Session 1

Patient-Level Context

Session 1 highlighted the importance of a comprehensive and integrated approach to addressing behavioral health workforce challenges at the patient level. Discussion topics included integrating behavioral and physical health care, utilizing robust training programs that promote career mobility and workforce diversification, highlighting efforts to improve patient outcomes in underserved communities, and examining the economic impact of workforce shortages as a significant barrier to equitable care. Speaker highlights can be found in Box 2.

PROJECTED COST AND ECONOMIC IMPACT OF MENTAL HEALTH INEQUITIES IN THE UNITED STATES

Daniel Dawes, founding dean and professor, senior vice president, global health, Meharry School of Global Health, moderated the first session. He discussed the substantial economic impact of mental health inequities, emphasizing the projected costs associated with these disparities. He said that the United States is estimated to spend an avoidable and unnecessary $477.5 billion annually related to mental health inequities. In 2040, that cost is estimated to increase to $1.26 trillion per year—and looking at the compounded costs from now until 2040, the total would be $14 trillion (Dawes et al., 2022). That is $42,000 for every U.S. individual. He explained that this staggering cost includes direct expenditures and indirect costs, such as lost productivity and increased social services demands due to untreated or inadequately treated mental health conditions (see Table 1). These figures highlight the

economic impact that mental health inequities have on individuals, the health system, and the broader economy. The research found that human immunodeficiency virus (HIV) rates are nearly double across all insurance types and age groups among people with mental health conditions. Additionally, mental health conditions are more common among individuals of any race who have diabetes; and people with mental health conditions are more than twice as likely to experience a stroke.

Dawes pointed out that mental health inequities disproportionately affect marginalized and underserved communities, including racially and ethnically

TABLE 1 Excess Costs Arising from Mental Health Inequities.

NOTES: Projections in U.S. dollars; B = billions; T = trillions.

SOURCES: Presented by Daniel Dawes on July 10, 2024; Dawes et al., 2024.

minoritized, low-income, and rural populations. For example, his own research found 116,722 excess premature deaths beyond what would be expected for these population groups (Dawes et al., 2022). Among the groups, deaths among the African American population were the highest, followed by the Latino and Native American populations. He stressed that these disparities are exacerbated by systemic barriers in the health care system.

Dawes advocated for a holistic approach to tackling mental health disparities, which involves integrating mental health care with broader health care systems and policies. He called for implementing integrated care models that address both mental and physical health needs, facilitating better coordination of services and improving overall health outcomes. Such models, he suggested, should be supported by policies that ensure equitable access to care. He called for collective efforts across sectors that can mitigate the economic burden and promote a healthier society.

BEHAVIORAL HEALTH INTEGRATION AND DEPRESSION CARE EQUITY

Henry Chung, professor of psychiatry at Albert Einstein College of Medicine, discussed integrating behavioral health into primary care settings. Chung began by stressing the importance of doing so as a strategy to enhance access,

particularly for racially minoritized patient populations, and to reduce the stigma associated with mental health services. He highlighted the Montefiore Medical Group’s approach, which centers on the collaborative care model (CCM) (Reist et al., 2022), a systematic approach involving primary care providers, behavioral health specialists, and care managers who work together to treat common mental health conditions such as depression and anxiety within the primary care setting.

Chung shared an example, the Montefiore CCM,¹ initiated with support from the Center for Medicare and Medicaid Innovation (CMMI) in 2016–2019. The project used the model in a population health context—focusing on screening for anxiety and depressive disorders in a racially diverse, lower-income population in the Bronx, a borough of New York City. Chung explained that, instead of using a colocation model for screening and referral, outcomes are achieved through routine mental health screening during primary care visits. This approach includes systematic follow-ups by care managers, who use measurement-informed care and a registry to guide treatment adjustments by primary care providers. Additionally, timely case reviews by psychiatrists and interventions by behavioral health specialists are incorporated as needed.

Chung discussed the evidence base supporting the effectiveness of the Montefiore CCM and reported that patients showed clinically and statistically significant pre–post improvements as early as 12 weeks (Blackmore et al., 2018). He also shared newly published data: Over 2 years, the CCM reduced inpatient admissions, ER visits, and medical specialty office visits (for example, with endocrinologists, cardiologists, etc.) (Chung et al., 2023). He noted that patients who were initially screened positive and deemed to have clinically relevant symptoms of depression or anxiety did not get treatment. He reported that even though 9,297 patients were initially eligible for treatment, only 56 percent of them agreed to it, and only 42 percent received any (Blackmore et al., 2022). He views this as an opportunity to make a bigger difference with this population. His data also showed that African American and Hispanic patients are less likely to receive minimally adequate collaborative care followup; however, when they do receive follow-up, they have better outcomes than White patients (Yang et al., 2024).

