Bill a good start in reforming mental-health care

By Dominic A. Sisti

and Arthur Caplan

The mental-health-care system in the United States too often neglects the needs of Americans living with serious mental-health conditions and addiction. The system is fragmented and underfunded, and treatment is often provided in nontherapeutic places like jails and prisons.

U.S. Rep. Tim Murphy (R., Pa.) is ready to do something to fix this mess. Murphy is trained as a clinical psychologist, has years of experience in mental-health care, and, in an interview with CNN, he alluded to the serious challenges of mental illness in his family when he was growing up.

Murphy's legislation, the Helping Families in Mental Health Crisis Act, includes important commitments to build on evidence-based psychosocial interventions. Provisions of the bill include dollars to expand assisted outpatient treatment - a model of compulsory treatment in the community that has been shown to work well for some individuals. Other highlights include increased capacity for crisis inpatient care, community mental-health clinics, and criminal justice reforms to reduce the number of nonviolent mentally ill individuals sent to prison.

The bill would also modify existing federal law, such as the Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA), to open blocked lines of communication among family members, universities, and clinicians about the well-being of loved ones in crisis.

We support him. But facets of his bill continue to concern us.

First, the bill is rooted in the assumption that individuals with mental illness are dangerous and extremely violent. Murphy invokes mass shootings as evidence that our mental-health system is dangerously broken. While his conclusion is correct, his premise is not.

Individuals with serious mental illness are rarely violent toward others. Violence due to mental illness usually takes the form of suicide. To be sure, catastrophic events happen - but these are tragic outliers. Remaking the mental-health system without rational gun laws won't change this reality.

Murphy is not a fan of the federal Substance Abuse and Mental Health Services Administration (SAMHSA). He wants to more or less strip it of power. We agree that some programs funded by the agency lack strong evidence to support them, but organizational reform, rigorous evaluation, and improved peer review of grant applications could remedy this problem. We also agree that the agency should include more clinicians and researchers with advanced training among its leadership ranks. Nonetheless, SAMHSA serves a unique and important political role in providing a voice to individuals with mental illness that can reach the upper echelons of the federal government. Fair-minded reform of the agency should be given a chance.

Murphy's bill also includes the creation of a mental-health-care policy laboratory to draw on important preventive research. For example, the bill singles out the North American Prodrome Longitudinal Study - a decade-long multicenter program aimed at developing ways to detect and arrest the early signs of schizophrenia in children and adolescents. This research, and other innovative research programs, must continue for long-term gains in relieving individuals and the community of the scourge of severe psychotic illnesses.

But we also need practical solutions for the here and now.

Murphy should consider commonsense provisions that target poverty, toxic stress, trauma, adverse childhood experiences, and awful schools, as they often are the root causes of psychiatric pathologies. Programs that provide perinatal support to underprivileged mothers and access to high-quality day care would go a long way to help families function well.

"Housing first" programs - where the housing needs of the homeless are addressed with no strings attached, with other services provided as needed - also deserve attention and funding. And the bill should encourage the use of psychiatric advance directives - documents that allow individuals to lay out treatment preferences before they are in crisis.

Finally, without an increase in the number of mental-health-care professionals, many of the bill's big ideas will founder. We need to incentivize medical students to become psychiatrists - particularly child and adolescent psychiatrists - using loan-forgiveness programs and reimbursement reforms. We need to pay front-line mental-health-care providers much better for their very challenging jobs and to attract and retain our brightest caregivers.

The Helping Families in Mental Health Crisis Act marks an important turning point in the effort to reform mental-health care. Though it needs further thought, this bill could, if it becomes law, be a real breakthrough.

Arthur Caplan is director of the Division of Medical Ethics at New York University's Langone Medical Center department of population health. arthur.caplan@nyumc.org