Executive Perspective Executive Perspective is a regular column in Public Health Reports in which leaders of offices under the Assistant Secretary for Health and agencies of the U.S. Department of Health and Human Services offer their views on public health topics of the day. In this column, Pamela S. Hyde, Administrator, and Kana Enomoto, Principal Deputy Administrator, of the Substance Abuse and Mental Health Services Administration, review the heavy burden of behavioral health disorders in the United States, recent progress made in prevention and treatment, and six steps needed to make further headway. Frederic E. Shaw, MD, JD Acting Editor, Public Health Reports
WHAT IS BEHAVIORAL HEALTH WORTH? Pamela S. Hyde, JD Kana Enomoto, MA
The behavioral health field has much to celebrate. In the past few years, there have been many advances in the science about what works to prevent, treat, and support recovery from mental and substance use disorders. Whether through domestic efforts (e.g., President Obama’s Now Is the Time plan to increase access to mental health services1) or international efforts (e.g., the United Nations’ International Day Against Drug Abuse and Illicit Trafficking to increase awareness that drug use disorders are preventable and treatable2), mental health and substance abuse issues have emerged from the shadows onto a global stage. With implementation of the Patient Protection and Affordable Care Act3 and the Mental Health Parity and Addiction Equity Act,4 more than 60 million Americans will gain access to new or expanded coverage for mental health and substance abuse services.5 This broadening of our health system accomplishes some wide-ranging goals in providing services for individuals with behavioral health conditions that previously were much harder to obtain. Enactment of these laws has prompted the largest expansion of mental health and addiction coverage and potential reimbursement in a generation, creating a path to better medical treatment of mental and substance use disorders. It also means that many health plans must cover preventive services, such as depression screening for adults and behavioral assessments for children, at no cost to the insured. Insurance plans cannot deny coverage or charge more due to preexisting health conditions, including serious mental illnesses. These laws establish a foundation that will help Americans access behavioral health services 6
as routinely as they seek other forms of medical attention. Increased screening, early detection, and access to evidence-based treatment brings hope that behavioral health outcomes will improve and the systemic marginalization of individuals with behavioral health conditions will diminish and eventually disappear. These developments should make patients, providers, researchers, policy makers, and other stakeholders feel good about the progress that has been made. But we would be unwise to rest on our laurels, because the job is far from done. Americans still undervalue behavioral health. Despite making great strides in such areas as raising awareness about suicide and the need for behavioral health care and expanding benefits for millions of Americans, major gaps remain in the nation’s behavioral health safety net. First, too many people with behavioral health conditions languish in jails and prisons when they could and should receive services in the community. As many as 20% of inmates in jails and prisons suffer from a serious mental illness, while as many as 60% have substance abuse conditions.6,7 Second, people with behavioral health conditions remain subject to personal and institutional discrimination, which affects their recovery, treatment, and willingness to seek help. For instance, a recent report from the National Alliance on Mental Illness suggests that as many as 80% of people with serious mental illness are unemployed.8 According to the National Institute of Justice, arrests for misdemeanor drug offenses and related nonviolent crimes can have a permanent dampening effect on the employability of people in long-term recovery, even without a conviction.9 Many people who are homeless suffer from mental health and substance abuse conditions. In 2010, 26.2% of all sheltered people who were homeless had a severe mental illness and 34.7% had chronic substance use issues.10 Much work remains to ensure that people with the most serious behavioral health conditions have
Public Health Reports / January–February 2015 / Volume 130
Executive Perspective 7
access to gainful employment, safe housing, education, and a role in their community. Despite their prevalence and impact, most people are unaware that behavioral health conditions affect huge swaths of the U.S. population. Data from the Substance Abuse and Mental Health Services Administration show that, at any given time, about one in four Americans meets the criteria for a mental or substance use disorder. During the course of Americans’ lifetimes, half will experience mental illness, addiction, or both. And at some time in their lives, nearly all Americans will experience the impact of a mental or substance use disorder in themselves or their families. Unfortunately, up to half of all people with mental illness and 90% of people who meet the criteria for a substance use disorder do not get the treatment they need.11 This treatment gap exacts a toll on American health and economic well-being. Suicide presents an apt example. While the