The Best and Worst States for Your Mental Health, 2015

Where our nation's mental health is concerned, disparity, not parity, rules.

Mental Health America released a new report today.  It's entitled Parity or Disparity: The State of Mental Health in America, 2015.  The report offers the first cumulative ranking of mental health status and access to services for all fifty states and the District of Columbia.

Source:  Data from www.mhascreening.org

The report includes measures of mental health status and access for adults and children, drawn from national databases that are regularly updated.  Altogether, they paint a very interesting picture of how states measure up to one another in protecting the mental health of their people.

The best states for your mental health?  Massachusetts leads the list, followed by Vermont, Maine, North Dakota, and Delaware.  Rounding out the top ten are Minnesota, Maryland, New Jersey, South Dakota, and Nebraska.

There are traditionally liberal and traditionally conservative states in the top ten, so what does that tell us?  Two things at least.  First, neither party has a monopoly on mental health policy, and so political compromise and consensus are more than possible when everyone works together.  Second, treating investments in mental health as a priority matters.

How about the bottom ten?

Idaho, Arkansas, Montana, Oklahoma, and New Mexico are in the next-to-last group of five.  And the bottom five are Louisiana, Washington, Nevada, Mississippi, and - last of all - Arizona.  As it turns out, no single region dominates the bottom ten.  And there's room for improvement most anywhere.

What's the best way to reduce the disparities among the states?  A concerted effort to invest in early identification and intervention would be a start.

Why are mental health conditions the only chronic conditions we wait until Stage 4 to treat, and then often only through incarceration? By that late stage, treatment is expensive and recovery is difficult to achieve - just as it is with Stage 4 cancer or Stage 4 heart disease.

When half of mental illnesses manifest by age fourteen, why do we wait ten years - until the diseases have robbed people of schooling and jobs, broken apart families, cost people insurance and housing - before we step in?

The problem is that too many policy makers are trapped in Stage 4 thinking.  They wait too long for crises to occur, and then respond inadequately when they do.

We could change this way of thinking, and change the trajectories of people's lives.  And - whether you think your state should have been ranked higher or lower - this report can help us do this.

To read the full report, click here.

For more information, email me at pgionfriddo@mentalhealthamerica.net.

The Missing Mental Health Element in the Ferguson Story

By now, everyone has heard the news from Ferguson, Missouri.  An unarmed 18 year old named Michael Brown was shot and killed by a police officer.  Michael Brown was black.

Some of the events surrounding the shooting are in dispute.  But what isn’t in dispute is that for the past two weeks, a community has been torn apart by race – a community that until recently was best known for its proximity to St. Louis and its designation as a Playful City, USA.

Picture credit: Health Affairs

Media reports since the August 9^th shooting have focused almost entirely on one angle – race relations. 

We’ve heard about unrest in the city, the National Guard, police in riot gear, and danger in the streets.  We’ve heard about the District Attorney’s ties to law enforcement, and concerns that a too-white Grand Jury may be racially motivated not to indict the police officer involved in the deadly shooting.

But the media have been strangely silent about a different angle – this community is experiencing an ongoing trauma.  And where are the mental health services it so desperately needs?

Make no mistake about this.  Race matters.

I have written in the past about people such as Anna Brown, Miriam Carey, and Allen Daniel Hicks, Sr., a mother, a dental hygienist, and a coach.  None survived encounters with the police during times of crisis.  

And we know they are not the only ones.

But what these people had in common was that the final crises they experienced were in part medical. In some respects, that makes them more sympathetic than Michael Brown.  In others, unfortunately, it allowed media to dismiss what happened to them as aberrations brought on in part by their medical emergencies and suspicion of mental illness (an assumption that proved to be fatally incorrect in all three cases).

So the message frames in those stories quickly dissolved.

But when we’ve got a community at “unrest,” the story frame lives on. 

But let’s read between the lines.  This isn’t just a community at unrest, this is a community in distress.

And it is time we did something about that.

I have posted a version of this blog on Mental Health America’s web site, which you can find here.  In that blog, you’ll find several resources to help communities in distress, ranging from local MHA affiliates to national helplines, to tools and training aimed at helping communities recover from tragedies.

