Health Policy, Advocacy, and Public Education

Good afternoon.

It is a pleasure to welcome you to the Annual APA meeting in beautiful San Diego! I am delighted to join more than 10,000 of my fellow psychiatrists for 4 days of learning and engagement here in California. I hope you’ll leave this meeting inspired and recharged for the important work you do!

I am honored and thrilled to have had the privilege to serve this wonderful organization and its membership, as well as the field of psychiatry. This past year has been one of the most rewarding in my life. And it has gone incredibly fast! I have learned a tremendous amount and worked hard to serve you, the membership of the APA.

Last year, I spoke to you about the importance of partnerships in forging the path forward toward prevention, and you will see that this year’s program is peppered with outstanding sessions that address this important theme. Indeed, this year saw the APA develop a variety of partnerships. For example, we have partnered with the American College of Obstetrics and Gynecology to prepare practice guidelines for the treatment of peripartum depression, a key approach to preventing untoward mental health outcomes in children. And that is terrific news!

But, in fact, our partnerships have not been only in the medical or clinical arena. They also have been in the health policy space. I would say that perhaps the most surprising thing about this year was just how much of the focus was on working with the U.S. government, on both sides of the aisle, as well as with high-ranking government officials to improve policy that will have effects on our patients, on our profession, and on our membership for years to come.

Together with the wonderful APA Staff, I went to Capitol Hill repeatedly to work with the House and Senate. Some of our work was clearly advocacy, much of it was education.

Yes, APA expends a tremendous amount of effort making sure that our elected leadership has the most up-to-date, scientific information regarding psychiatric diagnoses and treatments. APA expends a tremendous amount of effort to ensure that legislation around parity and insurance are to the benefit of our patients. APA expends a tremendous amount of effort to make sure our government officials know what our patients need to recover and live a full life. And that is terrific news!

In fact, just 2 weeks ago, we engaged in a major advocacy effort. An impressive coalition of medical societies went to visit seven Republican senators on Capitol Hill. The Front-Line Physicians Coalition, representing over 560,000 physicians across the country, is comprised of six major medical associations representing pediatricians, family physicians, internists, obstetrician/gynecologists, and of course, psychiatrists. There we were, a powerful voice gaining access to governmental leaders to discuss with them our grave concerns about the American Health Care Act and its anticipated negative impact on our patients and their families. Strikingly, mental and substance use disorders were very much on the minds of all the members of the coalition. Whether it was the OB/GYNs’ president talking about babies in opioid withdrawal ending up in the NICU or neonatal intensive care unit, or the internists’ president talking about depressed patients with diabetes who could not adhere to treatment, or the pediatricians’ president talking about suicidal behavior in adolescents, everyone was committed to making sure that psychiatry was right there, front and center at every last one of the seven conversations. That was exciting. That was rewarding. And while I do not know for sure that we changed many minds, we certainly embraced the opportunity to try to do so.

And why were we so adamant about trying to persuade senators to eschew the American Health Care Act? As you know, before the Affordable Care Act, or ACA, people with mental health issues struggled to obtain insurance coverage to help them access care. While not perfect, the ACA changed that by requiring companies to cover those with pre-existing conditions, including mental health conditions, and by mandating coverage of treatment for mental and substance use disorders. This law strengthened parity protections first outlined in federal law in 2008. As physicians, none of us wants to see these advances rolled back. We want to ensure patients continue to have access to care and that their mental and substance use disorders are treated just like any other ailments. That was the message the Front-Line Physicians Coalition brought to Capitol Hill.

Harkening back to one of the first activities of my presidency, I recall the Senate Summit on Mental Health, organized by its sponsors, Senators Bill Cassidy and Chris Murphy. As APA President, I gave a provider’s view on the bipartisan Mental Health Reform Act of 2016, sponsored also by Senators Lamar Alexander and Patty Murray. There were stakeholders of many different backgrounds present: National Alliance on Mental Illness, foundations focused on mental health, National Institutes of Health staffers, and of course, plenty of APA representation.

