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This handbook is the definitive resource for understanding current mental health policy controversies, options, and implementation strategies. It offers a thorough review of major issues in mental health policy to inform the policy-making process, presenting the pros and cons of controversial, significant issues through close analyses of data. Some of the topics covered are the effectiveness of various biomedical and psychosocial interventions, the role of mental illness in violence, and the effectiveness of coercive strategies. The handbook presents cases for conditions in which specialized mental health services are needed and those in which it might be better to deliver mental health treatment in mainstream health and social services settings. It also examines the balance between federal, state, and local authority, and the financing models for delivery of efficient and effective mental health services. It is aimed for an audience of policy-makers, researchers, and informed citizens that can contribute to future policy deliberations.



Foundations of American Mental Health Policy


Chapter 1. Mental Health Policy: Fundamental Reform or Incremental Change?

The history of mental health policy has been characterized by a series of cycles of fundamental reform, each followed by a period of incremental gains. The nineteenth-century moral treatment movement gave rise to the asylum. The mental hygiene movement of the turn of the twentieth century led to the development of small inpatient units and outpatient services in academic medical centers. Community mental health centers were introduced by a reform movement in the 1960s, which also brought us Medicare and Medicaid. And a community support movement in the 1970s and 1980s shifted the focus from the early treatment of mental illnesses to providing support for individuals already disabled by mental disorders. What might look like retrenchment to the fundamental reformers can look like slow progress to those on the ground. A sequence of incremental changes can bring progress, even in conservative times. At this point in time, as we find ourselves immersed in the uncertainty about the future of health reform and the place of behavioral health within it, there are many questions for mental health policy. This chapter explores those questions and issues in the United States.
Howard H. Goldman, Joseph P. Morrissey

Chapter 2. Division of Labor: Function Shifts and Realigned Responsibilities in the Evolving Mental Health Services System

The past several decades have witnessed tumultuous changes in the delivery of public mental health services in the United States. These changes resulted more from policy developments in the health and social welfare sectors than from the mental health services sector itself, notably the passage of Medicare and Medicaid legislation and expanded Social Security benefits. In the process, functions in the custody, treatment, and social control areas once served mostly by state mental hospitals were transferred to agencies outside the direct control of state mental health authorities. The resultant mental health services landscape expanded enormously but without central or coherent policy direction. Efforts to overcome the resulting fragmentation focused on a variety of clinical, management, and funding initiatives including renewed efforts to integrate primary care and behavioral health. Current evidence supports primary care integration for depression and other common mental disorders. However, specialty-based behavioral health services still appear optimal for persons with severe mental illness; whatever advances in psychiatric treatments might occur in future years, social welfare policies and supports will continue to shape their life chances and well-being.
Joseph P. Morrissey, Howard H. Goldman

Chapter 3. Economic Perspectives on the Organization and Governance of Mental Health Care

This chapter examines the allocation of responsibilities for meeting the needs of people experiencing a mental disorder. These responsibilities have shifted among the private and public sectors; federal, state, and local governments; and between the mainstream of health policy and specialized policymaking. In general, the organization of the system that treats and addresses the needs of people with mental illnesses is far more complex, and involves more actors, than the comparable organization of the systems that address the problems of people with other types of health conditions, but over time, the systems have become more similar. This evolution reflects both changes in treatment practices and changes in societal attitudes and programs.
Sherry A. Glied, Richard G. Frank

Contemporary Issues in Mental Health Policy: Treatment Interventions and Supports


Chapter 4. What Is the Meaning of Recovery?

The mental health field is currently operating with two distinctly different meanings of the concept of “recovery.” While the traditional, clinical sense of having recovered from a serious mental illness has been around since the eighteenth century, the more recent meaning of living a full, self-directed life with an on-going serious mental illness emerged from the Mental Health Consumer/Survivor Movement in the late 1980s. Based on a disability rights framework, this new meaning of recovery has since spawned a movement of its own, promising to push mental health services beyond symptom reduction to a restoration of functioning and community inclusion in the face of a psychiatric disability. This chapter explores both meanings of the term recovery, argues for their complementarity in addressing different situations, and reviews the evidence that exists for interventions to promote community inclusion. Evidence suggests that persons with serious mental illnesses can function in a range of valued social roles and are more likely to do so when provided person-centered care that promotes self-management. More work remains in transforming care to this orientation, and additional work is needed to address the social determinants of mental health in creating more supportive and inclusive communities, comprising an interface between the concepts of personal recovery and citizenship.
Larry Davidson, Timothy Schmutte

