There is no doubt that we are in an era of significant policy and practice change for behavioral health and the broader health care field. The Mental Health Parity and Addiction Equity Act of 2008, the Affordable Care Act and the National Dialogue on Mental Health have all brought increased focus and attention on health care. Unfortunately, a number of large-scale incidents of violence have also ignited inaccurate conversations about the association between violence and mental illness.
What is the future of behavioral health within the context of this momentous change? Given the magnitude of the challenges, along with the opportunities that are present, we believe that now is the time to reframe how we address behavioral health needs and adopt a public health framework for the field.
We know that behavioral health needs are widespread. Approximately 25 percent (one in four) of adults and 20 percent (one in five) of children experience a mental health disorder. Approximately one in ten persons experience an illicit drug or alcohol abuse problem. There are disparities in access to and quality of care. Suicide is the 11th leading cause of death overall and the 3rd leading cause of death among young people.
Advances in treatment research have shown us that the majority of individuals can and do recover, even from the most serious forms of mental illness, including schizophrenia. We also have increasing recognition that mental and emotional well-being is essential to everyone’s overall health. The World Health Organization (WHO) has defined health for decades as “a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity” (WHO, 1946). However, behavioral health is often not discussed in the context of physical health or wellness, and when it does enter the conversation, it typically focuses on symptom reduction.
We also have broader knowledge that health is influenced by many factors, including stress, availability of support, experiences of trauma, access to behavioral health care, educational and economic opportunities and the social and physical environment. Yet the field continues to focus almost exclusively on increased access to treatment as the solution for all behavioral health problems. While access to an excellent, recovery-oriented treatment system grounded in the best science is essential, we must shift from focusing solely on treatment as the answer for all behavioral health challenges.
Traditional behavioral health treatment systems are also extremely passive. We wait for individuals to develop a behavioral health diagnosis before we intervene and only focus on those with a diagnosis because of how health care is financed. However, fewer than one out of three adults and one out of two children with a diagnosable mental disorder receive mental health services, and the majority of people who do access care only come one time. This means that a significant number of people experience mental health challenges but never receive treatment. Further, this means that treatment systems are designed to address the needs of a small proportion of the population, while spending billions of dollars on expensive high-end treatment. Finally, we know that even if someone does not have a diagnosable mental health condition, he/she may not be mentally well.
In contrast to a traditional behavioral health approach, taking a public health approach allows behavioral health to employ a more robust set of strategies and interventions to address the range of conditions that people experience. Below are five truisms that we believe provide a public health framework for the behavioral health field:
1. We need to focus on POPULATION HEALTH. A public health approach focuses on universal or population health as well as individual health. Whether or not we have a diagnosable behavioral health condition, we all appreciate that we have mental health needs just as we all have physical health needs. Yet the behavioral health field focuses on the 5–25 percent of the population with a behavioral health diagnosis and waits for everyone else to develop one before intervening. As entities like accountable care organizations (ACOs) emerge that are financially incented to keep populations healthy, there will be a greater need to develop population approaches that address behavioral health needs, especially since unaddressed behavioral health needs impact overall health and drive health care costs.
2. We need to MOVE UPSTREAM. Prevention and early intervention are more efficient than treatment. Fortunately, there are evidence-based early intervention programs available for even the most serious forms of mental illnesses including schizophrenia. There are also known risk factors for behavioral health conditions, including having a biological family member with a mental illness, limited social support and experience of a traumatic event. This means that we can intervene with individuals and communities who are at risk for a behavioral health condition before they develop an illness. Physical health care recognizes the importance of taking this approach by working to prevent diabetes and other health conditions through the promotion of healthy eating and exercise.
3. We need a BROADER RANGE OF RESPONSES. There are many ways to intervene to improve health status. However, the behavioral health field continues to primarily use medication and psychotherapy. We need to use a broader array of public health strategies such as policy changes, public education and redesigning social and physical environments. For example, we can use programs such as Mental Health First Aid to educate the public about how to support individuals who are experiencing a mental health challenge. Finally, we need to attend to the social determinants—such as exposure to violence and poverty—that contribute to our mental health. Innovative programs such as the collaboration between the City of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services and the Mural Arts Program, the Porch Light Program, provides an opportunity for individuals to improve their own physical environments, serves as a chance for communities to positively contribute to their neighborhoods and provides hope.
4. We need to focus on HEALTH PROMOTION. Health is more than the absence of symptoms. A public health approach focuses on holistic health promotion such as exercise and nutrition. We know that there are universal protective factors that promote wellness such as the availability of social support and stress management skills. However, because of the focus on symptoms and pathology, our knowledge of protective factors is rarely used for behavioral health promotion. Employing these kinds of activities should be a part of a behavioral health approach.
5. We need to think BEYOND THE TREATMENT BLACK BOX. It is essential for behavioral health practitioners to redefine their role and see themselves beyond the “treatment black box.” We need to be able to apply our broad knowledge and skills across the continuum of mental health challenges and in a variety of settings. For example, consulting with child-serving systems on how to more effectively address behavioral problems can reduce the need for more significant mental health interventions.
We all benefit from public health initiatives every day, by wearing helmets and seat belts, drinking fluoridated water, riding in bike lanes and washing our hands. Yet we have not used a public health framework to address one of the most critical health issues facing our society today—behavioral health. In order to move to a public health framework, we will need to change current fiscal policies that prevent us from paying for early interventions. Despite these constraints, Philadelphia has moved aggressively to implement a range of innovative public health behavioral health strategies, including some featured at www.healthymindsphilly.org We have also focused on implementing a number of the innovative behavioral health and physical health integration models that are highlighted in this issue to ensure optimal health care. We need to promote broader access to these models, and we also need to think about what other innovative practices we can do as a whole city to promote health.
We all have a role in improving our own emotional and mental well-being, as well as our family members, friends, co-workers and the broader community. As John F. Kennedy said so eloquently in 1963, “We must promote—to the best of our ability and by all possible and appropriate means—the mental and physical health of all our citizens.”