There, I had the opportunity to describe how widely prevalent mental illness is, with over 68 million Americans experiencing a psychiatric or substance use disorder in the past year, more than 21% of the total U.S. population. If you examine lifetime rates, estimates approach 50%. More striking, the latest data shows that more than 41,000 Americans die by suicide per year, 20% more than by motor vehicle accidents, at about 34,000. Just as ghastly, drug overdose is the leading cause of accidental death in the U.S., with more than 52,000 lethal drug overdoses in 2015. This, despite promising gains in medical research and public awareness.

I discussed how as a nation, we continue to fail Americans with mental illness every day, and the multiple contributors to this failure, too. Fragmented health delivery and reimbursement systems, limited funding for medical research, a lack of coordination in both Washington and state capitals, obsolete regulations, workforce shortages, and the enduring stigma surrounding mental illness all pose barriers to appropriate, effective treatment. Of course, we can do better, but we need to act on several fronts.

We must continue to work with our governmental partners to ensure increased support for the National Institute of Mental Health, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism. Why? Because the only way to gain traction in the prevention and treatment of psychiatric and substance use disorders is through research into their neurobiological causes and identification and testing of treatments that work.

We also must train more mental health providers, especially psychiatrists. There simply are not enough of us. This can be illustrated with the following thought experiment. Consider that since 21% of the population will suffer from a psychiatric disorder in any given year, as I just mentioned, that translates into a stunning fact: out of 100,000 persons, 21,000 need psychiatric care each year; 4,200 have serious mental illness. Yet, some counties in the U.S. have only 3.5 psychiatrists per 100,000. Can you imagine that three or four psychiatrists could serve such a patient base, even with collaborative care models and use of physician extenders?

But that is not all. We must enforce the Mental Health Parity and Addiction Equity Act. Seven years after this landmark legislation was enacted into law, insurers creatively continue to discriminate against patients with mental illness, especially by failing to maintain adequate provider networks. But the multiple strategies in use by insurance companies are varied indeed, including more onerous preapprovals for psychiatric than for other medical care. We simply must expand federal efforts to enforce compliance with the parity law. This was a central element of my message to the Senate Summit participants and remains a critical goal for APA.

Another, very different, type of governmental activity that APA engaged in this year and just as essential was meeting with high-ranking government officials. For example, Robert M. Califf, M.D., the then commissioner of the Food and Drug Administration (FDA) invited APA to participate in the FDA’s stakeholder listening session. The goal was for APA to bring burning issues to the attention of the FDA. The FDA was clearly seeking to engage those of us most affected by its decisions—patients and their families, physicians, and health care delivery services—to maximize the likelihood that its policies take into account the nuances of the “real world” and are ultimately better received. But perhaps more important than what I was able to convey to Dr. Califf, was what I learned from him. He entreated the major medical associations to work on practice guidelines. Specifically, his point was that since the FDA could not possibly give approvals for every reasonable use of a medication, he and his colleagues relied on medical associations’ practice guidelines to fill in the multitudinous spaces in which there are no approved medications, or where treatment refractory conditions lead us to search for alternatives. This served as an impetus to work closely with APA staff to formulate a strategy for developing practice guidelines in a more streamlined fashion while following the rigorous standards of the National Academy of Medicine. And that is terrific news!

A third type of advocacy effort that we at the APA engaged in this year was congressional briefings. Congressional briefings provided the opportunity to meet with House staffers and members of the public to give them information about critical issues in psychiatry. We held one on suicide and another on the opioid epidemic, two devastating public health crises where psychiatric conditions play an essential role. The notion was to persuade the attendees to stay focused on these deadly problems.

