2009 SLC Keynote Address

by Katherine C. Nordal, PhD

March 1, 2009 — Before I begin my prepared remarks, I also want to personally welcome all of you to this, our 26th State Leadership Conference — the first for many of you and my first as the full-time APA Executive Director for Professional Practice. We are excited to have so many of psychology's leaders in one place at one time and we are all indebted to the work you have done and will continue to do for our profession.

I know that as a result of your SLC experience you will leave Washington exhausted but invigorated and feeling empowered to lead your colleagues and SPTA members to becoming part of the solution to the health care challenges facing our country. And what an exciting time this is in our nation's capital—with the hope for some real change in the way we deliver health care to our citizens.

There are many challenges to and opportunities for psychological practice I could have spoken about this afternoon. You will hear about several during the SLC content sessions: Health Information Technology and record keeping in an electronic environment; accountability, outcomes and measurement of clinical effectiveness; managed care and insurance company practices that limit patient care; and our aggressive federal legislative agenda around reimbursement issues, including the re-valuing of our psychotherapy codes and the addition of psychologists to the Medicare "physician" definition.

But given the current focus on health care reform, our keynote speaker's address to follow and our advocacy agenda for the Hill visits on Wednesday, I have chosen to focus primarily on psychology's role in health care for my remarks this afternoon.

Let's start with a brief look at some of the challenges in our health care system:

We all know that it is a broken and fragmented system with high and rising costs and variable quality. Private and government-funded programs cover close to 190 million lives. We have 46 million uninsured citizens.

We spend $2.3 trillion dollars annually on health care, almost twice as much per person as any other industrialized nation. But studies show that we are not getting what we are paying for. Fully a third of our spending is wasted on treatments, drugs and tests that do not improve outcomes.

Compared to other countries, we Americans have higher out-of-pocket expenses, forego care due to cost and experience higher rates of medical error. At the heart of this problem is failure to coordinate care. Merely expanding access and coverage will not solve all of our problems. We need integrated care and we need to pay more attention to prevention and wellness care, something that we psychologists know a lot about!

So, what about funding for mental health?

In 2003, we spent approximately $78.5 billion dollars on mental health care and treatment for substance use disorders. More than half of that care was publicly funded. Only one fourth of mental health or substance abuse care was paid for by commercial insurance carriers and approximately one fifth by patients themselves.

Historically, mental health and substance abuse treatment has been more dependent on government funding than physical health care. That trend is expected to continue over the next decade, although the long-term impact of the new mental health parity law is not yet known.

Mental health and substance abuse funding is predicted to reach $239 billion dollars by 2014, but will continue to fall as a share of overall healthcare spending, to just under 7 percent.

Prescription drugs account for a higher proportion of spending in mental health than in overall healthcare spending and that trend is expected to continue over the next decade. Estimates suggest that by 2014, prescription drugs will account for fully 30 percent of all mental health spending.

The economics of health care, and particularly behavioral health care, are sobering and present ongoing challenges. But in spite of these challenges, there are tremendous practice opportunities for psychologists. Let's consider some of the populations we serve.

One group is persons with serious mental illness. According to 2008 data from the National Institute of Mental Health, more than one quarter of adults, or almost 58 million individuals, suffer from a mental disorder in a given year. Approximately 6 percent of adults and 9 percent of children suffer from a serious mental illness. And almost half of those with any mental disorder have two or more disorders.

According to the World Health Organization, mental illness, including suicide, accounts for more than 15 percent of the disease burden in established market economies — more than is caused by all cancers combined!

Suicide is the leading cause of violent deaths worldwide. Suicide claims 30,000 American lives annually and is a leading cause of death among young persons. The rate of suicide among 15-19 year olds has tripled since the 1950s — another alarming indication of a broken health care system and the tragic consequences of unmet treatment needs.

A significant portion of the population with serious mental illness receives either no care or inadequate care. Deinstitutionalization has been a huge failure because we have not adequately invested in community-based care and psychological rehabilitation.

Deinstitutionalization moved patients from hospital beds to prison beds or to no bed at all. Jails are the de facto mental health system for this population because being arrested is, for many, the only way they can get any care at all. This pitiful situation, unfortunately, has reinforced the idea that SMI is hopeless and untreatable.

