Obama calls for changes to mental health care

• President proposed spending millions more on screening and treatment
• Obama also said researchers should resume studying causes of gun violence
• Affordable Care Act will give mental health coverage to millions of Americans

Mental health advocates hailed President Obama's sweeping agenda to improve mental health care, part of his larger plan to reduce gun violence in the USA following the shooting last month in Newtown, Conn.

After decades of disappointment, advocates for the mentally ill said they are cautiously optimistic that the nation may finally take meaningful action to repair a broken system.

"There are mental health professionals and educators cheering all over America," said Dewey Cornell, director of the Virginia Youth Violence Project, after reading Obama's plan. "No single action is going to solve the problem, but there are many actions here that will help."

Obama's speech — and his emphasis that most people with mental illness are not violent — will go a long way toward removing the stigma of mental illness, said Michael Fitzpatrick, executive director of the National Alliance on Mental Illness. He also welcomes a national dialogue on mental health, rather than simply another presidential commission. "These are things we've been asking for, for years," Fitzpatrick said.

Some mental health advocates said they hope the country can sustain the momentum to complete Obama's ambitious agenda.

"The president has taken exceptionally important first steps to address the deficiencies in our national mental health system," said Ron Manderscheid, executive director of the National Association of County Behavioral Health and Developmental Disability Directors. "However, we must recognize that these are only first steps in what must be a multi-year undertaking that will require transformation of how the mental health community provides services."

While Obama called on Congress to take a number of steps, he also listed a number of executive actions that he will take himself.

First, Obama will issue a presidential memorandum directing the Centers for Disease Control and Prevention to "research the causes and prevention of gun violence."

Researchers have complained that they have been barred by Congress from using funds to "advocate or promote gun control." Some in Congress have said this means that CDC cannot study the causes of gun violence. But with 30,000 homicides and suicides a year, Obama's plan notes that, "Research on gun violence is not advocacy; it is critical public health research that gives all Americans information they need."

Obama also will ask Congress to provide $10 million for the CDC to further study the relationship between "video games, media images and violence."

Judith Palfrey, the former president of the American Academy of Pediatrics, notes that gun-related injuries caused 6,570 deaths among children and young adults under 24 in 2010. In a recent editorial in The New England Journal of Medicine, she noted that gun injuries cause twice as many deaths in children as cancer and 15 times as many as infections.

Obama will also send a letter to health care providers, clarifying that federal law doesn't prevent them from reporting threats of violence to police. Many doctors are unsure what they can reveal about patients' mental health, due to strict federal patient privacy laws.

Richard Bonnie, a professor of medicine and law at the University of Virginia, said Obama's proposal to improve the reporting of involuntary commitments to the national gun background check system "is an important goal," but difficult to achieve.

"If it were easy, the states would have set up procedures for doing it already," Bonnie says. "The basic problem is that mental commitment proceedings are handled in very different ways from state to state and even from locality to locality within a state. Many states have no system for recording these cases in any centralized way. And many cases that would result in an involuntary judicial order in some states do not lead to such an order in other states because they are handled without judicial involvement."

But Bonnie said, "States should not impose reporting duties on doctors concerned about possibly suicidal patients, as New York just did, because doctors need flexibility to decide the best way of protecting patients. ... Imposing reporting duties could deter patients from seeking treatment."

Obama said he will also clarify that the Affordable Care Act doesn't prevent doctors from asking their patients about guns in their homes. The American Academy of Pediatrics encourages doctors to ask about guns in the home as a way to prevent injuries in children.

The pediatric group has clashed over the issue with Florida lawmakers, who in 2011 passed the Firearms Owners' Privacy Act, barring doctors from asking about guns in the home, "essentially gagging health care providers," Palfrey says in a recent article in The New England Journal of Medicine. Last June, a judge issued a permanent injunction preventing Florida from enforcing the law. Florida Gov. Rick Scott, however, has appealed her ruling. Three other states are considering similar bills.

"We also need to free health care providers from legal constraints on their violence-prevention efforts," Cornell says. "I don't think many people know that in some states doctors cannot talk to their patients about violence and are impeded in their efforts to help persons who are at risk for violence."

