Transforming Mental Health And Addiction Services

For the past fifty years the model for care and advocacy in the mental health and addiction field, usually referred to as “behavioral health,” funds treatment programs and waits for “patients” with behavioral health conditions to arrive. The result is relentless unmet need. The National Survey on Drug Use and Health estimates that in 2019 only 45 percent of adults with any mental illness received mental health services and that only 10 percent of people age twelve or older who had a substance use disorder received substance use treatment—estimates that are consistent with those of the four previous years.¹ Recent behavioral health policy advances include achieving parity in financing and expansion of access to behavioral health care as part of the Affordable Care Act and other policies (see online appendix exhibit A).² Yet more needs to be done to address the persistently poor behavioral health outcomes for so many,¹ particularly for people of color, including immigrants; those with low incomes; and those from disadvantaged communities.³

Meanwhile, advances in neuroscience and clinical experience highlight the importance of early interventions to address risk factors for mental illness such as adverse childhood experiences.⁴ These advances emphasize the importance of effective interventions during the early stages of a first psychotic episode⁵ to counteract negative behavioral health outcomes. Improvements in these outcomes would be reflected in patient engagement and willingness to complete treatment, as well as in participation in mainstream society through employment, good relationships with families, and social connections for people with behavioral health conditions.⁶ Achieving these ends requires an emphasis on prevention and equity and challenges the biomedical model with the need to shift to a community-based model that brings care to the person in need and focuses on the outcomes that matter most to them.

The coronavirus disease 2019 (COVID-19) pandemic and protests against racial injustice have called attention to systematic inequities in health and mental health outcomes,⁷ creating political momentum for bold policy reform. We maintain that major changes to systems of health and social services in the US are possible at this juncture because of widespread recognition of the magnitude of the behavioral health problem, the deleterious social consequences intersecting with a deadly epidemic,⁸ and escalating public demand for behavioral health services.⁹

Policy priorities for mental health and addiction over the next four years must emphasize equity and innovation. Exhibit 1 presents three goals related to these priorities, along with examples of suggested or prevailing policies that align with them. In this article, as part of the National Academy of Medicine’s Vital Directions for Health and Health Care: Priorities for 2021 initiative, we review services for mental health and addiction, which is a natural grouping given that about half of the people who experience a mental illness during their lifetime will also experience a substance use disorder and vice versa.¹⁰ The Vital Directions initiative intends to provide evidence-based guidance for policy makers on opportunities and challenges in health, health care, and biomedical science. The National Academy of Medicine convened this transdisciplinary author group to outline high-priority challenges in mental health and addiction policy. We identified the three areas of behavioral health policy in greatest need of reform—inadequate access to care (waiting for patients to access the system), criminalization of people with behavioral health disorders, and underappreciation of the role of social determinants—as essential to address for effective treatment. In this article we describe relevant evidence from clinical practices and larger-scale structural interventions to address persistent problems in behavioral health policy. We also identify needed research and policy goals to achieve future change. We call attention to how local conditions appear central in the adoption and successful implementation of these policy goals, as contextual factors at the macro level (for example, financial resources), meso level (for example, organizational culture and structure), and micro level (for example, patients’ preferences) are all products of the local environment.¹¹ Supportive leadership at the community and health system levels will need to address bureaucratic obstacles through changes in regulation and having a voice in resource allocation and funding priorities.

Policy Goals

Improved Access To Behavioral Health Services

Instead of opening a clinic door and waiting for people to arrive, the behavioral health care system needs to meet people “where they are.” This entails active outreach, engagement, and dealing with each individual’s clinical and socioeconomic circumstances. It requires regulatory flexibility and a revised view of effective integrated care across settings.

