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Congress considers ambitious overhaul of US mental health care

Benedict CareyThe New York Times

Lawmakers, patient advocates and the millions of Americans living with a psychiatric diagnosis agree that the nation's mental health care system is broken, and Thursday, Congress will hear testimony on the most ambitious overhaul plan in decades, a bill that has already stirred long-standing divisions in mental health circles.

The prospects for the bill, proposed by Rep. Tim Murphy, R-Pa., are uncertain, experts say, given partisanship in both the House and the Senate and the sheer complexity of the mental health system. And its backing of the expanded use of involuntary outpatient treatment has drawn opposition from some advocacy groups.

But the bill, the Helping Families in Mental Health Crisis Act, does have more than a dozen Democratic co-sponsors in the House, and several mental health organizations are supporting it. Last week, both houses of Congress adopted one of its central provisions, expanding funding for outpatient treatment programs through other legislation. On Thursday, the House Energy and Commerce health subcommittee is scheduled to hear testimony on the entire bill, which includes more than two dozen measures.

"It's the most comprehensive mental health bill we've seen in a long, long time, and that in itself is an accomplishment," said Keris Myrick, chief executive of the Project Return Peer Support Network and president of the board of the National Alliance on Mental Illness, which supports some parts of the bill. "I think almost everyone sees things in the bill that are long overdue but also things they're very concerned about."

Among those opposing the bill because of its involuntary treatment provisions is the Bazelon Center for Mental Health Law, whose president, Robert Bernstein, said, "Many serious organizations seem to have an 'any port in the storm' mentality, supporting this bill even though it includes dangerous provisions."

Murphy, a clinical psychologist from Pittsburgh, put together the legislation at the behest of House Republican leaders after the massacre at Sandy Hook Elementary School in Newtown, Conn., in 2012. He spent a year hearing testimony about the current system, a patchwork of community clinics and state hospitals chronically short of funding that leaves millions of people with mental illness without treatment, often homeless or in prison.

"It's a broken system, and we're not going to fix it by throwing a little money here or there," Murphy said in an interview. "We know that when people get care, they get better, but there are simply not many options: Clinics are reducing services, there are not enough psychiatrists or psychologists to go around - we found all sorts of barriers to care."

Widely backed provisions of the bill include streamlining payment for services under the Medicaid program and providing funds for clinics that meet standards for rigorous, scientifically supported care.

The bill also provides money for suicide prevention programs and for so-called telepsychiatry, or remote video therapy, which is seen as especially crucial in rural areas.

Provisions calling for increased training for police officers and emergency medical workers in how to identify and treat people with mental disorders are also widely approved. The police and paramedics often act as ad hoc social workers, dealing with people with mental problems when they are hurt or break the law.

About 350,000 Americans with a diagnosis of a severe mental illness like schizophrenia or bipolar disorder are in state jails and prisons, while the number of psychiatric beds available has shrunk to 35,000, according to a coming analysis by the Treatment Advocacy Center, a nonprofit group that favors expanded access to treatment.

"The situation has been getting progressively worse for 50 years, to the point where we now have 10 times more people with severe mental illness in prisons and jails than in mental hospitals," said E. Fuller Torrey, of the Stanley Medical Research Institute, a nonprofit organization supporting research in schizophrenia and bipolar disorder, and a strong supporter of the bill.

But the bill's backing for involuntary treatment is highly contentious. It would provide state grants for so-called assisted outpatient treatment programs under which certain mentally ill people with a history of legal or other problems could get court-ordered therapy, which in most cases would mean trying to ensure they take their medication.

The result: more people treated earlier, and more treated against their will.

"This becomes a civil rights issue quickly, and it can drive people away from seeking services when they fear treatment will be forced on them or they'll be locked up," said Gina Nikkel, president and chief executive of the Foundation for Excellence in Mental Health Care, which advocates a more holistic, less medication-oriented approach to recovery.

In the past two decades, 45 states have adopted laws allowing compelled treatment in some cases, with varying requirements and levels of enforcement. Kendra's Law, passed in New York in 1999, is one that researchers have monitored closely. One recent analysis, led by investigators at Duke University, found that since the law was passed, patients were much less likely to land back in the hospital or be arrested. Mental health and Medicaid costs for them dropped by about half.

The Murphy bill also proposes amending federal medical privacy protections - the now-familiar HIPAA laws - to allow parents or other caregivers access to a patient's medical information. Under current law, those records are private once a person becomes an adult, and as a result, caregivers are often effectively cut out treatment decisions. The bill seeks to bring them back in, with a provision that will also generate strong political resistance, experts said.

Finally, the bill proposes to sharply scale back many of the programs funded by the Substance Abuse and Mental Health Services Administration. This agency, with a $3.6 billion budget, has long financed programs that critics say are not backed by good evidence.

"When something has been funded for a long time, it's tough to let it go," Murphy said. "What we're saying is that if a program works, then show us the evidence that it does, and we'll keep it. If the evidence is not there, then the taxpayers shouldn't pay for it."


By BENEDICT CAREY
The New York Times