You’ll also find a call to action to join our #B4Stage4campaign, which launches in September, at Mental Health America.  You will hear much more about this campaign in the coming months.  It is designed to move our attention around mental health to where it belongs – on prevention, early identification of concerns, and early intervention. 

And it is designed to get public officials and the media to recognize that managing distress comes first and prevents violence, and to demand that they put resources into families and communities before mental illnesses progress to “Stage 4,” when “danger to self or others” is the only standard we have – a standard that leads too frequently to incarceration or tragedies like these.

Finally, you’ll find mental health screening tools and other resources you can use for yourself or with family and friends, especially if you – like me – keep imagining what your life would be like if your child were the victim here, or if your community was the one falling apart.

Mental Health, America

اضغط هنا لمشاهد الفديو كامل 

I started writing Our Health Policy Matters three and a half years ago, right after the 2010 mid-term elections.

Since then, I have written about two policy areas about which I am passionate – public health and mental health.  As I explain below, I am about to change my professional focus.  And while I will be speaking about one more than the other in the future, for me these two areas are related. Let me explain why.

Mental health and public health are first and foremost about wellness.  They are about identifying risk factors for disease and eliminating or mitigating them.

Many of the same environmental risk factors contribute to poor health, especially poor mental health.  These include poverty, violence, abuse, and neglect.  When we address or mitigate these risk factors, we improve our nation’s health and mental health together.

We often place the burden of responsibility for maintaining one’s health squarely on the shoulders of individuals.  But this is a too-narrow approach.  We cannot prevent every physical illness by eating right and exercising, nor can we prevent every mental illness by simply willing it away.

What we forget sometimes is a simple, self-evident concept about wellness – the brain is a part of the body, and there is no health without mental health.

This leads to two unintended consequences.  The first is this.  In our effort to help people understand the linkage between mental illnesses and addictions, we use a term – behavioral health – that often implies to laypeople that these illnesses are bad behavior, and nothing more.  Mental illnesses therefore seem less serious than other chronic diseases – even though they shave twenty-five years or more from life expectancy.

The second is that we divide health care and mental health care into two non-integrated treatment systems.  We know the result.  Mental health care is poorly supported.  Our community support systems are inadequate.  People with serious mental illnesses are overrepresented in the homeless population.  Our jails and prisons have become our new state hospitals.

When we ignore the importance of promoting mental health and preventing mental illness and integrating care and treatment, we underestimate the power of recovery. 

Mental illnesses can be managed, just as any other chronic conditions can.  Recovery from cancer is possible – and even the norm for many – and so, too, should recovery be the norm for many mental illnesses.

When do not put resources into prevention, integrated care, and recovery, we make mistakes.  Because mental illness is often a childhood disease and there is a long lead time between the emergence of symptoms and the receipt of appropriate care, we make two mistakes in particular.  We overburden both our educational and primary care systems.

Our educators never expected to confront – as first-line responders – such needs in their classrooms.  Our primary care providers never expected to become experts in the early identification of mental illnesses.  Yet half of mental illnesses appear by age 14, and the vast majority of medications for mental illness are prescribed by primary care providers.

This system leads to failure.  I have explained why in other columns, and in an essay I wrote in 2012 for Health Affairs.  And I have written a book about the subject – Losing Tim – that will be published by Columbia University Press in the fall of this year.

But now I have been offered an extraordinary opportunity to do something more.

In a few weeks, I will become President and CEO of Mental Health America.

MHA is a Washington, D.C. area group that has advocated for mental health for over a century.  With 228 local affiliates scattered around the nation, MHA has an extraordinary history of leadership in the modern mental health movement in America – one that I hope to continue.

I am already part of an MHA family.  My wife Pam is, and will remain, CEO of the MHA Palm Beach County affiliate – the Mental Health Association of Palm Beach County.  And my daughter Lizzie works in direct services for the MHA affiliate in Connecticut, the Mental Health Association of Connecticut.

