Ben Miller: Mental health: Come out, come out wherever you are

Ben, I share your frustration with the void of mental health discussion in the healthcare debate.  I attribute this to a number of causes:

The body/mind split that typifies the healthcare lobby.  The mental health lobby is mostly agnostic to the larger healthcare debate because it doesn't really involve their funds.  In this they are short-sighted because I believe that designated funds and carve-outs for mental health will eventually disappear and then we will be more under-funded than now.

Collaborative Care has yet to make a strong case for the need to integrate behavioral specialists in primary care.  The IMPACT research probably makes the best financial case for care coordination, but they use extended-duty nursing staff rather than mental health professionals for care coordination and problem-solving therapy.  Their findings might actually undermine rather than reinforce our case.

Legislation requires "bumper sticker messages" that people can write on posters and yell at congressional meetings.  Integrated care is a nuanced model that is difficult to simmer down.

I do think that Twitter is a way to reach a broad audience with bumper sticker tweets that connect them with more information.  Thanks for taking the lead on this.

Descartes has proven to be more of an issue that I originally thought!  Back in August, President Obama visited the seacoast area and I was fortunate enough to attend.  One of the audience members asked the President about the role of mental health in the reform efforts.  His response was positive in that he confirmed his support for parity of mental health in the reform process.  That being said, after reading the Parity Act, I'm not that optimistic about the government's operational definition of "parity.

So as I mentioned above, parity in and of itself is not sufficient. Please read the Cunningham Health Affairs article for more info on his take. It is great that the President is aware of the mental health community. If we want to transform the healthcare system, we need more than just awareness - we need creativity and vision to end the fragmentation that plagues our healthcare system. Could vision come through our publications, research networks, or even our social networks??? Now is our time to make our voice heard!  

My name is Jeff Goldsmith and I wanted to respond to several points.  I am a psychiatrist and an addiction expert with the American Society of Addiction Medicine, Board.  We have been pushing hard for several years to get Parity for mental health and addictions and were thrilled to get it last year.  I have chaired a symposium about Parity two years ago and they indicated that anti-parity folks continue to fight parity for years and Vermont had to pass three parity laws to get things moving in parity for their state.  While i am not political in general, I thought this issue was crucial for the moment.  We need a national system that supports Parity in principle, and we don't have it yet.  So keep an eye pealed, and this Fall is the time for guidelines to come out for Parity.  So far the President's cabinet members haven't come out with guidelines. 

Second, your organizational name includes Collaboration, which i wholeheartedly support.  Collaboration is crucial for primary care and family health care.  Half of mental healthcare is done by primary care providers and not psychiatrists.  So we all need to collaborate with each other to provide the best care.  I wish that Congress would collaborate more too.  Medical Educators have not taught collaboration well in the past and I hope we do a better job in the future.  Collaboration is not consultation, nor referral.  It is working together, and you know that well in your position. 

Jeff, thank you first for your post, and second for all the work you have done to advance mental health. You are right that we need to take advantage of any and all opportunities to advance mental health anyway we can. My post, and your response both highlight the need for large scale (read national) change in a fragmented and flawed system. In today's senate finance committee bill (Chairman's Mark - Baucus), there is mention of mental health and required coverage of mental health and substance use. I honestly need more time to get to what this means, but it is at least a start. Let's continue to collaborate on this issue as often as we can. Good points and great discussion.    

Jeff, you make a valid point regarding how family medicine educators may have a particular influence on the practice of collaboration. My recent dissertation (2/09) examined the referral practices of family physicians with a national survey of AAFP's national research network. The participants voiced what they consider a "void" in optimal mental health services for their patients. The results suggest family physicians' unfamiliarity with the various psychotherapists available to their patients (counselors, family therapists, social workers, psychologists, and psychiatrists). Further studies need to be done exploring the depth of understanding that family practice residents and medical students are given regarding the services of different talk therapists. Without completely appreciating the unique expertise of various psychotherapists, it is not surprising that collaboration would be limited.