Remarks by
A. Kathryn Power, M.Ed.
Director
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
Mending the Gaps in America’s Mental Health Care
America’s Health Together
February 2, 2006
San Francisco, CA
PowerPoint version
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
[SLIDE 1. Title slide]
Good morning. Thank you, Dr. Heldring, for inviting me to meet with this impressive group. I’m delighted to be part of any discussion about opportunities to mend the gaps in mental health care. It’s incredibly important for us to focus on what we can do because―together―we can do so much. I, like Henry Ford, have great faith in our Nation’s ability to overcome challenges. As Ford observed,
[SLIDE 2. Ford quote]
“What’s right about America is that although we have a mess of problems, we have a great capacity in intellect and resources to do something about them.” Each person here represents the amazing ingenuity and resourcefulness that we can apply to mending gaps.
What are some of those gaps? Unfortunately, gaps in mental health care have existed for centuries. They extend across the lifespan, affecting individuals of every age. They involve individuals of every gender and every racial, cultural, and economic group. These gaps also affect individuals in underserved rural areas and inner cities. Essentially, the gaps in mental health care apply to all Americans. We all are affected by the personal, social, and economic burden of untreated or inadequately treated mental illnesses.
Mending gaps in mental health will be an ongoing challenge―for me, it is the challenge of today. The dominant factor in American society today is change―continuing change, inevitable change. These changes dictate that we make decisions now about how we are going to address current gaps as well as prevent future gaps. We absolutely must continue to craft health care systems that provide the level and quality of mental health care every one of our citizens deserves.
Let’s consider some of the ongoing changes affecting mental health care.
[SLIDE 3. Ethnic and cultural minorities]
Within the next half century, more than 50 percent of our Nation’s population will be people of color. Ethnic and cultural minorities already bear a disproportionately high burden of disability from mental disorders. This burden does not arise from a greater prevalence or severity of illnesses in these populations. Instead, the burden results from care that is less available and of poorer quality, and often is not culturally competent. Misdiagnosis may contribute to the burden. Just as one example, African Americans are more likely to be over-diagnosed for schizophrenia and under-diagnosed for depression.
[SLIDE 4. Older Adults]
Our aging population presents another current and emerging mental health challenge. Within the next quarter century, the number of older adults will double. Aging baby boomers soon will be flooding the health care industry, placing an increasing demand on mental health services.
By 2030, an estimated 15 million older adults will experience a mental illness. Older individuals facing retirement or coping with the death of a family member or friend may be overwhelmed with sadness, loneliness, and anxiety. Physical illness can lead to depression, putting older adults at increased risk of poor recovery. Compared to other age categories, older adults have the highest rate of suicide in the country, especially for men. Substance abuse, including the misuse of prescription medications, is increasing in the older adult population.
Even though older Americans are vulnerable to mental illnesses, only about 30 percent of older adults who need mental health services receive them. Older Americans are less likely to seek help than their younger counterparts due to a number of factors. They are concerned that a diagnosis of a mental illness may jeopardize their health care and insurance continuance. They worry about their financial security and independence and fear potential embarrassment, isolation, or being declared incompetent. They may fear institutionalization. Ageism also plays a part. There is a misconception that depression is “normal” for older adults—it’s not…and it should not be accepted as such.
The American family is undergoing significant changes that add to the normal stressors of everyday life. More children live in families where both parents work—and work longer hours. A growing percentage of children are being raised by single parents. The percentage of children living in poverty, however, has remained fairly constant over the past several years. Currently, an estimated 12 million American children live in poverty. Poverty has detrimental effects on living conditions, access to health care, and nutrition…all of which contribute to health status.
[SLIDE 5. Children]
A significant gap is represented in the limited mental health care treatment our children receive. Up to 9 percent of American children have an emotional or behavioral problem . Only 20 percent of those with problems are identified and receive mental health services. These childhood disorders may exacerbate and persist if early intervention does not occur. They can lead to a downward spiral of school failure, poor employment opportunities, and poverty in adulthood.
This dismal prediction is confirmed by research. According to a recent report funded by the National Institute of Mental Health, mental illnesses exact a heavy toll that begins in youth. Half of all lifetime cases of mental illness begin by age 14. Despite the availability of effective treatments, there are long delays—sometimes decades—between the onset of symptoms and when individuals seek and receive treatment.
The same study also revealed that an untreated mental condition can lead to more severe, more difficult-to-treat illnesses and to the development of co-occurring illnesses. Lack of integrated treatment of co-occurring mental and substance use disorders is a serious mental health care gap because it requires cross-training and the merging of two traditionally separate fields of practice.