Despite the successes, Chung acknowledged several challenges in implementing such models. He said that the role of community health workers and peers needs to be further explored in the work of integrating primary and specialty care. He also called for more community engagement to decrease the

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¹ See https://www.reliasmedia.com/articles/140836-collaborative-care-combines-medical-behavioral-health-treatment (accessed September 30, 2024).

stigma associated with receiving care for depression and anxiety—especially in minority communities.

TELEPSYCHIATRY COLLABORATIVE CARE TO IMPROVE RURAL ACCESS AND CAPACITY

John C. Fortney, professor in the department of psychiatry and behavioral sciences at the University of Washington and senior research health scientist at the VA Puget Sound Health Care System, discussed enhancing access to mental health care through telepsychiatry collaborative care—which he described as a variant of collaborative care—and emphasized the severe disparities in access to behavioral health services between urban and rural areas. He presented national data illustrating that rural counties are significantly underserved in terms of mental health professionals compared to their urban counterparts (Thomas et al., 2009); the approximately 1,000 urban counties have 32,000 psychiatrists, but the approximately 1,000 rural counties have 900 (Ellis et al., 2009). The ratios are similar for other types of mental health specialists, such as psychologists and social workers. He reported that 77 percent of counties have unmet needs for specialty mental health prescribers and that mortality is the biggest predictor of this severe unmet need (Thomas et al., 2009). Poverty is the next biggest predictor. Unmet need in rural counties contributes to poorer mental health outcomes and a heightened need for innovative solutions, such as telepsychiatry collaborative care, that can increase both access and capacity, he said.

Fortney described how telepsychiatry can enhance the CCM by allowing psychiatric consultants to support primary care providers remotely, thereby expanding access and ensuring comprehensive care management through a team-based approach that integrates a behavioral health care manager within the primary care practice and virtually colocating a mental health specialist (see Figure 1). The telepsychiatry CCM increases access by reducing drive times for patients and by leveraging the relationship between the patient and the primary care provider, which reduces stigma and increases acceptance of mental health treatment.

Fortney referenced a series of studies he and his colleagues have conducted to assess the effectiveness of the telepsychiatry CCM. In 2007, the Telemedicine Enhanced Antidepressant Management Trial consisted of patients randomized to telepsychiatry or usual care. The former had significantly better remission rates and antidepressant adherence at 6 and 12 months and significantly higher remission rates, i.e., completely symptom free by 12 months (Fortney et al., 2007). In 2013, a second trial in Federally Qualified Health Centers (FQHCs) focused on depression (Fortney et al., 2013). Patients randomized to the telepsychiatry CCM were three times more likely to be in remission

by 12 months. A more recent study in FQHCs funded by Patient-Centered Outcomes Research Institute (PCORI) and focused on post-traumatic stress disorder (PTSD) and bipolar disorder (Fortney et al., 2021) also found large treatment effects across a range of outcomes, such as mental health functioning, recovery assessment scale, PTSD symptoms, and mood states. This and other evidence reported in a systematic review of clinical trials (Whitfield et al., 2022) showed that the remote CCM works over a range of disorders and settings and is scalable, he concluded.

CROSS-SECTORIAL PARTNERSHIPS TO ADDRESS GROWING BEHAVIORAL HEALTH WORKFORCE CHALLENGES

Bridgette M. (Brawner) Rice, associate dean for research and innovation and the Richard and Marianne Kreider Endowed Professor in Nursing for Vulnerable Populations at the Villanova University M. Louise Fitzpatrick College of Nursing, highlighted the collision between the escalating demand for mental health services and the system’s inability to meet this demand, exacerbated by the COVID-19 pandemic. According to Rice, innovative partnerships across various sectors—including health care, social services, education, and community organizations—are essential to develop sustainable solutions and prevent avoidable health crises, such as suicide and substance misuse, exacerbated by untreated mental health conditions. She discussed how community members and laypersons could be engaged effectively to provide

initial mental health support, thus extending the reach of the strained health care system. She advocated for a model where community members are trained as mental health “navigators” to identify and refer individuals experiencing mental health issues, acting as a bridge to professional care and reducing the burden on traditional health care settings.

Rice provided two examples from her work in Philadelphia. Project Gold (Brawner et al., 2021) involved aspects of HIV prevention and psychotherapy strategies to reduce HIV-sexually transmitted infection (STI) risks for 108 young Black people (aged 14–17) dealing with mental health challenges. They engaged trusted adults to train and prepare high school students to identify and label emotions and triggers and consider safer sexual practices. They saw increased condom use and prevention beliefs and reduced sexual partners and depressive symptoms (Brawner et al., 2019, 2021).

The second project targeted gun violence in the community. Rice and her colleagues leveraged an existing community boxing program that was a partnership with a faith institution and public service agency to address impulse control among inner city youth by bringing in behavioral supports to train boxing coaches to identify young people in need of behavioral health services and get them connected to trained clinical care providers. Rice also described unpublished results showing that the first 3 months saw improvement in a variety of desired outcome metrics, including anger inhibition, depressive symptoms, repetitive thoughts and behaviors, and violent attitudes and beliefs.

