Charting the Future of Public Mental Health Care

1. Charting the Future of Public Mental Health Care South Australia Research Day March 27, 2008 Lloyd I Sederer, MD Medical DirectorNew York State Office of Mental Health

2. Outline • A view from up high • New York State • Recovery • Context • Psychotic Illness, Consumers and Interventions • Transforming Mental Health Care • Research • Conclusions

3. Patterns of Mental Illness and Care 50% of the population: no lifetime mental illness Who gets care: • 25% of all those with MI • 50% of those with serious MI • Where care is given: • General Medical Sector • Mental Health Specialists • OMH Financed System 50%--some MI in lifetime GM 20-25%some MI within any year MH 10-15%mild impairment 5-7%moderate impairment O 5-9% (Kids) 3-5% (Adults) Severe Impairment NYS OMH 4.07

4. NYS Office of Mental Health • State agency reporting to Governor of NYS (19 million people, 57 counties and NYC) • OMH directly run services • 26 Psychiatric Centers (PCs):Centers of Excellence • Adult, Child and Family, and Forensic Centers • 5500 inpatients • 17,000 employees • 50 mental health clinics in state prisons • Two Research Institutes • Psychiatric Institute – Columbia • Nathan Kline Institute – New York University • 2500 statewide community based programs (NGOs) • OMH licenses, regulates and funds • Budget • $ 3+ billion/year for MH provided by OMH and $3+ billion/year through other state agencies (e.g., Medicaid)

5. Recovery as the New Paradigm • Mental Health Commissions in USA: • - 1978 First Lady Roslyn Carter • - 2003 Commissioner Michael Hogan • “The biggest change in mental health from 1978 to today is that… …we now know that recovery is possible for any individual with a mental illness” Rosalyn Carter But what does Recovery mean and how do we support it?

6. Recovery • A process of managing one’s mental illness, moving beyond its devastating psychological effects, and pursuing a personally meaningful life in the community • Involves hope, motivation, personal responsibility, individual goals, and participation in community life - but not necessarily the absence of symptoms

7. Recovery: over the long term, many people achieve substantial relief from severe mental illness • 1. Bleuler (1978). The Schizophrenic Disorders. New Haven, Yale Press • 2. Huber et al (1975). Long-term follow-up…Acta Psychiatrica Scand. 53:49-57. • 3. Ciompi & Muller (1976). Lebensweg und alter…Berlin. Verlag Springer. • 4. Harding et al. (1987). Vermont longitudinal study…Am. J. of Psychiatry 144: 718-735. • 5. Tsuang,M. et al (1979). Long-term outcome…Arch. Gen. Psych. 36:1295-1301

8. National Context - USA • Recipients denied recovery opportunities • NCS-R: 25% (1990)  40% (2001) of people with SMI getting any treatment • Schizophrenia PORT Concordance: 25% (1975)  40% (1997) • Onset and Lag times • Average age of onset of mental illness is 14 years (Kessler) • Average lag from onset of mental illness to entry into care is 9 years (Kessler)

9. 1972 31% receive food stamps 33% receive Medicaid No SSI 7% receive SSDI No section 8 housing 1998 63% receive food stamps 60% receive Medicaid 41% receive SSI 30% receive SSDI 4% have housing voucher Resources to People with MI in USA have Increased The improvements in resources and benefits came largely from mainstream federal programs. They contributed to increased—if still marginal—well being…AND to complexity and fragmentation. Frank and Glied, 2006

10. New York State2005 Medicaid Funded Services • “Coordinated” Care aka “Uncoordinated” Care • 29% of adults with SMI used only inpatient care • 27% of children/adolescents used only inpatient care • 28% of inpatient discharges were followed by an outpatient visit within 7 days; 42% within 30 days • Readmissions • 20% @ 30 days • 41% @ 180 days • Adult OMH PC ALOS • ~ 1 year (= $230,000/per person per year)

11. The Paradox of MH Systems • Clinical talent and dedication • Investment of money and resources • People with mental disorders can and do recover • But results are far from optimal: • The care system often lacks accountability, integration and coordination • The care system avoids risks more than manages them

12. Psychotic Illness • 90% of patients will have at least one psychotic relapse within five years due to • high attrition rates from treatment • failure to implement EBPs • limitations of available therapeutics • Psychosis is likely neurotoxic • Schizophrenia • Neurocognitive deficits - abnormalities in perception and information processing • Persistent dimension of the illness that directly and permanently limits functioning