[SLIDE 6. Co-occurring Disorders]
Nationwide, about 4 million Americans have a serious co-occurring disorder. This is a staggering number of individuals who need integrated treatment. This number, however, pales in comparison to the number of individuals who already have one disorder and may be at risk of developing the other disorder. More than 15 million Americans have a serious mental illness; an equal number have a substance use problem. That adds up to more than 30 million vulnerable members of our families and our communities in whom we must prevent co-occurring disorders.
Within our communities, there are special populations at greater risk and who have a larger and more immediate need for integrated treatment services. Individuals who are homeless or incarcerated, or those who are being released from institutions back into our communities—these are groups in need of immediate services. Their illnesses present the greatest burden of cost to our communities and the greatest threat to our public health. About 50 percent of homeless adults with serious mental illnesses have a substance use disorder. About 70 percent of incarcerated persons who have a serious mental illness also have a substance use disorder.
There are other mental health gaps, such as for women and for Americans living in underserved areas. Each group presents unique strengths and vulnerabilities that must be addressed through appropriate care.
[SLIDE 7. Women]
Women are more at risk for anxiety disorders and depression. They attempt suicide twice as often as men. They also are at risk of domestic violence, one of the leading causes of injury to American women ages 15 to 44. Domestic violence often carries with it serious mental health consequences, including post-traumatic stress disorder, depression, anxiety disorders, eating disorders, and substance abuse.
[SLIDE 8. Rural Americans]
Health care gaps exist in rural areas as well as in our inner cities. Rural America is home to approximately 25 percent of our population. Yet, rural issues are often misunderstood, minimized, and not considered in forming national mental health policy. Far too often, policies and practices developed for metropolitan areas are erroneously assumed to apply to rural areas.
Compounding the problem of rural isolation is this fact: Rural Americans are less likely than other Americans to have private health insurance benefits for mental health care. There is also a chronic shortage of mental health professionals in rural areas. Of the 1,669 federally designated mental health professional shortage areas, more than 85 percent are rural. The recent murder/suicide in Red Lake, Minnesota, is an example of the potential and tragic consequences of the rural gap in mental health care.
Let me state just one broad fact about suicide because suicide is the most dramatic, measurable evidence of gaps in mental health care that cross all demographic boundaries. This fact is from 2002, the last year for which we have comparative figures. In that year, in the United States, for every two individuals who died by homicide, three individuals died by suicide.
What are we to make of these gaps? From my perspective, each of these gaps in mental health care highlights tremendous opportunities for positive change…and to bring hope and recovery to millions of Americans. Health care in America is at a pivotal point where reform must occur, and mental health must be a vital part of that reform. Our Nation, our communities, and all of us hold a vested interest and a tremendous stake in doing what is right to make high-quality care accessible to any man, woman, or child needing services.
We have a solution to the challenges of mental health care gaps. The solution is called mental health transformation.
[SLIDE 9. Mental health transformation]
Mental health transformation is a broad-based approach that the Substance Abuse and Mental Health Services Administration (SAMHSA) has adopted to introduce fundamental change in the way mental health services are perceived, accessed, delivered, and financed. I have provided each of you with a copy of Transforming Mental Health Care in America: The Federal Action Agenda. This action agenda identifies the first steps that SAMHSA, in partnership with agencies from nine Federal departments, will take to guide mental health transformation.
[SLIDE 10. Federal Partners Workgroup]
Our agenda is built around the goals laid out in the final report by the President’s New Freedom Commission on Mental Health. These are the goals. In a transformed system:
[SLIDE 11. Goals]
- Americans understand that mental health is essential to overall health.
- Mental health care is consumer and family driven.
- Disparities in mental health services are eliminated.
- Early mental health screening, assessment, and referral to services are common practice.
- Excellent mental health care is delivered and research is accelerated.
and
- Technology is used to access mental health care and information.
These are lofty goals that will require comprehensive and collaborative strategies to achieve. Last year, SAMHSA and other stakeholders asked the Institute of Medicine (IOM) to develop specific steps that Federal and State organizations and other stakeholders could use to transform mental health care. A previous IOM report, called Crossing the Quality Chasm: A New Health System for the 21st Century, put forth a strategy for improving health care overall. The IOM built on this groundbreaking report to prepare a second report, called Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series . Similarly, the IOM found that between the mental health care we have and the mental health care we could have “lies not just a gap, but a chasm.”
Continuing with the second report, the IOM reached this conclusion: The framework proposed to improve health care overall also is applicable to mental health care. This conclusion, in itself, is hardly surprising given the inextricable link between physical and mental health care. In fact, the IOM concluded that America’s health care system overall cannot be improved adequately unless equal attention is given to the problems of mental and substance use conditions.
