The diagnoses and severity of mental and substance problems vary widely -- from distress caused by a life-changing event to severe depression to physical dependence on alcohol. Each year more than 33 million Americans, many of whom are working adults, use health care services for such conditions. And research shows that successful, cost-effective treatments exist. However, as with general health care, the delivery of high-quality interventions can be spotty, and poor care has serious consequences: Mental health problems and alcohol and drug issues are leading risk factors for suicide. Furthermore, the consequences ripple throughout the U.S. education, legal, and welfare systems and the workplace in the forms of lost productivity, low academic achievement, and dysfunctional behavior.
"America will not have a high-quality health system if equal attention is not given to mental health issues and substance-use problems," said Mary Jane England, president, Regis College, Weston, Mass., and chair of the committee that wrote the report. "Mental health is inextricably linked with health and well-being, but treatment for mental conditions and inappropriate use of substances is often separated from other health care."
Health services for these conditions have been isolated not only from other components of the health system but also from each other, despite the fact that many people have both mental conditions and problems with alcohol or drugs. To make collaboration and coordination of care the norm, service providers should link relevant areas of their own organizations and form ties with other providers, the report says.
Government agencies, purchasers, health plans, and accrediting groups also should create incentives and policies to increase collaboration among all health care providers, the report says. The U.S. Department of Health and Human Services should lead these efforts by establishing a permanent, high-level mechanism to foster greater coordination across the department's mental, substance-use, and general health care agencies.
A broad range of providers is licensed to diagnose and treat mental health and substance-use illnesses. Consequently, their training levels and therapeutic approaches often differ, leaving the overall work force with an uneven distribution of the knowledge and skills necessary to provide consistent, high-quality services. Congress should authorize and fund a Council on the Mental and Substance-Use Health Care Work Force to develop and implement plans to help professionals improve the quality of their care, the report says. Licensing boards, accrediting organizations, and purchasers should adopt any national standards identified by the council, which would operate as a partnership between the public and private sectors.
Likewise, government programs, employers, and purchasers should allocate funds in ways that better support the delivery of high-quality care, the committee said. For example, states should revamp how they purchase health care services, giving more weight to the quality of care that vendors would provide.
Health professionals' ability to quickly obtain and share information on a patient's health and potential treatments is essential to effective care, the report says. Federal and state governments should revise laws, regulations, and administrative practices that hinder such information sharing.
Public-private partnerships are now developing an information technology system called the National Health Information Infrastructure (NHII) to make the exchange of health information easier. But so far, these efforts have not adequately dealt with health care for mental and substance-use problems, the report says. HHS and the U.S. Department of Veterans Affairs should take steps to ensure that NHII will thoroughly address such conditions. Additionally, federal and state governments, purchasers, and foundations should offer clinicians and groups who treat these problems incentives to invest in the information technology needed to fully participate in NHII.
HHS should synthesize and disseminate scientific evidence on effective services for mental and substance-use conditions, the report adds. It also should lead efforts to significantly develop an infrastructure for measuring and improving the quality of mental and substance-use health care. To this end, the department, working with the private sector, should charge and fund a group similar to the National Quality Forum -- a private, nonprofit organization -- to identify and put into practice quality measures in these areas. And HHS should oversee a coordinated research agenda for improving care.
The report -- like the Institute of Medicine's 2001 report CROSSING THE QUALITY CHASM: A NEW HEALTH SYSTEM FOR THE 21ST CENTURY -- envisions a revamped health care system that not only is centered on the needs, preferences, and values of patients, but also encourages teamwork among health care workers and makes much greater use of information technology. Patient-centered care is especially important in the delivery of mental health services and treatments for addictions, the report says, because of the stigma sometimes associated with interventions and greater use of coercion into treatment compared with general health care.