Chapter 5. Balancing Access to Medications and Psychosocial Treatments

Despite a noted patient preference for psychosocial treatments (defined here as psychotherapy, counseling, coaching, and case management), people receiving mental health care in the United States are more likely to be treated with medications than they are with psychosocial treatments. While there are problems with inappropriate use of medications, including both undertreatment and overtreatment, there is little doubt that psychosocial treatments are underused, and that is the focus of this chapter. The disconnect between patient preferences and services used is due to several policy-level factors. There is no shared consensus or viable information source to determine which psychosocial treatments are evidence-based, clinician training is poorly regulated, credentialing and licensure practices often are not competency based, location of care is inconvenient, it is complicated to measure quality of care, and there are no incentives to offer evidence-based treatment. In this chapter, we discuss these limitations and offer examples of successful programs that specifically address these problems. We end with a series of recommendations to policy makers in the United States to ensure patients with mental health challenges are guaranteed access to the treatments they need and prefer.
Patricia A. Areán, Anna Ratzliff

Chapter 6. Are There Enough Inpatient Psychiatric Beds?

In this chapter, we examine key issues and controversies surrounding whether the current psychiatric inpatient bed supply is adequate or alternatively whether more psychiatric beds are needed. Fueled by changes in federal and state mental health policy, insurance reimbursement practices, the scientific evidence for the effectiveness of mental health treatments, and care management practices, psychiatric service systems are constantly changing in ways that can affect overall psychiatric bed need within a region. Consequently, to assess whether the current bed supply is adequate in relation to the population need for psychiatric beds, it is essential to both compare local information regarding the capacities of the various types of inpatient psychiatric facility providers and consider the impacts of regional use of community mental health services and supports that may diminish the need for inpatient beds. It is also important to consider the effects of professional shortages, which may increase the overall costs of additional psychiatric inpatient beds. Well-designed inpatient capacity simulation models that take into account the complexity and dynamics of psychiatric inpatient utilization and sources of payment for psychiatric inpatient care may help fill gaps in our current understanding of the need for added bed capacity.
Eric Slade, Marisa Elena Domino

Chapter 7. Mandated Community Treatment in Services for Persons with Mental Illness

This chapter addresses a complex and persistent challenge for mental health services delivery: What to do about adult members of our communities who suffer from debilitating psychiatric illnesses such as schizophrenia but fail to receive consistent and effective treatment. Many are gravely disabled and/or pose a danger to themselves or others, but are often unable or unwilling to adhere to recommended treatment until they deteriorate to the point of requiring involuntary hospitalization or are arrested for a minor crime. Involuntary outpatient commitment—often termed ‘assisted outpatient treatment’—was developed as one potential remedy to address this population of ‘revolving door’ patients. In this civil court procedure, a judge orders a person with mental illness to comply with recommended treatment. We discuss involuntary outpatient commitment in the broader context of mandated community treatment, review the controversies about its effectiveness, the ethics of its use and discuss some potential alternative approaches. Mandated community treatment, if properly targeted and implemented with sufficient resources, can offer a less-restrictive alternative to hospitalization or arrest with the goal of ensuring that beneficial treatment is consistently maintained, rather than delaying intervention until confinement is required.
Marvin S. Swartz, Jeffrey W. Swanson

Chapter 8. Shared Decision-Making and Self-Directed Care

Patient involvement in health care is driven by ethical, theoretical, and practical considerations and has clear implications for mental health policy. The realization that patients and clinicians need to collaborate closely for successful treatment is especially salient for people with chronic health conditions. Indeed, the mental health field is witnessing a proliferation of patient-centered practices. We focus on two general strategies: shared decision-making (SDM) and self-directed care, both of which require patient involvement in mental health service delivery and in promoting mental well-being. These strategies also require a fundamental shift in issues of the working relationship in the production of health outcomes; who controls the work in mental health services? How do we balance preferences and expertise in making key decisions to promote mental health and well-being? This chapter wrestles with these issues and highlights research evidence for practices that promote SDM and self-directed care. We also describe key challenges in implementing these approaches and point to directions for future research.
Michelle P. Salyers, Yaara Zisman-Ilani

Chapter 9. Suicide Prevention: Rising Rates and New Evidence Shape Policy Options

Suicide is the 10th leading cause of death in the United States and rates have risen steadily in the past 15 years. However, investments in and policy commitments to suicide prevention are minimal. Within the last two decades, knowledge about what is effective to prevent suicide has grown dramatically. Additionally, awareness of successful efforts, especially in healthcare settings, has grown. National legislation creating a new national suicide prevention program for adults, coupled with the developments above, suggest that a renewed approach to suicide prevention is possible. This chapter will review patterns in suicide, review knowledge about prevention and intervention, and suggest policy priorities to reverse recent trends.
Michael F. Hogan

Chapter 10. How Should the United States Respond to the Opioid Addiction and Overdose Epidemic?

