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Improving the Quality of Health Care for Mental and Substance-Use Conditions (2006)

Chapter: 1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions

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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
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1
The Quality Chasm in Health Care for Mental and Substance-Use1 Conditions

Summary

Each year more than 33 million Americans use mental health services or services to treat their problems and illnesses resulting from alcohol, inappropriate use of prescription medications, or illegal drugs. Together, mental and substance-use illnesses are the leading cause of combined death and disability for women of all ages and for men aged 15–44, and the second highest for all men. When appropriately treated, individuals with these conditions can recover and lead satisfying and productive lives. Conversely, when treatment is not provided or is of poor quality, these conditions can have serious consequences for individuals, their loved ones, their workplaces, and the nation as a whole.

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In this report, whenever possible, we use the phrasing “substance-use problems and illnesses” rather than the terms “addiction” or substance “abuse.” We do not use the term “addiction” because some consider it pejorative; because it is not a formal diagnostic term; and because many of the conditions, problems, and policies discussed in this report pertain to people with much less severe alcohol and other drug-use conditions. We chose not to use the term substance “abuse,” both because it is diagnostically imprecise in the context of this report and because outside of strict diagnostic nomenclature, it too can be considered pejorative. We instead use the phrases “substance-use illnesses” when discussing the diagnostic family of alcohol and other drug-use illnesses and “substance-use problems” when discussing the problems associated with the unhealthy use of alcohol and other drugs. Nonetheless, these words appear in some places in the report because they are used so often in the literature, and it is not always possible to interpret the meaning of the word “abuse.”

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

Although science continues to advance our knowledge about the etiology of mental and substance-use problems and illnesses and how to treat them effectively, health care for these conditions—like general health care—frequently is not delivered in ways that are consistent with science, ways that enable improvement and recovery. Moreover, care is sometimes unsafe; more often, it is not delivered at all. This gap between what can and should be and what exists is so large that, as with general health care, it constitutes a “chasm” as defined in the 2001 Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century. Using that report as its template, this report puts forth an agenda for improving the quality of health care for mental and substance-use conditions.

MORE THAN 33 MILLION AMERICANS ANNUALLY RECEIVE CARE

Each year more than 33 million Americans use mental health services or services to treat their problems and illnesses2 resulting from alcohol, inappropriate use of prescription medications, or illegal drugs. Approximately 28 million Americans aged 18 or older (13 percent of this population) received mental health treatment in an inpatient or outpatient setting in 20033 (SAMHSA, 2004a), and more than 6 percent of American children and adolescents aged 5–17 had contact with a mental health professional in a 2-month period according to the 1998–1999 National Health Interview Survey (Simpson et al., 2004). The rates are higher still for adolescents: 20.6 percent of those aged 12–17 (5 million youths) received treatment or counseling for emotional or behavioral problems in 2003 (SAMHSA, 2004a); in addition, more than 3 million Americans aged 12 or older (1.4 percent of this group) reported receiving some kind of treatment during 2003 for a problem related to alcohol or other drug use (SAMHSA,

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Whenever possible, this report uses the words “problems” and “illnesses” (as opposed to “disorders”) because “disorder,” as defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), refers to “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (emphasis added) (American Psychiatric Association, 2000:xxxi). The committee’s use of the word “problem” acknowledges that not everyone with a need for mental health care has such significant impairment that it qualifies as a “disorder.” Nonetheless, the word “disorder” appears often in this report because it is used so frequently in the literature.

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This figure does not include treatment solely for substance use.

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

2004a). Combining mental and substance-use problems and illnesses, more than 20 percent of U.S. adults aged 18–54 received care for these conditions during a 12-month period between 2001 and 2003 (Kessler et al., 2005). Millions more reported that they needed treatment for their mental and/or substance-use (M/SU)4 problems or illnesses but did not receive it (Mechanic and Bilder, 2004; SAMHSA, 2004a; Wu et al., 2003). Fewer than half of adults aged 18–54 who met a definition of severe mental illness received treatment for the condition during a 12-month period between 2001 and 2003 (Kessler et al., 2005). And in contrast to the more than 3 million Americans aged 12 or older who received treatment during 2003 for a problem related to alcohol or other drug use, more than six times that number (approximately 21.6 million, or 9.1 percent of this age group) reported abusing or being physiologically dependent upon alcohol; illicit drugs such as marijuana, cocaine, heroin, hallucinogens, or stimulants; prescription drugs used for nonmedical purposes; or a combination of these (SAMHSA, 2004a).

