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Mental Health’s Great Gray Area (Op-Ed)

Most acts of violence are committed by people who are not mentally ill. And people with mental illness are more likely to be victims of violence than perpetrators. But tragedies like those in Newtown, Aurora, and Tucson nevertheless tend to jump-start vital conversations about mental-health services and policy. So we have to ensure that we accurately identify policy changes that would actually improve our collective response to mental health issues.

As the commissioner of one of the country’s largest behavioral health systems, Philadelphia’s, I know we can effectively treat most of those who seek treatment, even for the most serious forms of mental illness, such as schizophrenia. And we have laws that allow us to involuntarily commit those who don’t seek treatment but are clearly a danger to themselves or others.

People who don’t fit into either category, however, fall into what I call the “gray zone.” This is where even the best behavioral health systems face the greatest challenges.

The onset of serious mental illness typically occurs in the late teens and early twenties. Symptoms of serious mental illness often emerge slowly over this period and can be difficult to detect. After a mass shooting, we often hear from friends and relatives of the perpetrator that they felt something was amiss but weren’t sure what to do about it. And clearly those who are experiencing behavioral health issues themselves may not recognize their need for treatment.

That is the crux of the gray-zone problem: not that we don’t know how to treat these individuals, but that too often, we aren’t given the chance. Usually this causes distress that individuals and families experience in isolation. But sometimes it can lead to more public tragedies.

Dearth of prevention

One factor preventing behavioral health systems from aggressively reaching out to people in the gray zone is funding flexibility. Currently, mental health professionals are required to show the “medical necessity” of services to be reimbursed by Medicaid, Medicare, or private insurance (the primary sources of funding for behavioral health care). Only services focused on ameliorating an active mental health condition are reimbursable.

This means funding agencies like mine typically devote less than 3 percent of their budgets to prevention and early intervention. That leaves families and communities to fend for themselves when it comes to identifying those who need help and navigating the system to get it.

Behavioral health systems across the country need more flexibility to fund “upstream” activities focusing on outreach, early identification, and engagement. We should probably be spending at least a third of our budgets on prevention and early-intervention services.

First aid

Despite current limitations, Philadelphia is undertaking several low-cost and potentially high-impact responses to gray-zone issues. One of the most promising is called mental health first aid, a program to teach the public the basics of spotting behavioral health issues and addressing them earlier. The goal is to increase the community’s ability to recognize these issues and to give them the confidence to assist relatives, friends, coworkers, and others who may be experiencing psychological distress.

Philadelphia’s program is perhaps the most audacious in the country, with a target of training 10 percent of the city’s population, including teachers, first responders, parents, and others. So far, the enthusiastic public response has shown a thirst for this kind of information.

The city has also launched an online screening resource that can help detect mental health issues early and recommend ways to get help.

As we continue our painful national discussion of how to prevent the next Newtown – a discussion that must address gun control as well – we need to avoid stigmatizing mental illness, keeping in mind that violence is rarely associated with it. At the same time, we need to clearly identify policy changes that will allow us to improve our overall approach to mental health in this country. Yes, we need more consistent and sustainable funding. But we also sorely need more flexibility to spend our current funding in ways that allow us to intervene earlier and more effectively with those in the gray zone.

–Dr. Arthur C. Evans, Commissioner, DBHIDS