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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

Transformation in Action: On the Frontlines of Mental Health Care

October 25, 2007
San Diego, CA

PowerPoint Version

[Slide #1]

Thank you, John [Maynard, CEO of EAPA] for your kind introduction and for your invitation to join you today as we “sail together into a new era.” I’m pleased to be with you because this is an exciting time to be in the field of behavioral health care. Today, more than ever—in the face of a global economy, natural and manmade disasters, and the ever-present threat of terrorism—it is very clear to me that behavioral health is an urgent public health priority.

Former U.S. Surgeon General C. Everett Koop said very succinctly that, “Health care is vital to all of us some of the time, but public health is vital to all of us all of the time.” We cannot afford to ignore the mental health and substance abuse needs of any of our citizens if we want to have healthy workplaces and healthy communities.

Science has triggered dramatic changes in the way we think about behavioral health. Once believed to be debilitating, lifelong conditions, mental disorders are now understood to be as treatable as most physical illnesses. Today—given the right combination of treatment and support and a voice in decisions concerning their care—people with mental and substance use disorders can and do recover.

In fact, most people with mental and substance use disorders work; I’ll share some statistics with you in a moment. This means that each and every one of you is on the frontlines of our efforts to ensure that all Americans have the opportunity to live, work, learn, and participate fully in their communities. And that means that each and every one of you can make a difference in the lives of the people you serve.

[Slide #2]

In my time with you today, I’d like to pose, and answer, four key questions that I hope will inspire and empower you to make important changes in your places of work and in your communities:

1. Why do we do the difficult work of transforming our mental health systems to be recovery-oriented, client-centered, and evidence-based?
2. What is the role of business in mental health transformation?
3. Where is such transformation happening?
4. How can each of us play a role?

Why Do We Do This Work?

Individually and together, each of us is engaged in the challenging work of transforming the mental health system in the United States, and around the world, for one very simple reason: People are the bottom line. After all…people, not organizations, are our most valuable assets.

People create. People innovate. In the places we work, it’s the individual efforts and the relationships that people form that ultimately determine whether businesses succeed or fail.

As employers, we understand the importance of promoting general health care services. Clearly, our employees are not able to function at their best if their diabetes is not under control or if they are worried about whether they can afford their blood pressure medication. Now, we must focus equal efforts on promoting the quality of the behavioral health care services we sponsor. The data I’m going to share with you tell us why.

[Slide #3]

Mark Twain famously said, “There are three kinds of lies: lies, damned lies, and statistics.” If only the statistics we have about the prevalence of mental and substance use disorders and their impact on the workplace were lies, we could all go home. But they show us all too clearly that mental illnesses and substance use disorders are prevalent and costly for business. Consider these facts:

• One in every five adults, or nearly 60 million Americans, experiences some type of mental disorder each year. In fact, at some point during his or her lifetime, the average American adult has a 46 percent chance of developing one or more mental illness or substance use disorders.
• Contrary to popular belief, most individuals with mental illnesses such as substance use disorders work, except for those individuals with the most severe mental illnesses. Of the 20 million adults who abuse or are dependent on alcohol or drugs, 15.5 million, or nearly 77 percent, are employed.
• According to the National Survey on Drug Use and Health, conducted annually by SAMHSA, 6 percent of adults employed fulltime and 8 percent of adults employed part-time experienced a mental illness in the past year.
• By the year 2010, depressive disorders will become the second largest cause of mortality after heart disease.

But the people who have mental and substance use disorders are not nameless, faceless statistics. They are the people you pass in the hallway, the faces you see in the lunchroom, the co-workers you say “good morning” to at the coffee pot. They have families and homes and hopes and dreams. And we know that with the right kind of treatment and support, they can and do recover.

[Slide #4]

Unfortunately, less than half of adults with behavioral health disorders get the treatment they need. And even individuals who do seek help may receive treatment that has not kept pace with current best practice research.

Why don’t individuals get the help they need? Among adults with serious psychological distress who reported an unmet need for treatment in 2005, cost—including lack of or inadequate insurance—was the most frequently reported reason for not obtaining treatment. But nearly a quarter of respondents said that isolation, discrimination, and negative attitudes about mental illness kept them from seeking help. These misperceptions may be even more pronounced in the workplace.

