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BEHAVIORAL HEALTH, WHY IS IT SO IMPORTANT?


It is plain that behavioral healthcare services are not well understood generally.  There are a variety of reasons for this, and in fact there are piles of studies that point this out. 

 

In keeping with our service orientation here at Aspen Practice, P.C., part of our focus is to heighten awareness about what actually are 'behavioral health services.'  Below, we have begun to answer some of these questions by starting to offer a few summaries and the beginning of our series of position papers about what is essential in understanding behavioral healthcare and its day-to-day impact. 

 

We hope these resources will briefly answer why these services are so important.  Please also look at our Links Page for other valuable resources in understanding these services. 


Behavioral Health..?

1 Out of Every 2 United States Citizens will have a diagnosable behavioral health condition at some point in their life time.

Read The Research


Executive Summary/White Paper

Behavioral Healthcare, a worthy investment for states:

Know the history, the research, and this will be clear.

Read Summary


1 Out of Every 2 United States Citizens will have a diagnosable behavioral health condition at some point in their life time.

The term behavioral health is one that was adopted roughly a decade ago to fold the issues of adjustment problems, behavioral issues, mental health and substance abuse all into one term.  There are two comprehensive studies in the past few years that illustrate why addressing behavioral health is so critical, and even so the central nature of behavioral healthcare is not a new idea.  Roughly a quarter century ago, Cummings and VandenBos (1981) illustrated that by providing appropriate behavioral healthcare general 'medical' utilization could be reduced by as much as 50%.  The findings of this study has been replicated a number of times across other equally large, or larger, healthcare systems since that time.

  • Cummings, N.A. and VandenBos, G.A.  (1981).  The twenty year Kaiser-Permanente experience with psychotherapy and medical utilization:  Implications for national health policy and national health insurance.  Health Policy Quarterly, 1(2), 159-173.

Recent Studies - "About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life, with first onset usually in childhood or adolescence."

President's New Freedom Commission

In 2002 President Bush charged this Commission (see link for more details), "....to study the problems and gaps in the mental health system and make concrete recommendations for immediate improvements that the Federal government, State governments, local agencies, as well as public and private health care providers, can implement."

Mental Illnesses Presents Serious Health Challenges

"Mental illnesses rank first among illnesses that cause disability in the United States, Canada, and Western Europe.12 This serious public health challenge is under-recognized as a public health burden. In addition, one of the most distressing and preventable consequences of undiagnosed, untreated, or under-treated mental illnesses is suicide. The World Health Organization (WHO) recently reported that suicide worldwide causes more deaths every year than homicide or war .13

In addition to the tragedy of lost lives, mental illnesses come with a devastatingly high financial cost. In the U.S., the annual economic, indirect cost of mental illnesses is estimated to be $79 billion. Most of that amount - approximately $63 billion - reflects the loss of productivity as a result of illnesses. But indirect costs also include almost $12 billion in mortality costs (lost productivity resulting from premature death) and almost $4 billion in productivity losses for incarcerated individuals and for the time of those who provide family care.14

In 1997, the latest year comparable data are available, the United States spent more than $1 trillion on health care, including almost $71 billion on treating mental illnesses. Mental health expenditures are predominantly publicly funded at 57%, compared to 46% of overall health care expenditures. Between 1987 and 1997, mental health spending did not keep pace with general health care because of declines in private health spending under managed care and cutbacks in hospital expenditures.15"

    • "In 1997, the United States spent more than $1 trillion on health care, including almost $71 billion on treating mental illnesses."

Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication

This was a huge study in which "...more than 15,000 Americans participated in the two National Comorbidity Survey Replication studies..."  In short, during "...any given year, 18 percent of respondents suffered from a serious anxiety disorder, 10 percent from depression or bipolar illness, 9 percent from an impulse disorder and 4 percent from alcohol or drug addiction."  And, only "40% of those who researchers deemed would have qualified as mentally ill said they had received some kind of treatment, and often that was from someone other than a mental health provider." 