Community And Home Outreach:

In contrast to specialized clinics, community-based organizations (that is, organizations providing a wide range of services, including social services)¹² can offer prevention, access to early identification, and treatment of behavioral health conditions provided by trusted caregivers. With supervision from licensed professionals, staff in community-based organizations can deliver integrated evidence-based behavioral health preventive programs and treatments¹³ in non-English languages offered by trusted staff members to help patients engage in services. Because these organizations also offer access to social resources such as temporary housing, they can substantially reduce hospital use and improve quality of life.¹⁴ For example, for people with severe mental illness, the assertive community treatment model has been shown to greatly reduce hospital use through preventing and treating crises in the community, with on-call availability 24/7.¹⁴

Home visits can effectively treat maternal depression and improve behavior among children by identifying unmet behavioral health needs among families and increasing engagement in services.¹⁵ Meal delivery programs improve diet and functioning among older people with depression and disability while also integrating behavioral health services. But these modalities of behavioral health services confront challenges in demonstrating return on investments; typically lack infrastructure for technology, personnel, and innovation of services; and face financial stress. Partnerships between community-based organizations and academic research institutions can facilitate a sharing of resources and expertise to facilitate implementation of in-home care.

Telehealth:

Telehealth supports the delivery of behavioral health treatments, with outcomes for some conditions and circumstances comparable to receiving in-person care.¹⁶ Barriers to more widespread use have included licensing and reimbursement issues, the reluctance of insurers to create new benefits, and providers’ concerns about their relationships with patients. Although the response to COVID-19 has diminished some of these barriers, implementing telehealth for behavioral health at scale will confront issues of privacy, quality, program integrity, and design of payment models.

Mobile Health Clinics:

Mobile health clinics provide screening, behavioral health medication management, referral, and timely access to behavioral health care.¹⁷ They are accessible and cost-effective (particularly for rural populations),¹⁷ improve patient satisfaction, and can reduce depression symptoms.¹⁸

Lower Threshold For Treatment:

Programs that make minimal demands on patients to participate in behavioral health treatment (for example, not requiring drug abstinence or commitment to a number of treatment sessions) are associated with improved retention and low rates of adverse events compared with more restrictive programs.¹⁹ Examples include syringe exchanges and overdose prevention programs to reduce harms associated with the use of illicit drugs and naloxone reversal kit distribution to address opioid overdose (see appendix exhibit B).² The COVID-19 pandemic has led to more use of these lower-threshold approaches, such as medication-assisted treatment and counseling for substance use disorders. During the COVID-19 pandemic, medication-assisted treatment regulations have been eased in some programs, allowing buprenorphine treatment initiation to occur remotely and narcotics treatment programs to dispense fourteen- and twenty-eight-day take-home supplies of methadone compared with the standard take-home amounts of two or seven days’ supplies for anyone with less than two years of enrollment in a treatment program.²⁰ Open access to virtual behavioral health visits can lower the rate of no-shows, demonstrating how accommodating diverse modalities to behavioral health eases access to treatment.²¹

Decriminalization And Crisis Response

Criminalization Of Behavioral Health Conditions:

Police often play a central role in the lives of people with serious mental illness. Today 7–10 percent of police encounters involve mental illness, and an estimated two million people with serious mental illnesses cycle through the nation’s jails every year.²² According to the latest data available from the National Inmate Survey, more than half of state prisoners and two-thirds of jail inmates meet diagnosable criteria for drug use disorders.²³ Also, 14 percent of prisoners and 26 percent of jail inmates meet the threshold for serious psychological distress in the past thirty days, compared with only 5 percent of the general population.²⁴ The absence of treatment resources in the community increases the risk for police contact and incarceration. This dynamic creates longer sentences and higher rates of jail recidivism, disproportionally affecting people of color, who are more affected by unjust policies such as disproportionate bail or inadequate legal representation. Emerging neuroscience has implied how crimes linked to illegal drug-seeking behaviors or primarily due to substance use disorders or mental illness should be decriminalized and treated as public health issues instead of identifying use of certain substances (for example, opioids)²⁵ or behaviors associated with untreated mental health conditions (for example, disturbing the peace) as criminal acts. Yet the evidence on the impact of decriminalization of drug use is limited.²⁶ Nonetheless, decriminalization might be offered in nonviolent drug infractions to address public safety concerns. The need to expand access to medication-assisted treatment, behavioral health services, and social resources instead of criminal sanctions is a public health imperative.

