Shifting the Paradigm to Prevention, Early Intervention
The Need: Mental illness affects 1 in 4 people in America and is the leading cause of disability worldwide. Researchers broadly agree that early intervention in serious mental illness, with intensive, coordinated services, is a defining factor in how far the disease progresses and the prognosis for a productive and successful life.
- Every year, 100,000 young adults in the U.S. experience their first psychotic episode, frequently involving debilitating hallucinations and delusions.
- Behaviors and symptoms that signal the development of a serious thought or mood disorder often manifest two to four years before a disorder is present.
- Nonetheless, the average delay in receiving appropriate diagnosis and treatment is an astonishing 5 months after the illness takes root and the patient suffers his or her first psychotic break.
- The longer the illness goes untreated, the more likely that young person will spiral down a damaging course, unable to graduate, unable to form relationships, unable to hold a job.
The Potential: Early intervention in mental illness comes with a measurable cost benefit. But most counties in California lack the training or capacity to offer such services.
- A joint analysis by the National Academies of Sciences, Engineering and Medicine determined that every $1 investment in prevention and early intervention for mental illness and addiction programs yields $2 to $10 in savings in health costs, criminal and juvenile justice costs and low productivity.
- A multi-year review by the National Institute of Mental Health found patients with first episode psychosis who received early intervention, with coordinated specialty care, experienced greater improvement in their symptoms, relationships and quality of life; and were more involved in work or school compared with patients who did not receive these services.
- Nonetheless, just 24 of California’s 58 counties offer these comprehensive services, and we lack a statewide strategy for implementing such programs and measuring outcomes.
The Economic Toll: The failure to ensure every young person in every county in California has access to early intervention puts a heavy burden on taxpayers, employers, hospital systems and public services.
- Untreated mental illness results in more than $193 billion in lost earnings each year in the U.S., according to national studies.
- Mental disorders are the single most expensive category of health costs for many employers, across all industries and sizes.
- Approximately one in eight visits to hospital emergency rooms involve mental health or substance abuse disorders, and such patients are more than twice as likely to require hospitalization compared with other types of patients.
The Human Toll: In most cases, we can effectively bring serious thought and mood disorders, including schizophrenia, bipolar disorder and major depression, into remission if we intervene early with appropriate, evidence-based treatment. But we consistently fail to do so, and the human toll is evident.
- One third of the people living homeless in California are diagnosed with untreated mental illness.
- One third of the inmates in California prisons are living with mental illness.
- Each year in the U.S., more than 44,000 people die by suicide, largely because of untreated mental illness.
- A recent one-year study found the death rate for young people diagnosed with psychosis was 24 times higher than their peers in the general population.
How AB 1315 (Mullin) Addresses an Unmet Need
Why AB 1315? Because this legislation marks a necessary and decisive step toward shifting the paradigm of mental health delivery in California. It comes with a written pledge from private industry to raise funds for the public/private partnership the bill creates, and has the support of more than two dozen organizations that are leaders in the field, as well as influential players in the technology and research communities.
What does it do? The bill would generate new private sector contributions to expand services for early detection and intervention in mental illness. The account created with these funds, known as EPI-Plus, would increase funding available to counties for creation and expansion of evidence-based programs that have proven successful at stemming psychosis-related disorders such as schizophrenia, bipolar disorder and depression before they become disabling.
Why is that needed? The research is clear that early intervention in serious mental illness with intensive, comprehensive services can arrest the disease before it becomes disabling. Model programs in operation in California, New York, Oregon and multiple other states and nations have shown dramatic benefits when young people receive treatment in the early stages of illness, often resulting in rapid remission of symptoms. But fewer than half of California counties offer such services because of limitations in funding and training capacity. And the 24 counties that do offer such services can’t support programs large enough to meet local demand.
Can’t we meet this need with MHSA dollars? No. By statute, the bulk of MHSA funding – 80 percent — goes toward care for people whose mental illness is already full-blown, often leaving them homeless, incarcerated, or hospitalized. Rather than redirecting existing resources, AB 1315 (Mullin) adds new money to the equation, largely drawn from the private sector, to expand statewide capacity for prevention and early intervention.
