You should. It directly affects about one-fifth of the adult population of the United States and an unknown but substantial proportion of school-age children. Indirect effects include loss of productivity and limitation of career choices for patients and their family members, serious burdens on the criminal justice system, problems in schools, increases in physical medical problems and the total cost of heath care — and, yes, direct threats to everyone's security.

Whether you realize it or not, you almost certainly know someone who is mentally ill. Even if you didn't, mental illness has a large effect on your life because of the costs it imposes on society. The President's New Freedom Commission on Mental Health, in its recent report on the problem, estimated the annual cost of treatment in the United States at $71 billion, with another $79 billion in indirect costs such as loss of productivity. What you are less likely to recognize is that mental illness poses numerous challenges operations research analysts are well prepared to answer — if they learn what they need to know. And now, following the commission's report, policy-makers may be ready to listen.

Scope of the Problem


In the 1980s, in one of the most comprehensive studies of mental health ever undertaken, the National Institute of Mental Health studied incidence and epidemiology of mental disorders in five areas: New Haven, Conn., Durham, N.C., Baltimore, St. Louis and Los Angeles. The institute concluded that, in any six-month period, about 20 percent of all adult Americans suffer from some form and degree of mental disorder. They also found that the incidence of certain disorders, especially depression, is rising from age cohort to age cohort. Since their studies were based on surveys rather than full clinical examinations, their numbers have been questioned. What remains clear is that the incidence of mental illnesses is distressingly high and that much of it goes unreported and untreated.

Other more recent studies have generally corroborated the conclusion that incidence is rising. Psychiatrist E. Fuller Torrey — who is nationally renowned for treatment and research work in severe mental illness, especially schizophrenia — recently (2002) presented an intriguing case for a general five-fold rise in severe mental illness in the United States over the past 150 years. His review includes plausible, although admittedly speculative, theories of why some of the rise might be attributable to infectious and environmental factors — another reason why mental health is everyone's concern.

Another effect of mental illness is its burden on the police, criminal justice and prison systems. Most mentally ill people in the United States are first diagnosed as a result of being arrested, usually for non-violent minor offenses. These people add greatly to police forces' work, courts' caseloads and jails' occupancy, at considerable cost. In many cases, odd but non-violent behavior leads to violence against them by others, including police.

Mental illness is significantly implicated in the dramatic rise in homelessness, as well. The degree to which it contributes is controversial among those who have studied the problem, but a common estimate is that about one-third of the homeless in the United States are mentally ill. Homelessness contributes to the increase in crime, as well, albeit not in the way many people suppose: Although the mentally ill homeless are predominantly non-violent, they form an attractive pool of victims for criminals who are often violent but mostly not mentally ill.

Recommendations for System-Wide Reform


Much of the current mental health problem in the United States can be traced to systems failures. Readers of OR/MS Today may remember reading, as early as 1995 [Samuelson 1995], that poor information and the fragmented system of care appear to be among the major causes, if not the major cause, of both poor quality and high cost. The Institute of Medicine came to a similar conclusion in 2001, recommending an overhaul of the national health care system to establish common goals, support redesign of care processes, allocate resources more effectively, and improve information infrastructure and technology. The institute specifically emphasized the establishment of monitoring and tracking processes.

The New Freedom Commission relied heavily on the Institute of Medicine's recommendations in developing its own. Their recommendations were:

• developing a national campaign to reduce stigma and encourage seeking care;
  
  
• addressing mental health with the same urgency as physical health;
  
  
• realigning and redesigning health care planning to be more consumer — and family — driven, more comprehensive, and better tracked;
  
  
• eliminating disparities (cultural, financial and geographic) in access to quality care;
  
  
• improving and expanding early mental health screening, assessment and referral;
  
  
• more closely connecting treatment to research-based evidence of effectiveness; and
  
  
• using information technology to improve consumers' access to care and knowledge of their options and providers' coordination of care.

• widespread closings of inpatient hospitals;
  
  
• the failure of community mental health programs, largely because of funding cuts, lack of planning to monitor patients' compliance with treatment, and insufficient monitoring of programs' effectiveness;
  
  
• inadequate supply of assisted living and housing arrangements for moderately mentally ill people;
  
  
• decreasing availability of inexpensive housing for people who do not need assisted living but do have limited career prospects;
  
  
• increasing tendencies to treat drug possession and public nuisance behaviors as primarily criminal offenses, rather than triggers to referral for treatment; and
  
  
• the evolution of case law to make involuntary treatment much more difficult to impose, especially for people who do not appear dangerous.

The result has been chaos and ineffectiveness. As Torrey acidly observed, "I could ask the most thought-disordered person with schizophrenia to come up with a scheme for deinstitutionalization, and the product would be better than what we have." [Torrey, 2001, p. 24]

In addition, people who require mental health care tend to need to see more providers than most people with physical ailments. Funding policies by both the federal government and private insurers encourage psychotherapists to specialize, offering either "talk therapy" or medication but rarely both. Fourth-party reviewers retained by insurers often second-guess providers' care decisions; many providers have responded by limiting the records and notes they keep. Therefore, information sharing and standardized record-keeping among providers, already identified [Samuelson, 1995 and February 2000, Institute of Medicine, 2001] as critical to continuity and quality of care, tend to be especially poor in mental health. This problem confounds epidemiology and studies of efficacy of treatments, as well.