Crisis Response And Community Reentry:

To decrease the likelihood that people with serious mental illness will interact with the police, and to decrease recidivism for those who do, an evidence-based crisis response system is warranted. This typically consists of a “high-tech” dispatch system, mobile crisis teams, a first responder drop-off location with crisis stabilization beds, personnel and data tracking for follow-up care, and an identified group of peer supports. The Crisis Assistance Helping Out on the Streets (CAHOOTS) model dispatches mobile teams of health care and crisis workers to provide the care and services people need instead of immediately involving law enforcement (see appendix exhibit B).² The most recent Cochrane Review of crisis intervention for people with severe mental illness²⁷ concluded that it was less expensive than standard care, avoided repeat hospital admission, and improved the mental state of service users more than standard care. However, there were methodological limitations in studies reviewed and no differences in death rates between those in crisis intervention and those in standard care. The research evidence on crisis response interventions²⁸ bears largely on diversion from jail to psychiatric facilities and less on patient outcomes, highlighting the need for additional high-quality research in this area.

Access to evidence-based treatment can improve reentry outcomes for incarcerated populations. Best practices include a warm hand-off (in-person connection of the patient from one health care provider to the next service), assisting with Medicaid enrollment,²⁹ and creating linkages to community programs.³⁰ When a crisis response system is implemented in combination with Medicaid expansion, recidivism rates can decline significantly.³⁰ Design and implementation of crisis response systems occur at the local level, and federal policy should promote these initiatives through waivers from the Substance Abuse and Mental Health Services Administration or the Centers for Medicare and Medicaid Services.

Limiting Confrontations With Police:

The default option for people experiencing behavioral health crises, such as suicidality, homelessness, or drug overdoses, should be a response by mental health clinicians or trained paraprofessionals to deescalate crises, avoid unnecessary police contact, and get people to appropriate care.³¹

Social Context And Social Needs

Social context (for example, living in poverty, witnessing violence) contributes to negative mental health outcomes and greater prevalence of substance use disorders. That is why people who live and work with behavioral health issues have long advocated for emphasizing the social context as salient in recovery.⁶

Structural racism in the United States exacerbates behavioral health conditions and interferes with members of oppressed communities obtaining high-quality behavioral health care. Obstructive policies and actions include discriminatory lending practices for housing and business; urban renewal and planned shrinkage, which displaces residents of color and damages social networks;³² disinvestment in public infrastructure; and policing that infringes on the civil rights of residents, leaving Black, Latinx, and Native American families in neighborhoods with higher exposure to violence.³³

The consequences of these policies, including poverty and economic insecurity (see appendix exhibit B),² are detrimental to behavioral health for Black, Latinx, and Native American youth.³⁴ Chronic stress reduces options to engage in healthy behaviors, and direct and indirect exposure to community violence in childhood heightens risk for behavioral health conditions.³⁴ Policy makers can thus help improve the population’s behavioral health outcomes through structural interventions to meet social needs, such as affordable housing, education, and job opportunities.

Targeting Social Determinants:

Investments in housing security, nutrition, education, and employment can reduce depression and anxiety disorders.^35,36 Policies addressing social determinants of health include improving early child development programs, promoting access to fair employment and living-wage work, ensuring a social safety net through social programs or cash transfers (such as the Supplemental Nutrition Assistance Program), and enhancing the living environment (such as “green spaces” and good air quality).³⁷

Early Childhood Interventions:

Family psychosocial intervention for preschoolers has been found to lower rates of teacher-reported behavioral health problems and result in higher academic performance for children in second grade.³⁸ Well-implemented early childhood interventions have demonstrated benefits well into adulthood, including lower rates of unemployment, lower rates of criminal activity, and less substance use (see appendix exhibit B).²

Policies To Promote Economic Stability:

Economic instability and limited opportunities for social mobility increase the prevalence of behavioral health problems and worsen existing illnesses.³⁶ Ensuring a living wage, particularly for young people with lower-education backgrounds, members of ethnic and racial minority groups, and people living in poverty, would be an important step toward ensuring economic and social stability.

Social programs can work toward equitable quality of life. Guaranteeing a minimum income to achieve healthy living by expanding Earned Income Tax Credit benefits would decrease poverty and strongly encourage work.³⁵ Another option is cash transfer programs similar to those offered during the COVID-19 pandemic.