But my professional life is about to change.  For now, this will be my last Our Health Policy Matters column. 

I’ve appreciated the platform this column has given me, and hope that I have used it responsibly.  And I’m grateful to the thousands of readers who have come to this site each month.

I hope our paths will cross often in the future.  And I hope that when you think about Mental Health America, you will always think about mental health, America.  And about the work we still need to do to make mental health the norm for everyone.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

New Programs Show Value of Health and Behavioral Health Integration

A Kaiser Health News sampling of the latest headlines about Obamacare reflects our continuing anxiety over the law just months before it is fully implemented.

The most interesting to me was this one.  According to a new CNN poll, only 43 percent of the public favors Obamacare.  But of those who oppose it, only 35 percent do so because it is too liberal.  Sixteen percent say that it is not liberal enough!

No matter how you feel about Obamacare, one of the most significant changes it facilitates will be the integration of health and behavioral health care – meaning that care for both physical and mental illnesses will soon be delivered together.

This only makes sense.  People with cancer, for example, often develop depression or anxiety that complicates their care.  And people with mental illness often develop physical conditions – sometimes as a side effect from the medications they take – that can cut twenty-five years from their lives.

Integrating health and behavioral health care has not been the norm over the past century. 

In a nutshell, this is because regular health care evolved from an acute care model – the idea that we could cure disease with aggressive, short-term interventions.  Mental health care evolved from a chronic care model – that mental illnesses could be managed, but not prevented or cured.

What we have learned in the last 20 to 30 years shows that both models can be useful in treating all diseases.

So we began to manage some diseases that we could not cure using a newer chronic disease model.  HIV/AIDS treatment is an example, but so are today’s treatments for many chronic conditions, including cancers, heart diseases, diabetes, and hypertension.  And we began to use an acute care model to treat mental illness, offering short-term stabilization in addition to longer-term therapies.

With diseases co-occurring and treatments often intersecting, care integration was the logical next step.

In its 2010 document, Evolving Models of Behavioral Health Integration in Primary Care, the Milbank Memorial Fund offered numerous examples of the care integration approaches that have evolved over the past twenty years. 

And while care integration has been slow to gain traction, that is about to change as a result of the Affordable Care Act.

Access to insurance despite pre-existing conditions, prohibitions on rescinding coverage after a person gets a chronic disease, and greater parity in health and behavioral health benefits are three reasons why, from a consumer perspective. 

More billing options and better reimbursement rates for primary care providers offering behavioral health screening and support services are two reasons why, from a provider perspective.

And the call for early intervention to prevent future tragedies is one big reason why, from a purely political perspective.

This week and next, I have the good fortune of being witness to two cutting-edge integration initiatives that reflect our changing environment. 

I serve on the Board of Directors of the Jerome Golden Center for Behavioral Health, and this week attended the grand opening of its new primary care clinic.

For the first time in its forty year existence, this safety net community mental health center will offer formal primary care services in the same location in which it offers behavioral health services.  Patients will benefit from one-stop shopping, and receive monitoring and treatment for health conditions as they are treated for behavioral illnesses. 

Integrating health services into behavioral health services in this way is a far less common approach to integration than doing it the other way around.  HRSA, for example, notes that 70 percent of community health centers offer at least some mental health services.  But some people – especially those with serious mental illnesses – often access only behavioral health providers, because they are reluctant or unable to seek out care in multiple locations.

And in the coming week, I’ll be at the annual meeting of Mental Health America for a presentation by the Mental Health Association of Palm Beach County about its Be Merge initiative.  Through Be Merge and related initiatives, MHAPBC is training primary care and mental health providers to work together in any model to integrate health and behavioral health services.

The initiative has won Mental Health America’s 2013 Innovation in Programming Award, and is clearly ready for prime time.  MHAPBC has made the training and toolkit available online through the University of South Florida, for use by agencies and providers throughout the nation.

As these two initiatives show, integration has finally arrived.  Better late than never.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

The Stories Behind the Headlines: Is This the Best We Can Do?

Health policy has often been in the news headlines this month.  