Does this duplicate existing state and county efforts? No. It expands those efforts. Nor does it require counties to redirect funds from other priorities. Counties would have the opportunity to apply for a grant that doubles their investment in prevention and early intervention. We’ve amended the bill to clarify that it in no way requires redirection of existing federal grants.
How will this shift the paradigm of care? Counties currently straddle a difficult chasm: The need for crisis services for people suffering from mental illness is great and undeniable. But we’ll never get ahead of the problem unless we move our treatment model from Stage 4 crisis care to early prevention and intervention. This bill provides incentive for California to move toward a collaborative, statewide strategy that emphasizes early intervention and incorporates counties large and small. In addition, it creates an historic opportunity for the private sector to join forces with the state and counties in the battle to transform the mental health treatment model, ensuring diseases of the brain are treated with the same urgency and sweep as diseases of the body.
Why Train Primary Care Providers in Basic Psychiatry?
The Need: The United States is experiencing an alarming and well-documented disconnect between the demand for psychiatric services and the number of trained psychiatrists.
- Fifty-five percent of counties in the continental U.S. have no psychiatrists, and 77 percent have a severe shortage.
- Seventy percent of practicing psychiatrists are age 50 or older, and approaching retirement.
- Forty percent of practicing psychiatrists operate on a cash-only basis, meaning they accept no insurance.
- By 2025, the demand for psychiatry will outstrip supply by 15,600 psychiatrists, or 25 percent.
The Demand: Meanwhile, demand for mental health services is on the rise.
- Mental disorders topped the list of most costly medical conditions in the U.S. in 2013, at $201 billion.
- Estimates indicate one in four families are struggling with some aspect of mental illness.
- In hospital emergency rooms, lack of access to psychiatric care has reached crisis levels, with patients waiting an average of 23 hours for transfer to appropriate services.
The Consequences: Primary care practitioners are living with the fallout.
- An estimated 40 percent of patients seen in a primary care setting on any given day have an active psychiatric problem.
- A recent study found two-thirds of primary care clinicians reported difficulty accessing psychiatric services for their patients.
- Fewer than half of primary care patients with mental illness receive any
The Fix: Assembly Bill 1340 by Assemblymember Brian Maienschein would help ensure that the primary care providers on the frontlines of treatment recognize the signs of mental illness.
- Currently, the majority of primary care providers receive minimal training in psychiatric diagnosis and treatment as part of their medical education.
- The bill would require that the Medical Board of California consider including in its continuing medical education requirements a course on integrating mental and physical health care in primary care settings, especially as it pertains to children.
- MHSA 101 – A primer on California’s landmark 2004 Mental Health Services Act.
- 2016 Evaluation: MHSA Program Outcomes – In May 2016, the Steinberg Institute, in partnership with the County Behavioral Health Directors Association, conducted an evaluation of outcomes related to a broad spectrum of programs funded through the 2004 Mental Health Services Act. The analysis included programs classified as full-service partnerships, which provide intensive wraparound services to people with serious mental illness, as well as programs aimed at prevention and early intervention. The review found FSP services correlated with a marked reduction in homelessness, arrests, and hospitalizations for clients; and that PEI services correlated with a reduction in psychotic symptoms, reduction in substance abuse, fewer hospitalizations; higher employment rates; and increased quality of life.
- 2016 MHSA Trends Report – A sampling of 17 counties shows funding generated by the 2004 Mental Health Services Act has fueled a substantial increase in the number of residents receiving mental health services.
- 2015 Evaluation: MHSA Full-Service Partnership Outcomes – In March 2015, the Steinberg Institute, in partnership with the County Behavioral Health Directors Association, conducted the first evaluation of outcomes related to full-service partnerships, a treatment model funded through the Mental Health Services Act that provides intensive wraparound services to people with serious mental illness. The review found tens of thousands of people utilized full-service partnerships in the fiscal year studied, and that the services correlated with a marked reduction in homelessness, hospitalizations and jail time for clients.