Quotes above from Scientific American Mind's summary by Jamie Talan (2005) Half are mentally ill. 16(3), 9.

Ronald C. Kessler, PhD; Patricia Berglund, MBA; Olga Demler, MA, MS; Robert Jin, MA; Kathleen R. Merikangas, PhD; Ellen E. Walters, MS

Archives General Psychiatry. 2005;62:593-602.

Context  Little is known about lifetime prevalence or age of onset of DSM-IV disorders.

Objective  To estimate lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the recently completed National Comorbidity Survey Replication.

Design and Setting  Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using the fully structured World Health Organization World Mental Health Survey version of the Composite International Diagnostic Interview.

Participants  Nine thousand two hundred eighty-two English-speaking respondents aged 18 years and older.

Main Outcome Measures  Lifetime DSM-IV anxiety, mood, impulse-control, and substance use disorders.

Results  Lifetime prevalence estimates are as follows: anxiety disorders, 28.8%; mood disorders, 20.8%; impulse-control disorders, 24.8%; substance use disorders, 14.6%; any disorder, 46.4%. Median age of onset is much earlier for anxiety (11 years) and impulse-control (11 years) disorders than for substance use (20 years) and mood (30 years) disorders. Half of all lifetime cases start by age 14 years and three fourths by age 24 years. Later onsets are mostly of comorbid conditions, with estimated lifetime risk of any disorder at age 75 years (50.8%) only slightly higher than observed lifetime prevalence (46.4%). Lifetime prevalence estimates are higher in recent cohorts than in earlier cohorts and have fairly stable intercohort differences across the life course that vary in substantively plausible ways among sociodemographic subgroups.

Conclusions  About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life, with first onset usually in childhood or adolescence. Interventions aimed at prevention or early treatment need to focus on youth.


 

 

Behavioral Healthcare, a worthy investment for states:

Know the history, the research, and this will be clear.

 

Michael R. Bütz, Ph.D.

Aspen Practice, P.C.

Billings, Montana

Contact us for a Printed Version of this Document office@aspenpractice.nt

 

 

 

 


Initial Statement

The financial costs of supplying healthcare ‘seem’ to be increasing; and behavioral healthcare* ‘appears’ to be one of those costs. But, looking back over the past fifty years in an admittedly brief and incomplete history it is argued that this system of care never truly had an opportunity find root with appropriate funding and implementation. Research shows us that when adequate behavioral healthcare systems are in place substantial cost savings may be found not only financially, but also as measured in terms of human suffering. And, half of the citizens in the United States will, at some point in their lives, suffer from a diagnosable behavioral health issue.

    * The term 'behavioral health' is one that was adopted roughly a decade ago to fold the issues of adjustment problems, behavioral issues, mental health and substance abuse all into one term.


There are many maxims or phrases we are all familiar with, among them pithy statements such as: "Penny wise and pound foolish," and/or "If you don’t know your history you’re doomed to repeat it," and/or "We seem to keep re-inventing the wheel." While there is a reason that these succinct expressions have had lasting power over time, they also have had application. In this day and age, these expressions, maxims or phrases have no greater relevance than in the field of behavioral healthcare.

Many states, faced with budget deficits look to cut and prune these systems of care to address short-term budget deficits. And, admittedly, in some cases educated and wise choices are made in this regard. All too often, however, these cuts are made with little knowledge of the system, nor the long term effects these cuts will have on budgets well into the future. When such cuts are made without consideration of the history of behavioral healthcare the result is, pardon the repetition, penny wise and pound foolish– with ballooning costs in the long run for not only behavioral healthcare, but healthcare ‘in general,’ even in the short run! And, this does not take into account the toll of human suffering, lost lives, and lost recoveries of personal dignities and freedoms fought for so hard, by so many. What weighs in the "balance" are not only dollars, but human lives and the integrity thereof.

So, what of behavioral healthcare’s history; and does it illustrate that budgetary imprudence and human suffering go hand in hand? While admittedly grossly oversimplified, there are a few nodal developments, events and sets of research findings that make this point in fairly common sense fashion.

