Yesterday was the inaugural meeting of the federal Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC). While the acronym is a mouthful, the meeting is an important step to better health and quality of life to members of our community with the most significant needs; individuals with schizophrenia, bipolar disorder and major depressive disorder. Health and Human Services (HHS) has prioritized mental health alongside two other top priorities: opioid abuse and childhood obesity.I’ve attended many government meetings on mental health and suicide prevention in Washington DC over the past decade but this represents my first mental health meeting next to the Capital at the HHS offices Hubert Humphrey Building. It’s a clear signal that mental health is a priority to the US government and our healthcare system.
HHS Secretary Dr. Tom Price began with the challenges for the 10 million people with serious mental illness; including lifespan, homelessness and incarceration disparities. “Recovery is the expectation” with employment and social connectedness being mentioned during the discussion. According to Price, prejudice and apathy have weakened the way we address these issues but they require the same expertise and commitment as cancer or heart disease treatment. Secretary Price also called out the importance of family support and inclusion in the collaborative process to evolve our health care system.
There were prior mental health initiatives under Presidents Jimmy Carter and George W. Bush, but Secretary Price explained that the ISMICC is the first to report to Congress and he expressed strong confidence in the newly appointed Assistant Secretary for Mental Health Dr. Elinore McCance-Katz. This new role reports directly to the Secretary of HHS and Dr. McCance-Katz is the first psychiatrist to lead SAMHSA.
The charge of the ISMICC is three-fold:
- Report on advances in treatment, recovery and prevention;
- Provide rigorous assessment that is candid and sober; and
- Make specific recommendations on policy reform.
“I firmly believe mental health care does not receive the emphasis or resources it needs,” Secretary Price stated, adding “We need a true continuum of care from outpatient to inpatient.” Lisa Dixon from Columbia University shared her feelings on the inspirational opening: “My heart is in my hands with the promise for what this group might achieve.”
All branches of government were represented. Department of Housing and Urban Development Secretary Dr. Ben Carson spoke next sharing his lifelong interest in psychology. He explained that his mother struggled with major depression when he was growing up and was hospitalized.
One of the highlights for me personally was the active participation of the Center for Medicare and Medicaid Services. Kimberly Brandt described the largest health insurer in the world with 130 million covered lives and $1 trillion in spending. She identified several key CMS initiatives; including states reporting on outpatient follow-up to psychiatric inpatient services, the prevalence of smoking for individuals with serious mental illness, and expanded telehealth opportunities for delivering crisis psychiatry services. She also pointed to an upcoming CMS meeting on September 8 which will lay the groundwork for innovations in behavioral healthcare payment models.
Dr. McCance-Katz shared with the ISMICC ten key areas that she hopes to hear addressed in the dialogue:
- How do we move treatment back to community supports and services for those in jail or prison?
- How do we improve therapeutic relationships and what role might advanced directives play?
- How do we increase evidence-based practices like Assertive Community Treatment, Assisted Outpatient Treatment, and linkages to peers?
- How do we improve civil commitment laws?
- How do we improve access to care, especially given that 35% of people with serious mental illness receive no treatment at all?
- How do we address the long waits frequently experienced in hospital emergency departments, ensuring adequate acute care, crisis intervention and additional levels of care?
- How do we improve recovery supports and ensure better evidence for these approaches?
- How do we protect privacy rights?
- How do we address workforce deficits, including the numbers and geographic distribution?
- How do we incorporate co-occurring substance use services?
Next, four panelists presented on federal advances to address challenges in SMI and SED.
Dr. Joshua Gordon from the National Institute of Mental Health offered a strategic framework for SMI and SED research that would deliver personalized interventions. He presented RAISE as an example of success using this approach (RAISE stands for Recovery After an Initial Schizophrenia Episode).
Gordon also prioritized suicide prevention and described the NIMH RFA on applied research to evaluate the effectiveness of the Zero Suicide in Healthcare systems model.
SAMHSA’s Paolo del Vecchio leads the Center for Mental Health Services and started with the stark disparity between people with SMI/SED related to receipt of evidence-based practices. For example, unemployment rates for individuals with serious mental illness are extraordinarily high. 70% of individuals express a desire to work but only 2% receive evidence-based supported employment services.
