness--and often without the full range of community supports and services necessary to provide effective care. Consequently, it is not unusual for a person with mental illness to end up back on the street, receiving inadequate treatment in the community, after being discharged from a psychiatric hospital.
This situation contributes to a rising population of the "homeless mentally ill," and seems to provide evidence for the claim that deinstitutionalization has failed. In fact, both deinstitutionalization and community mental health care constitute good public policy if they are correctly implemented. What is lacking in the vast mental health service delivery system that has grown up over the past 40 years is competitive, results-oriented accountability.3
Overview This year, over $69 billion will be spent on direct treatment for mental illness, yet many afflicted individuals will receive ineffective care--or no care.4 Consequently, there is a growing mental health care crisis in America today, and constituents are turning to policymakers for solutions. What is mental illness, and how can it best be treated? What are the most serious forms of mental illness? Can insurance parity, new Medicaid programs, or increased funding improve ineffective services? This paper is written to provide a starting point for policymakers facing these and related questions by offering the following:
• A definition of mental illness, serious mental illness, and mental health problems;
• A review of community resources that prevent mental illness;
• An introduction to the major categories of serious mental illness;
• An introduction to treatment for serious mental illness;
• A recommendation for improving effectiveness of mental health services; and
• A review of some current policy issues.
WHAT IS MENTAL ILLNESS? Mental illness is surprisingly difficult to define. Unlike physical illness, there is neither a pathogen that can be identified and treated nor a viral or bacterial infection that can be readily observed. The affected organ is, of course, the brain, and many mental illnesses are associated with changes in brain chemistry. But the etiology, or cause, of mental illness remains largely unknown.
Behavioral scientists work with a "biopsychosocial" model,5 which means that a given mental illness (such as depression) may have a biological component (such as a genetic neurological predisposition to depression); a psychological component (such as negative thought processes feeding depression); and/or a social component (such as a significant loss that triggers depression). The biopsychosocial model of mental illness has proven useful for research and treatment, and provides a good starting point for the policy arena as well.
Two Definitions of Mental Illness The National Alliance for the Mentally Ill (NAMI), the nation's largest mental health advocacy organization, defines mental illness as a "disorder of the brain" that "disrupts a person's thinking, feeling, moods, and ability to relate to others...[and] often results in a diminished capacity for coping with the ordinary demands of life."6 NAMI works from the premise that most people with serious mental illness need medication and that recovery often requires counseling and community support services as well.
NAMI is involved in the policy arena at both the state and federal levels and is known for its focus on "serious mental illness" rather than milder forms. Targeting serious mental illness makes good sense, from both a clinical and a practical point of view. With limited resources, policymakers should address the needs of those who are most seriously ill on a priority basis.
The 1999 Surgeon General's Report on Mental Health defines mental illness as "diagnosable mental disorders...characterized by alterations in thinking, mood, or behavior...associated with distress and/or impaired functioning."7 In this definition, "diagnosable" is the operative word, and it is what distinguishes mental illness from other, less serious problems in dealing with the typical tasks of life.
Saying that mental illness is diagnosable means that its symptoms meet the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders--Fourth Edition (DSM-IV). The DSM-IV, published by the American Psychiatric Association, lists observable/reportable criteria for every recognized classification of mental illness. For instance, to be diagnosed as suffering depression, an individual would have experienced for a period of time at least five of nine specific symptoms, including sad mood, sleep disturbance, low energy, difficulty concentrating, and thoughts of self-harm. Since public and private health insurers typically rely on DSM-IV diagnoses when considering coverage for mental illness, this manual has come to play a critical role in mental health care policy.
Drawing on a combination of these definitions, the following is a working definition of mental illness that could be used by policymakers: "Mental illness is a biopsychosocial brain disorder characterized by dysfunctional thoughts, feelings, and/or behaviors that meet DSM-IV diagnostic criteria."
WHAT IS "SERIOUS" MENTAL ILLNESS? Although the above definition provides a useful starting point for policymakers who are considering mental health matters, it is too broad in that it includes some types of mental illness that lie outside the realm of public policy and are best addressed by an individual's family and community. The DSM-IV definitions were not designed to identify the most critical health needs that should be prioritized by policymakers; rather, they were developed by mental health researchers whose goal was to provide distinct classifications for all experiences outside the "norm." Such deviations from the norm that are included in the DSM-IV range from simple cases of caffeine intoxication to life-threatening major depression.
Caffeine intoxication results from the ingestion of excessive amounts of caffeine, which results in symptoms such as restlessness, insomnia, and nervousness. Although many college students have experienced the results of a caffeine overdose while studying for exams, it is unlikely that this form of "mental illness" is serious enough to warrant treatment covered by public programs or private insurance.
Major depression, on the other hand, can be debilitating in the extreme and often includes suicidal thoughts or actions. Untreated, it can literally end in death. More often, it leads to a life of increasing dysfunction at home, at school, or in the work place. It is clear that this form of mental illness is serious enough to warrant treatment and that effective treatment should be made available either through private insurance or through the public mental health system.
Serious Mental Illness Defined Mental health researchers and policymakers have labored for some time to define serious mental illness (SMI) in order to distinguish it from less severe forms of dysfunction. This definition is critical to ensuring that care is provided for the most serious and damaging cases of mental illness. Identifying and treating SMI is every bit as important as treating physical disabilities, such as loss of hearing. Private insurance and public funds should prioritize the needs of those with serious mental illness, whereas assistance from family, friends, and the community may be sufficient to address less severe forms of mental illness, such as bereavement or conduct disorder.