Assessment of the United States Behavioral Health System Today

The President’s New Freedom Commission on Mental Health, rightly asserted that, among other issues, there is stigma that surrounds mental illness, behavioral healthcare is delivered in a fragmented fashion, and that there are unfair treatment limitations and financial requirements placed on mental health benefits through private health insurance companies. Moreover, as stated in this report:

      "Mental illnesses are shockingly common; they affect almost every American family. It can happen to a child, a brother, a grandparent, or a co-worker."

This Commission also reported that mental illnesses rank first among illnesses that cause disability in the United States, Canada, and Western Europe. The World Health Organization (WHO) was also cited as reporting that suicide worldwide causes more deaths every year than homicide or war. The Commission also illustrated that mental illnesses come with devastatingly high financial costs – an estimated indirect cost of $79 billion annually. Ultimately, the Commission’s Interim Report stated the following.

      "…the mental health delivery system is fragmented and in disarray…lead[ing] to unnecessary and costly disability, homelessness, school failure and incarceration."

In 2005, a huge study was completed in which "...more than 15,000 Americans participated in the two National Comorbidity Survey Replication studies..." For brevities sake, this study found that half, half, of the population of the United States will suffer a diagnosable behavioral health disorder at some point in their lifetime.

The Dawn of Community Mental Health Centers

In the mid 1950’s a wonder drug came into existence that would forever change the face of human suffering. Initially labeled a tranquilizer this wonder drug, Thioridazine, calmed the mental illnesses of many in state institutions. And, at the same time, with the advent of this new medication a possibility arose that these individuals could return to their home communities and live fuller integrated lives with their family and friends.

Later that decade, behavioral healthcare providers gathered to discuss and study this possibility (Mental Health Study Act of 1955). Parenthetically, President Bush’s New Freedom Commission referenced above was not the first of its kind, it was one of five comprehensive studies on these matters conducted over the past fifty years. This first Study conducted in 1955 also was mindful of the promise of a more cost-effective form of treatment, as costs would naturally go down when states did not have to simply house and feed these individuals to the extent they had in the past.

All groups generally agreed that these individuals would require a well integrated network of behavioral and developmental healthcare, and this system of care was originally set forth in 1963 by President Kennedy with the Community Mental Health Centers Act. This act was meant to ensure that all Americans had access to, as it was phrased at that time, "mental health care". Dimensions were added in 1965, including serving the mentally retarded population as well.

This promise of these acts, though well intended, was never fully realized. And, it was roundly agreed that the system was not delivering care in the fashion intended. What seemed to occur is that despite these systems of care being set up; each state did so with a slightly different twist and a somewhat different understanding of what funding would look like for a well integrated system of care. Despite federal guidance at the time, and dollars being set aside to fund these systems, dollars found their way elsewhere into other state coffers. In many cases, while the mandate still existed the funding did not. These Community Mental Health Systems were not only delivered in rather different ways, but many were now too under-funded to address the original mandate fully.

In the mid 1970s the Carter Administration took the Community Mental Health System under study and in 1977 developed the Mental Health Systems Act. This Act moved to fund and manage the system more appropriately in order to better serve the mission that had been laid out by President Kennedy in 1963. In 1980 it was passed, and as they say, ‘ready to roll.’

OBRA’s Effects

Despite the Mental Health Systems Act being in place, the Regan Administration’s Omnibus Reconciliation Act (OBRA) of 1981 in effect reversed the Carter Administration’s move to integrate the system more tightly and fund it appropriately. After OBRA’s enactment, existing funding for Community Mental Health Centers was reduced by 20-30% or thereabouts, not increased, and the remaining funds were fragmented into block grants.

On a federal and/or national level what followed this under-funded Community Mental Health System were even more costly systems of care. These systems either initially promised savings that logically did not make sense (managed care) or were often one of the only treatment alternatives available (psychiatric hospitalization). There were fissures in the system of care created by fragmented and inadequate funding, and the resulting environment provided an opportunity for these businesses. What emerged, and is all too well documented, were managed care companies and ‘for-profit’ psychiatric hospitals that thrived in the 80s and early 90s. The eventual outcome produced by both systems of care has been featured on national news in years since, and yet their outgrowth came as a natural consequence to the fragmentation and inadequate funding of the Community Mental Health Centers. And, for clarities sake, both enterprises were ‘for-profit,’ and this profit came at an expense state government and persons served by those systems.