Why is it that psychologists do not currently play a major role in treating patients with serious mental illnesses? And why is it that psychologists do not have a larger important presence in the systems that provide most of the care?

Psychiatrists and subdoctoral personnel mainly provide this care, perhaps largely because of personnel funding issues in these systems. When I came out of graduate school in the early days of the community mental health centers, we had four full-time psychologists on staff in a semi-rural area. As federal funds waned and these programs came to rely increasingly on state and local funding, psychologists were replaced with social workers and counselors.

Now many of those positions are occupied by case managers with no graduate degrees at all. Psychiatrists continue to provide medication management, but many centers also use nurse practitioners. However in Louisiana, where psychologists have prescribing privileges, some of them are filling a need in these settings.

Our colleague Dr. Sandra Wilkniss, a practitioner who is very active in implementing recovery-oriented services at many sites in the Chicago area, knows that psychologists can play a critical role in the psychosocial rehabilitation of those with serious mental illness.

Psychologists are uniquely qualified to help bridge the 15 to 20 year gap between identification of evidence-based practices and their routine use with patients by fostering the development of evidence-based practices, interpreting evidence from interventions, supervising new clinical interventions, contributing diagnostic and assessment expertise, and facilitating a substantial research agenda.

How about our veterans?

More than 250,000, or one in five of our American servicemen and women have come back from Iraq with brain injuries. Among enlisted ranks deployed to Iraq, 12 percent return from a first deployment with PTSD, 18.5 percent from a second deployment, and 27 percent from a third or fourth deployment.

Rates of PTSD for reservists appear higher than those for active duty soldiers. Suicide rates among returning male veterans in the 18 to 29 year age range appear to be at least double the rates for men of the same age who are not veterans. Our discipline, with psychologists like Drs. Terry Keene and Edna Foa, has developed state-of-the-art evaluation and treatment protocols for PTSD. And our colleagues in neuropsychology have developed the methods for evaluating and rehabilitating individuals with traumatic brain injury.

Our criminal justice system houses a large number of individuals with unmet behavioral health needs.

A 2008 Pew Center report indicated that almost two and a half million Americans were in state and federal prisons and jails and more than five million on probation, parole or some other form of supervision. And on any given day in America, more than 1.5 million children have a parent behind bars. Our incarceration rate is the highest among all nations. Half of those released from prison wind up back behind bars within three years. In the last 20 years we spent six times more dollars on prisons than on higher education. What is wrong with this picture?

The rate of serious mental illness in the prison population is significant and is three to four times that of the general population. An even larger percentage suffers less serious mental illness.

By 2005, more than 107,000 women were incarcerated. They are disproportionately women of color, in their early to mid-30's, unmarried mothers of minor children, survivors of physical and/or sexual abuse and from fragmented families. The very high prevalence of physical and mental disorders in this population makes them the highest risk population in American public health.

Three-quarters of these women have symptoms of mental disorders, compared with 12 percent of females in the general population. More than 90 percent of these women reported being a victim of interpersonal violence. Most incarcerated women never receive treatment and the scant treatment provided is inconsistent and of questionable quality.

I have been in a women's prison in Jackson, Mississippi, as part of a faith-based initiative, and have witnessed first-hand the suffering of these women and their unmet psychological needs. If lucky, they get medication. If more lucky, they might have the benefit of self-help groups. Rarely do they get the psychotherapy they need.

While women are currently a very small but growing portion of the adult prison system, girls today make up 25 percent of youth in the juvenile justice system. A "typical" female juvenile offender is 15 years old, from a racial and ethnic minority group, urban, lives in a single-parent family home, does not attend school, has minimal work and social skills, has a history of physical and/or sexual abuse and a high rate of sexually risky behavior.

According to the Department of Justice, in 2003 there were almost 110,000 incarcerated juvenile offenders. Three-quarters reported mental health problems and more than half of them had had prior outpatient treatment or hospitalization. One large study of Chicago area youth found that 66 percent of males and 75 percent of females in juvenile detention had at least one psychiatric disorder and 50 percent either abused or were addicted to drugs. More than half of these youth met criteria for severe emotional disturbance.

Another group with tremendous needs is our students on college and university campuses. There are 20 million college students in the United States. Approximately 10 percent of students receive services at university counseling centers, where more than one million counseling sessions were provided in 2008.