Del Vecchio surveyed the principles of coordinated care: medications, therapy and recovery supports while highlighting approaches that integrate all three components. Great emphasis on the need for a coordinated continuum of crisis care and the Zero Suicide in healthcare. “We prepare people for a life of recovery, not a life of disability.”
Dr. John McCarthy with the Department of Veterans Affairs, Office of Mental Health Operations, described the advances in treatment and access. While the overall number of veterans in the US has declined since 2005, the penetration for those receiving treatment with the VA has increased 24%. The growth in outpatient mental healthcare is up 85% over the same time period.
McCarthy reported on the substantially increased hazard ratio of suicide for individuals with serious mental illness and the July 2017 findings from Dr. Mark Olfson related to the very significant suicide risks for individuals in the immediate aftermath of a psychiatric hospitalization. He described several VA initiatives to address these risks; including the Veterans Crisis Line, 400 suicide prevention coordinator staff nationwide and the REACH vet program, which uses predictive analytics to determine those at highest risk.
Finally, the Bureau of Justice Assistance’s Ruby Qazilbash shined a light on the prevalence of people with SMI in the criminal justice system. She cited data that approximately 4% of the general population has a serious mental illness, but 17% of the 11 million annually incarcerated in the jail population has a serious mental illness. She also described the frustrations of local law enforcement, whose experience can find one in ten calls involve mental health, contacts which require twice as long to resolve as other police activities.
After the lunch break, a second panel presented non-federal advances.
Lynda Gargan with the National Federation of Families for Children’s Mental Health shared her own powerful personal journey of challenges and successes regarding her son.
Columbia University Medical Center’s Dr. Lisa Dixon reviewed the evidence for Coordinated Specialty Care for individuals experiencing a first psychosis, which demonstrates dramatic reductions in inpatient hospitalization and strong improvements in school and/or work progress. She asserted that “being productive equals a basic human need.” People want to work. It’s an essential part of recovery. And… Individual Placement and Support (IPS) is very effective, creating employment rates as high as 78%.
Dixon also reviewed the impacts of peer supports strategies; concluding that they reduce the use of acute services, result in decreased depression and substance use and increase engagement and hopefulness (Bellamy et al, 2017, “An update on the growing evidence base for peer support,” Mental Health and Social Inclusion).
Dr. Sergio Aguilar-Gaxiola from the University of California encouraged a focus on a comprehensive view of the non-medical determinants of health, including co-morbid medical diseases, smoking, obesity, physical inactivity, poverty, trauma, poor social connectedness and homelessness.
Formerly medical director for the state of Missouri, Dr. Joseph Parks is the lead psychiatrist at the National Council for Behavioral Health. Parks discussed the challenges of access to care; including a psychiatry workforce shortage, psychiatric boarding with people waiting in hospital emergency departments for mental health services and insurance gaps. He also encouraged the enforcement of parity requirements to appropriately resource services.
Using a data driven approach, Parks recommended a framework for strengthening community treatments and crisis services. He stated that standard definitions of levels of care (using placement criteria like the LOCUS and CALOCUS) will ensure better matching to needed supports and ultimately decrease the shortage of psychiatric inpatient beds.
Committee member Elyn Saks summarized the four presentations stating the most important element is access to care. She also encouraged a thoughtful analysis of the use of coercion and force in behavioral healthcare treatment, and suggested we create more engaging treatment.
There was generous and passionate input from everyone in the room. One of the most memorable threads related to the word “Interdepartmental.” Dr. Ken Minkoff with ZiaPartners, Dr. Clayton Chau of the Institute for Mental Health and Wellness St. Joseph Hoag Health System and author Pete Earley, among others, encouraged the ISMICC to action around the central importance of integrated solutions across federal departments. Minkoff shared his involvement in both the prior Presidential mental health initiatives and stated this is the first-time integrated solutions have been the goal.
What an amazing day… an amazing opportunity… an amazing mission… and an amazing group of people. I am truly honored!
- December 13, 2017 – First report to Congress with a summary of advances in SMI and SED, evaluation of the effect of federal programs and impact on public health and specific recommendations for actions that the departments can take to better coordinate.
- October 15, 2017 – First draft of the report with a seven-day turn around for feedback from the ISMICC.
- November 15, 2017 – Second draft modified with comments with another seven-day turn around for further feedback.
- ISMICC Non-federal committee members are serving a three-year term.
- A second report to Congress is required by the 21st Century Cures Act in 2022.