13. Good Treatment is Sufficiently Comprehensive:One Year Relapse Rates With Integrated Services for People with Schizophrenia • The combination of optimal psychosocial and pharmacological intervention for management of symptoms has been termed “illness management and recovery” Percent 54% 27% 23% 14% + Problem Solving Case Management & Medication + Family Education + Social Skills Training Falloon, IRH, Held, T, Coverdale, JH, Roncone, R, Laidlaw, TM. (1999) Psychosocial Interventions for Schizophrenia: A review of long term benefits of international studies. Psychiatric Rehabilitation Skills, 3, 268-290

14. The Reality of Serious Mental Illness How do People with Long Term Illness Progress to A Full Life? Initial Wellness Onset of illness/ psychosis ? Consumer Capabilities Relapse Adjusting to life with psychiatric disability Symptom Relief For too many people, repeat…again and again Hospitalization Hospitalization Time/ Course of Illness/Recovery

15. What do Consumers Want? • To live…in their community • To work…in their community • To participate fully…in their community

16. Services Evolve As Our Vision Evolves Housing Comm Clinics Rehab Services/Work Peer Services Health Care Comm. Clinics Day Tx Case Mgt Group Homes Hospitals Protection Era Treatment Era Recovery Era

17. Transforming Mental Health Care • Housing • State Psychiatric Centers of Excellence • Community Based Care • Co-occurring disorders • MH and Health • MH and Substance Use Disorders • Employment • Poverty • Violence and Mental Illness • Public Mental Health Quality Improvement

18. Housing (USA)Fewer People with SMI are Living In Inappropriate Settings Frank and Glied: Better But Not Well

19. Housing for People with SMI • Specific challenges in housing for people with psychiatric illness • Long duration of illness • Variable course of illness and disability • Separating housing from support services • What form of housing works - • For who? – adult, youth, forensic • At what point? • Housing First --->>

20. Housing: The “Continuum of Care” Model Independent Living Supervised Apartments Increased Consumer Capabilities Halfway House Quarter Way House Hospital Reduced levels of Support

21. NY/NY III Evaluation • Do NY/NY III participantsuse fewer/more appropriate public resources than similar individuals who do not participate, or than they used prior to beginning the program? • Are the health, social measures, employment rates, and attainment of educational degrees of NY/NY III participants better than those of similar individuals who do not participate, or than they were prior to beginning the program? • Are certain types of characteristics (housing/recipient) more effective/improved outcomes more than others, including location of housing? • Is there bias in the kinds of individuals who are selected to participate in NY/NY III? • Is NY/NY III a cost-effective program? • Are consumers satisfied with NY/NY III housing and housing services?

22. State Psychiatric Centers of Excellence • Reduce long stay (>1 year) patients in adult facilities • Convert portion of long stay adult inpatient beds to acute/intermediate level of care increasing annual admissions • Enhance programming in adult and forensic facilities • Mental health • Wellness • Expand state operated outpatient services, including clinics and residences • Deploy our experienced staff to meet community needs • Strengthen facility involvement with community-based services

23. State Psychiatric Centers of Excellence Health and Mental Health Promote consumer health and wellness SPAN Smoking Cessation, Prevention, Activity, and Nutrition

24. OMH SPAN Poster

25. 5 14 Multiple Risk Factors 12 4 10 Odds ratios 8 Single Risk Factors 6 3 4 2 2 0 BMI >27 Smoking TC >220 DM HTN Smoking+ BMI Smoking+ BMI + TC >220 Smoking+ BMI + TC >220 + DM Smoking+ BMI + TC >220 + DM + HTN Co-Occurring Disorders: Health and Mental Health Cardiovascular Risk Factors The Framingham Study BMI = body mass index; TC = total cholesterol; DM = diabetes mellitus; HTN = hypertension. Wilson PWF et al. Circulation. 1998;97:1837–1847.

26. No Data Less than 4% 4% to 6% Above 6% Diabetes and Gestational Diabetes Trends: US Adults, BRFSS 1990 Mokdad et al. Diabetes Care. 2000;23:1278-1283.

27. Diabetes and Gestational Diabetes Trends: US Adults, Estimate for 2010 No Data Less than 4% 4% to 6% Above 6% Above 10% www.diabetes.org.

28. Prevalence of Diagnosed Diabetes in General Population Versus Schizophrenic Population Percent of population Schizophrenic: General: 50-59 y 60-74 y 75+ y Harris et al. Diabetes Care. 1998; 21:518. Mukherjee et al. Compr Psychiatry. 1996; 37(1):68-73.

