3. Treatment
3.1. Access to Treatment
(3.1.1) NAMI believes that individuals with serious mental illnesses must have access to treatments that have been recognized as effective by the Food and Drug Administration (FDA) and/or the National Institute of Mental Health (NIMH).
(3.1.2) NAMI strongly opposes measures that are intended to limit, or actually do limit, the availability and right of individuals with serious mental illnesses to receive treatment with "new generation" medications such as atypical antipsychotics, selective serotonin reuptake inhibitors, and voluntary electroconvulsive therapy (ECT) administered by appropriately trained and licensed practitioners.
(3.1.3) No one currently taking a medication and doing well on that medication should be switched to another medication, even the generic version of the original, simply because the second medication is cheaper.
3.2 Early Diagnosis
(3.2.1) Early diagnosis and early initiation of treatment are both medically effective and cost effective. However, safeguards must be established to ensure against the abuse of over-diagnosis and over-prescribing of medications, particularly with children, adolescents, people of color and persons who are elderly.
(3.2.2) In particular, NAMI urges full use of the early periodic screening, diagnostic tool (EPSDT) for children. Treatment plans for children and adolescents must be reviewed every three months.
3.3 Mental Health Screening
(3.3.1) NAMI strongly supports Goal 4 of President Bush’s New Freedom Commission report on mental health issued in July 2003 and calling for early mental health screening. In this nation, approximately 10% of children and adolescents have mental illnesses, yet only 20% of them are identified and receiving services. Mental health screening is essential to address this gross under-identification of youth with mental illnesses. Research shows that early identification and intervention leads to better outcomes and may lessen long-term disability. It also avoids years of unnecessary suffering.
(3.3.2) Screening for the health and well being of children is a well-established practice in this country. We screen for vision, lead poisoning, hearing, scoliosis, tuberculosis, appropriate developmental progress and more. Campaigns of misinformation, stigma and fear must not stand in the way of appropriately identifying youth with mental illnesses and intervening with appropriate services.
(3.3.3) Federal, state and local leaders should take affirmative steps to implement mental health screening for children and adolescents, with the following guidelines and protections in place:
(3.3.3.1) Mental health screening must be voluntary and available for all children.
(3.3.3.2) Parental consent or consent from legally authorized surrogates must be obtained for all mental health screening.
(3.3.3.3) Mental health screening must not be used in a discriminatory manner.
(3.3.3.4) All individuals administering mental health screening must be appropriately trained and qualified both to administer the screening instruments and to interpret the results.
(3.3.3.5) All information related to screening must be kept strictly confidential and the privacy of youth and their families must be protected.
(3.3.3.6) All mental health screening instruments must be shown to be reliable and effective in identifying children in need of further assessment.
(3.3.3.7) Validity studies must be done to ensure that screening instruments are culturally and linguistically appropriate and administered in a manner appropriate for culturally and racially diverse communities.
(3.3.3.8) Schools must never use mental health screening results or the refusal to consent to screening as a basis for any adverse action against a child or family.
(3.3.3.9) All children identified through screening as potentially requiring mental health services must be referred for an immediate comprehensive mental health evaluation by a qualified and trained professional.
(3.3.3.10) Children ultimately identified as requiring mental health services must be immediately linked to and offered appropriate treatment and services and provided with comprehensive information about treatment options, the mental health treatment system, and family and community support resources.
(3.3.3.11) Early identification and intervention must be part of a national effort to build a comprehensive children’s mental health system of care for the millions of children and adolescents who require these services and their families. Families with children living with mental illnesses deserve nothing less.
(3.4.1) Every person with a serious mental illness must have an individual treatment plan (ITP) responsive to his or her changing needs. The plan needs to include, but not be limited to, health care, education, housing, rehabilitation services, and community support services. Treatment for persons with serious mental illnesses, who have other disorders or disabilities, including substance abuse (dual diagnosis), should encompass a wide array of options.
Options should be determined by the consumer in conjunction with family members and those significantly involved in treatment and service provision.
(3.4.2) A treatment plan reflecting assessed needs may include a range of available services. Criteria for determining the treatment plan should include assessment of behaviors resulting from changes in environment as well as the skills development and social supports needed to respond to these changes.
(3.4.2.1) Criteria for determining the treatment plan should include assessment of behaviors resulting from changes in environment as well as the skills development and social supports needed to respond to these changes.
(3.5.1) Outpatient treatment must be readily accessible to the individual in his or her own community. The treatment must include new-generation medications, symptom therapy, supportive psychotherapy, assertive community treatment (ACT), and rehabilitation.
(3.5.2) Easily accessible emergency services and available 24 hours a day, seven days a week. Emergency services should not have to be accessed the criminal justice system. If a person is in a psychotic state and is subject to arrest, specially trained personnel must have authority to determine the intervention needed and to refer to the appropriate level of care.