While there are about 2,500 psychologists in addition to other mental health providers in 2,000 campus counseling centers across the U.S., many report being underfunded and understaffed while seeing more students with serious psychological disturbance. And the recent experiences on campuses like Virginia Tech highlight the important services that our counseling psychologists offer across the country.

Psychologists' expertise is needed throughout our educational system. There are 14,000 local school districts with 114,000 public and private schools, serving over 52 million students in grades K-12. While 13.5 percent of those students receive special education services, the majority of those served have developmental, learning, or physical handicaps.

Many other students with behavioral, emotional and substance abuse disorders receive minimal services through their school districts. An estimated 21,500 individuals work as school psychologists, but only 7,000 are doctorally trained.

While overall rates of high school graduation reached as high as 84 percent by the year 2000, that leaves at least 16 percent of our students who do not graduate. Psychological, emotional, behavioral and substance abuse problems in addition to pregnancy account for a significant percentage of dropouts. Alarmingly, as reported by SAMHSA, almost five and a half million youth between 12 and 17-more than one-fifth of that age group-received counseling for emotional or behavioral problems during 2005. And an estimated one in ten youth at least suffers from serious emotional disturbance.

Our schools need psychologists like Dr. Tammy Hughes to assess children's eligibility for special education services; provide psychotherapy services; implement preventive services; consult with teachers and school staff; conduct program and system evaluation; and supervise other school mental health providers. Strong school-based mental health programs can attend to health and behavioral concerns, relieve unnecessary pain and suffering, reduce dropout rates and help to ensure a level of academic skills required to enter higher education or the workforce.

And let's not forget about the kids in preschool and childcare facilities. An increasing number of children are being expelled from preschool and childcare facilities for severely disruptive behaviors and emotional disorders.

In my practice, I was often amazed by the referrals of these very young folks and their parents who were at a loss to explain and cope with the difficult situations their child's behavior presented. And preschool teachers and child care workers often are desperate for help in working with these students.

Dr. Jana Martin, one of our California practitioners, consults with preschool programs. She knows that delivering mental health services and support early and quickly are necessary to avoid permanent adverse consequences for these children. Without intervention, their disorders will worsen. We know that about half of students with serious emotional disturbance never graduate from high school.

At the opposite end of the age spectrum are older adults who need and benefit from our services. The U.S. population is aging, and the proportion of older adults is growing rapidly. The rate of depression in older adults is distressing. Up to 9 percent of those in primary care settings meet criteria for major depressive disorder. Estimates of less severe depression range from 10 to 25 percent in community and primary care settings, and up to 50 percent in nursing home and medical settings.

Most do not get the treatment they need. Depression has a huge impact on the health and functioning of older adults: exacerbating illness, prolonging recovery from illness and surgical procedures, increasing levels of pain, worsening functional disability and increasing the rates of suicide and mortality from disease.

Psychologists have a range of skills important for working with this population: cognitive and psychological evaluations to differentiate normal aging from disease, side effects of medications, adjustment reactions or combinations of these problems; assessment of emotional disorders and suicide risk; consultation to family members and other health care providers; and program evaluation and outcomes research. Psychologists also help older adults understand how emotions and memory impact their physical health. Many health problems, such as high blood pressure, diabetes and chronic pain, require taking medications, staying on a proper diet and exercising regularly. A psychologist can help an older adult make the necessary lifestyle changes that can lessen the need for medication and improve functioning.

Neuropsychologists are uniquely qualified to evaluate the functional significance of brain disease or injury in a way that neuroimaging cannot. They can explain how injury or disease affects the patient and what kinds of interventions are necessary to improve daily functioning.

One area where many psychologists do not think about plying their trade is the business world. While I/O psychologists occupy a unique role in large companies and industry, psychologists who are health services providers can offer many services for businesses: programs targeting workplace stress; workplace violence prevention and intervention; manager training to facilitate early identification and referral of employees in need before their job performance is significantly impaired; and career and job coaching, just to name a few.

Increasingly, employers concerned about health are offering workplace programs to target obesity, a serious health problem. Two-thirds of all Americans are overweight or obese and many of them will develop diabetes, coronary artery disease or other diseases related to obesity. Psychologists have a critical role here, having developed interventions to address obesity.