news media highlight cases of violence by individuals with untreated psychosis, few people realize that, in 2011, suicide quietly claimed more than twice as many lives (39,518) as homicide (16,238) and five times as many deaths as those who had human immunodeficiency virus/acquired immunodeficiency syndrome (7,638). Suicide is the 10th-leading cause of death in the U.S. overall, with significant variations by age and race/ ethnicity. While the greatest number of deaths occurs among middle-aged non-Hispanic white males, the highest per capita rate is among American Indian/ Alaska Native young people aged 15–24 years, for whom suicide is the second-leading cause of death.12 And for every completed suicide, there are 25 attempts.13 That means nearly one million Americans attempted suicide in 2012 alone.14 Suicide and nonfatal self-inflicted injuries cost approximately $41 billion in medical and work loss costs each year.13 Drug overdose from prescription drugs is another growing problem that has garnered more media attention in recent years. But still, few Americans know that more than 100 people die every day as a result of a drug overdose, making drug overdose from both prescription and illicit drugs the leading cause of injury death in the U.S. Among people aged 25–64 years, drug overdose now causes more deaths than motor vehicle accidents.15 Additionally, in 2011, drug misuse and abuse caused about 2.5 million emergency department visits, of which more than half were related to prescription drugs.16 Excessive alcohol use and underage drinking also have a steep price. The Centers for Disease Control and Prevention estimates that nearly 88,000 alcoholrelated deaths per year are from chronic causes such
as alcoholic liver disease and cirrhosis, as well as from acute causes such as motor vehicle accidents and poisoning. More than 4,000 of these deaths are among underage young people. Alcohol is the third-leading preventable cause of death in the U.S.17 Furthermore, those with behavioral health conditions have higher rates of cigarette smoking and, therefore, bear a disproportionate burden of the medical consequences of tobacco use, which is the leading cause of preventable death in the U.S.18 Recent data from the National Survey on Drug Use and Health show rates of cigarette smoking in those with serious psychological distress to be 42.1% compared with 18.2% in those without mental health concerns.19 In addition, those with mental and substance use disorders represent 24.8% of adults; however, they used 39.6% of all cigarettes smoked by adults in the U.S. in 2011.20 As a result of elevated tobacco use and a number of other risk factors, people with serious mental illnesses, such as schizophrenia and bipolar disorder, experience significant health disparities and are at increased risk for early mortality. Estimates range from 8.2 years of potential life lost (YPLL) in a nationally representative sample of people with mental illnesses and substance use disorders21 to 25 YPLL for individuals with serious mental illness served by the public mental health system.22 A study of more than 8,000 adults with schizophrenia in Sweden found that men died 15 years earlier and women died 13 years earlier than people in the general population due to higher rates of mortality (not higher prevalence) from cardiovascular disease, cancer, and respiratory disease. With regard to costs to communities, behavioral health conditions are involved in one of every four community hospital stays; are the leading cause of hospitalization for children aged 1–17 years; are ubiquitous in jails, prisons, and homeless shelters; and, in 2011, accounted for 29% of all Social Security disabled-worker beneficiaries for those younger than 50 years of age.23–26 The World Economic Forum, tasked with identifying cost drivers of global economic burden, identified behavioral health conditions (including mental illnesses, alcohol, and drug use disorders) as having the highest direct and indirect costs compared with other non-communicable diseases (e.g., cardiovascular disease, chronic obstructive pulmonary disease, diabetes, and cancer). Worldwide, by the year 2030, mental illnesses and substance use disorders will account for $6 trillion in direct and indirect costs and 35% of lost economic output due to non-communicable diseases. The anticipated costs and economic loss due to behavioral health conditions are significantly greater than the second-leading cost driver: cardiovascular disease
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($1 trillion in direct and indirect costs and 33% of lost economic output). In addition, the lost economic output due to mental illnesses and substance use disorders is greater than the anticipated loss incurred by all cancers (18%), diabetes (4%), and chronic respiratory diseases (10%) combined.27 Despite these high costs to individuals, families, and society, Americans are far less willing to pay to avoid mental illness than to avoid general medical conditions, even for a comparable benefit in terms of quality of life. In one study of a nationally representative sample of Americans, participants were given vignettes describing mental and general medical illnesses. Although the participants rated the mental illnesses as potentially more burdensome, the amount they were willing to pay for treatment was 40% less for the mental illnesses than for the physical illnesses.28 In a separate study