(3.5.3) Partial hospitalization should be used selectively with monitoring to ensure that the stay is goal-oriented.
(3.5.4) Treatment in the community must include new-generation medications, symptom therapy, supportive psychotherapy, and rehabilitative programs.
(3.5.5) Community systems must be comprehensive, person-centered, and integrated and should include medical, dental, and personal-care services as well as daily-living skills, supported housing, education, and pre-vocational and vocational training.
3.6 Inpatient Treatment
(3.6.1) Inpatient services ranging from short-term acute care or respite care to long- term care must be available and accessible. Linkages between inpatient and outpatient treatment and community support systems must be in place to ensure continuity of care.
(3.6.2) Short-term and longer-term hospitalization must be provided as determined to be necessary by the ITP.
(3.6.3) Long-term care must be available for the few who are unable to live in their communities.
3.7 Family Involvement in Treatment
(3.7.1) Family members are a central resource in the treatment of children and adults living with serious mental illnesses and should be an integral part of the treatment team and empowered to facilitate mutually agreed upon treatment team goals. Research overwhelmingly shows that when families take an active part in treatment decisions, consumer outcomes are better. While families do not cause or maintain serious mental illnesses, their knowledge of and relationship with the consumer is unique and can be a significant help in determining the best course of treatment.
(3.7.2) In no case should the presence of a loving, caring family be used as a substitute for a delivery system that provides for all of the person's treatment and rehabilitative needs.
(3.7.3) The consumer is the reason the mental health treatment system exists. The consumer–or in the case of an unemancipated child, his/her representative–is the most important member of the treatment team.
The consumer should be encouraged to participate fully in planning, monitoring, and evaluating treatment. Other treatment team members should assure that their focus is on meeting the consumer's needs, not the desires of the system or service providers.
(3.7.4) Common courtesy dictates that consumers and family members be treated with compassion, dignity and respect. They must also be provided with extensive education to understand all aspects of the illness in order to be more effective in its treatment.
(3.7.5) Family and consumer advocacy should always be encouraged. In circumstances where the mental health system is understaffed, under-financed, and services uncoordinated, or other problems impede proper service delivery, family and consumer advocacy is effective and powerful.
(3.7.6) Sometimes, because of stigma and lack of information regarding serious mental illnesses, the family is not involved. Their absence does not usually indicate that they don’t care or are not concerned. Mental health workers must understand this and work to strengthen family relationships. When family members become educated and are respectfully involved, in a way they experience as empowering, their approach to the patient and the treatment system changes.
(3.7.7) In such cases where consumers do not want their family members involved, their wishes must be respected. At the same time, extensive educational efforts should be made to help these consumers understand that their families are not to blame for the illness and that recovery is more likely if all interested parties work together.
(3.7.8) All treatment and services provided to children living with serious mental illnesses and their families should be child centered and family driven, with the needs of the child and family dictating the types and mix of services provided. The families, surrogate families and legal guardians of children with serious mental illnesses should drive the treatment planning and delivery process, in close consultation with the treating providers. Children living with serious mental illnesses should be included in all aspects of treatment planning whenever possible.
Family driven means that the treatment provider gives the family the information and skills to make informed decisions as equal partners in the treatment planning and delivery processes. Children living with mental illnesses should be included in all aspects of treatment planning whenever possible.
Families must have a primary decision making role in the care of their own children as well as the policies and procedures governing care for all children in their community, state, tribe, territory, and nation. This includes:
- Choosing supports, services, and providers;
- Setting goals;
- Designing and implementing programs;
- Monitoring outcomes;
- Partnering in funding decisions; and
- Determining the effectiveness of all efforts to promote the mental health and well being of children and youth.
(3.7.9) Child-serving systems and their funding mechanisms should be designed to allow families with children living with serious mental illnesses to easily access appropriate mental health and related services. Child-serving systems should be designed with cross-system and interagency collaboration to ensure an appropriate coordination of services for children and families. Families should not be required to navigate multiple, complex and overly bureaucratic systems to access appropriate services for their child.
3.8 Outcome Measures
NAMI believes that community-based services must include regular measurements of consumer and family satisfaction and dissatisfaction with these services. These measurements are best conducted by independent consumer and family satisfaction teams who interview service recipients using continuous quality improvement methodology.
3.9 Non-endorsement of Specific Medications or Treatment Modalities
As a matter of policy, NAMI does not endorse any specific treatment or service for serious mental illnesses. NAMI does advocate for general models of service such as evidence-based programs and clinical practices.
3.10 Access to Psychiatric Medications
(3.10.1) NAMI supports the following integrated and comprehensive federal strategies to ensure open access to psychiatric medications in the current budget deficit environment.