Obama said he will also send a letter to state health officials clarifying which kind of mental health care Medicaid plans must cover. Medicaid, a federal health insurance program for the poor and disabled that is administered by states, is the largest funder of mental health services in the country, the plan notes. The Affordable Care Act will make another 17 million people eligible for coverage.

Obama said he will also clarify which mental health and substance-abuse treatment benefits are considered "essential" in the new Affordable Care Act health exchanges. These are state programs to provide coverage for the uninsured, which must cover at least a minimum number of health needs, such as certain preventive services. The law also requires these health plans to cover mental health.

Obama said he also will finalize regulations on equal coverage for mental health. This coverage was provided by a 2008 federal law, but there are still no final regulations about how already existing health plans must implement that law.

Lastly, Obama said he will "launch a national dialogue," on mental health led by the secretary of health and human services and the secretary of education.

"The sense of shame and secrecy associated with mental illness prevents too many people from seeking help," the plan says.

Obama also called on Congress for more funding. He proposed spending $50 million to train 5,000 mental health professionals to work with young people in communities and schools.

The president also proposed a new program, Project AWARE (Advancing Wellness and Resilience in Education), to reach 750,000 young people with mental illness and refer them to treatment. The plan notes that 75% of mental illness appears by age 24.

Project AWARE would include $15 million to train teachers and other adults to detect and respond to mental illness in children and adolescents, as well as another $40 million to help school districts and other community institutions make sure young people get help they need.

The president also proposed $25 million for state efforts to identify and treat adolescents and young adults, ages 16 to 25, who often fall through the cracks after school. That's crucial, says Fitzpatrick, because half of teens with serious emotional disturbances drop out of high school before graduating.

"As anyone who works in schools knows, we do not have enough counselors and psychologists to help all of the students who have serious mental-health needs," Cornell says. "Every high school has students with mental illness and substance-abuse problems, and others who are coping with traumatic and abusive experiences in their home or community."

Cornell also praised the "greater focus on prevention rather than crisis response. We should not focus simply on what to do after someone starts shooting without placing a primary emphasis on prevention of shootings, and this means addressing the mental-health concerns, bullying and other conflicts that often precede violence. Many mass shootings can be prevented if we start early enough and reach out to troubled persons rather than waiting until the shooting starts. ... If we can provide our schools and communities with a team of mental health and law enforcement professionals that can be called upon to help in threatening situations, we can prevent many shootings."

Keris Myrick says she would like to see improved access to care. Myrick was once turned away from a hospital when she tried to be admitted for psychiatric help. Although she had private insurance, "they told me I would have a better chance getting in if I had Medicaid."

Myrick, president of the board of the National Alliance on Mental Illness, is being treated for schizo-affective disorder, which can cause hallucinations as well as mood disturbances, such as depression. "I was told I couldn't go back to school, that I couldn't work," Myrick says. But today, she has two graduate degrees and runs her own company, which peer support to people with mental health needs.

Myrick says she hopes the president's focus on mental health will reduce its stigma, and help show Americans that "there is a wide spectrum of people living with mental illness."

Liza Gold, a forensic psychiatrist at Georgetown University Medical Center, praised Obama for taking a comprehensive approach to protecting children.

But she says that mental health agencies are still impoverished, and that the mentally ill today lack essential services, such as employment assistance and structured residential housing, which can help them live on their own outside of institutions.

Palfrey praised Obama for putting together his initiative so quickly. "I hope all citizens will take it seriously and that our community will come together."

Doris Fuller, executive director of the Treatment Advocacy Center in Virginia, commended Obama for trying to address the stigma of mental health. She notes that killings such as that in Newtown reinforce the image of the mentally ill as violent.

Although about half of rampage killings are committed by people with untreated, severe mental illness, such as schizophrenia, Fuller says, only 1% of those with serious mental illness are violent.

Fuller's center has put forth its own action plan, which includes a pilot program on "outpatient commitment." Unlike an inpatient commitment, in which someone is institutionalized, outpatient commitment occurs when a judge orders a mentally ill person to undergo treatment in their community.

"There is a role for involuntary commitment in recovery," Fuller says. "We must be able to send people into treatment who won't seek treatment themselves."

"It's a terrible thing that it take terrible acts for everyone, from the public to the president, to look comprehensively at this situation," Fuller says. "But we can't think in silos, such as just looking at gun control. If we leave the mental illness treatment piece out of it, we will never get to a solution."