The U.S. needs better integration of mental health services with primary care and greater reliance on community health workers.
The time may be ripe to reshape the nation’s mental health care system. As more Americans than ever grapple with anxiety, depression, and other mental health challenges —problems heightened by the pandemic — an influx of new funding from the federal government has opened up possibilities for needed reform.
Approaches taken in other countries can be a source of inspiration. In nations as diverse as Australia, the Netherlands, Pakistan, and Uganda, a variety of strategies have been used to expand access to treatment and promote well-being. These range from using text-based platforms for screening people and offering treatment to supporting community-based organizations in combatting unemployment, loneliness, and other problems that can worsen mental health.
We asked four experts what it would take to expand access to treatment for people with mild or moderate symptoms and what we can learn from international models of mental health care. They call for exploring nontraditional ways of identifying people who need help and providing them with a range of supports, including educational and self-management tools. They also say the U.S. needs better integration of mental health services with primary care, along with greater reliance on community health workers to foster trust and provide support.
If you were going to transform the nation’s approach to mental health care, where would you start?
Gionfriddo: With more widespread mental health screening of our entire population. It’s the cheapest thing you could possibly do, and it would allow us to characterize things like the effects of the pandemic in real time. The findings would also enable us to customize services to different geographies and patient populations. Right now, our understanding of need is shaped by advocacy groups, care providers, and payers, who are only seeing a sliver of the population.
What have you learned from responses to Mental Health America’s screening tools, which are free and anonymous?
Gionfriddo: We’ve conducted 8 million screenings since 2014 and more than 2.5 million since the start of the pandemic, which gives you a sense of how distress has increased. Overall, we have found that three-quarters of help-seeking people have never been diagnosed with a mental health problem but still screen positive or would be classified as having moderate to severe symptoms. Although it’s a help-seeking group, not the general population, that finds our screening tools, we’re discovering the help-seekers do look a lot like the general population during the pandemic.
What we have learned is that they don’t all want professional help. Nearly all want information. Many want some do-it-yourself tools, while others say they want to talk to somebody like a peer or family member. Only a few — perhaps 25 percent — want to see a professional. If we thought about designing a system based on what people actually want, as opposed to what we think they might need, we would be able to ramp up quickly.
Australia encourages people to access government-funded, web-based mental health clinics that offer screenings and telephone assessments and provide referrals to treatment. Those who want less intensive treatment can access educational modules on conditions such as depression, anxiety, and post-traumatic stress disorder. How could we expand access to screening and referrals here in the U.S.?
Gionfriddo: Even before the pandemic, I would have said whenever somebody is doing a blood pressure screening on an adult, they should be doing a mental health screening. You don’t need expertise to administer the screen; it’s not a Rorschach test. You answer the questions, get a score, and a referral to a website that has more information — all in a couple of minutes. During the pandemic, we need to keep thinking about doing screening and vaccination at the same time. The technology is there, and the ability is there. In terms of making referrals, probably the quickest route to getting something similar done here is a public–private partnership, where the government partners with organizations to provide information and resources to people seeking help.
What do we know about how different groups of people have been affected by the pandemic?
McGinty: The hard-hit groups seem to be folks who have low income, folks who are Hispanic, and young adults. That’s showing up consistently in study after study. The big question is how does that translate into future mental health needs? If the needs are immediate, can we ramp up screening, treatment, and delivery of wellness interventions for these groups? But longer term, how resilient are these groups? How much bounce back are we going to see as the pandemic ends and the economy recovers? These are big open questions. I think for people for whom economic drivers are important — which the literature suggests is a lot of people experiencing psychological distress — we are going to see longer-term needs.
There’s been more attention to the mental health effects of the pandemic on young people, given all the disruptions to their education and social lives. But data collected previously also showed concerning trends. For instance, although historically Black youth have had low a suicide rate, it’s been rising in recent years. By 2018, suicide was the second-leading cause of death among Black children ages 10 to 14 and the third-leading cause of death among Black adolescents ages 15 to 19.
Smedley: It is an alarming trend. You have this confluence of risk factors, particularly for Black youth, including police violence against Black Americans. You also have kids of color in communities who are being exposed to violence and likely experiencing deep trauma as a result. In most cases, it’s not treated or addressed. We know this kind of trauma can have lifelong effects.
I don’t think there’s any one simple solution. We’ve got to be deeply engaged with youth, their parents, and community organizations, devoting some political and economic capital to this challenge. Half of kids under 18 are kids of color. These young people are our economic future, so it’s imperative that we step up efforts to prevent and treat emotional distress with culturally appropriate, community-based services and interventions.
Gionfriddo: Our data show that across all ages for people who identify as biracial, Asian, Pacific Islander, Native American, or Indigenous, rates of suicidal ideation trend, as a group, 5 percentage points higher or worse than for other groups. The biracial group has really taken it on the chin for some time by often not being fully accepted by either racial group, and more recently Asian and Pacific Islanders have as well, by being unfairly blamed for the pandemic. Each group will cite different reasons for thinking about suicide, and I think there is some really important information in that.
This can guide us to solutions that are much more targeted. Someone who identifies as LGBTQ and multiracial, for example — that’s a situation where the risk is magnified. We’re seeing suicidal or self-harm ideation in help-seeking, high-risk groups of young people, with that profile closing in on rates of 65 percent or more. So let’s figure out how to target specific resources to them, not by using the same strategies that may not be working but by asking them what they need and want.