Earlier this year, Employee Benefit News and the Partnership for Workplace Mental Health surveyed more than 500 employers, representing companies of all sizes across the country. When asked about barriers that impede mental health treatment, an overwhelming 80 percent of respondents said that “shame and stigma” may still be associated with a mental illness diagnosis. More than half, 56 percent, said, in their belief, because of “concern that their employer or coworkers could find out.”

The survey’s authors point out: “Today’s increasingly competitive, 24/7 workplace rewards tenacity and often has little room for vulnerability…[but] allowing stigma and corporate culture to keep employees from seeking needed treatment wastes valuable potential.” I couldn’t agree more, and that’s why I’m so glad that EAP programs exist. We know that mental disorders are as treatable today as most physical illnesses. We must make clear that it is not only acceptable but preferable for someone to get the help he or she needs.

[Slide #5]

We must make this clear because when employees don’t receive treatment for mental and substance use disorders, the individual, the employer, and the community suffers.

We know that many individuals with chronic medical conditions have untreated, comorbid mental illnesses or substance use disorders, and this complicates their recovery from both conditions. For example:

• The presence of type 2 diabetes nearly doubles an individual’s risk of depression, and an estimated 28.5 percent of diabetic patients in the United States meet criteria for clinical depression. Diabetic patients with depression are less likely to adhere to special diets or to refill medications.
• Approximately one in six patients treated for a heart attack experiences major depression soon after their heart attack, and at least one in three patients have significant symptoms of depression. Depressed patients who have suffered a heart attack are about 3.5 times more likely to die.

Individuals with comorbid conditions suffer, but so too does the employer’s bottom line. People with untreated mental and substance use disorders often require more costly medical services. Nobody wins in this scenario.

Employers are affected in other ways when people don’t get the mental health and substance abuse treatment they need. Mental illness is associated with more days of work loss and work impairment than many other chronic conditions, including diabetes, asthma, and arthritis. Approximately 217 million days of work are lost annually due to productivity decline related to mental illness and substance abuse disorders, costing United States employers $17 billion each year. That alone gives businesses 17 billion reasons to be certain their employees receive the behavioral health care services they need.

There are less tangible effects, as well. Employees who are depressed at work have been shown to lower the morale of their coworkers, resulting in a higher turnover and general discontent.

“Presenteeism” is also a major source of concern for employers. The term refers to when an employee goes to work sick but cannot work at full capacity. Researchers report that this can affect employers three times—first by the low productivity of the employee at work; secondly, when the worker leaves; and a third time when other workers have to compensate for the affected worker’s low productivity.

Indeed, employers have found that in many cases, the indirect costs of employee health issues substantially exceed the direct costs of health care.

Certainly, some individuals will come to the workplace with a pre-existing mental health problem. But the stress of today’s fast-paced, information-laden, global economy can also take its toll.

Last year, researcher Sarah Burgard from the University of Michigan reported the results of a fascinating study which revealed that the fear of losing one’s job takes a greater toll on mental and physical health than actual job loss or a brush with life-threatening illness. Chronic job insecurity keeps employees in a perpetual state of “fight or flight” and this prolonged stress can weaken their immune system and lead to symptoms of depression. EAP staff are in a good position to keep their fingers on the pulse of workplace changes that may affect an employee’s mental and physical health and his or her functioning on the job.

Who Will Do This Work?

Addressing this level of need in the workplace is a tall order indeed, particularly within the context of a fragmented mental health system that is guided more by outdated science and outmoded financing than it is by the needs of the individuals it serves. Clearly, no one individual or agency can do this alone.

The agency I head—the Center for Mental Health Services in the Substance Abuse and Mental Health Services Administration—has led an unprecedented, collaborative effort at the Federal level to implement the recommendations of the President’s New Freedom Commission on Mental Health. The Commission called for fundamental transformation of the mental health system in this country, to one that is recovery-focused, consumer-centered, and evidence-based. This is no small task, but I am pleased to report that business leaders have been a key partner with us. In fact, in many ways, business is leading the way.