Living Environment:

Policies to improve the living environment include addressing affordable housing, eradicating environmental pollution, ensuring minimum housing standards, and securing the rights of tenants.³³ The majority of families who qualify for housing assistance benefits do not receive them³⁹ despite evidence that the Department of Housing and Urban Development’s Section 8 housing vouchers, which assist low-income and other people in obtaining safe housing, benefit adult mental health.³⁵

Supporting Positive Development Of Young People Of Color:

In a review of evidence-based psychosocial interventions tested with ethnic minority youth, Armando Pina and colleagues⁴⁰ found no “well-established” interventions effective for treating trauma or stress reactions, self-injurious behavior and suicidality, or comorbid disorders or multidisorders. There is an urgent need to fill these gaps for young people of color and to implement behavioral health models of care that respond to their unique circumstances, including discrimination on the part of peers and teachers. Young people of color who are also sexual or gender minorities experience disproportionately high rates of suicidal behavior and homelessness, so this should be an area of particular concern.⁴¹ Policies that view youth homelessness from the lens of intersecting marginalized identities can improve conditions for youth of color.⁴¹

Investment In Public Health And Integrated Care:

Funding of public health and social structures is made more effective by engaging the local community in decisions, in fund allocation, and in activities to integrate social and health care services (see appendix exhibit B).² It is critical to have people with lived experience (having direct experience in the current system) in leadership positions of health care services and with decision-making power over research and program funding allocations.

Policy Recommendations

Attaining these major policy goals requires shifts in the workforce, structures of accountability, outcome measurement, payment reforms, and financing of behavioral health care in the United States. Exhibit 2 presents examples of proposed or existing policies that support these recommendations, which we discuss below.

Workforce

The shortage of behavioral health providers is compounded by the lack of racial, ethnic, and language diversity in the behavioral health workforce.⁴² Offering loan repayment programs to underrepresented minorities, investing in training, and tracking improvements in the workforce represent opportunities for reform at the federal level.

Also, behavioral health care providers must better address the health implications of the social context of their patients’ lives. This includes understanding the role of social determinants of health in behavioral health disorders (for example, food insecurity and neighborhood violence). Structural competency training allows behavioral health workers to recognize and respond to institutional racism, as well as to help intervene on institutional and policy levers of impact in behavioral health outcomes.⁴³ Health systems should require provider training in the role of structural racism and implicit bias and in practicing cultural humility.⁴⁴

Providers need training to become familiar with effective treatments, including effective medications,⁴⁵ but also with the role that structural inequities (for example, food and housing insecurity) play in the biological basis of behavioral health disorders. Congress could increase funding for loan forgiveness or repayment programs for nonphysicians specializing in behavioral health treatments to broaden the basis of care providers (see appendix exhibit B).²

Scaling up the community health and peer recovery workforce also should be a priority (see appendix exhibit B).² Including peers in a behavioral health workforce reduces substance use and relapse rates; improves social supports; and increases treatment retention, patient satisfaction, and hope across diverse patient samples.⁴⁶

Providers must center the preferences of the patient in treatment. Shared decision making is collaborative communication to help patients understand treatment options, identify their preferences in behavioral health care, and reduce coercion in treatment.⁴⁷ Common barriers to shared decision making include provider resistance, given the limited time in clinic visits,⁴⁷ but this can be addressed by implementing decision aids (for example, video presentation describing treatment options), which patients can use outside of the visit, relieving some of the time demands on the provider.

Accountability And Outcome Measurement

Simply tracking the number of people receiving behavioral health services does not reveal whether people received appropriate and effective care. To support a new direction in behavioral health, accountability measures must focus on outcomes at both the individual level (for example, living independently, employment and educational attainment, and quality of life)⁴⁸ and the population level (for example, overdose events, suicide, interpersonal violence, homelessness, incarceration, and recidivism rates). One underused strategy to improve accountability is simulated patient studies (that is, mystery shoppers),⁴⁹ which can assess where concerns about access to and quality of behavioral health care are greatest (see appendix exhibit B).²

Financing And Organization

A transformed behavioral health system requires new economic and organizational mechanics. We advocate for policy makers to collaborate across sectors, aggregating funds from multiple agencies outside of federal and state health care agencies (for example, housing and education) to align with the Health in All Policies approach.⁵⁰

Feasible modifications to current Medicaid and Medicare risk-adjustment capitated payment models for private managed care can encourage plans to devote sufficient resources to behavioral health care.⁵¹ In times of economic crisis, it is essential to invest in behavioral health programs instead of cutting back supports.