The national epidemic of addiction to and overdose from opioids is the worst public health crisis the United States has faced in decades. The health care system is critical to the public policy response, both because of the services it can provide people with opioid use disorder and the changes in clinical practice it must make to prevent new cases of addiction. For historical and cultural reasons, health services for people with opioid use disorder are often of uneven quality and poorly integrated with the rest of health care. However, effective services are available that can make a major contribution to pushing back against the epidemic. These include opioid agonist therapies (e.g., buprenorphine maintenance), antagonist therapies (e.g., extended-release naltrexone), and psychosocial treatments. Interventions that reduce the mortality and morbidity risks of opioids, such as syringe exchange and naloxone provision, are also critical to an effective public health response. Supply-side policies within the US health care system are also essential because overprescribing is at an extraordinarily high level both historically and currently in comparison to other nations. A range of monitoring, educational, and incentive-based interventions show promise of returning the United States to a more rational prescribing pattern.
Keith Humphreys, Harold A. Pollack

Chapter 11. Early Intervention in Psychosis: From Science to Services

Early intervention services for psychotic disorders were first tested in Australia and Europe in the 1990s. These efforts stimulated interest to develop early intervention programs in the United States and in 2016 the National Institute of Mental Health identified a treatment model called Coordinated Specialty Care (CSC). This team-based approach includes psychotherapy, medication management, family education and support, case management, and work or education support, and is the foundation for nationwide efforts to support early intervention services for individuals with a first episode psychosis (FEP). This chapter focuses on the following key policy questions related to early intervention services for FEP and in particular the CSC model: What has been the impact of CSC programs? What strategies can most effectively support implementation of these programs? How should quality of care be assessed in CSC programs? and How can they be financially sustained? For each area, specific questions are posed, prior relevant studies are summarized, and future directions for research are proposed along with recommendations for policy makers. Other key issues reviewed include the importance of decreasing the duration of untreated psychosis, whether CSC programs should be offered to clinical high-risk populations before the advent of psychosis, and strategies for sustaining good outcomes following receipt of CSC services.
Thomas E. Smith, Lisa B. Dixon

Chapter 12. Policy Effects on Mental Health Status and Mental Health Care Disparities

Policies that are directed at increasing access to mental health care for ethnic minority communities are needed. However, our review suggests that insurance alone is unlikely to result in substantial decreases in mental healthcare disparities for ethnic minority communities. We also consider disparities affecting sexual and gender minority populations, undocumented individuals, and African Americans and Latinos who are unjustly incarcerated. Comprehensive programs, such as collaborative care within health care settings, are needed to decrease these disparities. We propose that quality of care for healthcare organizations should include measures of disparities so that eliminating disparities would be considered an indicator of high-quality care. Mental health policy advocates should not only support policies that increase access to quality care for minorities, but also support anti-discrimination policies that are likely to have a major impact on the mental health status and mental healthcare use of minority populations.
Jeanne Miranda, Lonnie R. Snowden, Rupinder K. Legha

Contemporary Issues in Mental Health Policy: Cross Sectors and Populations


Chapter 13. Mental Health Insurance Parity: How Full Is the Glass?

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008, the federal law requiring parity in coverage for mental health and substance use disorder (MH/SUD) services and medical/surgical services offered in group health insurance plans, was the culmination of over fifty years of advocacy and debate. Advocates had pushed for parity in response to long-standing differences in the generosity of private insurance benefits for MH/SUD vs. medical/surgical services that left many with mental disorders without sufficient financial protection from the costs of treatment. The Affordable Care Act (ACA), which expanded coverage of MH/SUD and other services for millions of Americans, extended parity requirements to many other populations. This chapter discusses the history of parity and related policies, their primary goals, and research that examines the effects of MHPAEA and ACA parity policies. It will then discuss market failures that remain for MH/SUD services.
Haiden A. Huskamp

Chapter 14. Housing for People with Serious Mental Illness

This chapter summarizes the state of knowledge on the housing arrangements of people with serious mental illness (SMI) in the United States. Americans with serious mental illness have the legal right to live in as integrated housing as feasible and we estimate that more than 90% of people with SMI live in the community and not in institutions or specialized programs. However, the lack of affordable housing, discrimination in the rental market, difficulties accessing community-based health services, and insufficient benefits still contribute to people with serious mental illness being at greater risk for homelessness, inadequate or unaffordable housing, or incarceration. This chapter describes what we know about the housing situations of people with SMI, the challenges they face in the rental housing market, and the effectiveness of different program models for providing housing and services. The chapter concludes with a discussion of emerging topics for research and policy on housing for people with SMI.
Josh Leopold

Chapter 15. What Is the Role of Schools in the Treatment of Children’s Mental Illness?

