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Mental Health Care In America: Not Yet Good EnoughRICHARD FRANK AND Sherry Glied chose the title Better But Not Well for their seminal 2006 work on U.S. mental health care since 1950. Better But Not Good Enough would be an apt title for this thematic issue of Health Affairs, published with the support of the MacArthur Foundation. The United States has clearly crossed a watershed in the past year, with passage of federal parity legislation finally burying the nonscientific distinction between "mental" and "physical" illness. But to say there’s been progress in understanding these brain disorders—not to mention in the care provided those suffering from them—doesn’t negate the fact that there’s still much farther to go. Consider how the science of mental illness has evolved since Health Affairs’ first MacArthur-funded section on the subject in 1990. Among myriad discoveries made since then is that roughly 80 percent of the genes expressed elsewhere in the human body are also expressed in the brain. That helps explain the fact that the chemical compound serotonin has wildly different bodily functions—serving, for example, as a brain neurotransmitter as well as a key substance in the blood, liver, and gastrointestinal tract. Yet while we know that conditions like depression and anxiety are linked to disruptions in the brain’s serotonin pathways, we still have no firm understanding of how selective serotonin reuptake inhibitors (SSRIs) like Prozac really work. Needless to say, any interaction between brain serotonin and serotonin in the stomach remains beyond our comprehension. So in the meantime, our scientific understanding lacking, we medicate the depressed with SSRIs and other drugs and give antipsychotics to those with schizophrenia. We’re gratified when the drugs work for many patients, as well they do. But as the papers in this volume make clear, we are also flummoxed in sorting out science from pseudoscience, or even putting to use the evidence we have before we get even better data. This is true throughout health care, but the anomalies seem truly devastating in mental health care. Take the mounting evidence of the useful role of prevention and early intervention—probably employed even less in mental health care than elsewhere. In this issue’s Report from the Field, writer Steve Bogira quotes Chicago mental health clinic head Dr. Carl Bell as saying he feels as if he’s in the "iron lung business," providing care that is increasingly out of step with science. This lag is compounded by the fact that mental health treatment, especially for lower-income populations, is still a low-priority societal activity—often brought into focus only amid terrible tragedy. We now know that the April 2007 shootings at Virginia Tech were preceded two years earlier by an episode in which the shooter, Seung-Hui Cho, was ordered by a Virginia special justice to seek outpatient mental health treatment that he never got. It’s therefore dismaying to read of one subsequent finding by the state’s mental health law reform commission—that about half of those who were evaluated for emergency services by the state’s community service agencies were people much like Cho, who weren’t currently in treatment. Clearly, well beyond implementation of parity laws, much remains to be done to improve both treatment and quality of life for the mentally ill. Robert Drake and colleagues focus on Social Security Disability Insurance, since more than a quarter of adults on SSDI have a primary psychiatric impairment. Most want to work but are limited to no more than twenty hours a week—when the evidence suggests that "supported employment" would both save money and help them do better. What’s more, many proposals now popping up as health reform initiatives could improve mental health treatment immeasurably. Comparative effectiveness research has already established that the older generic antipsychotics work as well as a class as the newer, branded, more expensive atypical ones. And stepped-up quality improvement efforts, write Audrey Burnam and colleagues, could increase the effectiveness of mental health treatments provided to veterans. Come to think of it, how about aiming for this title for Health Affairs’ next theme issue on mental health care: Why Not the Best?
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