Miller: We make accessing care so hard — too hard, especially when kids are in a crisis. It’s one of the cruelest ironies that I see in health care. The more problems you have or the more acute of a crisis you are in, the harder you have to work. From getting a referral to a prior authorization, we often require kids to have a diagnosis before we pay for their care. We need to make it possible for people to be seen by a mental health professional wherever they show up. Let’s lower the barrier to access so that folks can be seen in a time frame that works for them, not just the system.
McGinty: The good news is that young adults are more willing to seek treatment and are more aware of mental health than adults.
To expand capacity, some have suggested going beyond psychiatrists and psychologists, who are in short supply, and even beyond nurses or social workers, who make up the bulk of the U.S. mental health workforce. They point to the use of peer specialists, or people with lived experiences, as well as community health workers, or CHWs, who in some countries offer mental health supports. How can we make better use of CHWs here?
McGinty: It would be really helpful to have CHWs who are from communities they’re serving act as intermediaries to help build trust and connect people with care. Otherwise, people might have to make 25 calls to find a provider who resembles and understands them, and they don’t know how to do that. I also like the flexibility of the CHW model. They can do a wide range of things, depending on credentials, from basic cognitive behavioral therapy to interventions to address loneliness. It’s a model we should be seriously thinking how to scale.
What’s holding it back?
McGinty: The payer barriers are enormous. To the extent we do reimburse for CHWs, the payments tend to be very specific: You have to have this credential, and you can only deliver that service to exactly this specific person, if that’s reimbursed at all. It kills the flexibility of the model. We need to think about innovative financing mechanisms that get away from fee-for-service.
Miller: We need to create a national plan to scale and support these models. For example, we can train community members how to respond when confronted by someone who is feeling symptoms of depression, drinking too much, or even actively suicidal. This sort of task-shifting or task-sharing approach — using CHWs or other nonclinicians to act as coaches or navigators — works in other countries. To me, it’s the most potent idea everyone from our communities to Congress could embrace right now.
What about things we haven’t tried — for instance measuring the outcomes of mental health treatment on a broad scale, as the United Kingdom does?
Miller: We could start by assessing the measures we have and either simplifying them or getting rid of ones that are irrelevant, an issue highlighted several years ago by the National Academy of Medicine. Many measures don’t often give us the information we want to assess whether treatment is having a meaningful impact on the patient’s life. Did a person feel better? Were they able to achieve their goals? These sorts of person-focused, functional questions are rarely the focus of our measurement but are the types of things that matter to people.
What other policy changes are needed? How do we leverage payment policy, particularly for public programs like Medicare and Medicaid, to build a more robust mental health system?
McGinty: I think there’s an opportunity to do a lot of good around the integration of primary and behavioral health care. We’re so bad at it as a country. We made a little progress when CMS began paying for mental health care screenings and management of mental health conditions in primary care, but the evidence suggests this isn’t enough. To bill for these codes, primary care practices have to have a lot of structural components in place, including having a psychiatric consultant and a data tracking system. Some practices have no way of financing that. I don’t think we quite know what the solution is, but it’s something along the lines of bundled payments that enable practices to finance the infrastructure needed and reach more than just Medicare beneficiaries. That would incentivize primary care physicians to do this work.
Many mental health professionals, including psychiatrists, don’t accept Medicaid even though the program (along with the Children’s Health Insurance Program) is the single-largest payer of medical and behavioral health services, covering more than 80 million Americans. What will it take to expand access for Medicaid beneficiaries in particular?
Miller: Because of expected budget deficits connected to the pandemic, there is an opportunity for states to consider structural reforms to Medicaid programs — to create new types of integrated models that could expand access to care. This is top-of-mind for Medicaid directors right now. We recently partnered with the National Association of Medicaid Directors to offer a “Medicaid Forward” strategy for states. Among other strategies, we recommend states focus on prevention and partnering with community organizations to meet members’ social needs. We also point to the need for greater incentives for primary care providers to screen for and refer patients for behavioral health needs. The American Rescue Plan does create a new optional Medicaid benefit to help people experiencing a mental health or substance use disorder crisis. And the law provides additional funding for pediatric mental health services.
Smedley: Medicaid is a lifeline for many low-income adults, seniors, and children. We need to ensure that Medicaid offers comprehensive benefit packages and preventive services. Higher reimbursement will certainly help attract more providers to address the needs of the Medicaid population. For a brief time, shortly after the Affordable Care Act passed, Medicaid reimbursements were required to be equivalent to Medicare reimbursement, an important step to address provider shortages. I’m hopeful that Medicaid will also follow Medicare’s lead in authorizing telemental health services, and importantly, audio-only services for those who may not have access to broadband or comfort with technology.
The pandemic relief bills passed in 2020 and this year have included close to $8 billion for mental health care, raising the Substance Abuse and Mental Health Services Administration’s budget from $6 billion to $13.5 billion in just a few years. How do you hope the agency will use it?
Gionfriddo: It’s a lot of money — far more than they’ve ever seen. And while these dollars are “one-time” appropriations, there are already new dollars being added by the Biden administration to permanent funding as well. To get it out, they are going to have to give some states and communities the opportunity to innovate. While there is an opportunity to give long-standing providers of safety-net services a needed financial boost, I also would like to see a lot more money invested in prevention and early identification, especially for kids, because we have neglected the earlier stages of serious mental health concerns for far too long. I hope the pandemic has finally opened our eyes to that.