Don’t Make Mental Health Policy About the Stigma

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Cost of not caring: Stigma set in stone by Liz Szabo, USA TODAY.

This second article of a USA Today series, Mentally Ill Suffer in Sick System, this morning began exploring, "the human and financial costs that the country pays for not caring more about the nearly 10 million Americans with serious mental illness." But the article didn’t address any of the aggregate human costs nor any of the financial costs the country pays due to serious mental illness. Maybe future articles will, and that’s what I would like to encourage with this post.

Now, admittedly, USA Today isn’t in the top 10% of resources I normally rely upon for keen insights and emerging trends and drivers in healthcare, but nonetheless I think they deserve enormous credit for using their national reach to bring greater awareness to a critically important issue.

From a public policy perspective, however, this first contribution is wide of the mark in advancing the type of dialogue that could actually lead to meaningful public policy initiatives impacting mental and behavioral health services. So though I very much doubt their editors will ever see this post, I would like to provide some input that might be useful in developing content for future articles in the series.

Today’s article focused on two themes: the latent impact that stereotypes associated with mental illness still have, often creating self-absorbed obstacles to seeking and receiving much-needed diagnosis, treatment, support services and ongoing care; and the dramatic lack of sufficient resources committed to helping those who are brave enough to seek assistance and support.

Of course, stigmatism is still very real, yet very difficult to understand: it isn’t just a case of stereotyping and ignorance. Mental illness is difficult for many of us to comprehend because the mechanism responsible for its existence is the same mechanism we use to understand it. Most of us can use our brains to understand heart disease, diabetes and lung cancer. But somehow using our brains to explore and reason through a disease process that in others (or, to be sure, often ourselves) impacts our thinking can be uncomfortably counterintuitive.

The inherent stigmatization isn’t just in the fact that someone with mental illness is, "different." It’s the added frustration of having difficulty understanding why they are different. An individual receiving chemotherapy for cancer may look different than their appearance prior to disease. Someone who has had an amputation resulting from diabetes has a noticeable difference in appearance. But mental illness very often doesn’t carry with it the externalities of these changes in appearance (the manifestation of behavioral health consequences resulting from mental illness may lead to dramatic changes in appearance, but those are usually self-chosen much the same way one would choose a different hair color or style).

So while it may be said that ignorance is a lack of understanding acted upon, I agree we should continue to concentrate efforts on building understanding and awareness through continued education, rather than trying to coach away ignorance through reprimand and humiliation that too often characterize so many public awareness campaigns.

Such efforts have had beneficial impact: as a society we are generally much more accepting today than 20 years ago that mental illness is not a self-chosen condition bearing the shame of poor choices and moral subservience. And they have concurrently raised awareness about the urgent need to develop more effective public policy to address accelerating mental and behavioral health needs.

And so, as related in the USA Today article, the most emotionally convenient and expedient approach to lobbying for additional funding in support of MH/BHS is to continue making the case that mental illness should be viewed just as any other disease of a human organ – since the brain is, after all, a human organ. This reflects the inherent strategy that fighting the stigmatization of mental illness will hold sway over those able to increase funding of MH/BHS policy initiatives. But I don’t think it will because every dollar allocated to healthcare is becoming increasingly precious.

From a policy perspective, I believe it is both folly and a wasted effort to spend valuable resources on lobbying for more funding without being able to provide realistic and achievable budgetary offsets. To do this, advocates of MH/BHS programs need to focus their time and energy on generating evidentiary support for where and how funding of existing programs that address the consequences of mental illness can be more effectively invested in programs that diagnose and treat mental illness – i.e., before that illness results in consequences which place resource strain on other areas of social health and welfare (e.g., utilization of hospital emergency departments and the criminal justice system, the economic impact on families and the cascading effect that has on the rest of society). This is, I assume, what USA Today claims the series intends to do via relaying the “human and financial costs” of mental illness. We will see.

In healthcare, we are now living in an era where the expectation that research and evidence support clinical decision-making has steadfastly made its way into organizational administrative and financial decision-making. Quite obviously, we cannot hope that will ever be the same in Congress, but through the Affordable Care Act and various programmatic changes impacting state Medicaid budgets legislators are by default forcing healthcare providers to much more carefully analyze alternative investments – and to use return on investment as a tool for that analysis. Mental health advocates need to recognize this reality if they want their efforts to ultimately result in constructive public policy consistent with their overarching goals and objectives.

I really hope this understanding is reflected in future articles in the USA Today series. I understand anecdotal human-interest stories that tug at the heartstrings help sell newspapers, but they contribute very little to the knowledgebase of understanding needed to assess where and how limited resources can best be reallocated to address this tremendously difficult challenge that we all face as a society.

Cheers,
  Sparky

Picture Credit ~ Jim C. Jeong for USA Today

Mental Health in Crisis

The cost of not caring: Nowhere to go ~ The financial and human toll for neglecting the mentally ill is the first in a new series of articles being produced by USA Today tackling this hugely critical issue (by Liz Szabo). Rep. Tim Murphy, R-Pa. (a child psychologist) declares that, "we have replaced the hospital bed with the jail cell, the homeless shelter and the coffin. How is that compassionate?"

Mental health services and programming has taken it on the financial chin as an unfortunate lesser of evils political choice among state programs that have traditionally provided funding. According to Robert Glover, executive director of the National Association of State Mental Health Program Directors, $5 billion was cut from 2009 to 2012, while 4,500 public psychiatric hospital beds were eliminated (a 10% reduction).

Mental illness is still not broadly well understood in a way that even starts to approximate its impact on society. The USA Today article estimates that approximately 10 million Americans with serious mental illness are not receiving care. While at the same time, individuals with serious mental illness have a probability of dying 23 years younger compared to others.

The costs to society are dramatic: in excess of $440 billion a year. And only about one-third of that total goes to medical care. Much of it reflects disability payments and lost productivity. And that amount does not include lost earnings or tax revenue spent on prisons.

The timing is not good. State budgets are already being stretched and the national focus is on how to take costs out of the system – not add more. Medicaid expansion is likely to help identify greater need for mental health services without any commensurate plan in place to address those needs.

Yet we simply cannot afford to continue down the care delivery path we have forged. Mental illness is often a root cause for various physical illness and chronic conditions. Tragic events like Sandy Hook Elementary, Virginia Tech and Fort Hood remind us of the potential incident costs of untreated mental illness – but a fitting analogy of those events to the broader problem might be comparing the tragedy of an airplane crash to the number of traffic fatalities across the country each year.

Recently in true Washington partisan fashion Republicans and Democrats illustrated their shared compassion for those suffering from mental illness by drafting legislation designed to promote political distinctiveness rather than policy progress (though it should be noted that in this instance the Democratic initiative has to be viewed as politically reactive). Here’s hoping maybe someday that will change and this country can start having the very serious and much needed conversation on how to address this terrible crisis.

Cheers,
  Sparky

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