Many individuals using services to address their mental or substance-use problems require only a short-term intervention to address their condition (Bernstein et al., 2005; Fleming et al., 1997; Ockene et al., 1999). They may be experiencing, for example, anxiety or other distress over the loss of a loved one or a job or some other life-changing event. They may be engaging in occasional heavy drinking or be teenagers experimenting with drugs. These and other less severe problems that many individuals encounter at some point in their lives are not considered mental illnesses or drug dependence but are occasions during which an individual might need assistance to cope with a stressful situation, change unhealthy behaviors, and prevent the condition from worsening. Mental illnesses and substance dependence, in contrast, involve significantly more distress, disability, chronicity, and physical risk and interfere with performing routine activities such as working, attending school, or participating fully in relationships.

Individuals with M/SU problems and illnesses represent a wide range of diagnoses, severity of illness, and disability. What they all have in common, however, is the hope that when they seek help for their condition, they will receive care that is safe, effective, and of good overall quality. They expect that such care will enable them either to recover completely from an acute mental or substance-use illness or manage the illness successfully so they can live happy, productive, and satisfying lives. As articulated in the 1999 Surgeon General’s report on mental health (Anthony, 1993 as cited in DHHS, 1999:98):

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Throughout this report we use the acronym M/SU to refer to “mental and/or substance use.”

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
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… a person with mental illness can recover even though the illness is not “cured”…. [Recovery] is a way of living a satisfying, hopeful, and contributing life even with the limitations caused by illness.

Although a conceptual model of recovery from chronic M/SU illnesses is not yet fully developed (Onken et al., 2004), recovery as articulated in the Surgeon General’s report has been an accepted concept in use for over a century for individuals with alcohol-use problems and illnesses (White, 1998). More recently, recovery has become a widely accepted goal not just of mental health care (NAMI, 2005; New Freedom Commission on Mental Health, 2003), but of treatment for all individuals with M/SU problems and illnesses.

CONTINUING ADVANCES IN CARE AND TREATMENT ENABLE RECOVERY

The U.S. Surgeon General, the National Institutes of Health (NIH), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Institute of Medicine (IOM), and many others (DHHS, 1999; IOM, 1997) continue to document ongoing advances in our understanding of M/SU problems and illnesses. These advances include the development of efficacious psychotherapies, drug therapies, and psychosocial services, as well as strategies for delivering these treatments effectively. Dissemination of information on brain functioning—the interplay of genetic, environmental, biological, and psychosocial factors in brain function and M/SU illnesses; our ability throughout our lives to influence the structure and functioning of our brains through environmental and behavioral factors (our brains’ “plasticity”); and improved treatments—has helped educate consumers,5 the health care community, and the public at large about M/SU problems and illnesses and the effectiveness of care for these conditions. Now that NIH has made translation of bench science to clinical applications a high priority in its strategic plans for the coming years (NIMH, 2005; Zerhouni, 2003), society is poised to reap even greater returns from developments in such basic science fields as genetics, proteomics, neuro-

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The committee notes that many different words are used to refer to individuals who are in need of or receive M/SU health care, including “patient,” “client,” “consumer,” “survivor,” “recipient,” “beneficiary,” and others. The committee respects the different perspectives represented by proponents of each of these terms. For convenience, we use the terms “patients,” “consumers,” and “clients” interchangeably in this report because of their widespread use by the public at large and within general and specialty health care systems. The use of these words is not intended to exclude the families of adults who, with the consent of the individual patient, can play an essential therapeutic role. With respect to children and adolescents, we always intend these words to include families and other informal caregivers.

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

imaging, and animal models of behavior (Gould and Manji, 2004; Sarver et al., 2002; Tecott, 2003).

The past decade also has seen rapid growth in the science of evaluating the costs and effectiveness of health interventions. These approaches increasingly demonstrate that care for many M/SU problems and illnesses can be both effective (i.e., it can work) and cost-effective (i.e., it can represent a good value). Recent studies have used these approaches to evaluate a variety of mental health interventions, ranging from use of a specific medication (clozapine) in populations with schizophrenia (Essock et al., 2000; Rosenheck et al., 1999), to using specific models for treating depression in primary care (Pirraglia et al., 2004), to providing supported housing for homeless persons with mental illness (Rosenheck et al., 2003). These and other mental health interventions have been found to be as or more cost-effective than many treatments currently provided in general medical practice. Consistent with these findings, more than half of adults who received treatment for mental health problems in 2003 reported that their treatment improved their ability to manage daily activities “a great deal” or “a lot” (SAMHSA, 2004a).