To cite three examples, CDC released a new report about causes of death.  CMS published data showing wide variations in hospital charges for common procedures.  And, in the context of a newly-reported Oregon Medicaid expansion study, states have been making decisions about Medicaid expansion.

Let's look at the mental health policy stories behind the headlines.

Suicide on the Rise

The CDC reported this month that as of 2009, there were more deaths from suicide in the United States than there were from motor vehicle accidents.

Suicide rates increased by over 28 percent among men and women aged 35-64 from 1999 to 2010.  While men were three times more likely to commit suicide, the rate increased more for women (32 percent) than for men (27 percent).

Suicide rates are highest in the west, but they are increasing in 39 states.

Men are most likely to commit suicide with firearms, women with poison.  The most rapidly growing cause is suffocation.

During the same period, results were down slightly among elders, and up slightly among youth.  CDC speculated that the bad economy could be affecting rates.  It also noted that baby boomers have had elevated suicide rates throughout their lives.

So what are we doing about this?  The recent Medicaid and Medicare debates suggest a whole lot less than we should be.

Oregon Study Links Medicaid Expansion to Reductions in Mental Illness

By now, everyone knows that the Florida legislature decided not to expand Medicaid to over 1 million residents.

Florida isn’t alone – it looks like elected officials in approximately half the states will turn down Medicaid expansion for at least this year, and forfeit billions of dollars that could be used for patient care.

Many expansion opponents latched onto a study published this month in the New England Journal of Medicine to support the case against expansion.  The study analyzed the results of an Oregon Medicaid expansion program over a two-year period.  It concluded that the Oregon expansion had no effect “on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions.”

Expansion proponents looked for a silver lining, arguing that the study also showed that Oregon’s expansion improved access to care and increased the use of preventive services.

But both seemed to overlook the study’s most definitive conclusion – diagnoses of depression went down by 30 percent among those covered by the Medicaid expansion. 

Mental Health America notes that depression has been estimated to cost $77 billion annually.  So how many billions could we save by cutting depression rates by 30 percent?

And why isn’t this garnering all the headlines?

New CMS Data Show Wide Variations in Payments for Psychosis Care

This past week, the Centers for Medicare and Medicaid Services (CMS) released data on charges for hospitals throughout the country.  The release attracted plenty of attention, because there were wide variations in what different hospitals charged for the “same level of care.”

CMS wants high-charging hospitals to lower their charges.

Those charges, however, may not be the most important numbers in the data.  The real headline is in what Medicare actually pays for the “same level care” throughout the country.

If you suffer from psychosis, you’re better off being hospitalized in Maryland – where Medicare pays an average of $11,277 per discharge, twice as much as it does in a half dozen other states – than in any other place in the country.

The variation in payments in states – even within geographic regions – was astonishing.   I put a table with the numbers for all the states on my State Rankingspage, but here are just a few examples.    Alabama hospitals were paid only $5,256 per discharge, while those in Florida were paid $7,006 and those in Georgia $6,605.  Connecticut hospitals were paid $8,239 (note: the overall number of discharges was very small for Connecticut), while those in Massachusetts were paid $7,494.  North Carolina hospitals were paid $6,188; those in Virginia were paid $5,851 and those in the District of Columbia were paid $9,444.  California and Oregon hospitals were paid $8,916 and $8,816, respectively, but Washington hospitals were paid only $6,504.

You can see information for all the states here.

When we look at the three reports together, they certainly beg at least this question.  Is this really the best we can do?

Paul Gionfriddo will be speaking at the breakfast meeting of the Middlesex (CT) County Coalition on Housing and Homelessness on Friday, May 17, at 8 a.m.  It is open to the public; RSVP to ann@anendinten.org. 

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

Veterans and Mental Illness

On a sultry June morning in our national’s capital last Friday, I visited the Vietnam Veterans Memorial. 

Scores of people moved silently along the Wall, viewing the names of the men and women who died in that war.  Some stopped and took pictures.  One group of men about my age surrounded one name for a photo.  Two young women posed in front of another, perhaps a grandfather or great uncle they never got to meet.