of clients currently enrolled in methadone maintenance programs for opioid addiction, the amount clients were willing to pay for services fell 80%–90% short of the actual cost of treatment.29 So why is behavioral health undervalued and what can we do to bring its perceived value to a level on par with physical health? Even with more awareness of the burdens caused by behavioral health conditions, prevailing social norms and beliefs undervaluing behavioral health prevent us from taking full advantage of the available science regarding evidence-based prevention, treatment, and recovery support programs. As federal leaders, we hope to engage our public health partners across the nation in improving the way Americans value behavioral health through six Es. First, we must examine the underlying assumptions, beliefs, and values for cultural norms that prevent whole communities from investing in their own behavioral health and wellness. We must then use qualitative and quantitative data to educate ourselves on how to influence these beliefs and behaviors. We must enlist the public in changing social norms around mental illness and substance misuse so that people are more willing to invest in behavioral health treatment and support for themselves, their families, and their communities. We must employ the best prevention, treatment, and recovery support services based on scientific evidence and the rich experiences of our diverse communities. We must evaluate the needs of the population and the outcomes of our programs. And, finally, we must engage individuals, families, schools, businesses, and others to ensure that all Americans receive the support they need to achieve optimum behavioral health. These posits signal a roadmap to achieve the highest return on investment in the prevention, treatment, and recovery
support of mental illnesses and addictions. Together, we can improve the behavioral health of the nation. Pamela S. Hyde is the Administrator and Kana Enomoto is the Principal Deputy Administrator at the Substance Abuse and Mental Health Services Administration, Department of Health and Human Services in Rockville, Maryland. Address correspondence to: Kana Enomoto, MA, Substance Abuse and Mental Health Services Administration, Department of Health and Human Services, 1 Choke Cherry Rd., 8th Fl., Rockville, MD 20857; tel. 240-276-2000; fax 240-276-2010; e-mail .
REFERENCES 1. The White House (US). Now Is the Time: the President’s plan to protect our children and our communities by reducing gun violence. 2013 Jan 16 [cited 2014 Oct 1]. Available from: URL: http://www .whitehouse.gov/sites/default/files/docs/wh_now_is_the_time_full .pdf 2. United Nations Office on Drugs and Crime. International Day Against Drug Abuse and Illicit Trafficking [cited 2014 Oct 1]. Available from: URL: http://www.unodc.org/drugs/en/june-26 /index.html 3. Pub. L. No. 111-148, 124 Stat. 119 (2010) amended by Pub. L. No. 111-152, 124 Stat. 1029 (2010). 4. Pub. L. No. 110-343, 122 Stat. 3881 (2008) (codified as amended at 29 U.S.C. §1185a and 42 U.S.C. §300gg-26). 5. Beronio K, Po R, Skopec L, Glied S. Affordable Care Act expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans. Washington: Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation; 2013 Feb 13. Also available from: URL: http://aspe.hhs.gov/health/reports/2013/mental/rb_mental.cfm [cited 2014 Oct 1]. 6. Aufderheide D. Mental illness in America’s jails and prisons: toward a public safety/public health model. Health Affairs Blog 2014 Apr 1 [cited 2014 Oct 1]. Available from: URL: http://healthaffairs .org/blog/2014/04/01/mental-illness-in-americas-jails-and-prisonstoward-a-public-safetypublic-health-model 7. Dart T. How we shaft the mentally ill. Chicago Tribune 2014 Jul 29 [cited 2014 Oct 1]. Available from: URL: http://www.chicago tribune.com/news/opinion/commentary/ct-cook-county-tom-dartjail-mentally-ill-0729-20140729-story.html 8. National Alliance on Mental Illness. Road to recovery: employment and mental illness. Arlington (VA): NAMI; 2014. Also available from: URL: http://www.nami.org/Template.cfm?Section=Policy _Reports&Template=/ContentManagement/ContentDisplay .cfm&ContentID=169263 [cited 2014 Oct 1]. 9. Solomon AL. In search of a job: criminal records as barriers to employment. NIJ Journal 2012;270:42-51. Also available from: URL: https://www.ncjrs.gov/pdffiles1/nij/238488.pdf [cited 2014 Oct 1]. 10. Department of Housing and Urban Development (US). The 2010 annual homeless assessment report to Congress. Washington: HUD; 2011. 11. Substance Abuse and Mental Health Services Administration (US). Behavioral health, United States, 2012. HHS Publication No. (SMA) 13-4797. Rockville (MD): SAMHSA; 2013. 12. Centers for Disease Control and Prevention (US). Web-based Injury Statistics Query and Reporting System (WISQARS) [cited 2014 Jul 7]. Available from: URL: www.cdc.gov/injury/wisqars/index.html 13. Substance Abuse and Mental Health Services Administration (US). Results from the 2012 National Survey on Drug Use and Health: mental health findings. NSDUH Series H-47, HHS Publication No. (SMA) 13-4805. Rockville (MD): SAMHSA; 2013. 14. Centers for Disease Control and Prevention (US). Suicide: facts at a glance [cited 2014 Oct 1]. Available from: URL: http://www.cdc .gov/violenceprevention/pdf/suicide_datasheet-a.pdf 15. Centers for Disease Control and Prevention (US). CDC WONDER:
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16.