A large body of research shows likewise that treatment for alcohol and other drug problems and illnesses is effective. Many people who enter treatment decrease their substance use and have fewer problems (Finney and Moos, 1991; McLellan et al., 2000; Miller et al., 2001). Recent years have seen many scientific advances in understanding the behavioral and social factors that lead to substance use and dependence, in identifying key neuropathways and chemical changes that create the cravings characteristic of alcohol or drug dependence, and in developing mechanisms to block these effects. These advances have resulted in a spectrum of evidence-based pharmacological and psychosocial treatments for individuals who misuse or are dependent on substances—treatments that produce results similar to or better than those obtained with treatments for other chronic illnesses (McLellan et al., 2000). New medications, such as buprenorphine, are effective in significantly reducing opioid use (Johnson et al., 2000). In contrast to the first medication for opiate dependence (methadone), buprenorphine can be prescribed routinely in physicians’ offices. Naltrexone and acamprosate also show efficacy in treating alcohol dependence (Kranzler and Van Kirk, 2001; O’Malley et al., 2003) and may be more acceptable to patients than disulfiram, the first medication approved for treating that condition.6

Nonpharmacological treatments for drug dependence, such as cognitive behavioral therapy and motivational enhancement treatment, have also

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Disulfiram produces a very uncomfortable physiological reaction in the individual when alcohol is consumed, and does not reduce craving.

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

demonstrated efficacy. Twelve-step mutual support groups such as Alcoholics Anonymous are effective as well, particularly as an adjunct to treatment and as a form of long-term aftercare (Emrick et al., 1993; Tonigan et al., 2003; Weisner et al., 2003). Contingency management, a treatment modality that employs positive reinforcement for desired behaviors and withholding of reinforcement or punitive measures for undesired behaviors has shown efficacy for treatment of the use of alcohol, cocaine, and other psychostimulants (Higgins and Petry, 1999). Brief advice from a physician and office-based alcohol counseling interventions have been shown to reduce episodes of binge drinking as well as alcohol use in problem drinkers (Fleming et al., 1997; Ockene et al., 1999). Organizing care to address co-occurring conditions, such as by integrating alcohol and drug treatment with medical services (Weisner et al., 2001) and combining substance-use and mental health services, also optimizes outcomes (Moggi et al., 1999), as well as cost (Parthasarathy et al., 2003). The latter approach is particularly effective for adolescents, in whom co-occurring substance-use and mental health problems are very common (Clark et al., 1997; Sterling and Weisner, 2005). As a result of these advances, patients who enter and remain in treatment for use of alcohol, opioids, or cocaine are less likely to relapse or resume use (Gossop et al., 1999; Miller and Wilbourne, 2002; Prendergast et al., 2002).

Additional good news is found in recent studies showing some improvements in access to and receipt of care. Over the past decade, although the prevalence of M/SU problems and illnesses has remained the same, a greater proportion of adults aged 18–54 with these conditions has received treatment (Kessler et al., 2005). This has been especially true of those with the most severe mental illnesses (Kessler et al., 2005; Mechanic and Bilder, 2004). The rate of treatment for depression appears to have more than tripled between 1987 and 1997 (Olfson et al., 2002), and improvements have been seen in access to care and treatment for children (Glied and Cuellar, 2003).

On the other hand, the same reports showing improved access to care for people with the most severe mental illnesses show declining access for those with less severe mental illnesses (Mechanic and Bilder, 2004) and ethnic minorities (Kessler et al., 2005), and many people who need treatment for M/SU illnesses still do not receive it (Kessler et al., 2005; Mechanic and Bilder, 2004; SAMHSA, 2004a). Moreover, M/SU health care, like general health care, is frequently delivered in ways that are not consistent with scientific evidence. Sometimes care also is unsafe. When untreated or poorly treated, M/SU problems and illnesses can have serious consequences for the afflicted individuals, their loved ones, and society as a whole.