It is always an incredibly moving experience to visit the Wall.  It treats each of the people it memorializes with respect. There is no rank among those honored.  Officer or enlisted, rich or poor, each is given equal space and weight.

It is a form of acknowledgement and respect for which many veterans still fight.

Brave Vietnam veterans returned from Southeast Asia to educate our nation about the effects of war and violence.

I didn’t know anything about Post Traumatic Stress Disorder when I entered the Connecticut Legislature in the late 1970s.  I had only vaguely heard of “shell shock” from which some World War I and II veterans suffered.  At that time, the condition, like the way we thought of other mental illnesses, suggested some sort of stigmatizing weakness inherent in the individual.
Vietnam veterans changed our thinking.

They knew that PTSD was a real mental illness caused by violence. 

It took courage and strength to deliver this message to a nation not ready to hear it.  We didn’t know then that the violence of war, the violence of neighborhoods and families, and the trauma of natural disasters cause this illness.

As a result of their advocacy, the National Vietnam Veterans’ Readjustment Study (NVVRS) was conducted in 1983.

It found that a startling 830,000 Vietnam Veterans (26%) reported symptoms of PTSD, and many thousands more had other mental illnesses, such as Depression.  As the National Center for PTSD summarizes, a re-analysis of the data twenty years later suggested that up to a staggering 80% of Vietnam veterans reported at least some symptoms related to PTSD.

The Persian Gulf War introduced a new illness, Gulf War Syndrome, to our lexicon.  It is characterized by both physical and mental health problems. Only 8% of Gulf War veterans have been diagnosed with PTSD, possibly because their exposure to violence was of shorter duration.  But nearly 38%, or 263,000, Gulf War veterans sought treatment from the VA alone for illnesses and chronic conditions, many related to Gulf War Syndrome.

According to the U.S. Department of Veterans Affairs, an estimated 10% to 18% of returning Iraq and Afghanistan War veterans have PTSD, and up to 25% will have Depression.

Mental illness is as devastating in veterans as it is in any population.  According to the National Coalition on Homeless Veterans, on any given night 107,000 veterans are homeless.  76% of these men and women have behavioral health illnesses.  140,000 are imprisoned.  Half of these have mental health problems.

While I was in Washington, I attended a dinner with my wife Pam and her colleagues at Mental Health America and its affiliates around the country, at the completion of their annual conference and before the ringing of their symbolic freedom bell, forged from the chains once worn by people locked in mental institutions.  The 2011 Clifford Beers Award winner, Dr. Patricia Deegan, a survivor of schizophrenia, spoke of the courage of those who refuse to give in to the diagnosis of serious mental illness and to let it define them.

The Vietnam veterans who lobbied me had such courage, and refused to let PTSD define them.

We have fought three seemingly endless ten-year-plus wars in the last fifty years, and another one which caused significant physical and mental damage to its participants.  Millions of veterans and their families have been affected by PTSD.

Thousands of others who have been exposed to violence, terrorism, and natural disasters also share this experience.  

This should teach us an important lesson.

Mental illness doesn’t cause violence, but exposure to violence causes mental illness.

One of the things I love most about America is that although we are so diverse, we share a common purpose.   

The people whose names are on our national monuments - Washington, Lincoln, and the 58,272 on the Wall – remind us that this common purpose involves an entitlement to life, liberty, and the pursuit of happiness.

June 27 is PTSD Awareness Day.  It is a good day to remind ourselves why the bells of freedom mean so much to us all, especially the 7% of all adult Americans with PTSD.

The people whose names are on that Wall are remembered for sacrificing to give the rest of us a safer, more secure life.  They would not have forgotten those who came home with mental illness.

To receive an email notifying you of the publication of new Our Health Policy Matters columns, please email gionfriddopaul@gmail.com.  For a collection of hyperlinks used in past columns, please visit the Data Source Links page.

