Mental healthcare and behavioral healthcare continue in progress, despite serious gaps to healthcare delivery, daily well-being and quality of life metric inclusion. National and global steps in the right direction are appreciated.
I. The US continues to advance behavioral and mental healthcare. Questioning can help shape healthcare response, personal attention, and, if necessary, long-term planning. Quite frankly, delegating responsible organizations to respond to the questions would also spark responsive change.
The US continues to work with coverage and access to pharmaceutical and non-pharmaceutical interventions. What is the accurate picture around coverage and access to behavioral and mental healthcare (pharmaceutical and non-pharmaceutical) in the US? How is coverage and access by demographic and insurance status, how much is the out of pocket expense and what does the denial claim pool look like? Pertaining to lack of access for care, how are metrics around negative outcomes accumulated and analyzed? What are estimated costs associated with caregiving support or lack of transportation?
The US justice system is specifically tuned into prisons, jails and drug courts. Where are we, nationally, as a united front alongside clinicians, courts, law and law schools, advocacy groups and the health industry? What is the plan for incarceration and drug courts when behavioral health care is unavailable? With consensus from all these agencies, what is the national plan to measure and improve mental healthcare for the incarcerated? How will local jails and various jurisdictions be held to new healthcare plans?
What does public health need to better account for mental and behavioral health outside of current data systems, Medicaid and Medicare data and prescription metrics? How do counseling, NAMI efforts, encounters with law enforcement, prison health, drug court data, denials and unaccessed care factor into public health metrics? What are the plans for expanded stakeholders at the state public health planning table?
The US health system has sought to improve medication adherence for those with mental health and behavioral health diagnoses. Where is the ambulatory care and private clinician medication adherence piece with national quality groups?
How will academics, education, certification and reimbursement align for clear scope of practice borders across states and territories?
What is the recommendation for defining deliberate mental health injury related to the workplace, and what is the plan to hold employers accountable through labor law enforcement?
The US has excellent support through nonprofits. There are several major national mental health organizations that support advocacy, policy and research, including NAMI, Mental Health America, NIMH, SAMSHA. And, there are many national organizations that support clinicians with mental health and behavioral health resources [1].
It’s unclear how these organizations work together for cohesive, efficient planning, identification and interventions for gaps in research and healthcare delivery, despite clear messaging by each separately. Is there a plan to streamline and form consensus with unity?
The US has made space for clinician advocacy. Decision-making on psychiatry, psychology and other expert advocacy positions continues [2,3]. Physician and non-physician associations, hospital and acute care, ambulatory care, government and other stakeholders are at the table. How can these organizations address the advocacy with decisiveness? Would scope of practice and telehealth decisions be a decent start?
The national research agenda around mental health has focused on both brain and biological research as well as behavioral intervention. Recent NIMH, NIH, federal and private partnerships have been phenomenal in response to mental health research needs. How are private and nonprofit research institutions aligning so that the research portfolio strategy is most effective? How is quality of research supported through academia, publication and implementation science partners?
What is the national plan for primary care and mental healthcare integration in regards to physician training, referral metrics (wait times, distance, network), reimbursement, quality accreditation, data aggregation, electronic medical record build and out-of-pocket considerations? What is the gameplan for streamlined terminology, including health quality of life associated with behavioral health and including improved diagnostic coding?
What are the plans, if any, to address a behavioral health or emotional health metric alongside vital signs? We did so for pain, the ‘sixth’ vital sign. Why wouldn’t we ask about emotion or mental health?
II. The US Department of Defense, US Veterans Affairs and healthcare partners have been sincerely dedicated to improving behavioral and mental healthcare for service members. Civilian healthcare is connected and should increase partnership visibility.
The US military [4-7] and Veterans Affairs [8] offer substantial resources and care for mental health. Utilization, rerouting or navigation issues, wait times, denials, out-of-pocket pay, satisfaction and comparisons to contracted care and civilian healthcare are often discussed in literature. Labor and staffing are also sporadically reported on. Perhaps standards around performance measures tracked, a transparent dashboard for behavioral and mental health, or means to most up to date data, could be a shared civilian-military accountability.
Professional mental health nonprofits and veteran organizations offer continued mental health support, as well [9,10,11].How this support is funded, reimbursed and navigated belongs in military and veteran behavioral health analyses.
There are 678 reviews and systematic reviews on PubMed for “military + mental + health” and there are 1,192 for “veteran + mental + health” since 2001. How is funding tied to quality of research, and how is synthesis, meta-analysis and literature review assured? What is the gameplan for layperson translation of research, particularly when the research population is representative?
Once research recommendations have been made, what is the strategic NIH, VA, DoD and charitable contribution plan for a behavioral and mental health research gameplan?