Payment based on population health encourages health systems to attend to all factors affecting population health, not just individual in-clinic treatment.⁵² Researchers have proposed integrating social services within behavioral health clinical care,⁵² including more value-based payment models (see appendix exhibit B).² The Health Resources and Services Administration has the power to fund and support the expansion of public health and social needs programs.

Other Recommendations

Partnerships:

Building strong academic-public partnerships⁵³ can help make use of research evidence and identify implementation research that is applicable to the needs of both policy makers and systems. These partnerships can efficiently institutionalize evidence-based practices by integrating effective programs, training, resource sharing, and funding into mainstream operational infrastructure instead of using “special initiative” status.

Data Systems:

Data residing only at the clinical or payer level that are not shared cannot inform needed structural policy change. Public health agencies should be able to track the effectiveness of their behavioral health systems by linking patients’ clinical outcome data and using the resulting analyses to target investments for system improvement. It is appropriate to review regulations such as 42 CFR, Part 2, to strike the right balance between data privacy and the need for behavioral health system improvement (see appendix exhibit B).²

Discussion

The United States is in the midst of overlapping crises, including the COVID-19 pandemic, overdose deaths due to substance use disorders,¹ the suicide epidemic,¹ and increasing health spending as a result of demographic forces and private-sector prices,⁵⁴ accompanied by poor treatment outcomes¹ and racial injustice. A transformation of behavioral health care, as proposed here, can help tackle these concurrent challenges. There is hope in the plethora of behavioral health treatment advances and service delivery models ready for implementation and dissemination. COVID-19 has demonstrated that rapid progress in health care policy and management is possible. HIV/AIDS activists demonstrated health care system and policy change when they sped the course of antiretroviral therapy development and delivery, in large part by challenging discrimination and political priorities. More recently, bipartisan social media campaigns (for example, Patients for Affordable Drugs Now) and joint interest coalitions (such as the Massachusetts Prescription Drug Affordability Coalition) have strengthened the legal negotiating power of users of the behavioral health system to pass comprehensive legislation. National polling has found strong bipartisan support for mental health coverage and addiction treatment policies (see appendix exhibit B).²

Systemic reform is achievable by the recognition of the urgent need for recovery from increasing rates of anxiety and depression and spiraling deaths from drug overdoses.⁹ Reform is necessary because of the public demand to tackle these emotional costs,⁹ amplified by the effects of the COVID-19 pandemic. It is often misleading to regard the “cost” of an illness to be the direct cost of treating the patient with the condition. Untreated behavioral health conditions are often more costly, in terms of both health care and the impact on broader social systems⁵⁵ (see appendix exhibit B).² A potential consequence of untreated substance use disorder in parents is economic and social deprivation affecting children, with a deterioration of family dynamics and finances leading to homelessness and contact with the justice system. Not addressing the social causes of addiction and mental health problems is expensive. The price of hopelessness, emotional instability, and chronic uncertainty can only lead to poor behavioral health, taking away the opportunity for recovery. Now is the time to implement systemic changes to a system that has failed too many for too long.

ACKNOWLEDGMENTS

Richard Frank has received consulting fees from Greylock-McKinnon Associates for activities completely unrelated to this article or mental health policy issues. Joshua Sharfstein has received funding from Sachs Policy Group for part-time consulting not connected to this article and has been an unpaid expert witness for the City of Baltimore’s lawsuit against opioid manufacturers. The authors thank Isabel Shaheen O’Malley for her assistance with the research and help with the manuscript. The following people also provided valuable support: Ekenedilichukwu Uwanaka, Andrew Hwang, Neerav Gade, Olivia Smith, Sheri Lapatin Markle, Tom McGuire, Francesca Galluccio-Steele, and Jessica Marx. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) license, which permits others to distribute this work provided the original work is properly cited, not altered, and not used for commercial purposes. See https://creativecommons.org/licenses/by-nc-nd/4.0/. [Published online January 21, 2021.]

NOTES

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