Disordered Spending on Mental Health

Mental health spending is a black box set to bust the state and federal budgets. To see how mental health providers manipulate state and federal spending to the detriment of virtually everyone else, consider how the “Population in Need” project coalition is seeking to extract more money from Colorado taxpayers.

In Colorado, and, it appears, 10 other states, “Population in Need” seeks to shake more taxpayer dollars loose for rent-seeking mental health providers by “inform[ing] policy planning” with indicators of “unmet need” for “low income” people with a serious behavioral health disorder (SBHD).

In Colorado, spending on mental health community programs and Medicaid mental health has increased by more than 26 percent since FY 2007-08. This year, the bureaucracy is asking for additional double digit percentage increases in spending. To support its claims, it has produced “Colorado Population in Need 2009,” a report showing that only a third of the low income people who need mental health services get them.

People who want to examine how the “unmet need” estimates were arrived at before they hand over their money are out of luck. The estimates are derived using “proprietary” software.

The good news is that the data that have been released make it clear that the report errs on the high side. These estimates are based on the 2001-2003 National Co-Morbidity Survey Replication Study (NCS-R), a survey of mental disorders in the United States. Thanks to this survey of just 9,282 people, the Population in Need report says that it can estimate the prevalence of mental illness in each and every Colorado county.

The NCS-R definitions of mental disorder follow the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). This means that everything from smoking,  to ADHD, to premenstrual syndrome is classified as a mental disorder. Due to an error, normal depression caused by bereavement is counted as a disorder, too.

As one would expect, the survey finds that the American population is seriously disordered. In fact, it suggests that 57.4 percent of Americans suffer from a mental disorder during their lifetimes.

To add insult to injury, the Population in Need report defines “low income” as 300% of the federal poverty level. This is equivalent to an annual income of $54,930 a year for a 3 person household without counting transfers like food stamps, Medicaid, and housing subsidies. For comparison, US median household income is in the neighborhood of $51,500 a year.

The NSC-R estimates include many disorders that neither need treatment nor pose any danger to the public. Kessler et al. (2005) noted that “unmet need for treatment may not be a major problem, because a high proportion of untreated cases might be mild or self-limiting.” They defined a serious disorder as one that led to a serious suicide attempt, a work disability due to mental or substance disorder, a positive screen for bipolar disorder, repeated serious violence, or 30 or more days “out of role.” Overall, 22.3 percent of all disorders were serious, and the twelve-month prevalence of any disorder was 26.2 percent. In all, the authors concluded that 5.7% of the population had a serious disorder in a 12 month period.

To boost its case for more spending, the Colorado People in Need report defines “unmet need” as people who have not accessed services but who are mentally ill using the broad NCS-R definition. Although it is clear that this is budgetary nonsense and that no private business would base spending on such flimsy figures, Colorado’s task force decided to use this definition. According to the People in Need report, it did this in the name of (expensive) consistency. The Population in Need report states that “the other 10 states conducting Population in Need Studies choose to use the term ‘unmet need’ to describe those who needed but did not access services” and the Colorado task force chose a definition that “would remain consistent with the other states.”

There little evidence that the benefits of current spending on substance abuse treatment exceed its costs. Large fractions of people diagnosed as nicotine, alcohol, cannabis or cocaine substance abusers stop abusing their drug of choice without treatment. As Tucker points out, “treatment is neither a necessary nor a sufficient condition for resolution.” Dawson et al. found that 75 percent of the people classified as alcohol dependent in one year were no longer alcohol dependent in the next year. Only 25 percent of those classified as dependent had received treatment. Lopez-Quintero et al. found that, of those who were classified as dependent on nicotine, alcohol, cannabis, and cocaine, 83.7%, 90.6%, 97.2%, and 99.2%, respectively, ultimately ended up ending their dependence, or being “in remission,” at some point in their life. Other studies suggest that the majority of those who go into “remission” do so without treatment.

In the UK, the NICE evidence-based guideline for Drug Misuse (Guideline Number 51) concludes that drug abusers should be offered information on self-help programs. It says that formal psychosocial interventions should focus on rewards for not using drugs, with vouchers for goods or services of increasing value as the period of abstinence lengthens. It does not recommend cognitive behavioral therapy for people who misuse stimulants or cannabis.

The evidence on the efficacy of treatment for depression appears to be as weak as that on the efficacy of treatment for substance abuse. For depression, NICE researchers conclude that “over the past 50 years there has been a significant expansion of theories and therapies for depression. However, only a relatively small number of these therapies have travelled the full empirical road and demonstrate that they are efficacious and can be cost-effective treatment options for the NHS.” For people with mild to moderate depression it recommends advising on getting proper sleep,  guided self-help, computerized cognitive behavioral therapy, and a structured group physical activity program.

Tax dollars are a finite resource. If rent-seeking coalitions manage to shift US policy from focusing on those with mental illnesses that pose a danger to the public to budget busting “treatment” for every disorder inventive clinicians can come up with, it is possible that failure to treat those who pose a real danger to themselves and others will become commonplace.

Although Colorado’s spending on mental health has increased dramatically, people with serious mental illness have seen their treatment options shrink. In its FY 09-10 budget request, the Department of Health and Human Services worried about the adequacy of Colorado’s inpatient mental health services, fearing that deteriorating service exposed the state to legal liability. It stated that “The waiting list has grown from 30 to 81 individuals waiting up to five months in jail to be admitted. The escalating waiting list poses an increasing risk of serious legal liabilities for the Department resulting from delayed admissions.”

In short, a state obsessed with expanding Medicaid and tax funded care to help “low income” people with incomes over $50,000 a year appears unable to budget for those who are so obviously ill that they present a significant danger to others. They sit in jail waiting for evaluation and treatment. While rent-seeking groups of therapists propose budget busting increases to “treat” relatively mild disorders, funding for The Colorado Mental Health Institute’s replacement of old, deteriorated, and broken furniture, fixtures, and equipment decreased from $166,483 in FY 2002-03 to $154,259 in FY 2007-08.

Print