Mental Health Budget Cutters on the Wrong Side of Reality

How do we help political leaders understand that the actions they take can have a profound, long-term effect on the mental health of our population?



copyright Mental Health America, 2011

David Shern, CEO of Mental Health America and one of the nation’s leading mental health advocates, has an answer.  Arguing that “the next century of mental health in the U.S. needs to be fundamentally different” from the last one, he makes the case for a new “vision for mental health now within our grasp.”

Speaking at an April 13th seminar sponsored by the Mental Health Association of Palm Beach County, FL, Dr. Shern offered a glimpse into a policy future that could reverse the epidemic of mental illness in America. 

“The United States has the highest rate of mental illness in the world,” he began, as he laid out the present state of mental health in the United States.

·         One in four of us have diagnosable mental illnesses each year.  Half of us will have diagnosable mental illness in our lives.

·         By 2002, serious mental illness cost us $193.2 billion in lost earnings per year, an amount greater than the annual revenue of every Fortune 500 company except one.

·         The mean age of onset of mental illness in America is 14, but treatment for mental illness is typically delayed for up to ten years.

·         Chronic disease, or disability, accounts for 70% of death.  Diabetes accounts for 3% of disability, arthritis 4%, cancers 12%, cardiovascular disease 15%, and mental illness over 20%.

Dr. Shern believes that we have accepted this current state of affairs for far too long.

Serious mental illness robs people of 25 years of life, but as he pointed out, “these are not death sentences.”  With proper diagnosis, care, and rehabilitation, even 50% of people with schizophrenia can largely or fully recover.

Dr. Shern says that there is a lot we can do about mental illness.  He believes that a 21^st century mental health system should focus on both prevention and treatment. 

Mental illness prevention strategies should be modeled on the hugely successful 20^th century public health program. 

He cited compelling evidence from a 2009 IOM report that addressing environmental factors, including child abuse and assault, neighborhood and family violence, and substance-abusing caregivers, can prevent mental illness.  He used as an example a long-term Seattle-based study, which found that at-risk children whose parents received training had a 38% reduction in mental illnesses 15 years later.

To illuminate the point some more, he presented data showing that when immigrants arrive in America, they have the lower rates of mental illness of their former nations.  After several years in this country, they experience mental illness at the higher rate of the rest of our population. 

His treatment strategies are modeled on inclusion and integration. 

In his talk, he advocated for a reversal of the 20^th century practice of segregating mental health care from other health care.  He promoted collaborative care models, in which primary care and mental health professionals practice side by side.  It’s a good investment, which one insurance company found saved $2 for every dollar spent.    

He sees hope in both the Mental Health Parity Act and the Affordable Care Act, which provide for better treatment coverage and more prevention dollars for mental health.  But he observed that it took more than a decade for Congress to pass the Mental Health Parity Act, despite strong public support for it.

He derives inspiration about the future from Dr. Julius Richmond, former Surgeon General, who said that societal change requires three elements – science, the ability to implement, and political will. 

We have the science to identify the best methods for preventing and treating mental illness, he said, and the ability to implement them.

But what of our political will?

Around the country, political leaders are making people with mental illness budget scapegoats.  In a recent blog, I wrote how states are pushing huge cuts to mental health. The same day Dr. Shern gave his talk, the U.S. House voted to repeal the ACA prevention dollars he referenced. 

It is as if they believe people with mental illness are responsible for unbalanced budgets. In the face of overwhelming evidence to the contrary, they act as if nothing they do for, or to, people with mental illness will make a difference.

If they listened to Dr. Shern, they would know that they were on the wrong side of reality.  Mental illness prevention and treatment programs are working and should be expanded. 

If legislators are not careful, a new mental health catastrophe may be just around the corner from the cuts they make. 

This is an important message for every American.  And every American, Dr. Shern concludes, must play a role in creating the political will we need to change our mental health trajectory for the better.

For more information, contact Mental Health America at www.nmha.org, the Mental Health Association of Palm Beach County (www.mhapbc.org) or your local Mental Health America affiliate.  You can also get information about mental health and mental health advocacy through NAMI (www.nami.org) or your NAMI affiliate. 

For information about this blog, or to subscribe to the Our Health Policy Matters weekly email, contact gionfriddopaul@gmail.com.