Rep. Murphy on refining the U.S. mental health system

In a panel discussion Friday morning, Representative Tim Murphy led the conversation about the changes that need to be made for mental health treatment. More specifically, he detailed his Helping Families in Mental Health Crisis Act (HR 3717). The bill was introduced in December and Murphy said the timing wasn’t a mistake: “I had committed to the parents at Sandy Hook Elementary School that we would have this bill before the anniversary of that tragedy.”

He explained to the audience at the Washington, D.C.-based American Enterprise Institute (AEI) that while not all individuals with mental illness are violent, it is an area of serious concern due to the number of tragedies that have been committed by someone with an untreated severe mental illness.

He started his discussion with some numbers:

• About 60 million Americans, about 20 percent of the population, have some degree of mental illness
• About 9.6 million Americans have a severe mental illness
• About 3.6 million individuals are without treatment

“It’s extremely important to understand what happens when someone is without treatment,” he explained. “When someone is without treatment, they can exhibit some violent or aggressive tendencies.” On the flipside, when someone is in treatment, there is a 15-fold decrease in the likelihood of violence, he said.

Not only can those with mental illness cause pain for others, but they are also at a higher risk of being victimized. For example, someone with a mental illness is three to four times as likely to be a victim of violence – rape, assault, robbery, etc. Also, children who are mentally ill are three times as likely as those who are not to be the victims of sexual abuse.

Mentally ill prisoners account for somewhere between 20 and 50 percent of all inmates, largely due to the closure of psychiatric institutions. In 1950, there were 550,000 inpatient psychiatric beds and today there are 40,000. “We’ve traded the hospital bed for the prison cell,” he said. “We have also traded the hospital bed for a mattress in a flophouse, a homeless shelter, or a blanket over some subway grate in our cities. It is inhumane and immoral and it puts us in something like a third world status.”

Barriers to treatment

Lack of inpatient options: There are not enough beds for individuals in acute crisis, and also inadequate options for those in outpatient treatment. Although there are good things happening in treatment and some modalities do work, there’s not enough of it, he said. H.R. 3717 will work to fix the shortage of inpatient beds by changing the “16-bed rule,” in which a program can only be reimbursed by Medicaid if it has less than 16 beds.

Lack of child psychiatrists: Currently there are 7,000 child psychiatrists for 15 million children. There should be 30,000, he said. “When there’s no help, there’s no hope. And when there’s no hope, people begin to feel the stigma of the emergency rooms, and of the police squad cars.”

HIPAA privacy rule, Family Educational Rights and Privacy Act (FERPA): As these laws currently stand, Murphy sees confusion. Although HIPAA protects both stored and sharing of personal health data, the rule can be a barrier, especially when family members are involved in the care.

“You can’t get permission from someone who doesn’t even know where they are, someone who is so severely involved in paranoia and psychosis,” Murphy said. “That’s wrong and it’s a misinterpretation of the law. If you’re in an auto accident and are in a coma, they don’t wait until you’re out of the coma to treat you. Why is it that way for mental illness? We need to refine those laws.”

The current bill aims to provide a clear definition on the HIPAA and FERPA laws so that providers and family members have access to important information when they need it. And others don’t.

“Imminent danger” standard: Dating back to the 1700s, this decision-making rule links the potential of harm to themselves or others in order to put them in treatment without their permission. The Helping Families in Mental Health Crisis Act would encourage states to adopt a treatment standard no longer dependent someone slitting their wrists, overdosing on drugs, or holding a gun or a knife to someone’s throat to determine that they need medical help.

The Act includes demonstration projects for assisted outpatient treatment (AOT) that will help providers and others understand the importance of this type of treatment is, added panelist E. Fuller Torrey, MD, founder of the Treatment Advocacy Center and executive director of the Stanley Medical Research Institute (SMRI). AOT allows an individual with severe mental illness live in the community as long as he or she takes the medicine prescribed. This is a very small number of people, only 1 percent of the severely mentally ill, he estimated, but the option is very effective.

Five states have shown that AOT treatment decreases hospital admissions. Studies in New York and North Carolina have shown that decreases in arrests and incarcerations, homelessness, episodes of violence, and costs.

Former Congressman Patrick Kennedy, who also served as a panelist, continued his advocacy. His “Checkup from the neck up” would include regular mental health assessments, ideally in the same office as a physical health exam. “Mental health [care/services] is not like going down the hall to the separate drinking fountain. It is a separate but unequal system,” he said.

No evidence-based treatments: Effective treatments are available, but there continues to be “weak accountability for federal dollars,” according to Murphy. “We’re going to change that.”

Same-day billing: Due to rules in Medicaid, it is difficult to get individuals into treatment in a timely manner. The Act aims to increase same-day access and billing.

Integrated care and integrated health records are also a focus. Jeffrey A. Lieberman, MD, director of the New York State Psychiatric Institute, cited the new buzzwords, “collaborative or integrated care,” and advocated for mental healthcare services to be embedded in general medical care. Likewise, primary care professionals should be embedded in mental health populations, he added.

Government issues

“Mental health knows no partisanship. In this town today, we are polarized by ideology. This is one area where we need to put that aside and work together to find common ground,” said Kennedy, author and lead sponsor of the Mental Health Parity and Addiction Equity Act of 2008.

Torrey despairs of the disinterest in Washington, DC that ranges from 10 recent presidents to federal agencies to members of Congress, adding that at any given time, there are 15 to 20 members of Congress who are directly affected by severe mental illness.

The panelists foresee increased accountability with oversight by the Centers for Medicare & Medicaid Services. “CMS will have more say than SAMHSA ever has had on funding mental health,” said Kennedy.