17. 18. 19.
20.
21.
22.
compressed mortality file: underlying cause-of-death [cited 2014 Jul 28]. Available from: URL: http://wonder.cdc.gov/mortsql.html Substance Abuse and Mental Health Services Administration (US). The DAWN Report: highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Rockville (MD): Department of Health and Human Services (US); 2013. Also available from: URL: http://www.samhsa.gov /data/2k13/DAWN127/sr127-DAWN-highlights.htm [cited 2014 Oct 1]. Murphy SL, Xu J, Kochanek KD. Deaths: final data for 2010. Natl Vital Stat Rep 2013 May 8;61:1-118. Department of Health and Human Services (US). The health consequences of smoking: a report of the Surgeon General. Washington: Government Printing Office (US); 2004. Substance Abuse and Mental Health Services Administration (US). Smoking rate among adults with serious psychological distress remains high. The CBHSQ Report 2013 Jul 18 [cited 2014 Oct 1]. Available from: URL: http://www.samhsa.gov/data/spotlight /spot120-smokingSPD.pdf Substance Abuse and Mental Health Services Administration (US). Adults with mental illness or substance use disorder account for 40 percent of all cigarettes smoked. The NSDUH Report 2013 Mar 20 [cited 2014 Oct 1]. Available from: URL: http://www.samhsa .gov/data/spotlight/spot104-cigarettes-mental-illness-substanceuse-disorder.pdf Druss BG, Zhao L, Von Esenwein S, Murrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care 2011;49:599-604. Parks J, Svedsen D, Singer P, Foti ME, editors. Morbidity and mortal-
23.
24.
25.
26.
27. 28. 29.
ity in people with serious mental illness. Alexandria (VA): National Association of State Mental Health Program Directors; 2006. Owens P, Myers M, Elixhauser A, Brach C. Care of adults with mental health and substance abuse disorders in U.S. community hospitals, 2004. HCUP Fact Book No.10. AHRQ Publication No. 07-0008. Rockville (MD): Agency for Healthcare Research and Quality; 2007. Pfuntner A, Wier LM, Stocks C. Most frequent conditions in U.S. hospitals, 2010. HCUP Statistical Brief #148. Rockville (MD): Agency for Healthcare Research and Quality; January 2013. Also available from: URL: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb148 .pdf [cited 2014 Oct 1]. James DJ, Glaze LE. Bureau of Justice Statistics special report: mental health problems of prison and jail inmates. Washington: Department of Justice (US), Office of Justice Programs; 2006. Also available from: URL: http://www.bjs.gov/index.cfm?ty=pbdetail&iid=789 [cited 2014 Oct 1]. Salkever DS, Gibbons B, Frey WD, Milfort R, Bollmer J, Hale TW, et al. Recruitment in the Mental Health Treatment Study: a behavioral health/employment intervention for social security disabledworker beneficiaries. Social Security Bulletin 2014;74:27-50. Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, et al. The global economic burden of non-communicable diseases. Geneva: World Economic Forum; 2011. Smith DM, Damschroder LJ, Kim SYH, Ubel PA. What’s it worth? Public willingness to pay to avoid mental illnesses compared with general medical illnesses. Psychiatr Serv 2012;63:319-24. Bishai D, Sindelar J, Ricketts EP, Huettner S, Cornelius L, Lloyd JJ, et al. Willingness to pay for drug rehabilitation: implications for cost recovery. J Health Econ 2008;27:959-72.