(3.10.1.1.) Increase the Federal Medical Assistance percentage (FMAP);
(3.10.1.2) Support the adoption of a Medicare prescription drug benefit;
(3.10.1.3) Advocate with the Center for Medicaid and Medicare Services (CMS) to provide written guidance on carve outs to Medicaid directors;
(3.10.1.4) Support increased funding to NIMH for research on psychiatric medications and access to these medications.
(3.10.2) NAMI supports the following integrated and comprehensive state strategies to ensure open access to psychiatric medications in the current budget deficit environment.
Oppose, at all costs, “fail first” provisions in state laws and policies; Support efforts by pharmaceutical companies to develop new medications but oppose pricing practices that make these medications unaffordable; Support adjunctive education programs about psychiatric medications and safe prescribing practices; Support the development of explicit medication access protocols.
3.11 Prescription Privileges for Psychologists, Workforce Shortages
NAMI does not endorse proposals currently before state legislatures to expand prescribing privileges to psychologists. NAMI acknowledges that serious shortages exist in the mental health professional workforce, particularly in public mental health systems and in rural and medically under-served regions of the country. However, there is no current evidence that expanding prescribing privileges to psychologists will address these shortages.
Additionally, NAMI calls upon the Substance Abuse and Mental Health Services Administration (SAMHSA), working in coordination with the National Institute of Mental Health (NIMH) and other relevant federal agencies, to undertake a national study and issue a report evaluating the scope and extent of workforce shortages in the mental health field, describing the impact of these shortages on access to quality care and treatment for people with serious mental illness, and recommending strategies for attracting and retaining qualified professionals in the mental health field, including in rural or medically under-served regions of the country.
3.12 Cultural Competence
NAMI recognizes that people of color face significant additional barriers to mental health treatment. This prevents minorities with mental illness from accessing much needed care. Barriers to treatment, such as lack of language access and lack of cultural competence, must be eliminated.
Treatment plans should be relevant to the consumer’s culture and life experiences. Plans shall be developed by providers who have the knowledge, skills and attitudes necessary to provide effective care for diverse populations. For people of color, recovery is more likely to occur when providers are culturally competent and when appropriate, they involve the consumer and family.
Limited English proficient (LEP) individuals must have equal access to mental health treatment. Cross-cultural communication in all services shall be available at all times through bilingual providers or certified interpreters. It is not acceptable to use family members or friends as substitutes for qualified interpreters.
3.13 Wellness
(3.13.1) People living with serious mental illnesses are at significantly greater risk for other serious medical illnesses such as diabetes, heart disease, cancer, and respiratory diseases. Recent research indicates that they also have much shorter life spans, as much as twenty-five years less than other Americans. This disparity has increased over time and demands increased attention and funding to promote wellness and preventive awareness among people with serious mental illness, their families, and health care practitioners.
(3.13.2) Wellness is essential to treatment and recovery. Consumers, family members and providers should promote and encourage wellness. Wellness encompasses mind, body and spirit. Wellness should include nutrition, exercise, rest, dental care, physical exams, and tobacco, drug and alcohol cessation.
(3.13.3) People living with serious mental illness have the same rights and expectations as anyone else to lead healthy lives. Wellness is an important part of the recovery process. Consumers must be empowered to achieve wellness through consumer education and peer support and taking control of their own health and recovery.
(3.13.4) Providers must make wellness a priority and provide access to effective programs and exercise. Useful programs include, but are not limited to, nutrition counseling, cooking classes, exercise programs, yoga, breathing exercises, smoking cessation, drug and alcohol programs, walking trails, exercise equipment at mental health centers and drop in centers, membership in gyms, and appropriate monitoring. Those who provide meals must ensure nutritious choices, including fresh fruits and vegetables. Those who provide treatment must be aware of and actively engaged in supporting wellness; and those who provide supportive environments, including housing and clubhouses, must provide environments that reduce health risks and support overall wellness.
(3.13.5) People with serious mental illnesses must have access to effective prevention and treatment with respect to alcohol, drug and tobacco addiction.
(3.13.6) NAMI calls for better access to dental care. Because of the impact of mental illnesses and the effects of the medications used to treat serious mental illnesses, access to dental care is a particularly important part of wellness for individuals with serious mental illnesses.
(3.13.7) NAMI also calls for better integration of physical and mental healthcare, including sharing relevant health indicators. Mental health care providers need to monitor key physical health indicators and the physical effects of medications. Primary care doctors must follow up on physical issues identified. There must be better infrastructure and funding to process important screening labs and tests for individuals with serious mental illnesses.
(3.13.8) The federal and state governments should provide fiscal incentives for integration of mental, physical and dental health services and funding for successful wellness programs. State programs that seek to reward healthy behaviors must be positive, relevant to individuals with serious mental illness, and not punitive in nature.
(3.13.9) Wellness is an important investment that will lead to decreased public cost, improved resource allocation, and reduction in stigma, thus improving the lives of all those affected by serious mental illnesses.