Although policymakers do not fully agree on which diagnostic classifications to designate as SMI, a working model could include the following categories:
• All cases of schizophrenia (a psychotic disorder);
• Severe cases of major depression and bipolar disorder (mood disorders);
• Severe cases of panic disorder, obsessive-compulsive disorder, and post-traumatic stress disorder (anxiety disorders);
• Severe cases of attention deficit/hyperactivity disorder (typically, a childhood disorder); and
• Severe cases of anorexia nervosa (an eating disorder).
Accordingly, this paper defines SMI as a subcategory of mental illness, based on both diagnostic classification and severity.8 All those who suffer from SMI are indeed disabled and in need of effective treatment, whether they are children, adolescents, adults, or elderly people.9
Severity Since severity is included in the definition of SMI, it is necessary to define what is meant by severe cases. For many diagnoses, including depression, the DSM-IV includes specifying the severity of a disorder as being mild, moderate, or severe. The DSM-IV defines "severe" as cases in which "many symptoms in excess of those required to make the diagnosis or several symptoms that are particularly severe are present, or the symptoms result in marked impairment in social or occupational functioning" (p. 2). In contrast, the DSM-IV defines as "mild" cases in which "few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairment in social or occupational functioning" (p. 2).10 Additionally, the DSM-IV includes a "Global Assessment of Functioning Scale" for measuring severity on a scale of 0 to 100. Scores under 50 are considered serious.
Using this definition, a mild anxiety disorder would be minimally disruptive and would be seen as a mental health problem to be addressed with indigenous community resources. On the other hand, a severe anxiety disorder would be significantly disruptive and would constitute a serious mental illness requiring professional treatment. This same distinction applies throughout all SMI categories with the exception of schizophrenia, all cases of which are considered severe.
LESS SEVERE MENTAL HEALTH PROBLEMS Although the needs of individuals with SMI should be prioritized, those who suffer less severe forms of mental illness can by no means be ignored. A compassionate society should assist all of those who are in need and should ensure timely treatment, which can prevent less severe mental health problems from developing into serious mental illness. Without social support, for example, an adult suffering bereavement could slip into a major depression. A child or adolescent exhibiting behavioral problems at school should receive attention and guidance. Likewise, a person dealing with a mild depression needs someone to offer support and a listening ear.
Such needs are best understood as mental health problems or mild mental illness, and they can often be addressed by family, friends, church or school counselors, employee assistance personnel, or the staff of a nonprofit organization. It would be a mistake for public/private insurers to consider such problems as being on the same level as SMI, thereby reducing the services that would be available for those with the greatest need. Indigenous community resources can prevent and address mental health problems by giving the sensitive, personal care and support that they, uniquely, can provide. This will allow public/private insurers to focus on addressing serious mental illness with well-funded effective treatments and high quality professional care.11
COMMUNITY RESOURCES Needless to say, the most important community resource for dealing with mental health problems is one's own family and friends. A timely word of advice or encouragement, practical help with a problem, and the support of loved ones who believe in us and walk with us through hard times are priceless resources for dealing with the stress and normal difficulties of life, and this support helps to prevent the development of greater mental health problems.
In addition, other resources within the community play a valuable role in preventing and addressing mental health problems. These resources include:
• Employers. Large organizations often offer employee assistance programs (EAPs) for their workers that provide resources for managing stress/anxiety such as gym privileges, yoga sessions, and support groups. Access to these supports, for example, could prevent an employee who is feeling "stressed out" from experiencing a debilitating panic attack. Since serious mental illness is costly to both the employee and the employer, it is good fiscal policy for companies to provide effective EAPs when possible.
• Schools. Schools can provide timely evaluation and appropriate support for children whose conduct is problematic while emphasizing the importance of personal responsibility. Such support could be as simple as changing a child's classes to reduce academic or social frustration. It might also involve working with the child's parents to explore opportunities for tutoring, mentoring, or sports activities. With parental approval, support might also be provided through meetings with a school counselor or psychologist who could provide encouragement and guidance for dealing with stress or possibly arrange to have the child tested for attention deficit disorder. It is important to deal with such needs as soon as possible, given that today's frustrated student could become tomorrow's dropout with even greater problems such as depression or substance abuse.
• Religious Institutions. Churches, synagogues, and mosques play a critical role in ministering to members who are struggling with mental health problems. Family members who are grieving over the loss of a loved one, older people who are experiencing isolation and mild depression, and couples having marital difficulties can all benefit from the support of their faith community. Many churches, for example, offer support groups and personal counseling for those in need, as well as 12-step programs, which have proven to be very effective in dealing with addictions. Such support provides important resources for men and women who are experiencing mental health problems, and it can help to avert the development of a major depression or other serious mental illness.
• Nonprofit Community Organizations. Nonprofits such as the Boy Scouts and Girl Scouts, sports clubs, and other community-based organizations often play an important role in the lives of those who are dealing with mental health problems. For instance, in scouting, a boy or girl from a dysfunctional family may find the camaraderie and mentoring that is sorely lacking at home. This support and sense of belonging may help to keep these youths from self-destructive behaviors or depression.
In these and other ways, resources within communities can help to address the mental health problems of their residents and prevent mild problems from spiraling into serious mental illness. Although individuals whose community offers few or none of these resources are at greater risk than those who have strong community support, the family or community should not be blamed for the emergence of SMI. The biopsychosocial model indicates that mental illness is the result of a variety of factors. In light of etiological uncertainty, it is far more beneficial to focus on identifying and providing the things that can help those who are suffering mental problems than it is to cast blame.