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

POOR CARE HINDERS IMPROVEMENT AND RECOVERY FOR MANY

Numerous studies document the discrepancy between the M/SU care that is known to be effective and the care that is actually delivered. A review of all peer-reviewed studies published from 1992 through 2000 assessing the quality of care for many different M/SU clinical conditions (including alcohol withdrawal, bipolar illness, depression, panic disorder, psychosis, schizophrenia, and substance abuse) found that only 27 percent of the studies reported adequate rates of adherence to established clinical practice guidelines (Bauer, 2002). Subsequent studies have continued to document clinicians’ departures from evidence-based practice guidelines for conditions as varied as attention deficit hyperactivity disorder (ADHD) (Rushton et al., 2004), anxiety disorders (Stein et al., 2004), comorbid mental and substance-use illnesses (Watkins et al., 2001), depression in adults (Simon et al., 2001a) and children (Richardson et al., 2004), opioid dependence (D’Aunno and Pollack, 2002), and schizophrenia (Buchanan et al., 2002). In a landmark study of the quality of a wide variety of health care received by U.S. citizens, individuals with alcohol dependence were found to receive care consistent with scientific knowledge only about 10.5 percent of the time (McGlynn et al., 2003).

In other clinical care situations, the absence of clinical practice guidelines further contributes to worrisome variation in the care individuals receive. One 1999–2000 study of the care received by children and adolescents at residential treatment centers in four states found that 42.9 percent were receiving antipsychotic medications without having any history of or current psychosis and were thus receiving such medications for “off-label” purposes (Rawal et al., 2004). Seclusion and restraints continue to be used in inpatient mental health facilities despite their resulting in substantial psychological and physical harm to patients (GAO, 1999), including an estimated 150 deaths in the United States annually (SAMHSA, 2004b), and despite a Cochrane Collaboration finding that “few other forms of treatment which are applied to patients with various psychiatric diagnoses are so lacking in basic information about their proper use and efficacy” (Sailas and Fenton, 2005).

Moreover, recent studies reaffirm that the health care system sometimes fails to provide any treatment for M/SU illnesses (Kessler et al., 2005; Mechanic and Bilder, 2004), even when afflicted individuals are receiving other types of health care and have financial and geographic access to care. A 1997–1998 national survey found that among persons with probable co-occurring M/SU conditions who received treatment for one condition, fewer than a third (28.6 percent) received treatment for the other (Watkins et al.,

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

2001). A later longitudinal study of 1,088 youths in residential or outpatient treatment for drug use showed that although 67 percent reported having severe mental health problems upon admission, only 24 percent reported receiving mental health services within the 3 months following their admission (Jaycox et al., 2003). The 2003 National Survey on Drug Use and Health documents similar failure to treat adults (SAMHSA, 2004a). And despite the very frequent co-occurrence of M/SU and general health care problems and illnesses, coordination among providers of M/SU care and the other sectors of care delivery is highly inadequate (New Freedom Commission on Mental Health, 2003).

Departures from known standards of care, variations in care in the absence of care standards, failure to treat M/SU problems and illnesses, and lack of coordination are of concern for many reasons. While they may often represent ineffective care, there is evidence that they can also threaten patient safety. In addition to the substantial psychological and physical harm to patients caused by the use of seclusion and restraints noted above, injuries from drug errors are common. A retrospective, multidisciplinary review of the charts of 31 randomly selected patients in a state psychiatric hospital discharged during a 4 1/2-month study period detected 2,194 medication errors during these patients’ collective 1,448 inpatient days.7 Of these errors, 19 percent were rated as having the potential to cause minor harm, 23 percent the potential to cause moderate harm, and 58 percent the potential to cause severe harm (Grasso et al., 2003). Moreover, because M/SU illnesses are leading risk factors for suicide (Maris, 2002), failures to diagnose and treat them effectively can be lethal.

The receipt of ineffective and unsafe care by large numbers of people with M/SU illnesses is of particular concern because some of the unique features of these illnesses—such as the symptoms of major depression or schizophrenia—and their treatments could render patients less able to detect and avoid errors and more vulnerable to the consequences of errors that occur. The residual stigma attached to some M/SU illnesses also may make individuals with these diagnoses less willing to report errors and adverse events, and less likely to be believed when they do so. Most significant, the delivery of ineffective or unsafe care, or the failure to deliver any care, has serious consequences for individuals, their loved ones, and the nation as a whole.

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These medication error rates are consistent with rates reported in studies involving general medical hospitals, but the distribution of the types of errors is markedly different: a much higher proportion of the errors (66 percent) occurred during the administration of a medication as opposed to its prescription, transcription, or dispensing. The authors note that at the time the study was conducted, medication administration was performed by medical technicians, as opposed to licensed nurses—a practice discontinued after the study (Grasso et al., 2003).