Whether your agency has 25 employees or 250,000, it represents a microcosm of the larger society with all of the fiscal, political, and social realities that impact the delivery of effective mental health treatment. As such, business is an excellent laboratory in which to implement needed changes in the way mental health services are perceived, accessed, delivered, and financed. This is transformation in action!

But you don’t have to reinvent the wheel because others have paved the way. SAMHSA is pleased to support the National Business Group on Health in this regard.

In 2004, the Business Group—which includes Fortune 500 companies and large public-sector employers—convened the National Committee on Employer-Sponsored Behavioral Health Services.

The Committee consisted of 25 benefits and health care experts including EAP professionals, health care benefits specialists, representatives from managed care and managed behavioral health organizations, and medical directors and benefits managers from Business Group member companies. Among the group’s findings, and their implications for the work we do, include the following:

• A significant proportion of individuals with behavioral health problems are treated exclusively in the general medical setting, which has become the “de facto mental health care system.” We must find ways to educate and collaborate with our colleagues in primary care so they are prepared to offer screening and treatment for common mental health problems and referral to the specialty mental health sector where warranted.
• While employers have focused their attention on the management of high cost chronic medical conditions, such as heart disease and type 2 diabetes, such management efforts have not fully addressed the significant additional burden of comorbid mental illness. For disease management programs to realize their full potential, we must foster better coordination between the general medical health care system and the specialty behavioral health care system.
• Limited behavioral health care services can increase employers’ non-behavioral direct and indirect health care costs. We can’t afford to be pennywise and pound foolish. Treatment for mental and substance use disorders is effective and it is cost-effective, too.

[Slide #6]

The first outcome of this partnership between SAMHSA and the National Business Group on Health is publication of a new guide titled, An Employer’s Guide to Behavioral Health Services, which recognizes the public sector for its use of evidence-based behavioral health care services and recommends that employers incorporate these services into their benefit designs. The Employer’s Guide serves as a roadmap for evaluating, designing, and implementing affordable and effective behavioral health care services.

Since the release of the Employer’s Guide, a number of large employers have implemented one or more of the recommendations. Two days ago, I was privileged to help present the Business Group’s first Behavioral Health Awards, which recognize innovation and best practices in the design and delivery of behavioral health care services in the workplace. Among the winners were:

• Aetna, which improved the health of its employees by implementing a program that encouraged primary care providers to screen for depression and monitor improvements in depressed patients’ symptoms.
• Cisco used health risk assessments to help identify behavioral health issues among employees, develop programs tailored to specific populations or disorders, and assist with program evaluation.
• Delta was able to reduce costs and improve access by restructuring its employee assistance program to be more responsive to the unique needs of its employees.
• GlaxoSmithKline’s preventive program teaches employees and managers interpersonal skills to manage stress, improve communication, and stay mentally healthy.
• And Pitney Bowes developed a personalized, employee-centered program that was able to get employees disabled by a behavioral health problem back to work as promptly and efficiently as possible.

This is transformation in action!

But large employers aren’t the only ones making great strides. In the Employee Benefit News survey I mentioned earlier, one quarter of the more than 500 respondents employed fewer than 100 people. Across all the companies that participated, 90 percent offer mental health coverage, 76 percent have EAPs, and 63 percent offer return-to-work assistance for employees on disability.

In addition, about two-thirds of companies surveyed offer workplace support for employees with mental health problems:

• 80 percent offer unpaid leave.
• 62 percent have flextime.
• 41 percent provide a change in office environment such as more privacy or the use of headphones.
• And 38 percent give employees the option to work from home.

Attending to the behavioral health needs of employees is good for individuals and for a company’s bottom line and we have some recent research that supports this fact.

[Slide #7]

A study conducted by the National Institute of Mental Health, and published in a recent issue of the Journal of the American Medical Association, found that enhanced and systematic efforts to identify and treat depression in the workplace significantly improved employee health and productivity, likely leading to lower costs overall for the employer.

The study included 604 employees from 16 large companies who were enrolled in a managed behavioral health care plan. All of them were identified during a Web-based and telephone screening process as having clinically significant depression. Half of the participants were randomly assigned to an intervention that included telephone support from a care manager and their choice of telephone psychotherapy, in-person psychotherapy, or antidepressant medication. The other half of the participants were assigned to usual care, which included feedback about their screening results, and advice to seek care from their regular provider.