[SLIDE 12. IOM recommendations]
- The IOM’s report will be publicly available soon. You will want to study its recommendations on how the mental health system should:
- Establish benchmarking and quality improvement models,
- Develop strategies to reduce the variable billing and reporting requirements,
- Provide supports and incentives that support providers in the delivery of quality care,
- Integrate primary and behavioral health care systems effectively, and
- Sustain professional education and workforce development.
Implicit in the IOM’s recommendations―as well as in the Federal action agenda and the President’s New Freedom Commission on Mental Health report―is one underlying tenet: Community-based care, which involves consumers, their families, and the communities in which they live, is the basis for system and social change.
The emphasis on community is critical. Community-based care reflects a public health approach to mental health. A public health approach is concerned with the health of an entire population, including its link to the physical, psychological, cultural, and social environments in which people live, work, and go to school. It affirms what we know about mental health—that it is essential to our overall health and to overall health of our communities.
Mental health transformation will be achieved when entire communities come together to provide mental health care that is consumer-driven and focused on recovery. The reality is, people can recover from mental illnesses. People do recover! Every organization that deals with children, families, and adults will have a vital role in sharing this message…and in collaboratively promoting and protecting the mental health of the individuals it serves.
Mental health transformation is a vision that requires the committed involvement of every organization represented in this room to make it real. I’d like to quote from Henry David Thoreau to describe your role. The pun in the last line is intended. In his conclusion to Walden, Thoreau wrote:
If you have built castles in the air,
Your work need not be lost;
That is where they should be.
Now put the foundations under them.
Your organizations already are funding many of the solutions to mental health care gaps. I am greatly encouraged by the expertise, knowledge, and sense of social responsibility you have brought to bear on the issues before us. Providing the kinds of mental health service and supports that our citizens need and deserve will take the best and brightest from every sector of society. It will require the ideas, energy, time, and financial commitment of those who work actively in the philanthropic community and in the behavioral health field, as well as those in government, physical health care, insurance, employment and housing, education, justice, and other groups.
Your organizations are uniquely positioned to help. As major philanthropic organizations, your leadership will be as essential as your funding initiatives. Leadership is demonstrated in attitude and actions, by those words and behaviors that inspire others to act similarly. It is about encouraging and supporting people…about applying new values and strategies to old problems…and about personally demonstrating the changes we seek to make. Each of you here clearly has the capacity to move your organizations forward on behalf of the millions of Americans with mental illnesses.
Your organizations can assist in public education activities to support suicide prevention efforts. You can participate in the advancement and implementation of a national campaign to reduce the stigma of seeking care. Targeted public education can increase awareness about the effectiveness of mental health services and encourage people to seek treatment.
The most effective way to reduce discrimination and stigma is through personal contact with someone with a mental illness. It’s wonderful that the media is portraying great leaders who accomplished astounding feats while also managing their mental health problems. The History Channel recently aired a documentary on Abraham Lincoln and his lifelong battle with severe depression. Lincoln is not the only national leader who dealt with both internal and external battles. Winston Churchill also spoke of his “black dog of depression.”
More important are personal stories from people such as us. Mental illnesses are common illnesses. They just don’t affect celebrities such as Brooke Shields, but any mother affected by serious post-partum depression. They affect our families, friends, neighbors, and coworkers. Nearly one in every five families in the United States has a family member with a mental illness.
These are the consumers and their families whose stories of recovery can help to eliminate the stigma of a mental health diagnosis and treatment. Public awareness of their experiences is vital to public acceptance of mental illnesses as common, treatable conditions.
Include consumers and families in your projects and on your governing boards. Listen to their stories…share them…learn from them. Their participation in transforming the mental health system is more than a critical piece of the process. Consumers are the reason for doing the difficult, but necessary, work of transformation.
Your organizations are uniquely positioned to help in other essential ways. Seek out opportunities to continue addressing disparities, expand and improve services, and build greater collaboration among public and private stakeholders. Help us to develop improved assessment and referral mechanisms and to speed research on treatment and recovery.
[SLIDE 13. Ending Ford quote]
To again quote Henry Ford, “Coming together is a beginning, staying together is progress, and working together is success.” We have come together at this meeting to find ways to mend the gaps in mental health care. We will make progress as we share our ideas and resources. We will measure our success not just in terms of greater cooperation and collaboration, although these are essential to our goal. Our real success will lie in creating a future in which every American, at any stage of life, has equal access to evidence-based services and treatments that offer the greatest hope of recovery. I look to you for your support. Thank you.
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