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

FAILURE TO PROVIDE EFFECTIVE CARE HAS SERIOUS PERSONAL AND SOCIETAL CONSEQUENCES

A Leading Cause of Disability and Death in the United States

A 1996 study of the global burden of diseases, injuries, and risk factors conducted by the World Health Organization and the World Bank assessed for the first time the relative burden of 107 of the world’s most common diseases as of 1990. Using the metric of disability-adjusted life years (DALYs), representing the combined effect of years of life lost to premature death and years of life lived with a disability, the study assessed fatal and nonfatal health outcomes and objectively calculated the relative burden of major diseases and injuries. The results documented for the first time the profound effect of M/SU illnesses on death and disability worldwide and in the United States. In developed regions of the world, unipolar major depression was the second leading cause of death and disability (next to heart disease) for all ages,8 and the leading cause for individuals aged 15–44. Alcohol use ranked highest for males aged 15–44 and fifth across all ages. Alcohol use also was an underlying factor in a substantial portion of traffic accidents (which were ranked fourth for all ages and sexes and second only to alcohol for males aged 15–44). Schizophrenia and bipolar disorder ranked thirteenth and fifteenth for all ages in developed regions. Other drug use ranked twenty-second. In developed regions of the world and in countries with established market economies such as the United States, when all neuropsychiatric conditions were combined, they were responsible for more death and disability than any other category of health conditions, outranking cardiovascular diseases; cancers; and a combined category of communicable, maternal, perinatal, and nutritional illnesses (Murray and Lopez, 1996).

The major causes of DALYs differ somewhat for the United States, but M/SU illnesses remain prominent. In 1996, unipolar major depression was second only to ischemic heart disease for American women as the cause of DALYs. For men, traffic accidents ranked second; alcohol abuse and dependence ranked fifth; and depression and drug use ranked tenth and eleventh, respectively. Combined, unipolar major depression, drug use, and alcohol abuse and dependence are the leading cause of death and disability for American women and the second highest for men (behind heart disease) (Michaud et al., 2001). If mental illness diagnoses other than unipolar major depression were included, the DALYs would be even higher.

Moreover, mental or substance-use problems and illnesses seldom occur in isolation; approximately 15–43 percent of the time they co-occur

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Predominantly because of the disability (rather than mortality) it produces.

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

(Kessler et al., 1996; Kessler, 2004).9 They also accompany a substantial number of general medical illnesses, such as diabetes, heart disease, neurological illnesses, and cancers (Katon, 2003); sometimes masquerade as separate somatic problems (Katon, 2003); and often go undetected (Kroenke et al., 2000; Saitz et al., 1997). M/SU illnesses significantly compromise the treatment outcomes for general health conditions, increase the use and cost of general health care (Katon, 2003), and have adverse consequences for workplace productivity and costs (as discussed below). Mental illness also is a major risk factor for the development of adverse health behaviors such as smoking, overeating, and a sedentary lifestyle (Katon, 2003).

Great Cost to the Nation

The disabilities and other adverse effects resulting from M/SU illnesses impose a sizable cost on the nation (Frank and McGuire, 2000). Considering health care spending alone, M/SU problems and illnesses represent the fifth most expensive category of health care conditions10 in the United States among individuals not residing in nursing homes or other institutions (Thorpe et al., 2004). Direct spending11 for M/SU health care by all health care purchasers in the United States totaled an estimated $104 billion in 2001 (82 percent for mental and 18 percent for substance-use illnesses), representing 7.6 percent of all health care spending (Mark et al., 2005). Additional costs attributable to M/SU illnesses (e.g., secondary health problems, loss of productivity in the workplace, and social problems requiring the involvement of the welfare and criminal and juvenile justice systems) are even higher. Nationally, the estimated direct and indirect costs for alcohol-related illnesses, injuries, and other consequences, excluding those associated with the use of other drugs, were estimated at $185 billion in 1998. More than 70 percent of these costs were due to lost productivity resulting from alcohol-related illness and premature death (NIAAA, 2000). These direct and indirect costs affect employers, the child welfare system, the juvenile and criminal justice systems, education systems, and other sectors of society.

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Among some treatment groups, rates of co-occurrence can be even higher. Among those with a nonalcohol drug-use disorder who sought treatment for that disorder, for example, 60.3 percent had at least one independent mood disorder, and 55.2 percent had a comorbid alcohol-use disorder (Grant et al., 2004a).

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Next to heart disease, trauma, cancer, and lung diseases.

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Includes only spending for health care in which M/SU illnesses are listed as the primary illness being treated. Thus, for example, costs of treating cirrhosis secondary to alcohol dependence are not captured; nor, for example, are other health problems brought on by substance use if the substance-use illness is not being treated, and other indirect costs of these illnesses, such as costs to the juvenile and criminal justice systems. Also not captured is care that is coded as another illness (e.g., back pain).