Properly Conceived, Behavioral Healthcare Saves Money and Stems Suffering

Not knowing our history is costly in a different way as well, as in 1981 Cummings and VandeBos shared a twenty year study with the field. A study that roughly indicated if individuals are provided appropriate behavioral healthcare, their medical costs will be reduced by margins of up to 50%. Aetna and Columbia healthcare systems have both replicated these findings. And, inversely without adequate behavioral healthcare medical costs rise proportionately. Similar findings have been published by Hawaii’s Medicaid System and the Columbia Medical Plan. The primary reasons are that many visits to primary care physicians are actually related to the behavioral health needs of the people they serve, and persons served with mental illness end up being heavy users of medical services.

A Basis for the Future

Knowing that one out of every two United States citizens will, at some time in their lives, have a diagnosable behavioral health issue is a daunting finding. Even more disturbing is that the most recent Commission to study this issue found that this system is "…is fragmented and in disarray." And, that according to the World Health Organization, issues directly related to these systems of care take more lives than homicides or wars.

For a variety or reasons, the behavioral healthcare systems have not been afforded the opportunity to create an integrated continuum of care that is appropriately funded in order to provide adequate care to each American as it was intended in 1963. The costs have, and continue to be, great for every step we make away from this path. Behavioral healthcare, when properly administered across a full continuum of care in an integrated fashion, has the potential to not only stem human suffering and save lives, but also to hold its own weight budgetarily and reduce hard medical costs by a substantial amount.

With the upcoming budgetary sessions across many of the states in our nation, it is our simple request here at Aspen Practice that elected officials, departmental executives and legislators bear these pieces of our history in mind to better serve the people of our nation.

End Notes


Presidents New Freedom Commission on Mental Health:  Achieving the Promise:  Transforming Mental Health Care in America.  (July, 2003).  http://www.mentalhealthcommission.gov/reports/FinalReport/toc.html

See page 3 of the Final Report.

Scientific American Mind's summary by Jamie Talan (2005) Half are mentally ill. 16(3), 9.

& Kessler, R.C., Berglund, P.A., Demler, O., Jin, R., Merikangas, K.R., Walters, E.E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 62(6), 593-602.

See also the National Institutes of Health Almanac, specifically the NIMH Legislative Chronology http://www.nih.gov/about/almanac/organization/NIMH.htm.

Cummings, N.A. and VandenBos, G.A.  (1981).  The twenty years Kaiser-Permanente experience with psychotherapy and medical utilization:  Implications for national health policy and national health insurance.  Health Policy Quarterly, 1(2), 159-173.

Lechnyr, R. (1993). The cost savings of mental health services. EAP Digest, 22.

VandenBos, Gary R. & DeLeon, Patrick H. (1988). The use of psychotherapy to improve physical health. Psychotherapy, 25, 335-343.

Lechnyr, R. (1992). Cost savings and effectiveness of mental health services. Journal of the Oregon Psychological Association, 38, 8-12.

Cummings, N.A., Dorken, H., Pallak, M.S. et al. (1990). The impact of psychological intervention on healthcare utilization and costs. Biodyne Institute, April 1990.

Borus, J.F. & Olendzki, M.C. (1985). The offset effect of mental health treatment on ambulatory medical care utilization and charges. Archives of General Psychiatry, 42, 573-580.

Hankin, J.R., Kessler, L.G. & Goldberg, I.D. (1983). A longitudinal study of offset in the use of nonpsychiatric services following specialized mental health care. Medical Care, 21, 1099-1110.

American Psychological Association.  (2006).  Defining Medical Cost Offset: Policy Implications.  Practice Directorate, Washington, D.C. http://www.apa.org/practice/offset3.html


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