IOM Report Focuses on the "Quality Chasm" in Mental Health and Substance Abuse Treatment

A new Institute of Medicine (IOM) report describes a "quality chasm" in the delivery of mental health and substance abuse treatment services—a chasm similar to the one described for general health care in the IOM's groundbreaking 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century. The word "chasm" is used to emphasize how deep the gap is between care that is known to be effective and the care that is actually delivered. The new report stresses the strong link between a person's mental health and general health and notes that quality problems in general health care cannot be resolved without attending equally to mental health and substance abuse care.

Together, unipolar major depression and substance use disorders are the leading cause of death and disability among women in the United States and the second-highest cause among men (after heart disease), according to research cited in the report. Each year more than 35 million Americans use health care services for problems and conditions resulting from mental illness or substance use disorders. Millions more need treatment but do not receive it. Although a range of effective treatments is available, the report cites recent research documenting that a majority of persons receive treatment that does not adhere to guidelines for evidence-based practices.

The recommendations for improving quality that were made in the 2001 IOM report on general health care can be tailored to apply to mental health and substance abuse care, the new report explains, as long as some distinctive features of behavioral health care are taken into account. Foremost among these features is the number of obstacles consumers of mental health care must face that are not encountered by consumers of general health care. In addition to the shame, discrimination, and stigma that "inappropriately nourish doubts about [consumers'] competence to make decisions on their own behalf," insurance coverage for mental health and substance abuse treatment is more limited. The report also notes that compared with consumers of general health care, consumers of mental health and substance abuse care are more often coerced into treatment.

Steps to address these issues and to move closer to the goal of patient-centered care are outlined in the report's first two recommendations. The first is that "all parties involved in health care for mental or substance use conditions should support the decision-making abilities and preferences for treatment and recovery" of consumers. The second recommendation states, "Coercion should be avoided whenever possible. When coercion is legally authorized, patient-centered care still is applicable and should be undertaken." Ways to provide such care when coercion is authorized include ensuring that policies and practices for determining an individual's dangerousness and decision-making capacity are transparent to consumers and their families; obtaining the best comparative information on safety, effectiveness, and availability of treatments and providers and using this information to make informed decisions; and maximizing patients' involvement in the selection of treatments and providers.

Another set of recommendations addresses the fact that the infrastructure needed to measure, analyze, and publicly report data on mental health and substance abuse care is less well developed than that for general health care. A related issue is the comparative lack of evidence-based strategies for disseminating information about effective interventions. The report outlines a five-part strategy for strengthening the infrastructure as well as specific steps for doing so. For example, one step emphasizes the importance of describing and categorizing available preventive, diagnostic, and therapeutic interventions and developing individual procedure codes and definitions for these interventions for use in administrative data sets. Another emphasis is on prioritizing research funds to develop reliable screening, diagnostic, and monitoring instruments that include a brief set of indicators for ongoing assessment of symptoms and functional status.

Another area that requires special attention for quality improvement is to deal effectively with the separation of mental health care services from substance abuse treatment services—and the separation of both types of services from primary care. Many of the IOM recommendations focus on better coordination of care—not only between mental health and substance abuse treatment providers but in a more encompassing way between these providers and primary care. The report describes "a continuum of evidence-based coordination models" that primary care providers and specialty mental health and substance abuse treatment providers can move along to achieve more effective collaboration. The continuum begins with formal agreements among these providers, followed by three models of increasing coordination—case management, co-location of services, and the delivery of mental health, substance abuse, and primary care through "clinically integrated practices" of the three types of providers.

Other recommendations in the IOM report focus on improving information systems and technology, strengthening the quality and capacity of the workforce, creating a more accommodating marketplace for mental health and substance abuse services by educating health care purchasers and policy makers, and developing a coordinated research agenda for quality improvement.

Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series is available on the IOM Web site at www.iom.edu.