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
Decreased Productivity in the Workplace

Evidence is mounting that M/SU illnesses result in a considerable burden on the workplace and cost to employers due to absenteeism, “presenteeism” (i.e., attending work with symptoms that impair performance), days of disability, and “critical incidents” such as significant task failures and accidents. All cause a decrease in workplace productivity. Depression is the most frequently studied M/SU illness with respect to the workplace because it is highly prevalent among working-age adults and associated with substantial work impairment (Burton et al., 2004; Kessler et al., 2001a; Stewart et al., 2003); however, substance dependence and generalized anxiety disorders also are very common and associated with high levels of work impairment (Kessler et al., 2001a).

As part of a 2001–2002 national survey of American workers designed to better understand the relationship between health and productivity, interviews were conducted to determine the effect of depression on worker productivity. “Lost productive time” (LPT) was measured by summing employee self-reports of the hours per week absent from work for health-related reasons and hours of health-related reduced performance on workdays. Workers with depression reported significantly more total health-related LPT than workers without depression—on average, a loss of 5.6 hours per week compared with 1.5 hours per week for those without depression. Fully 81 percent of LPT was attributable not to absenteeism, but to reduced performance while at work—the component of reduced performance often invisible to employers because it is not captured in routine administrative data as are absenteeism, use of leave, and disability (Stewart et al., 2003). Indeed, there is evidence that improving care for depression can increase worker productivity and decrease absenteeism (Rost et al., 2004).

The accuracy of retrospective data self-reported by individuals with depression has been questioned (because the symptoms of depression may predispose individuals to appraise their productivity negatively). Yet when worker performance is measured by other valid and reliable means (Kessler et al., 2004), major depression continues to be associated with poor work performance more consistently than is the case for other high-prevalence conditions (allergies, arthritis, back pain, headaches, high blood pressure, and asthma) (Wang et al., 2004).

Decreased Achievement by Children in School

Emotional and behavioral problems of children and the M/SU problems and illnesses of their parents also are important predictors of poor school outcomes. Risk factors for early school failure include maternal

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

depression; parental substance-use problems and illnesses; early behavior problems, particularly aggression; and maltreatment. Several M/SU-related risk factors, including parental trauma, maternal depression, maternal alcoholism, and other substance-use problems and illnesses also are associated with disorganized attachment behaviors in infants (i.e., insecure and inconsistent patterns of attachment to key caregivers) (Ainsworth and Eichberg, 1992; Carlson et al., 1989; Green and Goldwyn, 2002; O’Connor et al., 1987; Teti et al., 1995; van Ijzendoorn et al., 1999). Those behaviors in turn lead to lower IQ and poorer school performance (van Izjendoorn and van Vliet-Vissers, 1988; Zeanah et al., 2003). Children of untreated depressed mothers, for example, have significantly more behavior and school achievement problems than children of nondepressed mothers (Greenberg et al., 1999; Gross et al., 1995; Sinclair and Murray, 1998). Children who experience trauma also have higher rates of school problems than children who are not maltreated, including lower IQ scores, lower test scores in math and English, less social acceptance as perceived by the child, increased absence from class, and more grade repetitions (Eckenrode et al., 1995; Wodarski et al., 1990).

Although risk factors often associated with substance-use problems and illnesses (such as poor maternal nutrition, health, and prenatal care) make it difficult to attribute school problems solely to in utero drug exposure, it is clear that maternal substance-use problems and illnesses are strongly associated with adverse effects on children’s cognitive, physical, and social development. Maternal alcohol consumption during pregnancy is associated with intrauterine growth retardation and low birth weight, which affect later cognitive and social development (Streissguth et al., 1994). Children exposed to alcohol in utero also have been found to have behavioral and social difficulties, such as trouble cooperating and paying attention and problems with impulsivity (Spohr et al., 1994). Findings of studies of prenatal exposure to other drugs, such as cocaine, heroin, and amphetamines, suggest that such exposure results in lower general intelligence and impairs school functioning (Eriksson and Zeterstrom, 1994; van Baar and de Graaff, 1994; van Baar et al., 1994). Other studies have found that although prenatal exposure to cocaine does not affect intellectual ability or academic achievement, it does affect the ability to sustain attention (Richardson et al., 1996).