Public Health Reports / January–February 2015 / Volume 130
WHAT IS BEHAVIORAL HEALTH WORTH? Pamela S. Hyde, JD Kana Enomoto, MA
The behavioral health field has much to celebrate. In the past few years, there have been many advances in the science about what works to prevent, treat, and support recovery from mental and substance use disorders. Whether through domestic efforts (e.g., President Obama’s Now Is the Time plan to increase access to mental health services1) or international efforts (e.g., the United Nations’ International Day Against Drug Abuse and Illicit Trafficking to increase awareness that drug use disorders are preventable and treatable2), mental health and substance abuse issues have emerged from the shadows onto a global stage. With implementation of the Patient Protection and Affordable Care Act3 and the Mental Health Parity and Addiction Equity Act,4 more than 60 million Americans will gain access to new or expanded coverage for mental health and substance abuse services.5 This broadening of our health system accomplishes some wide-ranging goals in providing services for individuals with behavioral health conditions that previously were much harder to obtain. Enactment of these laws has prompted the largest expansion of mental health and addiction coverage and potential reimbursement in a generation, creating a path to better medical treatment of mental and substance use disorders. It also means that many health plans must cover preventive services, such as depression screening for adults and behavioral assessments for children, at no cost to the insured. Insurance plans cannot deny coverage or charge more due to preexisting health conditions, including serious mental illnesses. These laws establish a foundation that will help Americans access behavioral health services 6
as routinely as they seek other forms of medical attention. Increased screening, early detection, and access to evidence-based treatment brings hope that behavioral health outcomes will improve and the systemic marginalization of individuals with behavioral health conditions will diminish and eventually disappear. These developments should make patients, providers, researchers, policy makers, and other stakeholders feel good about the progress that has been made. But we would be unwise to rest on our laurels, because the job is far from done. Americans still undervalue behavioral health. Despite making great strides in such areas as raising awareness about suicide and the need for behavioral health care and expanding benefits for millions of Americans, major gaps remain in the nation’s behavioral health safety net. First, too many people with behavioral health conditions languish in jails and prisons when they could and should receive services in the community. As many as 20% of inmates in jails and prisons suffer from a serious mental illness, while as many as 60% have substance abuse conditions.6,7 Second, people with behavioral health conditions remain subject to personal and institutional discrimination, which affects their recovery, treatment, and willingness to seek help. For instance, a recent report from the National Alliance on Mental Illness suggests that as many as 80% of people with serious mental illness are unemployed.8 According to the National Institute of Justice, arrests for misdemeanor drug offenses and related nonviolent crimes can have a permanent dampening effect on the employability of people in long-term recovery, even without a conviction.9 Many people who are homeless suffer from mental health and substance abuse conditions. In 2010, 26.2% of all sheltered people who were homeless had a severe mental illness and 34.7% had chronic substance use issues.10 Much work remains to ensure that people with the most serious behavioral health conditions have
Public Health Reports / January–February 2015 / Volume 130
Executive Perspective 7
access to gainful employment, safe housing, education, and a role in their community. Despite their prevalence and impact, most people are unaware that behavioral health conditions affect huge swaths of the U.S. population. Data from the Substance Abuse and Mental Health Services Administration show that, at any given time, about one in four Americans meets the criteria for a mental or substance use disorder. During the course of Americans’ lifetimes, half will experience mental illness, addiction, or both. And at some time in their lives, nearly all Americans will experience the impact of a mental or substance use disorder in themselves or their families. Unfortunately, up to half of all people with mental illness and 90% of people who meet the criteria for a substance use disorder do not get the treatment they need.11 This treatment gap exacts a toll on American health and economic well-being. Suicide presents an apt example. While the news media highlight cases of violence by individuals with untreated psychosis, few people realize that, in 2011, suicide quietly claimed more than twice as many lives (39,518) as homicide (16,238) and five times as many deaths as those who had human immunodeficiency virus/acquired immunodeficiency syndrome (7,638). Suicide is the 10th-leading cause of death in the U.S. overall, with significant variations by age and race/ ethnicity. While the greatest number of deaths occurs among middle-aged non-Hispanic white males, the highest per capita rate is among American Indian/ Alaska Native young people aged 15–24 years, for whom suicide is the second-leading cause of death.12 And for every completed suicide, there are 25 attempts.13 That means nearly one million Americans attempted suicide in 2012 alone.14 Suicide and nonfatal self-inflicted injuries cost approximately $41 billion in medical and work loss costs each year.13 Drug overdose from prescription drugs is another growing problem that has garnered more media attention in recent years. But still, few Americans know that more than 100 people die every day as a result of a drug overdose, making drug overdose from both prescription and illicit drugs the leading cause of injury death in the U.S. Among people aged 25–64 years, drug overdose now causes more deaths than motor vehicle accidents.15 Additionally, in 2011, drug misuse and abuse caused about 2.5 million emergency department visits, of which more than half were related to prescription drugs.16 Excessive alcohol use and underage drinking also have a steep price. The Centers for Disease Control and Prevention estimates that nearly 88,000 alcoholrelated deaths per year are from chronic causes such
