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Friday, 15 December 2017

The Murphy Bill: Old Wine in New Bottles

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 By Andrea Blanch and David Shern (Originally published here)

In June, the Helping Families in Mental Health Crisis Act of 2015 (H.R. 2646) was introduced by Reps. Tim Murphy (R-PA) and Eddie Bernice Johnson (D-TX).  Several groups have applauded the bill for focusing attention on the need for strengthening the nation’s mental health system.  Unfortunately, the bill proposes very little new, contains provisions that could prove harmful to the very people it is intended to help, and ignores significant scientific advances in our understanding of the causes and treatment of mental illnesses.

Others have criticized in detail the bill’s emphasis on institutional and coercive approaches to treatment rather than on effective, voluntary community-based services; the elimination or drastic reduction in important programs overseen by the Substance Abuse and Mental Health Services Administration (SAMHSA); provisions that would curtail or limit enforcement of civil and privacy rights; and structural problems with proposed changes in federal mental health administration.  Here, we want to focus on another failing of the bill – the lost opportunity to build on what science has taught us during the past twenty years.

The Science.  There is now little doubt that mental illness and substance abuse result from a combination of genetic and environmental influences.  Some people are genetically predisposed to these conditions, and may develop symptoms even in the absence of other risk factors.  Others people are propelled down this path by traumatic events or adverse experiences, especially in childhood.  While the science is still evolving, it is clear that when children experience multiple risk factors –particularly in the absence of protective factors - the stress response system is overloaded and a “cascade of risk” is triggered.  These experiences can become ‘biologically embedded’ in the developing brain, causing a spectrum of behavioral health problems which, in turn, predispose a variety of general health and social problems.

These findings have important implications for the field. Clearly, an integrated public health approach is required - one that is person/family centered, addresses the social determinants of health, and powerfully combines primary prevention with treatment and rehabilitation.  Ignoring any of the components of public health is short-sighted.  For example, recent meta-analyses suggest that if major forms of childhood adversity were eliminated, a significant percentage of new cases of both child and adult psychosis could be prevented.  Similarly, the premature mortality of people with severe mental illnesses – a shocking statistic that has recently garnered national attention - underlines the multiple co-morbidities, disability and mortality associated with mental illness and illustrates the need for better access to care.

The Murphy bill nominally seeks mental health reform but fails to capitalize on these recent scientific advances and, in fact, is regressive in its approach.  There are fundamental flaws in the bill’s approach to treatment and rehabilitation as well as to prevention.

Treatment and Rehabilitation.  The bill continues to inaccurately portray mental illnesses in a simplistic, uni-dimensional, and stigmatizing manner.  It emphasizes and rewards coercive interventions and expands institutional treatment settings, while remaining silent on the need for community services such as housing, case management, rehabilitation and job programs. It diminishes the role of social support and advocacy, which are crucial in helping people live successfully in the community. In short, it continues to perpetuate the fiction that coercing individuals into a largely non-existent treatment and support system will remedy the problems experienced by people with serious mental illness.

The bill completely ignores the role of toxic stress and trauma in the lives of people diagnosed with mental illness and substance use disorders, essentially proposing a “one size fits all” mental health system.   In fact, for people with co-occurring mental illness, substance abuse and trauma histories, addressing all three problems simultaneously is the most effective approach.  The mental health system should be moving towards individualizing interventions, not creating legal mechanisms to force people into treatment that may not be working for them.  

The bill also does little to improve financing for needed services.  Other than permitting Medicaid to underwrite institutional settings, it focuses almost exclusively on SAMHSA funding, which comprises a tiny fraction of expenditures for the treatment of mental illnesses.  The bill largely neglects the major federal funder of services for people with serious mental illness, the Center for Medicaid and Medicare Services.  In summary, the bill fails to enact any real mental health reforms that would help people with serious mental illnesses, while further marginalizing them.   

Prevention and Early Intervention.  Perhaps more importantly, the bill fails to acknowledge or address the social determinants of health generally and mental health conditions specifically.  Elsewhere we have summarized legions of data that indicate serious problems with our overall health, documented by relative decreases in longevity, mediocre to poor overall health status, and the highest rates of mental illnesses in the world.  Many of the risk factors for behavioral health problems are the same factors associated with the overall deterioration of health.  Real mental health reform would use existing knowledge about reducing risk and increasing resilience to better underwrite overall health and wellbeing. 

Strategies to address the social determinants of health would involve dramatically strengthening implementation of primary prevention programs and policies to increase resilience and to reduce risk factors.  A number of rigorously tested interventions exist, with decades of follow-up data indicating long range effectiveness in preventing negative outcomes.  In fact, the durability of these responses has led us and others to characterize them as “behavioral health vaccines.”  The current bill explicitly restricts funding for primary prevention programs and features them only in direct relation to the development of severe mental illnesses.  Furthermore, by restricting the federal mental health agency’s scope to serious mental illness, the bill would hamper the ability of the federal government to develop broader social policies addressing risk factors and improving health.

The bill does include reference to early intervention strategies, although funding for these services is unclear. It is also unclear how these early intervention services would impact the most prevalent disorders (anxiety, depression and substance use disorders)- those that arguably are associated with the greatest population disease burden.

The Need for an Integrated Response.  Once before in our lifetime, the field of mental health was split into two camps - those who wanted to focus on people diagnosed with serious mental illness, and those who favored preventive strategies.  The rift in the field caused untold damage, leading to competition for resources and political influence and slowing progress.  Ultimately, the prevention field developed in relative isolation from treatment and rehabilitation, and public mental health services were restricted to individuals who had developed severe disability from their mental illnesses. This clearly makes no sense.  Unfortunately, the Murphy bill perpetuates just such a false and dangerous choice.  Real change requires an integrated, multi-pronged approach. 

Finally, the Murphy bill goes in a direction contrary to major trends in medicine.  Health systems are moving quickly towards Medical Homes, patient-centered care, shared decision-making, prevention, wellness promotion, increased emphasis on the social determinants of health, and self-management of chronic conditions.  Health systems are moving in this direction because these strategies work.  Patients who share responsibility for their own wellness get healthier faster.  The Murphy bill is based on the premise that people diagnosed with mental illness cannot make their own decisions.  This premise – like much else in this bill – is ill-informed and outdated.

The Murphy bill proposes a few good ideas, like ensuring compliance with mental health parity.  But a few good ideas can’t save a fundamentally flawed bill.  We have learned enough over the past twenty years to create real mental health reform.  We can do much better than this bill.  

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