These risks that place children on a dangerous trajectory toward school failure are compounded by the fact that academic failure itself breeds emotional and behavioral problems. Repeating a grade in school is associated with several specific behavioral problems and illnesses, such as ADHD, obsessive-compulsive disorder and other specific anxiety disorders, and major depressive disorder (Velez et al., 1989). Grade retention also predicts

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

school dropout and rapid, repeated adolescent pregnancies (Linares et al., 1991). This is not a minor problem. According to one national study, 7.6 percent of children repeat kindergarten or first grade (Byrd and Weitzman, 1994). Children who are unable to achieve mastery on standard measures of school achievement also are at risk for delinquent and antisocial behavior (Yoshikawa, 1995), and children with early reading difficulties have increased rates of conduct problems up to the age of 16 (Fergusson et al., 1997).

Increased Burden on the Child Welfare System

The nation’s child welfare system also is greatly affected by the high prevalence of and disability associated with M/SU illnesses. Foremost, children who are reported to and investigated by the child welfare system for maltreatment typically have experienced a number of known risk factors for the development of emotional and behavioral problems, including abuse, neglect, poverty, parental substance-use problems and illnesses, and domestic violence. As a result, almost half (47.9 percent) of a nationally representative, random sample of children aged 2–14 who were investigated by child welfare services in 1999–2000 had a clinically significant need for mental health care (Burns et al., 2004).

In addition, the U.S. Government Accountability Office (GAO) has found that, because of limitations on insurance coverage, some families resort to placing their children (most often adolescents with severe mental illness) in the child welfare system even though the family is not neglectful or abusive of the child. Because the child welfare system often is able to secure mental health services otherwise unavailable to them, parents use the system for this purpose even though they are placing their children in systems not designed to care for children who have not been abused or neglected (GAO, 2003). Doing so sometimes requires parents to give up legal custody of their children and place them in an out-of-home residential or foster care setting (Giliberti and Schulzinger, 2000). In Virginia, for example, a 2004 study of the use of the state’s foster care program for mental health services found that 2,008 children in foster care as of June 1, 2004—approximately 1 of every 4 children in the system at that time—were there either because their parents wanted them to have mental health care not fully covered by their insurance or because the family did not have access to any insurance (Jenkins, 2004).

Finally, the stresses involved with child protective services investigation and judicial decision making, and for those who are placed in foster care the stress of removal from home, also constitute risk factors for maladaptive outcomes, including emotional, social, behavioral, and psychiatric problems warranting mental health treatment (Landsverk, 2005).

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

Demands on the Juvenile and Criminal Justice Systems

Juvenile justice Between 60 and 75 percent of youth in the juvenile justice system have a diagnosable mental disorder (Otto et al., 1992; Teplin et al., 2002; Wierson et al., 1992), and it is conservatively estimated, although the evidence is less clear, that approximately 20 percent have a severe mental illness (Cocozza and Skowyra, 2000; Grisso, 2004). Many youths in the juvenile justice system with mental illness also have a co-occurring substance-use problem or illness. Although the research on this issue is limited, a recent study of juvenile detainees in Cook County, Illinois, found that nearly 30 percent of females and more than 20 percent of males with substance-use disorders had major mental disorders as well (Abram et al., 2003).

Moreover, like youths who are not abused or neglected but are placed in child welfare solely to obtain mental health services, many children who are not guilty of any offence are placed in local juvenile justice systems and incarcerated solely to obtain such services not otherwise available. Although no formal counting and tracking of such children takes place, juvenile justice officials in 33 counties in the 17 states with the largest populations of children under age 18 estimated that approximately 9,000 such children entered their systems under these circumstances in 2001; county estimates ranged from 0 to 1,750, with a median of 140. Nationwide the number of children placed in juvenile justice systems is likely to be higher; 11 states reported to GAO that they could not provide estimates even though they were aware that such placements occur (GAO, 2003).

In a subsequent 2003 survey of all (698) secure juvenile detention facilities in the United States,12 two-thirds of such facilities reported holding youths (prior to, after, or absent any pending adjudication) because they were awaiting community mental health services. In addition, seventy-one facilities in 33 states reported holding youths with mental problems or illnesses who had charges against them. As one detention facility administrator explained, “We are receiving juveniles that five years ago would have been in an inpatient mental health facility…we have had a number of juveniles who should no more be in our institution than I should be able to fly” (U.S. House of Representatives, 2004:8). A majority of detention facilities reported holding children under age 13; 117 reported holding children aged 10 and under; and 1 facility reported holding a 7-year-old child. Moreover, 27 percent of facilities holding children awaiting services rated the mental health treatment in their facility as “poor,” “very poor,” or “none.” The emotional toll on these children is high. Fully 48 percent of facilities that hold juveniles waiting for community mental health services report suicide attempts among these youths (U.S. House of Representatives, 2004).