as alcoholic liver disease and cirrhosis, as well as from acute causes such as motor vehicle accidents and poisoning. More than 4,000 of these deaths are among underage young people. Alcohol is the third-leading preventable cause of death in the U.S.17 Furthermore, those with behavioral health conditions have higher rates of cigarette smoking and, therefore, bear a disproportionate burden of the medical consequences of tobacco use, which is the leading cause of preventable death in the U.S.18 Recent data from the National Survey on Drug Use and Health show rates of cigarette smoking in those with serious psychological distress to be 42.1% compared with 18.2% in those without mental health concerns.19 In addition, those with mental and substance use disorders represent 24.8% of adults; however, they used 39.6% of all cigarettes smoked by adults in the U.S. in 2011.20 As a result of elevated tobacco use and a number of other risk factors, people with serious mental illnesses, such as schizophrenia and bipolar disorder, experience significant health disparities and are at increased risk for early mortality. Estimates range from 8.2 years of potential life lost (YPLL) in a nationally representative sample of people with mental illnesses and substance use disorders21 to 25 YPLL for individuals with serious mental illness served by the public mental health system.22 A study of more than 8,000 adults with schizophrenia in Sweden found that men died 15 years earlier and women died 13 years earlier than people in the general population due to higher rates of mortality (not higher prevalence) from cardiovascular disease, cancer, and respiratory disease. With regard to costs to communities, behavioral health conditions are involved in one of every four community hospital stays; are the leading cause of hospitalization for children aged 1–17 years; are ubiquitous in jails, prisons, and homeless shelters; and, in 2011, accounted for 29% of all Social Security disabled-worker beneficiaries for those younger than 50 years of age.23–26 The World Economic Forum, tasked with identifying cost drivers of global economic burden, identified behavioral health conditions (including mental illnesses, alcohol, and drug use disorders) as having the highest direct and indirect costs compared with other non-communicable diseases (e.g., cardiovascular disease, chronic obstructive pulmonary disease, diabetes, and cancer). Worldwide, by the year 2030, mental illnesses and substance use disorders will account for $6 trillion in direct and indirect costs and 35% of lost economic output due to non-communicable diseases. The anticipated costs and economic loss due to behavioral health conditions are significantly greater than the second-leading cost driver: cardiovascular disease
Public Health Reports / January–February 2015 / Volume 130
8 Executive Perspective
($1 trillion in direct and indirect costs and 33% of lost economic output). In addition, the lost economic output due to mental illnesses and substance use disorders is greater than the anticipated loss incurred by all cancers (18%), diabetes (4%), and chronic respiratory diseases (10%) combined.27 Despite these high costs to individuals, families, and society, Americans are far less willing to pay to avoid mental illness than to avoid general medical conditions, even for a comparable benefit in terms of quality of life. In one study of a nationally representative sample of Americans, participants were given vignettes describing mental and general medical illnesses. Although the participants rated the mental illnesses as potentially more burdensome, the amount they were willing to pay for treatment was 40% less for the mental illnesses than for the physical illnesses.28 In a separate study of clients currently enrolled in methadone maintenance programs for opioid addiction, the amount clients were willing to pay for services fell 80%–90% short of the actual cost of treatment.29 So why is behavioral health undervalued and what can we do to bring its perceived value to a level on par with physical health? Even with more awareness of the burdens caused by behavioral health conditions, prevailing social norms and beliefs undervaluing behavioral health prevent us from taking full advantage of the available science regarding evidence-based prevention, treatment, and recovery support programs. As federal leaders, we hope to engage our public health partners across the nation in improving the way Americans value behavioral health through six Es. First, we must examine the underlying assumptions, beliefs, and values for cultural norms that prevent whole communities from investing in their own behavioral health and wellness. We must then use qualitative and quantitative data to educate ourselves on how to influence these beliefs and behaviors. We must enlist the public in changing social norms around mental illness and substance misuse so that people are more willing to invest in behavioral health treatment and support for themselves, their families, and their communities. We must employ the best prevention, treatment, and recovery support services based on scientific evidence and the rich experiences of our diverse communities. We must evaluate the needs of the population and the outcomes of our programs. And, finally, we must engage individuals, families, schools, businesses, and others to ensure that all Americans receive the support they need to achieve optimum behavioral health. These posits signal a roadmap to achieve the highest return on investment in the prevention, treatment, and recovery
support of mental illnesses and addictions. Together, we can improve the behavioral health of the nation. Pamela S. Hyde is the Administrator and Kana Enomoto is the Principal Deputy Administrator at the Substance Abuse and Mental Health Services Administration, Department of Health and Human Services in Rockville, Maryland. Address correspondence to: Kana Enomoto, MA, Substance Abuse and Mental Health Services Administration, Department of Health and Human Services, 1 Choke Cherry Rd., 8th Fl., Rockville, MD 20857; tel. 240-276-2000; fax 240-276-2010; e-mail .