After 12 months, those in the intervention group were 40 percent more likely to have recovered from their depression compared to those in usual care. Participants in the intervention group also were 70 percent more likely to stay employed, and worked an average of 2 more hours per week than those in usual care.

The researchers noted that just the value of more hours worked among those in the intervention group who were employed, estimated at $1,800 per employee per year, far exceeds the $100 to $400 per person costs associated with the type of outreach and intervention program used in the study.

I’d like to echo the words of principal investigator Dr. Philip Wang, who said, “Employers should consider a depression screening and intervention program as a healthy, win-win investment.”

The services you provide as EAP counselors and managers is also a healthy, win-win investment. In an article about EAPs in the October issue of Psychiatric Services, the authors note, “EAPs ar uniquely positioned to provide relatively barrier-free preventive services and screening, early identification, short-term counseling, referral to specialty treatment, and other behavioral health interventions for the privately insured population.”

We must reach people with mental and substance use disorders early enough so that their condition doesn’t become debilitating. That’s where the care management, counseling, and referral services offered by an EAP can literally be lifesaving.

Indeed, when it issued its Employer’s Guide, the National Business Group on Health noted that, based on an analysis of current EAP services, an important function that EAPs provide is assessment and short-term counseling for individuals at risk of mental illness and substance use disorders and those with problems of daily living, such as divorce and grieving. Your work at the intersection of business and mental health care is transformation in action!

Where is Transformation Happening?

I know there are many of you here from other countries, and you may be wondering if the U.S. alone is working to transform the way we fund, deliver, and evaluate mental health services. I’m happy to be able to say that transformation is happening around the world!

Recently, the Center for Mental Health Services funded a project that studied national mental health system reform movements in seven countries—Australia, Canada, England, Italy, New Zealand, Scotland, and the United States. An analysis of policy documents and reports from these seven countries reveals a striking national-level policy consensus about the need for substantial if not radical change of their respective mental health systems.

Though each country must deal with unique fiscal, political, and clinical considerations, three common concepts that transcend international borders have emerged as pivotal in forming the basis for consensus. They are:

• The emergence of the recovery framework. Each of these countries believes that the hopeful expectation of recovery should underlie the design and practice of mental health care services.
• The rise of consumer activism. Consumers are no longer content to be at the margins of the mental health care system, and rightly so. They are the reason the system exists and they must be at the center of everything we do.
• And finally, a trend toward a more holistic and integrated view of mental and physical health. I’m reminded that no less an authority than Hippocrates, widely credited as the father of medicine, believed that the mind and the body are one. We must attend to both as good stewards of public health in this country and around the world.

[Slide #8]

Each of the seven countries has individually established priorities for reform. But a review of their activities reveals a perhaps surprising consensus on six international priorities:

1. Making mental health a public health priority, promoting mental well-being, and diminishing the stigma and discrimination associated with mental illness;
2. Improving access and enhancing the range of available services;
3. Assuring an adequate, competent, and skilled mental health workforce;
4. Making consumer involvement, response to individual needs, and recovery and wellness the focus of mental health care;
5. Integrating and linking mental health care with general health care and other sectors and services; and
6. Promoting evidence-based, measurable, and accountable mental health care.

[Slide #9]

I think you’ll see a significant convergence between these international priorities and the six goals of the President’s New Freedom Commission on Mental Health, outlined in its report called Achieving the Promise. And the Commission’s goals are closely aligned with the six priority areas for reform cited by the Institute of Medicine in its report titled Improving the Quality of Health Care for Mental and Substance-Use Conditions. Both of these documents are driving transformation of the mental health system in the United States.

I think it’s clear that—in the United States and around the world—we are all working to develop a mental health care system that is based on a belief in recovery, centered on consumer needs and preferences, grounded in evidence-based care, and led by a culturally competent, technologically savvy workforce. The people we serve deserve nothing less.