In the most recent briefing on the opioid epidemic, the APA lined up speakers that were simply spectacular. National leaders talked about what was needed to stem the increasing toll of prescription opioid misuse and its biological basis; they discussed the challenges of treating pain and the limitations of our toolbox to appropriately address it without exposing patients to the risk of addiction. The discussion ranged from the importance of research to find new methods for identifying vulnerable individuals to the need to delineate the neurobiological changes that lead to the inexorable addiction that haunts some of those exposed to prescription opioids, from descriptions of the different medication treatments currently available for opioid addiction and their pharmacology, including the limitations of medications with a short half-life as well as the importance of psychotherapeutic interventions, so critical to a holistic approach to psychiatric conditions. Discussion about how stigma is actually codified in the way that some insurance companies go about approving detox or inpatient treatment, increasing risk for relapse and even death, was heart rending, demonstrating that this is not an illness of the disenfranchised or marginalized, it touches every corner of our society, regardless of income or education.

But perhaps the biggest highlight of my presidency came at the end of 2016, when I had the privilege of watching President Obama sign the 21st Century Cures Bill into law. I was honored and grateful to have the opportunity to represent our great Association at this landmark event.

When President Obama and Vice President Biden came onto the stage, there was loud, protracted applause. What followed was one of the most moving ceremonies I have witnessed. President Obama and Vice President Biden spoke and acknowledged the deep love and respect they have for each other. They spoke about how this was the last bill that President Obama would sign into law. They talked about the amazing things that were in the new law: funds for medical research through the National Institutes of Health, including $1.5 billion for the Brain Research Through Advancing Neurotechnologies (BRAIN) Initiative; teeth for enforcing mental health care parity; strategies to improve the recruitment, training, and retention of a mental health and substance use disorder workforce; coordination of fragmented mental health resources across federal agencies through the establishment of an Assistant Secretary for Mental Health and Substance Use; grants to support integrated care models for primary care and behavioral health care services; a training demonstration program for medical residents and fellows to practice psychiatry and addiction medicine in underserved, community-based settings; grants to states to establish, improve, or maintain programs for screening, assessment, and treatment services for women in the peripartum for depression; decreasing criminalization of individuals with mental illness by supporting mental health courts and crisis intervention teams; combating the opioid epidemic with $1 billion over 2 years; and much, much more.

The 21st Century Cures Act is a huge step for mental health: the country is poised to make some major gains. Yes, it is emotional; yes, it is historic; but most importantly, our patients will see tangible improvements in their care. And that is terrific news!

Of course, the year also offered plenty of challenges. There have been a series of highly visible issues that required our attention: first around the Goldwater Rule and most recently about public statements regarding the alleged “futility” of medication-assisted treatment. I have heard from many of you on these issues, and the media has certainly been asking lots of questions. Throughout the year, APA has adhered to its responsibility to be methodical and careful, to speak up in such a way that the message might get through, to balance intended effect and unintended consequence.

As I wrap up my Presidency, I am pleased to be leaving the APA in strong standing. Our membership is more than 37,000 people strong—the highest numbers we have seen in 14 years. We have particularly seen growth in the number of women, African American, Asian, and Latino psychiatrists who are members of the APA, as well as the number of international members joining our ranks.

The APA is also in a strong position financially. Last October, I led the Board of Directors in a retreat to discuss the Association’s current and future finances. I feel confident that we are ready and able to meet whatever challenges the next 4 years may bring. This includes our move to a new waterfront development in Washington, DC, which will take place at the end of this calendar year, putting the APA just steps from Congress, the White House, and the headquarters of HHS.

So today, I have conveyed how strong APA is and given you a handful of examples of some of the partnerships that we have developed over the last year. As such, we are poised to seize our day! We are at the threshold of a wonderful era for psychiatry. We know more about the brain than ever, and new treatments are being developed that range from pharmacology to behavioral interventions and from brain stimulation to psychological treatments. As exciting, we have joined our sister disciplines in medicine to develop preventive strategies and influence health policy. These will form the centerpiece of 21st-century medicine and 21st-century psychiatry. And that, my dear colleagues, is terrific news!