REFERENCES 1. The White House (US). Now Is the Time: the President’s plan to protect our children and our communities by reducing gun violence. 2013 Jan 16 [cited 2014 Oct 1]. Available from: URL: http://www .whitehouse.gov/sites/default/files/docs/wh_now_is_the_time_full .pdf 2. United Nations Office on Drugs and Crime. International Day Against Drug Abuse and Illicit Trafficking [cited 2014 Oct 1]. Available from: URL: http://www.unodc.org/drugs/en/june-26 /index.html 3. Pub. L. No. 111-148, 124 Stat. 119 (2010) amended by Pub. L. No. 111-152, 124 Stat. 1029 (2010). 4. Pub. L. No. 110-343, 122 Stat. 3881 (2008) (codified as amended at 29 U.S.C. §1185a and 42 U.S.C. §300gg-26). 5. Beronio K, Po R, Skopec L, Glied S. Affordable Care Act expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans. Washington: Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation; 2013 Feb 13. Also available from: URL: http://aspe.hhs.gov/health/reports/2013/mental/rb_mental.cfm [cited 2014 Oct 1]. 6. Aufderheide D. Mental illness in America’s jails and prisons: toward a public safety/public health model. Health Affairs Blog 2014 Apr 1 [cited 2014 Oct 1]. Available from: URL: http://healthaffairs .org/blog/2014/04/01/mental-illness-in-americas-jails-and-prisonstoward-a-public-safetypublic-health-model 7. Dart T. How we shaft the mentally ill. Chicago Tribune 2014 Jul 29 [cited 2014 Oct 1]. Available from: URL: http://www.chicago tribune.com/news/opinion/commentary/ct-cook-county-tom-dartjail-mentally-ill-0729-20140729-story.html 8. National Alliance on Mental Illness. Road to recovery: employment and mental illness. Arlington (VA): NAMI; 2014. Also available from: URL: http://www.nami.org/Template.cfm?Section=Policy _Reports&Template=/ContentManagement/ContentDisplay .cfm&ContentID=169263 [cited 2014 Oct 1]. 9. Solomon AL. In search of a job: criminal records as barriers to employment. NIJ Journal 2012;270:42-51. Also available from: URL: https://www.ncjrs.gov/pdffiles1/nij/238488.pdf [cited 2014 Oct 1]. 10. Department of Housing and Urban Development (US). The 2010 annual homeless assessment report to Congress. Washington: HUD; 2011. 11. Substance Abuse and Mental Health Services Administration (US). Behavioral health, United States, 2012. HHS Publication No. (SMA) 13-4797. Rockville (MD): SAMHSA; 2013. 12. Centers for Disease Control and Prevention (US). Web-based Injury Statistics Query and Reporting System (WISQARS) [cited 2014 Jul 7]. Available from: URL: www.cdc.gov/injury/wisqars/index.html 13. Substance Abuse and Mental Health Services Administration (US). Results from the 2012 National Survey on Drug Use and Health: mental health findings. NSDUH Series H-47, HHS Publication No. (SMA) 13-4805. Rockville (MD): SAMHSA; 2013. 14. Centers for Disease Control and Prevention (US). Suicide: facts at a glance [cited 2014 Oct 1]. Available from: URL: http://www.cdc .gov/violenceprevention/pdf/suicide_datasheet-a.pdf 15. Centers for Disease Control and Prevention (US). CDC WONDER:
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16.
17. 18. 19.
20.
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Public Health Reports / January–February 2015 / Volume 130