[Slide #10]

At SAMHSA, as I mentioned earlier, we are helping make these priorities a reality by leading an unprecedented, collaborative effort among more than 20 Federal agencies and offices to help ensure that people with mental disorders have every opportunity for recovery. Together, SAMHSA and its Federal partners created The Federal Mental Health Action Agenda, which includes a set of concrete, actionable items designed to move the mental health system in this country toward our collective vision. As we head into the third year of our efforts, I’m pleased to say we are making significant progress in a number of key areas. In particular:

[Slide #11]

• We developed a consensus statement on mental health recovery that sends the clear message that mental and substance use disorders are treatable and that recovery is possible.
• We are supporting nine States that are developing the infrastructure necessary to reduce fragmentation of services across systems, increase their prevention and early intervention programs, and augment their investment in new technologies.
• We have launched a National Anti-Stigma Campaign with a focus on young adults. The campaign is designed to encourage, educate, and inspire young people ages 18 to 25 to step up and support friends they know are experiencing a mental health problem.
• We’ve also funded development of a National Strategic Plan on Behavioral Health Workforce Development. We know that a transformed system of care demands a workforce that is prepared to build resilience and facilitate recovery, not just manage symptoms. You are a critical part of that workforce, and we need your help.

How Can I Play a Role?

It’s clear to me that each and every one of you in this room has an important role to play in transforming the mental health system in each of the countries you represent. I’ve become fond of a quote attributed to an American officer and pilot Betty Reese. She said, “If you think you are too small to be effective, you have never been in bed with a mosquito.”

This is a shorthand way of expressing my firm belief that every one of us should feel empowered to make our own contribution, no matter how small, whether or not we’ve received some sort of official blessing or sanction. We don’t need to be the CEO or the Director to make a difference.

In fact, since we are talking about “sailing into a new era,” let me share with you a wonderful seafaring analogy. Each one of us can be a “trim tab” within your organizations, your communities, your States, and your countries.

A trim tab acts as a small rudder to turn the larger rudder of giant ships. R. Buckminster Fuller, inventor of the geodesic dome, saw the trim tab as a powerful metaphor for effective individual leadership. He believed that “small and strategically placed interventions can cause large-scale and profound change.”

Transformation is about large-scale and profound change. Ultimately, transformation is about newness. It is about new values, new attitudes, and new beliefs that are expressed in new behaviors of people and institutions. The greater the number of people who abandon the antiquated myths, outdated science, and outmoded financing of current mental health care, the faster transformation will occur.

You can make that happen. Earlier this year, Glen Hiemstra, author of Turning the Future into Revenue, addressed a group of CEO’s in Seattle. He asked them: “What does it take to be a more effective leader who uses the long term to shape the present, so that you and your company, we and our families are more likely to live in a future that we prefer, rather than a future that we fear?”

The answer, he said, is “thinking in the future tense. The task is not one of accurately seeing the future or deciding what we will do, in the future, but rather listening to the future as well as we can so that we can make better decisions right now, tomorrow, and the next day.”

Indeed, Hiemstra told his audience, “The future is something we do, by the choices we make and the choices we avoid.” We must make the choices that will lead to a system that values client autonomy, evidence-based care, and services and supports that promote recovery.

Wrap-Up and Conclusion

I know this sounds like a tall order, but I have no doubt that we are up to the task. Indeed the greatest risk of failure is not from making changes. Instead, the greatest risk of failure comes from struggling to maintain the status quo when change is all around us.

[Slide #12]

I recently came across Albert Einstein’s Three Rules of Work. They are:

1. Out of clutter, find simplicity.
2. From discord, find harmony.
3. In the middle of difficulty lies opportunity.

We have an unparalleled opportunity to effect positive change in individuals’ lives—and in the businesses that depend on their creativity and talents—by transforming the systems that serve them. Recovery is no longer just the current catchphrase in behavioral health—it is the fundamental concept on which a transformed mental health system is based.

In a transformed mental health system, individuals with mental and substance use disorders receive evidence-based treatment and services in the amount and type they need; provided in ways that are accessible and choice, empowerment, and respect acceptable to them; and that are designed to promote.

Our vision is clear, and failure is not an option. I want to extend my heartfelt thanks to each and every one of you who works on the frontlines every day, ensuring that we have healthy workers, robust businesses, and strong communities. This is transformation in action!

Thank you. If we have time, I’d be happy to take your questions.