Mental health takes its place at Rollins

When Benjamin Druss was a medical student more than 20 years ago, he set his sights on a career as a primary care researcher. He signed on for a residency in primary care—what better way to know the trials and tribulations of the field than to work as a primary care doctor, he thought. But in his first year as a medical resident, when he realized how much of work in primary care was related to psychiatric and psychosocial issues, he decided to add a psychiatry residency as well.

In the years since then, he and his team of researchers have studied the many issues—such as stigma, insurance regulations, and the lack of providers—that make mental health care so challenging in the United States. These issues still persist, but recent changes have led Druss to proclaim that there is no better time than now to advance the nation's mental health and research into it. The 2008 Mental Health Parity and Addiction Equity Act ended insurance discrimination by mandating equal coverage for treatment for mental health or substance use disorders. And now more people will have access to private or public insurance through the Affordable Care Act (ACA) and expansion of Medicaid (in some states). Those two laws have helped pave the way for the new Center for Behavioral Health Policy Studies (CBPS). The center, housed at the RSPH, brings together funded researchers focused on mental health.

"Schools of public health originally focused on an infectious disease paradigm, but there is increased recognition about the growing burden of chronic illness in the United States, and within chronic illness, mental health disorders in particular," Druss says. "There are many people involved in developing better treatments, but we also need to look at the population as a whole—how do we make sure people have access to care and that they stay in care. We're almost certainly going to see a growing mental health focus in public health schools in the coming years."

Currently, the RSPH is one of a few schools in the United States with an emphasis on mental health research. Druss himself is one of a handful of psychiatrists based at a school of public health.

"We would like to see a world with better care and better health for people with mental and substance use illnesses," he says. "Toward that end, the center reflects our goals in research, teaching, and service. We want to foster high-quality work that informs policy and is useful to policy-makers. On the teaching side, we are very much devoted to training the next generation of researchers, public health practitioners, and advocates."

The RSPH began a "Mental Health Concentration" in 2006 after students began expressing interest in organizing their electives, theses, and practicums around mental health. The interest in the concentration proved so successful that the RSPH started a certificate program in fall 2010. Each year, approximately 25 students enroll in the certificate program, and 58 have earned one thus far. Graduates have taken positions with state mental health authorities, advocacy groups in Washington, community mental health centers, and federal agencies. The CBPS is conducting a survey to track career choices of graduates who have earned the mental health certificate.

A group of like-minded students recently founded the Emory Mental Health Initiative (EMHI) to foster interest in mental health-related issues and careers. Says Meredith Craven 14MPH, "I joined the group to learn more about what it means to concentrate on mental health in the public health field."

Craven, who is working toward the mental health certificate and plans to get a doctorate in clinical psychology, says that in addition to education and community work, the EMHI provides career development for students. "Many of us had an interest in the mental health field, but we weren't sure what we could do with it," she says. "But in public health, everyone's path is different. Public health is constantly changing so you can create your own job."

Bridging the gap

On the research front, the CBPS is helping foster greater collaborations, which, in turn, will bring more attention to mental health issues, says Janet Cummings, assistant professor of health policy and management and a member of the center. "Ultimately, I think one of the biggest advantages to the center is the opportunity to increase the visibility of our work, and with increased visibility comes opportunity for new collaborations."

Research by the center's faculty is key to bringing attention to and fixing the gaps in the U.S. mental health care system, she says. Cummings herself has been instrumental in showing there are large gaps in geographic access to mental health clinics that are often the only source of care available to people who are uninsured or have public insurance. (Nearly half of all children in the United States are covered by public insurance programs such as Medicaid or do not have any insurance, she points out.)

"It's really frustrating after a tragic event (such as the shooting at Sandy Hook Elementary School in 2012) that people talk about children's mental health, but they do not know how big the gaps in the system are," she says. "We need psychiatric beds for children who are a danger to others or themselves, but beyond that you need the providers in the community for ongoing treatment. I see the ACA as an opportunity to take steps in the right direction, but there are a lot of structural barriers that have to be addressed. Expanding insurance coverage is an important step in the right direction, but if a provider isn't available, then having better insurance coverage will not improve access to care."

Cummings and other center faculty see their research as an important tool to document gaps, which they then hope will lead to calls for action. Druss and Silke von Esenwein, for example, are studying an integrated health care model to improve primary care for mental health patients. The three experts often work closely with center faculty members Jason Hockenberry, a health economist, and Kimberly Rask, an internist and health economist who directs the Emory Center on Health Outcomes and Quality.

"The longer I do research, the more I feel that our mental health system is becoming two-tiered," Cummings says. "If parents have resources, then there is a lot of available help for their children. But uninsured kids, those with public insurance, and even many in the middle class, are being relegated to the bottom tier."

Cummings believes her future research, and that of other mental health services investigators, will need to inform strategies to close the two-tiered mental health treatment system that exists today.

The Carter Center as partner

Partnering with others in the field is vital to such endeavors. "Other schools may have centers, but one thing that is unique about our center is our ongoing relationship with the Carter Center Mental Health Program and our affiliations with the CDC," Cummings says. "I think that is reflective of Ben's hard work over time to develop meaningful collaborations."

Druss is a member of the Mental Health Journalism Fellowship Advisory Board and Mental Health Task Force at the Carter Center, where he advises on new programming and an annual symposium, which features topics of concern to mental health practitioners, advocates, and researchers. He is also Rollins' Rosalynn Carter Chair in Mental Health, the first such endowed chair at a school of public health. The chair is reflective of the bridge between the RSPH and the Carter Center—the academic research base at the school and the Carter Center's action-oriented agenda.

