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New Hope for Mental Health

Psychiatric disorders have long been viewed as secondary to general medical illnesses, and despite the clear need, there are significant clinical and organizational obstacles to the treatment of mental health problems in general medical setting.
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The statistics are staggering: one in two Americans will struggle with a psychiatric disorder in their lifetime, according to the Centers for Disease Control and Prevention. The World Health Organization lists depression, schizophrenia and addiction among the five most common illnesses affecting people between the ages of 18 and 44. For those Americans living with often-undiagnosed conditions such as post traumatic stress disorder, depression, anxiety, addiction or an eating disorder, effective mental health care can have a significant beneficial impact on their health and well being. Consequently, any discussion of reforming the U.S. health care system must address mental health.

Psychiatric disorders have long been viewed as secondary to general medical illnesses. Depression and schizophrenia, for example, have borne social stigmas that are not shared by heart disease, diabetes, or other non-psychiatric medical conditions. Yet important interactions exist between psychiatric and general medical conditions. The American Heart Association reports that as many as one in five recovering heart attack patients are depressed. Untreated depression takes its toll: a patient with symptoms of depression who has a heart attack is nearly six times more likely to die in the six months following the attack than a corresponding victim who is not depressed, according to a study in the Journal of the American Medical Association (1).

Despite the clear links between psychiatric and non-psychiatric medical disorders, mental health care has experienced significant cutbacks in recent years. States cut more than $2 billion from mental health services between 2009 and 2011, according to the National Council for Community Behavioral Healthcare. In California, the number of acute inpatient psychiatric beds has fallen by more than a quarter over the past 15 years, according to the California Hospital Association. Private not-for-profit hospitals have struggled to provide short-term mental health inpatient care in the face of insufficient reimbursement. As more Americans with mental illnesses face fewer available mental health services, we risk rising rates of suicide, homelessness and mental health-related incarcerations -- especially among susceptible populations such as our returning troops.

In this current environment of a struggling economy, rising debt and political gridlock, it is not realistic to expect significant increases in funding necessary to shore up our mental health system. Nevertheless, the process of reform currently underway provides opportunities that should lead to improvements in the quality and efficiency of mental health care delivery. Several new initiatives, from patient-centered medical homes to accountable care organizations, create incentives for providers to ensure better outcomes for all of their patients. Given the statistics cited earlier, it is clear that providers must integrate mental health services if they are to be successful under these new models.

Despite the clear need, there are significant clinical and organizational obstacles to the treatment of mental health problems in general medical settings. A number of innovative models have sought to address these obstacles, and one -- collaborative care management -- shows particular promise. It involves locating a mental health specialist within primary care, establishing simple mental health treatment protocols, providing mental health screenings and conducting ongoing outcome measurement. When implemented correctly, collaborative care can seamlessly integrate mental health care with medical care, improve outcomes, reduce unnecessary readmissions and provide real value for the health care dollar. This model can also help meet the needs of some individuals with more severe mental illnesses, though others may continue to require settings that provide more intensive care.

The growing national recognition that successful integration of mental health services is key to improving our national health care system may afford this country its best hope in a generation for progressing toward effective and compassionate community-based mental health care. Academic medical centers, state mental health authorities, federal health policy leaders, health care professionals, patients and their families all now have a rare opportunity to work together to improve the quality and reduce the costs of mental health care. It is our hope that they make the most of this opportunity -- for their sake and for the sake of all Americans.

Dr. Pardes, a psychiatrist, is vice chairman of the board of trustees of NewYork-Presbyterian Hospital. Dr. Lieberman is Chair of Psychiatry, Columbia University College of Physicians and Surgeons and President-Elect, American Psychiatric Association.


(1) Frasure-Smith N, Lespérance F, Talajic M. Depression following myocardial infarction. Impact on 6-month survival. JAMA 1993;270:1819-1825