Rethinking Behavioral Health Care

Dr. David Mechanic, founding director of the Institute for Health, Health Care Policy and Aging Research at Rutgers University, came to UC San Francisco last week to deliver the annual John Eisenberg Legacy Lecture. His topic — the changing behavioral health care landscape — could not have been more timely.

With the launch of the Affordable Care Act, poor and underserved Californians with untreated behavioral health issues now have a pathway to get the care they need. But Mechanic reminded us that we have a long way to go before evidence-based medicine drives clinical decisionmaking for mental and behavioral health issues.

Mechanic pointed out that social forces, ideologies, and finances shape behavioral health more than treatment advances or evidence-based approaches; prevalent treatments rarely adhere to established evidence-based standards, and the premise floated in the 1980s that well-integrated community care would replace the functions of hospital care is a promise still far from fulfillment.

As we contemplate how to make mental health parity a reality, it is useful to plot our path with history in mind. Since 1950, Mechanic pointed out, there has been a 92% decline in hospitalizations in state and county mental health hospitals.

However, Mechanic has noted in earlier work that the deinstitutionalization of mentally ill patients was not followed by growth and improvements at the community level. Instead we have seen a growth in the use of pharmaceuticals. As Mechanic shared last week, primary care clinical practice has been dramatically influenced by the growth of antidepressants like SSRIs and other psychotropic medications. And he called out that general medicine practitioners, rather than specialists, prescribe 60% of all psychiatric drugs.

One result of this policy failure was the de facto criminalization of mental illness. This continues today. A recent article by the CHCF Center for Health Reporting and the Sacramento Bee revealed that mental health hospitalizations of Californians age 21 and younger increased 38% between 2007 and 2012. Physicians quoted in the article said there is a significant lack of resources in local communities. The perverse answer, one doctor said, was to wait until a patient committed a crime, because then services are made available. Well-integrated community care is still far from being realized.

Mechanic’s insightful lecture comes just as we enter full implementation of the ACA. We know that the optimal management of chronic mental illness, let alone mental health parity, will require significant attention and innovation by public and private payers, policymakers, and providers as we take triple aim at behavioral health, working to improve patient experience, advance population health, and reduce the per capita cost of health care.

As a primary care physician reflecting on Mechanic’s presentation, I found myself looking for a good continuing medical education (CME) course on behavioral medicine for doctors like me. And I’m still looking.

Note: The Eisenberg Legacy Lecture, funded by the California Health Care Foundation, honors Dr. John Eisenberg, a renowned internist and health services researcher who directed the Agency for Healthcare Research and Quality (AHRQ) from 1997 to 2002.