Reflections on important changes in behavioral healthcare

I prepared the following observations for the Mental Health Section Symposium held at the annual meeting of the American Public Health Association (APHA) in San Diego on Nov. 11.

I greatly appreciate the opportunity to join this panel. Behavioral healthcare has arrived at several critical turning points, and I hope to convey to you the gravity of these shifts.

Changed context: We still are very much a “Stage 4” system; most people don’t even begin to receive care until they are severely ill, often several years after initial symptoms appear. Yet, we also have embraced the promise and hope of recovery and prevention, each of which has altered the field in very positive and irreversible ways. Now, we are beginning to explore the benefits of care self-direction and life self-management by consumers. Clearly, these developments will have considerable impact on how the field operates, as well as positive impact on consumer recovery and community life.

Changed problems: At present, we are losing almost 200 people every day to death due to opioids and other drugs. We are losing another 125 people each day to suicide. We now know that depression is a very strong risk factor for opioid use. If one is depressed, the probability triples—yes, triples—that one also will do opioids. Hence, it is quite obvious that we must address mental health conditions if we are to have any hope of containing and reducing the opioid epidemic. Anecdotal evidence from the field suggests that at least half of adults with serious mental illness in our cities who are homeless also are addicted to opioids. This is a tragedy that cannot be overlooked. 

Changed approach: Over the past several APHA meetings, we have begun to explore population health management and the potential for a partnership between behavioral healthcare and public health in that endeavor. Just recently, US Surgeon General Jerome M. Adams, MD, MPH, issued a request for input on an important call to action to Improve Community Health and Prosperity. We must applaud the efforts of the surgeon general because he is moving in the same direction as we should be moving. We must work in communities to prevent trauma. However, we also must emulate the surgeon general’s use of language. Adams speaks about community health and prosperity, yet never uses the term population health management. The latter term is not well understood beyond narrow academic confines, and probably will not serve us well in the long run. Let’s change our approach and our language.

Changed opportunities: The midterm election probably saved the Affordable Care Act. With the US House in the hands of the Democrats, it is extremely unlikely that the Republican-controlled US Senate or the Trump administration will be able to overture the ACA. That is very good news indeed, since we will have the opportunity of an extended period to work on the issues that I have described here.

Yes, we must take advantage of the wonderful opportunity this breathing space has provided. Let’s get to work on the mental illness-opioid connection. Let’s embrace self-direction as a key approach. Let’s adopt language that will motivate beyond our own field. And let’s continue to implement needed changes in our approach to care that are supported by the ACA. We will benefit, and consumers will benefit.

My hat is off to Alfredo Aguirre, director of behavioral health services, San Diego County, and Wayne Clark, executive director, California Mental Health Services Authority, for organizing this APHA headline session.