"The key element of the relationship between the Carter Center and Rollins is that we work in the same space but in different ways," says Thomas Bornemann, director of the Carter Center's Mental Health Program. "We are not a research unit, but we're a voracious consumer of research. We're the real-world setting that Rollins can use to take its research to the community. It's really a relationship where both parties benefit."

Defining the link between primary and mental health care

Researchers have known since the late 1980s that people with a serious mental health disorder are generally sicker and die younger than those without such a disorder. The weak link between mental health care and primary or specialist care is one that Druss and von Esenwein have sought to better define.

They conducted a study in 2011 that looked at people with mental health disorders over a 17-year period. They found that people with mental disorders died an average of 8.2 years younger than the rest of the population. The average age of death was 66 years, compared with 74 years of age in the general population. Nearly all of the excess mortality was due to medical rather than mental health causes.

"In my work as a psychiatric resident at Yale, I saw how many of my patients' problems went beyond clinical issues, such as being on the right medication, and were in fact larger systems issues with getting access to decent care, particularly to primary medical care," says Druss. "At Emory, our work has increasingly expanded from a health services framework to a broader public health approach. This method looks at people with serious mental illnesses as a disadvantaged population for whom we must address formal health needs, health behaviors, and social and environmental issues if we are going to improve their health and longevity."

One idea that is gaining much attention nationally and from Druss and von Esenwein is that of an integrated health model, one that provides primary and mental health care in a coordinated fashion. When mental health care is integrated with primary care, often at the same location, mental health patients have greater access to primary and preventive care, and their health status significantly improves. For patients with a serious mental disorder, mental health clinics are often their first and only points of contact with the health care system. Moreover, when people with mental illness feel understood and trusted by their mental health provider, they tend to be more engaged with the health care system.

Von Esenwein is now focusing on evaluating integrated systems. She cautions that "integration" does not simply mean locating mental health and primary care in the same building.

"Patients should not have the sense that this hallway is for mental health appointments and this other hallway is for physical care; it should be a team practice," she says. "And if a practice is not sharing medical records, it's not integrated.

"Access to care is a long-term problem. There is a big research-to-practice lag in mental health care, even with other areas of physical medical care, such as cardiology. I think the population that we are working with is a difficult one, and the mental health system has a lot of catching up to do."

The ACA is pushing the movement for integrated services, von Esenwein says.

"It's a very exciting time in the mental health field," she says. "It's interesting to see it happen so fast. Mental health is getting a big boost from the Affordable Care Act, but we will have to see how it plays out."

Regardless of how the ACA unfolds, "the biggest sea change is that the system is transforming itself from focusing on individual patients to one that looks at how best to manage populations," says Druss. "We need to make sure that mental health has a central role in this new system. It needs to be front and center."

Improving mental health in Liberia

A Carter Center program turns lives around for those with mental disorders

"My officers believe they can beat the craziness out of a person," the police officer whispered to Janice Cooper, as they stood recently in a classroom in Liberia. They were discussing how the police should treat the mentally ill that they encounter. She reassured him that the training the officers would undergo would change that misguided belief.

Cooper frequently hears such comments from Liberians. In a country still trying to overcome the ravages of two civil wars and persistent poverty, Liberians have paid little attention to the issue of mental health. Currently, the country of 3.8 million people has only one psychiatrist and one mental health hospital. More than one-third of the population suffers from depression. Myths, such as "beating the craziness" out of a person or curing someone through faith healing, have been passed down from generation to generation. As a result, Liberians with mental health disorders are left untreated, chained to logs, or locked inside a room and frequently are abused. Cooper, a Liberia native and adjunct faculty member at Rollins, is leading an effort through the Carter Center to change attitudes and improve access to mental health services in her homeland.

In the past four years, the center's Mental Health Program in Liberia has trained nurses and physician assistants (PAs) to recognize and treat mental disorders. Because the need for mental health services is so great, the country cannot wait for doctors to graduate from medical school.

"We recognize that we'll never have enough psychiatrists to meet the needs of the mentally ill," Cooper says. Cooper worked with Gail Stuart, dean of the College of Nursing of the Medical University of South Carolina and an expert on psychiatric nursing, to develop a curriculum, which they in turn taught to Liberian nursing faculty. More than 100 health care professionals have been trained so far, and Cooper expects to exceed the program's goal of 150 by the time the program ends in August 2015.

Nurses and PAs also train in various clinical sites, including prisons and a children's clinic. Now eight of 15 counties have a clinical practice in a prison, all started by program graduates.

The initiative has moved beyond training health care professionals to help ensure a better working environment for them. Program staff helped Liberia expand their drug importation list to more than 20 to treat mental illness; previously Valium was the only drug on that list and often the only one available.

To ensure that people with mental illness are treated fairly, Cooper and her colleagues train police officers, journalists, pharmacists, and religious leaders on the various types of mental disorders, their causes, and treatment. Training sessions include a guest speaker who has a mental disorder. As Cooper has learned, these personal stories are much more effective in reducing stigma than public service announcements on billboards or radio.

"It's important for them to see a person fully functioning," says Cooper. "I've seen both police officers and journalists change their opinion as they listen to a story."

As training continues, the Carter Center is exploring replicating the program in Sierra Leone. Cooper also has collaborated with Benjamin Druss, the Rosalynn Carter Chair in Mental Health at Rollins, to evaluate the program. "To touch people with mental illness and students so dedicated to their craft every day is amazing, just amazing," she says.—Kay Torrance

Bio: Benjamin G. Druss