Sunday, September 18, 2005

Talk is cheap

Back when conservatism was still "compassionate," the Resident appointed his so-called New Freedom Commission on Mental Health, which called for a "fundamental transformation of the mental health care delivery system in the United States -- from one dictated by outmoded bureaucratic and financial incentives to one driven by consumer and family needs . . . "

Now the Resident has unveiled the exciting Action Agenda to achieve just that! Let's see, what actions are we going to take?

It turns out we're going to have federal leadership, and shared responsibility, and strategic alliances, and prototypes, and plans . . . I'm not sure what we're actually going to do.

Here are some typical Action Agenda Action Items:

  1. Initiate a national public education campaign. (Don't we already have those? "You may have pharmaceutical gullibility disorder. Take this pill!")
  2. Launch the National Action Alliance for Suicide Prevention. That's a public-private partnership that will oversee a strategy supported by a broad base of stakeholders. No more suicide!
  3. Educate the public about men and depression.
  4. Develop prototype individualized plans of care. (Every mental health provider in the world already develops individualized plans of care, but thank God, now we'll have a prototype!)
  5. Promote quality services in the workforce development system. Yup, they're gonna promote 'em. And they're going to develop an employer initiative. And they're gonna facilitate linkages. And they're gonna disseminate information through existing existing grant programs.
  6. Initiate a national effort focused on meeting the mental health needs of children. That turns out to be another public education campaign. They're also going to propose a comprehensive approach.
  7. Launch a web site.
  8. Protect and enhance the rights of people with mental illnesses -- by continuing current voluntary compliance initiatives.
  9. Launch the Federal Executive Steering Committee on Mental Health
  10. Include eliminating disparities in mental health services in the HHS "close the gap" initiative (which consists of a list of goals).

And so on. They're going to develop plans, promote strategies, facilitate linkages, expand agendas, and relabel some existing grant programs. SAMHSA says that $24 billion annually will be "made available" for the reforms, but that the cash is not all new money. I have looked through the plan and I'm not sure I can find any new money at all. But maybe I just haven't seen enough new money lately to remember what it looks like.

Critics of the New Freedom Commission view with alarm something called the Texas Medication Algorithm Project, which was funded by drug companies and touted in the Commission's original report. It's a "decision tree" that by an amazing coincidence, leads to drugs manufactured by the project's sponsors -- and it was based on the expert opinions of drug company consulants, not evidence. (See also here for a perspective from a chapter of the National Alliance for the Mentally Ill, with some additional links.) Since the New Freedom Commission also called for universal screening of children for mental illness, critics are viewing the whole thing as a conspiracy to drug half the population and send the profits to Pfizer.

To be honest with you, I've looked at the action agenda pretty closely and it doesn't specifically mention the TMAP or actually implementing universal screening. Nevertheless, presumably the critics see the plan as a first step toward those sinister ends. I would be worried about that if I took the "Action Agenda" seriously, but my expectation right now is that not very much will come of all this, except for massive digestion of forests into wood pulp and emission of enough hot air to exacerbate global warming.

We inappropriately medicalize many problems, but there really are people with mental illnesses. They don't need plans, strategic alliances, partnerships, campaigns, facilitation, task forces, or promotions. They don't need universal screening (although early detection of prodromal psychosis is good) and they certainly don't need more drugs. (Less drugs, please.) They do need stuff that costs money that doesn't go into the pockets of major political contributors. These include coordination of care among psychotherapists and counselors, psychiatrists, medical doctors, and social services. They need adequate insurance coverage for counseling, therapy and case management, and continuity of care, not just pills. They need access to supported housing and day treatment, or occasional home based services if appropriate. They need occupational rehabilitation, job training, and supported employment, or reasonable workplace accomodations, non-discrimination, dignity and respect. That'll be the day.