As the rhetoric heats up about the role of guns in our public life, and opioid addiction is considered a national emergency, there is a much deadlier epidemic that has incapacitated low-resourced communities for generations: poorly treated or untreated emotional/behavioral disorders. This quiet epidemic has persisted out of the public view, partly because the populations that are most impacted do not have the resources to organize and advocate on their own behalf. Mental healthcare services for this sector of the population are at best inferior, and treatment providers have been largely exempt from providing data to justify the return on investment by taxpayers. The consequences are dramatic, including giving this country the dubious recognition of having one of the highest rates of incarceration in the world. Indeed, the prison system is currently composed of poor people and minorities, many of whom are receiving mental health services the first time.
The robust prison industrial complex has increasingly become the preferred destination for housing the mentally ill, and for a system that does not practice rehabilitation, jails have become the modern day community behavioral health centers. For example, one of the largest prison systems in the country, Cook County Jail in Chicago, recently promoted a psychologist as the new warden. It is almost impossible for people with poorly treated or untreated mental health issues to have the cognitive and emotional resources to break out of the cycle of poverty. As a result, the promise of the New Deal – using public dollars to help poor people break this cycle – has largely been stagnant. In turn, this stagnation is an interaction between patients who are dealing with the enormous burden of generational trauma and a system of care that continues to resist adopting advances in medicine and health technology, to improve the quality of life for those who are the least fortunate among us.
The digital-industrial revolution, with all its advances in automation, digital health, and analytics, holds great promise to meaningfully bend the outcomes curve in the proper direction. Advances could help the development of digital health and analytics tools to objectively measure the severity of mental disorders, without the extended delay that is common in the current practice model. These advances could also change the practice model from episodic to continuous care; considering the high rate of smartphone acquisition by people with lower socioeconomic status, healthcare providers have unprecedented access to patients. This change in the practice model could improve engagement and avoid costly and unnecessary high-dollar services. Well-designed technological solutions, which are population and disease-specific, would likely improve workflows and provide much-needed support to providers at the time of care. In short, digitally augmented interventions could directly impact cost and quality of care.
The publicly funded behavioral healthcare sector needs to aggressively integrate technology-enhanced solutions such as mobile applications, activity monitors, prompting software, texts, and emails. Technology-enhanced solutions are essential because patients who present for mental health services tend to be more severe and exhibit multiple and diagnostically unrelated symptoms. The complexity of these presentations could be accounted for by the interaction between developmental disruption, trauma and social determinants of health. Poverty and mental health are intertwined; poverty makes its determinantal impact on the brain early in the development process due to the toxicity of chronic, unrelenting stress. Scarcity, neglect, and abuse also have a deleterious impact on the brain through unrelieved activation of the body’s stress management system, which in turn damage the structure of neurons. The consequences of poverty early in the development process is compounded as the result of the damage in parts of the brain that are essential for successful learning and management of emotion and behavior.
The evidence of poor care in the above populations is well documented and concerning. For example, approximately 52% of children in foster care receive psychotropic medication versus 4%-13% of the general population (Foster Children: HHS Guidance, 2011; Mackie et al., 2011). The lack of effective screening protocols is particularly problematic because primary care providers or pediatricians, with limited training in behavioral disorders, are prescribing a significant number of the psychotropic medications used by at-risk youth (Longhofer et al., 2011; Mayne et al., 2016). In 2012, the GAO conducted a survey and found that 48% of children in a group home, versus 12%–14% of children in other living arrangements, were taking a psychotropic medicine (Foster Children: HHS Could Provide Additional Guidance, 2014).
For all the reasons listed above, the publicly funded behavioral healthcare sector is ripe for disruption, to the extent that entrepreneurs can tolerate incremental changes and investors are willing to be patient and socially minded. Innovators in this sector should be willing make a case for adopting technologically-enhanced care to the provider community, which may be wary of change, and collaborate with funding sources to improve their risk tolerance and share data to demonstrate that financial bottom-line and good treatment outcomes are intertwined. The culture of service delivery in this sector is unnecessarily adversarial as if one can live without the other; however, it should be viewed as an arranged marriage in which each party needs to focus on the positive attributes of the other.
The market size for the publicly funded behavioral health ecosystem is substantial. For example, Medicaid is the single largest payer in the United States for behavioral health services; approximately 23 million Americans with Medicaid receive mental health services each year, which amounts to 50% of total Medicaid annual expenditures (Kaiser Family Foundation, 2017). Spending for patients with a behavioral health diagnosis is nearly four times higher than for those without a behavioral health diagnosis (SAMHSA, 2014). In the absence of innovations and improvement in the quality of care, the cost of care would likely continue to rise, and double-digit annual inflation is unsustainable. The timing for innovation could not be any better; there is money to be made while making a meaningful impact on the lives of the least fortunate among us.
- Foster children: HHS guidance could help states improve oversight of psychotropic prescriptions: Hearings before the Subcommittee on Federal Financial Management, Government Information, Federal Services, and International Security, Committee on Homeland Security and Governmental Affairs, U.S. Senate. 112th Cong. (2011) (testimony of Gregory D. Kutz).
- Kaiser Family Foundation, 50-State Medicaid Budget Survey Archives, (Washington, DC: Kaiser Family Foundation, October 2017), https://www.kff.org/medicaid/report/medicaid-budget-survey-archives/.
- Luxton, D. D., (Ed) (2015). Artificial Intelligence in Behavioral and Mental Health Care. San Diego: Elsevier/Academic Press.
- Longhofer, J., Floersch, J., & Okpych, N. (2011). Foster youth and psychotropic treatment: Where next? Children and Youth Services Review, 33, 395-404. doi:10.1016/j.childyouth.2010.10.006
- National Council (2017). The Psychiatric Shortage Causes and Solutions. Available at: https://www.thenationalcouncil.org/wp-content/uploads/2017/03/Psychiatric-Shortage_National-Council-.pdf
- Substance Abuse and Mental Health Services Administration. Projections of National Expenditures for Treatment of Mental and Substance Use Disorders, 2010–2020. HHS Publication No. SMA-14-4883. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.