The study was sponsored by the Annie E. Casey Foundation; CIGNA Foundation; U.S. Department of Veterans Affairs; Robert Wood Johnson Foundation; and the U.S. Department of Health and Human Services' Substance Abuse and Mental Health Services Administration, National Institute on Alcohol Abuse and Alcoholism, and National Institute on Drug Abuse. The Institute of Medicine is a private, nonprofit institution that provides health policy advice under a congressional charter granted to the National Academy of Sciences. A committee roster follows.
Copies of IMPROVING THE QUALITY OF HEALTH CARE FOR MENTAL AND SUBSTANCE-USE CONDITIONS will be available this fall from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at HTTP:/
[ This news release and report are available at HTTP:/
INSTITUTE OF MEDICINE
Board on Health Care Services
COMMITTEE ON CROSSING THE QUALITY CHASM: ADAPTATION TO
MENTAL HEALTH AND ADDICTIVE DISORDERS
MARY JANE ENGLAND, M.D. (CHAIR)
President Regis College Weston, Mass.
PAUL S. APPELBAUM, M.D.
A.F. Zeleznik Distinguished Professor of Psychiatry; Chair, Department of Psychiatry; and Director, Law and Psychiatry Program University of Massachusetts Medical School Worcester
SETH BONDER, PH.D.
Consultant Bonder Group Ann Arbor, Mich.
ALLEN DANIELS, ED.D.
Chief Executive Officer Alliance Behavioral Care Cincinnati
BENJAMIN DRUSS, M.D., M.P.H.
Rosalynn Carter Chair in Mental Health Emory University Atlanta
SAUL FELDMAN, D.P.A.
Chairman and Chief Executive Officer United Behavioral Health San Francisco
RICHARD G. FRANK, PH.D.
Margaret T. Morris Professor of Health Economics Harvard Medical School Boston
THOMAS L. GARTHWAITE, M.D.
Director and Chief Medical Officer Los Angeles County Department of Health Services Los Angeles
GARY GOTTLIEB, M.D., M.B.A.
President Brigham and Women's Hospital, and Professor of Psychiatry Harvard Medical School Boston
KIMBERLY HOAGWOOD, PH.D.
Professor of Clinical Psychology in Psychiatry Columbia University, and Director of Research on Child and Adolescent Services New York State Office of Mental Health New York City
JANE KNITZER, ED.D.
Director National Center for Children in Poverty Columbia University New York City
A. THOMAS MCLELLAN, PH.D.
Director Treatment Research Institute Philadelphia
JEANNE MIRANDA, PH.D.
Professor Department of Psychiatry and Biobehavioral Sciences University of California Los Angeles
LISA MOJER-TORRES, J.D.
Attorney Lawrenceville, N.J.
HAROLD ALAN PINCUS, M.D.
Professor and Vice Chair Department of Psychiatry University of Pittsburgh School of Medicine, and Senior Scientist and Director RAND-University of Pittsburgh Health Institute RAND Corp. Pittsburgh
ESTELLE B. RICHMAN
Secretary Pennsylvania Department of Public Welfare Harrisburg
JEFFREY H. SAMET, M.D., M.P.H.
Professor of Medicine and Social and Behavioral Sciences, and Vice Chair for Public Health Boston University Schools of Medicine and Public Health; and Chief General Internal Medicine Boston Medical Center Boston
TOM TRABIN, PH.D., M.S.M.
Consultant El Cerrito, Calif.
MARK D. TRAIL, M.A.
Chief, Medical Assistance Plans Georgia Department of Community Health Atlanta
ANN CATHERINE VEIERSTAHLER, R.N., S.C.S.J.A.
Registered Nurse Ancilla Convent Milwaukee
Chair National Mental Health Association Cartersville, Ga.
CONSTANCE WEISNER, M.S.W.,
Professor Department of Psychiatry University of California, San Francisco, and Investigator Division of Research Northern California Kaiser Permanente San Francisco
ANN E. K. PAGE, R.N., M.P.H.
RYAN PALUGOD, B.S.
Senior Project Assistant
Vanee Vines, Senior Media Relations Officer
Christian Dobbins, Media Relations Assistant Office of News and Public Information