Impacts from mental illness are debilitating for children, their families, and their communities. Comprehensive school mental health can provide services for all children, while supporting the school’s broader mission of improving academic outcomes and reducing disruptive behavior and suspensions. Universal mental health screening in schools can be enhanced by allying families in this process and configuring viable mechanisms for evaluation and treatment. Schools can effectively provide comprehensive mental health care with multitiered supports adjusted to fit the frequently changing needs of students and their families. Evaluation of school mental health interventions can illuminate impacts on academic and peer functioning, impairing symptoms, and well-being. Thoughtful evaluation helps refine programming and clarify cost-effectiveness. School mental health sustainability necessitates coordinated funding across multiple systems and payers, including health, mental health, education, special education, and public (Medicaid) and private insurance.
Sharon A. Hoover, Jeff Q. Bostic, Libby K. Nealis

Chapter 16. Policy Issues Regarding Employment for People with Serious Mental Illness

This chapter addresses three critical policy questions related to employment for the ten million working-age adults with severe mental illness (SMI): First, do disability policies influence the low rate of employment among people with SMI? Second, could policy changes improve employment of people with SMI? Third, could policy changes enhance access to supported employment? Current disability policies clearly influence employment of people with SMI. Most people in this population want to work and could work, but disincentives in the disability system and lack of access to effective supports limit their success. Given that disability policies limit employment, new policy could potentially improve employment outcomes. No consensus exists yet on what the changes should be. The field needs controlled research, especially involving early interventions. Although disability policy changes are uncertain, evidence-based supported employment is an effective strategy that could help people with SMI acquire and maintain employment. Yet the current funding process obstructs implementation and access. The United States needs a simple funding mechanism for evidence-based supported employment.
Robert E. Drake, Ellen R. Meara, Gary R. Bond

Chapter 17. Adults with Serious Mental Illnesses Who Are Arrested and Incarcerated

The disproportionately high percentage of adults with serious mental illnesses in correctional facilities is well documented. For decades, mental health officials, family members, and people with mental illnesses have implored local, state, and federal government officials to invest in community-based mental health services as a way to address this phenomenon. This chapter explores why it is that so many adults with mental illness are arrested and incarcerated, what is different about this problem today than years ago, how much recent progress has been realized, and what challenges must be addressed in the years ahead to make fundamental change. The chapter ends with a description of promising national initiatives that build on the accomplishments to date with the express purpose of reducing the number of adults with serious mental illnesses under correctional supervision.
Fred Osher, Michael Thompson

Chapter 18. Gun Violence Prevention and Mental Health Policy

How are gun violence and mental health problems connected (or not connected)? How effective are current laws designed to prevent firearm-related violence and suicide in the United States? What other feasible measures could be taken to meaningfully reduce the number of firearm injuries and deaths, without stigmatizing people with mental illnesses or unduly curtailing the rights of law-abiding gun owners? This chapter addresses such questions broadly from a public health perspective, examining key federal and state regulatory approaches to preventing intentional firearm-related injury—particularly as these approaches intersect with mental health policy. We describe the nature and scope of the problem and the unique challenge that it poses in the American context, where mass shootings continue to shape popular views of mental illness and public safety goals collide with individual gun rights concerns. We summarize empirical evidence for the effectiveness and shortcomings of mental-health-based gun restrictions at the point of sale. We describe a new generation of risk-based, non-criminalizing, time-limited, preemptive gun-removal laws as an important piece in the policy puzzle of gun violence and suicide prevention in the United States. Expert consensus recommendations on selected policies to reduce gun violence and suicide are discussed.
Jeffrey W. Swanson, Colleen L. Barry, Marvin S. Swartz

Chapter 19. Stigma as a Mental Health Policy Controversy: Positions, Options, and Strategies for Change