There are 51 evidence-based synthesis reports involving keyword “mental” and 13 reports involving “behavioral” on the VA ESP list [20]. Some of these reports are not applicable to mental and behavioral health.
Some ESP reports, including suicide prevention strategies for veterans, are dated as far back as 2009. What is the criteria that requires an ESP update?
VA ESP reports seek good quality evidence when reviewing pertinent studies [21]. How does this compare with EQUATOR definitions of quality? How is research funded to ensure quality to current and future studies, so that research studies are usable and are not excluded from synthesis?
Neither VA ESP guidance nor any other evidence guidance create an automatic build for healthcare delivery. What is the internal process between the DoD, VA and civilian healthcare to ensure that all service members and veterans are provided behavioral and mental healthcare rooted in best practice? How is reimbursement matched? How are AMA, American Psychological Association, American Psychiatric Association, National Association of Social Workers (NASW) and other professional organizations participating in - and held to - these standards? How are contracted civilian healthcare providers ready with evidence-based guidance?
Once interventions and clinical guidelines have been set, who is ensuring DoD, VA and contracted civilian healthcare partnerships are meeting the criteria?
Where is the implementation science report on any recruitment screening and pre-deployment mental health recommendations yet to be implemented at the DoD? How can civilian healthcare and social support assist?
How have DoD and military courts aligned with US justice, including with drug courts? How have DoD and military prisons aligned with US prisons for mental health treatment?
What are the data sources that federal, state and local health oversight use for mental health statistics? Which data sources account for current or prior military service? How can surveys and data sources align to account for prior military service? How can data sources be designed to account for dishonorably discharged/other discharge with previous military experience?
Third party reports paid for by veteran charities and interested nonprofits provide detailed insight. How have NIH and partners examined this funding, so that space is made for future portfolio allocation? If it is unacceptable to federal research organizations, military leadership and taxpayers that charitable nonprofits are paying for RAND analysis [16] without any recommendation follow-up assurance, how can infrastructure step in? If it is unacceptable that national hospital, medical and social support organizations push research recommendations to the military instead of assuming ownership, who can assist in accountabilities?
III. The World Health Organization (WHO) has taken an outstanding lead in mental health. The 2020 WHO Mental Health Atlas is a great step forward [22]. We can best support this work.
- Stakeholders should support by asking what funding is necessary to ensure consistent, expected Mental Health Atlas updates.
The 2022 WHO mental health report is comprehensive [23]. We can continue to support global mental health progress by addressing details. Some details for progress improvement could include:
Recommendations for coding improvements in healthcare billing, ICD, definitions and application around mental health.
Epidemiological improvements in data, including improved quality and improved methodology to account for cultural conceptualization of mental health disorders.
Improved streamlining of terminology. For example, heart disease and cancer have clear medical diagnoses across borders. Behavioral and mental health conditions should be afforded the same professionalism. Helpful standards would include training and education of the clinician, messaging from public health and authorities, and adherence to diagnostic coding.
Clarity on the strategic directions based on country income level. For example, 13% of the global population lives with mental health disorder and poverty disadvantage is a main risk examined by WHO. High income countries are demonstrating higher percentages on the report, without stratification to poverty level and without specific low and middle income country data gap acknowledgements. Clarity on where we are and where we want to be using country income level and poverty level within the country may assist.
Clarity to the gaps in mental health resources, services, information and governance listed. Is it possible to list how the gaps will be measured moving forward and who will assist in coordinated annual feedback?
Intervention and improvement monitoring of the three foci listed in the WHO plan.
How pharmaceutical access, coverage and research planning will include private and public stakeholders with consistency.
Strategic recommendations for policy analysis and policy implementation, including efficiency to research or modeling.
Acknowledgment of prison and drug use, and acknowledgement of special courts
Occupational Health and Safety review diligence [24,25]. The workplace component to the 2022 plan is strategic and wise.
How does military service factor into occupational health and safety in world health definition? What terminology will be used to include, not ignore, military service as an occupation vulnerable to mental health injury?
How would deliberate harm to mental health be defined, particularly for civilian occupational health, and how could that be worded?
References
https://www.aha.org/2011-02-07-national-mental-health-organizations
https://www.health.mil/News/In-the-Spotlight/Mental-Health-is-Health-Care
https://www.health.mil/Military-Health-Topics/Total-Force-Fitness/Psychological-Fitness
https://www.woundedwarriorproject.org/programs/mental-wellness
https://iava.org/big-6-priorities/combat-suicide/#combat-suicide
https://www.rand.org/pubs/external_publications/EP68425.html
https://www.rand.org/pubs/external_publications/EP67449.html
https://www.rand.org/pubs/external_publications/EP67357.html
https://www.hsrd.research.va.gov/publications/esp/reports.cfm
https://www.hsrd.research.va.gov/publications/esp/cam-ptsd.cfm
https://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:C155
https://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:R164
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