Starting in the 1960s, federal funding for health care specifically excludes payment for "institutions for mental disease." The IMD exclusion, as it is generally known, has impelled some providers to "bundle" mental health care with care for physical disorders, while many others have simply closed. This policy restricts access to care and confounds tracking of incidence, treatments and outcomes. The commission did not address the IMD exclusion.

An even more fundamental issue is the quality of diagnosis and treatment. As the commission stated, there is a large gap between typical practice in the field and research findings about treatment effectiveness. However, the commission's recommendations to close that gap, relying heavily on dissemination of accepted best practice as identified by research, may be too optimistic. Practice guidelines usually evolve from careful but limited research studies focusing on patients with a single, reliably diagnosed condition. The most severely ill patients present with complicated conditions and comorbidities (related ailments, such as substance abuse and physical ailments), often resulting in multiple diagnoses after considerable trial and error. Also, new medications have had unexpected benefits, causing psychiatrists to reassess diagnostic criteria. (This was the main point of Peter Kramer's 1993 best-seller, "Listening to Prozac.") The medical science may not be good enough to meet the commission's goals.

Challenges for Analysts


These issues constitute a challenge in which O.R. analysts can be helpful. Among the questions in which O.R. could be helpful are:

• How can access be improved and made less disparate among ethnic, cultural, income and geographic subpopulations?
  
  
• How can information be better captured, integrated, shared and utilized?
  
  
• Are there funding schemes that would be fairer and result in fewer distortions of the system, access to care and information about effectiveness?
  
  
• Can we evaluate objectively the benefit of jail diversion programs, community policing, mental health courts and other innovations that appear to hold substantial promise?
  
  
• Can effective screening programs be developed to identify people prone to mental disorder, particularly mental disorder leading to violence, before they resort to violence? (Unfortunately, given the low incidence of such mental disorders and the error rate of screening tests, the answer is likely to be "no" for a long time. See Samuelson, Winter 2000.)
  
  
• How much can security be increased by reducing the burden of nonviolent minor offenders on police and courts, reducing access to weapons by past violent offenders and other possible initiatives?
  
  
• Can we assist in information analysis that would support better diagnoses and evidence-based treatment?
  
  
• With better information, can we do a better job of assessing the effectiveness of security warnings, emergency preparedness and emergency response in limiting the mental health consequences of terrorism and other traumatic events?
  
  
• Can we help evaluate objectively the trade-off between the benefits of involuntary treatment when it is needed, and protecting the rights of the individual?

This last issue is extremely controversial. The commission did not address it. Consumer advocacy groups have strongly opposed any involuntary treatment. However, a feature of severe mental illness is lack of awareness of how sick one is. As Fred Frese, who recovered from schizophrenia and went on to become first a professional staff member and eventually director of the hospital to which he was committed, explained at a symposium on mental illness, "... it is highly likely that I would not be here if I had not been picked up by the police and given treatment against my wishes when I was in a psychotic state. Research indicates that 60 to 70 percent of mentally ill persons who receive forced treatment eventually realize that they have benefited from it, particularly after they begin to respond and recover." [Frese, 2000, p. 95] We have yet to find the right balance between respect for individuals' civil liberties, including privacy and the right to choose, and the benefits of treating those too sick to know they need treatment.

Conclusion


Although the commission's report was completed and released in July 2003, it seems to have gotten little attention from the news media and little "push" from the Bush administration. No doubt this is partly because the questions are complicated and the solutions are far from obvious — the kind of problems on which good O.R. analysts thrive. The issues are important, and the recommendations are ambitious. Systems analysis and evaluation will be needed to achieve the commission's goals. For O.R. analysts willing to learn the language, science, history and policy of mental health diagnosis and treatment, this subject could prove rewarding and provide an opportunity to contribute in one of the most important policy areas the nation confronts.

References & Resources

1. Frese, Frederick J. III., "Mental Illness, Treatment and Recovery: My Experience and Insight As a Consumer," George Mason University Civil Rights Law Journal, Winter 2000.
2. Institute of Medicine, "Crossing the Quality Chasm: A New Health System for the 21st Century," Washington, D.C.: National Academy Press, 2001.
3. Kramer, Peter, "Listening to Prozac," New York, N.Y.: Penguin, 1993.
4. National Alliance for the Mentally Ill, www.nami.org.
5. National Mental Health Association, www.nmha.org.
6. New Freedom Commission on Mental Health, "Achieving the Promise: Transforming Mental Health Care in America," Final Report, DHHS Pub. No. SMA-03-3832, Rockville, Md., 2003. Also available online from www.mentalhealth.samhsa.gov .
7. Robins, Lee N., and Regier, Darrel A., "Psychiatric Disorders in America: The Epidemiologic Catchment Area Study," New York, N.Y.: Free Press, 1991.
8. Samuelson, Douglas A., "Can Early Screening for Mental Disorders Reduce Criminal Justice Costs?" George Mason University Civil Rights Law Journal, Winter 2000.
9. Samuelson, Douglas A., "A New Frontier? Health Services Research and Medical Informatics," OR/MS Today, February 2000.
10. Samuelson, Douglas A., "Diagnosing the Real Health Care Villain," OR/MS Today, February 1995.
11. Torrey, E. Fuller, "The Invisible Plague: The Rise of Mental Illness from 1750 to the Present," New York, N.Y.: Free Press, 2002.
12. Torrey, E. Fuller, "Surviving Schizophrenia," New York, N.Y.: Harper Collins, 2001. (Fourth Edition)
13. Treatment Advocacy Center, www.psychlaws.org.

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