By Lloyd I. Sederer
May 13, 2015
The future for the next 10 years of mental health in America will not derive from sudden breakthroughs in decoding our DNA or fashioning designer drugs that are categorically different from what we have now -- though either or both would of course be welcome. A sanguine future is possible if we do what we know now a lot better (quality) and deliver what we know now to a lot more people (access).
The greatest gains we can achieve in the next 10 years in public mental health will derive from closing the gap between what we know and what we do in both mental health and the addictions. The "science to practice" gap, as it has been called, is the (hard to imagine but real) fact that advances in medical practice (in general medicine as well as psychiatry) are typically years in going from "bench (lab) to bedside."
I offer this prescription for the future of mental health in America, in David Letterman style:
10. Intervene early, with family skill building and trauma-based treatment, for youth from 3-7 years of age who show evidence of Adverse Childhood Experiences (ACEs).
9. Detect signs and symptoms of serious mental illness, psychotic illnesses like schizophrenia and bipolar disorder, in adolescence and deliver accessible, age-friendly First Episode Psychosis (FEP) services to alter the trajectory of illness and prevent disability, long-term suffering and social burden.
8. Deliver mental health and addiction screening and clinical management in primary medical care, including internal medicine, family practice, pediatrics, and OB-GYN, as standard practices like we see diabetes, asthma, hypertension, and other common, chronic medical conditions now treated and managed.
7. Add evidence-based treatments, including Medication Assisted Treatment (MAT) and cognitive therapies, to complement the 12-step programs that heretofore have underpinned the vast majority of addiction treatment programs delivered throughout the country.
6. End an era of criminalizing people with mental (and substance use) disorders and of using jails and prisons as institutions thought -- falsely -- to control illness and protect the public.
5. Establish Measurement-Based Care as a quality standard in mental health and substance use programs; we know our "numbers" for blood pressure, lipids, blood glucose/HgA1c, weight, and a host of other measurements of health and illness. We all monitor these numbers and fashion treatments that aim to normalize them. Measurement-based care can equally be used with mental and substance use disorders; until we do, we will merely be divining responses not actually determining them.
4. Discoveries in cancer treatment, for example, have made for more targeted, and effective, treatments. We are just beginning to see biological markers in psychiatry and the addictions that will tell us which patients are most at risk, and which treatments can improve their likelihood of success. Personalized (or Precision) Medicine, as this is called, used in mental health and substance use disorders will sharpen our approaches and improve rates of response.
3. Deliver mental health and addiction services that serve the patients first, not the convenience of practitioners or institutional bureaucracies. Offer hope and believe that people can recover, because they do -- building lives with relationships, purpose and contribution with illness. Engage patients in true shared decision-making, not as a slogan but as the essence of practice. We all are most prone to do what we want to do, not what the doctor says, so let's get to what the patient wants and leverage the powerful forces of individual choice and desire.
2. Chip away at the Social Determinants of Mental Illness. We know that only 10 percent of our health is determined by the health care we receive. The vast predominance of our health is determined by our environment and our habits. Where we live, income, access to good education, what we eat, what we don't do (like smoke or eat well or exercise), and the human supports in our lives that guide and sustain us are the principal determinants of all health, including mental health.
1. Stop paying hospitals and doctors for volume and reward them for humane, effective care that is prudently delivered. The GDP for the USA industry of health care exceeds the entire GDP for France; the USA pays far more per patient served than any other country -- without evidence that we are getting our money's worth. We don't need to spend more, we need to spend smarter.
Dr. David Satcher (former US Surgeon General) is famously known for saying "There is no health without mental health." Mental health disorders, including the addictions, are eclipsing all other disorders in terms of the global burden of disease and disability. We can try to run from these conditions, a historic proclivity and a perennially unsuccessful tack. Or we can build on the considerable work to date in introducing quality, effective mental health treatments and services, and spread these widely and deeply into every community and for every family in need. That would be a future to be proud of.