29. State PCs as Centers of Excellence: Monitoring Cardiometabolic Risk Factors • Now • BMI • FBS (or HbA1c) • Total Cholesterol • Later • Smoking • Hypertension • ? • Program implementation and evaluation

30. Cardiometabolic Monitoring at PCs

31. Cardiometabolic Monitoring at PCs

32. Cardiometabolic Monitoring at PCs

33. Smoking • What do we know? • ~ 70-80% of people (in USA) with serious and persistent mental illness smoke • > 50% of people (in USA) with MI smoke • People with SPMI and SMI consume ~40% of cigarettes • Depression is a risk factor for smoking • What can be done? • Evidence based interventions • Program development and evaluation

34. Community Based (Integrated) CareCo-occurring DisordersHealth and Mental Health • Provide medical care in mental health settings for people with SPMI and children with SED • Provide mental health care in primary care for people with high prevalence mood and anxiety disorders

35. Depression in Primary Care • Screening • PHQ 2/9 • Care Management • Care paths • Co-location, consultation, referral • Patient self-care • Monitoring and telephonic outreach

36. Community Based (Integrated) CareCo-Occurring Disorders MH and Substance Use Disorders • Interagency OMH-OASAS Task Force on Co-Occurring Disorders • Clinical, Regulatory and Fiscal plan for this year • Screening and Assessment • EBPs • Training • “Single Certification” • Dissemination: Center of Excellence for COD • Program Evaluation

37. Employment • It is what people with mental illness want • It is (in USA) what this disability group do most poorly at achieving • Lack of it produces poverty • Supportive employment programs have good evidence of effectiveness • Government provides disincentives to work

38. Violence • The real story with respect to mental illness and risk of violence: • People with mental illness are much more likely to be victims • There is an increased risk of violence, but attributable to: • Prior history of violence • Untreated illness, especially psychotic illness • Alcohol and drug use • What could be role of research? • Risk assessment, alert system? • Program evaluation? • Diversion before psychiatric hospitalization • Outpatient commitment

39. Public Mental HealthQuality Improvement • What is Quality Improvement? • What can government do to promote it? • Single, transparent set of quality standards • Public reporting of clinical performance • Leverage contracting • Pay for what supports quality and efficiency, not simply the production of “units of service”

40. Public Mental HealthQuality Improvement • NYC Quality Improvement • NYS Quality Improvement • Improving Psychiatric Medication Treatment • Quality and cost • ~ 500,000 adults and youth statewide • Scientific Advisory Group – Columbia/PI • Three Tracks • Enhanced State Psychiatric Center version • Outpatient Medicaid version – adult and youth • Consumer version • Initial Targets • Polypharmacy (focusing on antipsychotics and antidepressants) • Shift ratio of second generation and first generation antipsychotics • Focus on metabolic risks of SGAs

41. Biological Research • Biological Research • More promise than delivery to date • Prevention and treatment • Susceptibility genes and drug development • Pharmacology and genetics • Drug efficacy, side effects and differential diagnosis • Non-drug somatic interventions • TMS for schizophrenia

42. Psychosocial Research • Cognitive Remediation • Attention, psychomotor speed, learning • Generalizability? • RAISE (Recovery after an Initial Schizophrenia Episode) • Schizophrenia as a progressive/neurotoxic disorder • Prodromal interventions not effective • CATIE is comparative study of drug effectiveness • RAISE (design and pilot) will be a RCT to determine • If loss of function can be prevented after an initial psychotic illness • What clinical or service delivery interventions promote recovery • Access, engagement, retention • Medications, psychosocial treatments and work

43. Services Research  Policy Development • Performance Measurement and Program Evaluation • Housing • Employment • Court diversion, re-entry, involuntary treatment • Co-Occurring Disorders • Health and Mental Health • MH and Substance Use Disorders • Drug prescribing patterns • Consumer engagement, retention and satisfaction • Shared decision-making

44. Promoting Psychiatric Research • Annual Albany NY (state capital) research demonstration day for elected officials and government senior staff • State Psychiatric Centers Clinical Trials Network • Public Awareness campaigns on the developments and future of mental health care

45. What will it take to transform mental health care? Two masons were cutting stone for a church when a traveler asked each what he was doing? One said “I am killing myself cutting this stone day after day”. The other said “I am building a place for people to find peace”. See also:http://www.omh.state.ny.us/omhweb/News/pr_assessment_clinical_mh.html