There is perhaps no more contested phenomenon in mental health policy debates than stigma. From claims that it has dissipated to ones that see it as “the most formidable” obstacle to recovery, research on the prejudice and discrimination associated with mental illness raises issues about its roots, proper targets for change, and even the utility of the term itself. What remains unquestioned is stigma’s real and potentially devastating effects on individuals, families, systems, and societies. The purpose of this chapter is to introduce conceptual basics, summarize research from contemporary studies, and outline positions from two recent landmark guides on anti-stigma programming and policy. A key element in all efforts (the message) and one platform (media) is pursued more deeply. The chapter describes the strengths and weaknesses of change strategies and novel results from recent experimental research on messages. Remaining challenges that confront the design and implementation of stigma reduction efforts are considered.
Bernice A. Pescosolido

Chapter 20. How Shall We Promote Citizenship and Social Participation?

Citizenship is a framework for understanding and enhancing the strength of a person’s connection to the rights, responsibilities, roles, resources, and relationships that society offers to its members, as well as a sense of belonging that is validated by fellow citizens. We define citizenship, examine its historical roots, and discuss how we identified it as a central concept for extending social participation. We then report on approaches we have pursued to support citizenship and community engagement for individuals with mental illness and other marginalized identities, and the evidence to support these approaches. We also discuss issues related to advocacy by and for people with mental illnesses, including the use of legal remedies for housing, voting, and other tools available to support their full and participating citizenship. We conclude by discussing future directions for the development of the citizenship framework as a means of promoting the social inclusion, participation, and valued membership in the society of people with mental illness.
Michael Rowe, Allison N. Ponce

Future Issues in Mental Health Policy


Chapter 21. Evidence-Based Practices or Practice-Based Evidence: What Is the Future?

Although multiple evidence-based practices are available for the treatment of behavioral disorders, these interventions are not consistently delivered in routine care in the United States. This research to practice gap has created a large quality chasm that may be even larger for people with serious mental illnesses and those with substance use disorders. The process through which behavioral evidence-based practices are integrated into routine care is influenced by the same factors affecting the diffusion of other innovations, that is, characteristics of patients, providers, and the innovation, and system-level factors. Barriers related to each of these factors impede successful EBP implementation through their effects on fidelity and other implementation outcomes, and as a result, intervention effects are substantially smaller than those predicted from the original clinical studies. Key among these barriers are an innovation-related factor, that is, a process of evidence generation and research translation that has traditionally neglected the needs and realities of potential implementers and end-users, and several system-level factors, including financing policy, regulations, and the basic design of the behavioral healthcare system. These barriers are described in detail and strategies to address them and to develop new models growing out of effective practice are discussed.
Marcela Horvitz-Lennon

Chapter 22. New Financing Models in Behavioral Health: A Recipe for Efficiency or Under-Provision?

This chapter refers to innovations grouping services together for purposes of payment, such as shared-risk contracts, and pay-for-performance contracts and other forms of “bundling.” Bundling can improve the efficiency of the way in which inputs into health care are combined and the overall cost-effectiveness of care. When plans and providers operate in markets, adverse incentives can arise as well. This chapter emphasizes the importance of getting bundling right at a high level: paying private managed care plans, responsible for providing care to persons with behavioral health issues in the United States in Medicare, Medicaid, and some private health insurance, in a way that encourages them to accept and serve persons with chronic illnesses. Empirical evidence is reviewed for the effects of bundling in health plans, carve-outs, ACOs, and hospitals. The potential for bundling in critical areas of behavioral health care including early interventions in psychosis are considered.
Thomas G. McGuire

Chapter 23. Mental Health Disability, Employment, and Income Support in the Twenty-First Century

This chapter focuses on how the changing twenty-first century economy impacts employment opportunities and income supports for people with mental health disabilities. Specifically, the substitution of computers and other automated technologies for low-skilled labor disproportionately impacts people with mental health disabilities, who often rely on these jobs to remain in the workforce. The shifting demands for labor suggest that without further action, there is likely to be a growing burden of mental-health-related work disability. While workplace accommodations exist for other disabilities, there have been few successful programs for those with mental illness. This chapter identifies four main areas of policy making that may ameliorate this growing problem: first, changes in income support policy that recognize the special features of mental illnesses without dramatically increasing enrollment in SSI/DI; second, the further development of interventions that are administered earlier in the course of illness than has typically been the case and that are more tailored to the functional impairments associated with work; third, new approaches to matching people with mental illnesses with jobs that are consistent with their capabilities; and fourth, creating incentives for employers to adopt technology and workplace accommodations that target people with mental illnesses.
Sherry A. Glied, Richard G. Frank, Joanna Wexler


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