While there are many specific populations we serve in a variety of settings, I want to turn our attention now to a broader role for psychologists in the health care system, one which must focus increasingly on integrated care.

Why integrated care? Over time, health, mental health and substance use treatment systems have evolved in silos and independently from each other, as if the mind and body were two separate and unrelated systems. The physical health care system was not designed to address behavioral healthcare issues, and the mental health and substance abuse systems were not designed to adequately address physical health issues. As a result, our health care systems often fail to detect important aspects of the individual's overall health, typically resulting in significant costs to the individuals, their employers, the health care system and society.

We know that at least half of the care provided for common psychological disorders, such as depression, is provided in the primary care environment, not in specialty behavioral health settings. This is especially true for persons of color. Common adult disorders seen in primary care include substance abuse, depression, bipolar disorder, and anxiety. For children and adolescents, the most common problems include anxiety disorders, bedwetting, disruptive behavior disorders and ADHD.

In primary care settings, patients tend to present with psychological disorders of mild to moderate severity and at this level, they are much more amenable to treatment that can prevent more severe or chronic disorders. The consequences of unmet mental health treatment needs, which can contribute to or worsen a variety of physical health problems, are too costly to ignore.

Unfortunately, the first line of primary care treatment for psychological disorders is usually medication without the appropriate referral for psychotherapy. Prescription drugs are viewed as cost-effective, are widely accessible and are associated with less stigma than other mental health treatments. These factors, combined with greater access to primary care providers, has increased the use of and spending for psychotropic medications.

However, there are questions about the ability of non-psychiatric physicians, physician's assistants, and family nurse practitioners who prescribe an increasing share of psychotropic medications, to properly diagnose some of the more complicated conditions and to follow up properly with those patients to ensure high-quality care.

Patients who access the primary care system could benefit tremendously by having prescribing psychologists as an integral part of their health care team. Prescribing psychologists use a biopsychosocial model of care and have much more training regarding psychological disorders and psychotropic medications than any other prescribing health care professionals aside from psychiatrists. There is a dearth of psychiatrists and their ranks continue to diminish. Psychologists are the logical providers to fill these dire gaps in care.

Individuals with common medical disorders also have unusually high rates of co-morbid behavioral health problems, particularly depression. When these behavioral health issues are not adequately treated, health outcomes worsen because these individuals are not able to adequately manage their illness or follow prescribed treatment. They have higher medical costs and higher mortality than those without comorbid psychological disorders. Alarmingly, individuals with severe mental illness die of physical ailments an average of 25 years earlier than their counterparts without severe mental illness.

So how do we know that integrated care works both for the patient and the healthcare system?

As early as 1971 data indicated that between 50 and 80 percent of all medical visits involved patients with no identified physical problem. Overutilization of medical care by patients with co-occurring physical and psychological complaints has been clearly documented. A meta-analysis of some 91 studies demonstrated decreased medical utilization following psychological intervention for 90 percent of those studied.

Consider our colleague, Dr. Parinda Khatri, Director of Integrated Care at Cherokee Health Systems in Tennessee. She reports data from her health care system that offers dramatic evidence for the cost effectiveness of integrated care, including increased efficiency of primary care services delivery, an average 30 percent medical cost offset, improved patient adherence and decreased referrals to specialty mental health care.

Patient and provider satisfaction increased when a psychologist participated on the treatment team. Integrated care systems utilizing psychologists can produce better outcomes for fewer dollars!

So let's focus on what psychologists bring to the health care team. Psychologists are uniquely positioned to assume a greater role in managing both health and disease. We know how to manage the psychosocial aspects of acute and chronic disease by applying behavioral principles to lifestyle and health risk issues. Psychologists emphasize prevention and self-help approaches and partner with patients in a treatment relationship that encourages personal responsibility and builds resilience.

Psychologists, who possess research and critical thinking skills, can assist patients in evaluating and selecting among treatment options and in complying with complex and difficult treatment regimens. We also can co-manage treatment of the patient's psychological disorders. Psychologists' strong research background-a unique qualification among health care professionals-prepares us for key roles in the design, implementation and evaluation of prevention and intervention programs at the individual, family, system and community levels.