News Briefs

NIMH statement on CATIE results: The National Institute of Mental Health (NIMH) has released a statement cautioning providers and policy makers about changing reimbursement policies for antipsychotic medications in the wake of publication of results from the Clinical Antipsychotic Trials in Intervention Effectiveness (CATIE) study. The results indicated few differences between four second-generation antipsychotics and perphenazine, a first-generation agent that is much less costly. Because costs of antipsychotics will top $10 billion this year and second-generation drugs account for 90 percent of the market, NIMH officials fear that a "fail-first" policy with perphenazine will be implemented in some states or treatment settings. However, such changes would be premature, according to NIMH officials, because the CATIE results published in September are from phase 1 of a three-phase study and forthcoming reports will look at outcomes more relevant to costs and reimbursement. The full statement is available at www.nimh.nih.gov/about.

Web site on Medicare prescription drug benefit: The American Psychiatric Association (APA), in partnership with six other mental health organizations, has launched a Web site (www.mentalhealthpartd.org) designed to help mental health treatment providers, patients, and families understand the Medicare prescription drug benefit and make decisions. The benefit, known as Medicare Part D, goes into effect on January 1, 2006, and is widely expected to generate questions—and even confusion. Some of the topics covered on the new Web site are enrollment and eligibility, patient costs and subsidies, drug formularies and coverage determinations, exceptions and appeals, and continuity of care. The other organizations in the coalition are the American Association of Community Psychiatrists, the National Alliance on Mental Illness, the National Association of State Mental Health Program Directors, the National Council for Community Behavioral Healthcare, the National Mental Health Association (NMHA), and the Treatment Effectiveness Now (TEN) project. In addition, NMHA has created a workbook that provides basic information about the new drug benefit and tips on how to enroll and how to apply for financial assistance. The Medicare Prescription Drug Coverage Workbook for Mental Health Consumers is available at www.nmha.org or by calling the NMHA Resource Center at 800-969-NMHA (6642).

SAMHSA TIP for opioid treatment programs: The Substance Abuse and Mental Health Services Administration (SAMHSA) has released a new Treatment Improvement Protocol (TIP 43), Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Developed by a consensus panel on the basis of all relevant research findings and panel experience, the TIP helps to standardize and improve treatment for opioid addiction by providing modern, best-practice approaches to medication-assisted treatment for people addicted to opiates, mainly prescription narcotics or heroin. The protocol emphasizes the significance of retaining patients in treatment over an extended period to obtain successful outcomes and the importance of supportive services, such as counseling, mental health and other medical services, and vocational rehabilitation. The TIP also outlines best practices in the use of methadone, buprenorphine, and naltrexone, including appropriate dosages of medication, medically supervised withdrawal, medication maintenance, tapering off of treatment medications, associated medical problems, treatment for multiple substance use, and other critical aspects of treatment. The publication is available at http://ncadi.samhsa.gov.

NIMH education outreach to Latino men with depression: The National Institute of Mental Health (NIMH) has expanded its Real Men Real Depression campaign with Spanish-language materials to inform the Latino community. A national study found that 54 percent of Latino men who had at least one episode of major depression in their lifetime did not recognize having a mental health problem. Like U.S.-born white males, Latino men report being afraid that seeking treatment will endanger their jobs. Researchers have also noted that traditional gender roles in the Latino community may contribute to an unwillingness to talk about feelings of depression. The new materials include booklets, fact sheets, and broadcast and print public service announcements (PSAs). The PSAs feature Rodolfo Palma-Lulión, a recent college graduate who shares his experience with depression. More information can be obtained from bilingual information specialists by calling the campaign's toll-free number (1-866-227-6464). The materials in Spanish are available at www. menanddepression.nimh.nih.gov. In addition, as part of the American Psychiatric Association's recently launched Hispanic Mental Health Initiative, Spanish-language materials are available online at www. healthyminds.org. Materials include fact sheets and brochures on a variety of mental disorders that present science-based information on warning signs, treatment options, and prevention measures. Information on how to locate a Spanish-speaking psychiatrist is provided.