Rice concluded by emphasizing that while laypersons cannot replace trained health care providers, they can play a crucial role as navigators and connectors. She encouraged participants to work with cross-sectorial partners to create systems and supports that empower both the individuals that are in need and the workforce that treats them. She called for a paradigm shift in how behavioral health care is delivered, advocating for a more inclusive and community-focused approach that leverages the strengths of various sectors to address the complex needs of those with behavioral health issues.

SMI AND THE BEHAVIORAL WORKFORCE CRISIS

Nev Jones, associate professor in the school of social work at the University of Pittsburgh and faculty affiliate in the department of psychiatry, defined serious mental illness (SMI) as “long-term psychiatric disabilities, serious in their impact on people’s lives, and that almost always lead to multi-system involvement.” She added that most patients with SMI receive poverty- or disability-based income support. She began by stressing the urgent need to prioritize SMI services, the workforce that provides these services, and the attention allocated to this population. She sought to make this case in moral and ethical terms and by sharing both her research and lived experience.

Jones described what she called the crisis of an inadequately staffed public mental health sector—which she noted has gotten worse since the pandemic. She said that training for clinicians treating SMI has been deprioritized. She noted recent initiatives by the American Psychological Association to revitalize SMI training in clinical psychology programs but noted there is no equivalent initiative for counseling and social work programs. She also said that once graduates are licensed, they often leave the public sector for jobs in the private sector “where their salaries are going to multiply five- or sixfold.”

She argued that “hierarchies” of need exist within the public sector. As an example, she described the difficulty in sustaining the mental health unit within the Allegheny County Jail because it has had unfilled positions for years. She also said the kinds of intensive service programs that focus on people with SMI “often require people to work in shifts rather than an 8-to-5 schedule.” That includes mobile crisis outreach, assertive community treatment, inpatient, and partial hospitalization programs. She noted the staggering staff shortages in the “crisis services continuum,” especially in rural areas.

She also said that access to evidence-based or -supported practices for SMI is minimal in the United States and outcomes have not improved for the past 40 years, adding that “things are only getting worse, and that is a very evidence-based claim.” While acknowledging resource limitations across the behavioral health spectrum, she argued that strong economic reasons justify prioritization of services for people with SMI, given the societal burden, economic costs, and vulnerability of people suffering from SMI. She highlighted the mortality gap, noting that people with schizophrenia in the United States live, on average, 20 years less than their counterparts without the condition, attributing this disparity to “structural stigma” and the systemic devaluation of individuals with SMI.

In terms of solutions, Jones deviated from the views expressed by some earlier speakers and warned against the belief that peer specialists and community health workers, who are underpaid and often exploited, can fill the workforce gaps. She expressed concern that this approach is creating a group of people working for a nonliving wage, often with no possibility of career advancement in a field where status and pay are premised on advanced education and licensure. She argued that structural solutions for the entire workforce are needed, such as better training, wages, and working conditions, that will improve care quality and prevent workforce burnout and turnover. She encouraged incentives for training in social work and counseling programs, loan repayment and forgiveness programs, mentoring opportunities through professional associations, and increased Medicare and Medicaid reimbursement rates to push up public-sector salaries. Jones concluded by stressing that the crisis cannot be solved through workforce solutions alone—rather,

the deeper structural issues that are more fundamentally driving the problem need to be addressed.

DISCUSSION

Dawes queried the panel on whether resources spent on expensive emergency care settings could be better deployed to more effectively meet the needs of people in crisis—and what changes might come from reducing emergency department use. Chung suggested that integrated treatment teams were a better investment for SMI services, but Jones warned that the gap between need and availability is “staggering,” and the existence of models does not ensure their scalability within current resource constraints. Rice suggested that the model of using trusted laypeople could help with diversion from traditional emergency services for suicide prevention. Fortney agreed that for the non-SMI population, suicidal behavior drives emergency department use.

Judith Dey, an economist in the HHS Office of the Assistant Secretary for Planning and Evaluation Office of Behavioral Health, Disability and Aging Policy, said that one of her roles is studying the adequacy of the behavioral health workforce to meet the needs of everyone. She noted that many factors in addition to size of the workforce affect patient access to quality care, such as how a practice is conducted and organized, who practices and in what role, how they are trained, whether they stay, where they practice, how much they are paid, what kind of payment they accept, and the quality and types of services delivered.

She noted that many of the solutions proposed by workshop participants would require expanding interventions that work and creating the incentives, infrastructure, training, and payment to deliver these interventions to more of the people who need them. She said that Medicaid is leading the way in paying peer specialists, supporting team-based models, and creating programs like the Certified Community Behavioral Health Clinic (CCBHC), a care model that includes a complete scope of services, timely access requirements, integrated care coordinators, and a payment model that supports it all.

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