More than 7,000 federally qualified health centers serve 16.1 million patients who make 63.2 million visits annually. This setting is a ripe work environment for psychologists with an interest in both physical and mental health treatment. Thirty-nine percent of patients in these health centers are uninsured, 35 percent are covered by Medicaid and 15.5 percent by private insurance. Ninety-two percent of the patients are low-income and 53 percent of centers are located in rural areas. Working in such centers offers an opportunity for psychologists to make a real difference in the quality of life of the poor and marginalized.

And do you know where else we can have a huge impact both in terms of patient outcomes and cost savings? In helping to prevent and treat chronic disease!

Our keynote speaker today, Susan Dentzer, observed in a recent edition of Health Affairs that we have eliminated many causes of acute diseases, but have achieved longer lives plagued with chronic diseases. A World Health Organization report noted that the elimination of chronic disease risk factors — unhealthy diet, smoking and physical inactivity — could wipe out at least 80 percent of heart disease, stroke and type-2 diabetes worldwide.

Seventy-five percent of our two-trillion dollar health care bill annually is spent on chronic illness-heart disease, pulmonary disease, cancer, diabetes, arthritis, high blood pressure and depression. Almost two thirds of health care spending growth is due to our worsening health habits, particularly the endemic rise in obesity. Prevention is the key to having a healthy and productive workforce, which the U.S. needs to continue as a leader in the global economy.

More than 40 percent of U.S. citizens have one or more chronic conditions that account for 75 percent of all personal medical care spending. Sixty percent of these folks are of working age. Chronic disease is increasing among individuals in mid-life and early old age without regard to race, sex, ethnicity and income level.

Chronic disease is an equal opportunity disabler! Individuals with chronic conditions require life-long attention to manage symptoms, prevent complications and co-morbidities and save health care dollars.

Psychologists have a unique role to play in the prevention and management of chronic diseases. Psychologists have the diagnostic skills to quickly get to the root of the patient's resistance to adherence to treatment-which may be emotional difficulties, personality problems, substance abuse issues or longstanding exposure to trauma. We understand the interpersonal barriers to behavioral change and are skilled at motivational interviewing.

Psychologists know family systems and the impact of other family members on the patient's behavioral choices that maintain unhealthy behaviors. We are able to impact those systems and their components. Psychologists also understand environmental determinants of behavior and can design interventions to modify them.

Many of the treatment techniques and interventions widely used by other health care professions originated with psychology. These include: adherence protocols; pain management techniques; cognitive-behavioral therapy; biofeedback; self-help treatment approaches; injury prevention; smoking cessation strategies; treatment of eating disorders; pre- and post-surgical interventions; alcohol and drug abuse treatments; sleep hygiene protocols; obesity treatment; prevention and wellness interventions; and anger management techniques, to name a few. Our interventions can prevent unnecessary disability and improve the quality of life for individuals and their families.

We have done such a good job of giving our knowledge away that many do not recognize psychologists as the originators of these interventions. And many do not realize that we are the best at applying the interventions!

We are the leading experts in changing the unhealthy behaviors of individuals, families and systems. This is a unique contribution that our professional discipline makes to the healthcare workforce.

We have the skills to improve quality of life and at the same time dramatically reduce costs in our healthcare system.

You need to listen carefully to what I am about to say.

There are approximately 700,000 mental health providers, including psychologists doing psychotherapy, trying to earn a living by competing for a portion of the roughly 7 percent of health care dollars that are spent on mental health and substance abuse treatment. And remember that mental health and substance abuse treatment may be a shrinking portion of the health care dollar pie of the future, with more cost shifting to the public sector, and up to almost a third of those dollars going to psychotropic medications.

Increasing the numbers of lives covered and increasing numbers of providers will result in increased mechanisms to control costs and will require a higher order of accountability for both quality and outcomes. Additionally, 54 trillion dollars is spent on treatment of chronic disease, much of which is preventable or reversible with proper treatment, and much of which must be psychological in nature to be successful.

It is foolhardy for us to focus narrowly on mental health issues when the real opportunities to make a significant difference in the quality of life for most of our citizens are in the broader domain of general health care and in delivery systems that will have stringent demands for accountability with a focus on quality and outcomes.

It is time for us to view our discipline more broadly as a health care profession, with mental health as a subset of our expertise, and to communicate the breadth of our expertise to the public and policy makers. That will be part of your job during your Hill visits on Wednesday.

Can you do that?

"Yes we can!"

Thank you!