12  

Response rate = 75 percent.

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

Criminal justice In mid-2003, the nation’s prisons and jails held 2,078,570 persons—1 in every 140 U.S. residents13—and this rate has been increasing annually, from 601 persons in custody per 100,000 U.S. residents in 1995 to 715 persons in custody per 100,000 residents in 2003 (Harrison and Karberg, 2004). Although a rigorous epidemiological study of the prevalence of M/SU illnesses in correctional settings has not taken place,14 the U.S. Bureau of Justice estimates that approximately 16 percent of all persons in jails and state prisons report either having a mental disorder or staying overnight in a psychiatric facility, as do 7 percent of those in federal prisons (Ditton, 1999). Substance-use problems and illnesses play a larger role in incarceration. Approximately two-thirds of incarcerated individuals were under the influence of alcohol or drugs at the time of their offense, and nearly 60 percent of all state prisoners report using substances other than alcohol in the month prior to offending (Mumola, 1999). Moreover, in an average year, approximately one-third of new admissions to prisons result from parole violations, nearly 16 percent of which are drug-related (Hughes et al., 2001).

Because prisons and jails are legally required to provide medical treatment to inmates with medical needs (Haney and Specter, 2003; Metzner, 2002), approximately 95 percent of state correctional facilities report providing some form of mental health treatment to prisoners. The treatment provided includes screening for mental illness at intake (78 percent), assessing psychiatric problems (79 percent), delivering round-the-clock mental health care (63 percent), providing therapy or counseling (84 percent), prescribing psychotropic medications (83 percent), and providing reentry assistance (72 percent). On average, 1 in 8 prisoners in state prisons is engaged in structured counseling, and 1 in 10 is receiving psychotropic medication (Beck and Maruschak, 2001). The majority of jails also report providing some type of mental health treatment—most often screening at intake (78 percent), followed by psychotropic medication (66 percent), 24-hour care (47 percent), routine therapy or counseling (46 percent), and psychiatric evaluation (38 percent) (Stephan, 2001). Yet on average, mental health services are being provided at a level that is roughly half the estimated need (Wolff, 2004).

Although substance-use problems and illnesses play a larger role in incarceration than do mental illnesses, they receive less treatment (Wolff,

13  

The majority (66 percent) of these were in state or federal prisons, the remainder in local jails.

14  

A more rigorous study of the prevalence of M/SU illnesses in correctional settings, modeled on the prevalence studies of the general population in the United States (Kessler et al., 2001) and the correctional and general population in the United Kingdom (ONS, 1998), has been called for (Wolff, 2004).

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

2004). One study found that roughly one in four state prisoners received any treatment for substance-use problems, with a higher percentage (40 percent) receiving such treatment if they reported drug use at the time of their offense. The most common treatment received was self-help group/peer counseling (Mumola, 1999). Similarly, although substance-use treatment or other programs, such as education or self-help, were provided by the majority of jails (73 percent) in 1998, only 20 percent of convicted jail inmates who were actively involved with drugs prior to their admission to jail had participated in substance-use treatment or program subsequent to their incarceration. Treatment (i.e., detoxification units, group/individual counseling, and residential programs) was provided by approximately 43 percent of jail facilities. Nearly two-thirds of jails reported providing access to drug or alcohol education or self-help groups (Wilson, 2000).

How These Adverse Consequences Can Be Mitigated

The delivery of effective treatment for M/SU problems and illnesses could mitigate many of the serious individual and societal consequences discussed above. Findings of observational studies and some controlled trials indicate that effective treatment for depression, for example, can result in improved productivity in the workplace, and this might substantially offset the cost of the treatment (Goetzel et al., 2002; Simon et al., 2001b; Wang et al., 2003). Treatment for this and other M/SU illnesses also might help ameliorate the adverse effects of emotional or behavioral problems and illnesses on children’s educational achievement, as well as reduce the burden on the child welfare and juvenile justice systems. At a minimum, provision of effective treatment ensures that funds spent for treatment will not be wasted.

A CHARGE TO CROSS THE QUALITY CHASM

The high prevalence and adverse consequences of M/SU problems and illnesses, the availability of many efficacious treatments, and the widespread delivery of poor-quality care are increasingly being recognized by consumers, purchasers, care providers, and policy makers. Similar concerns about the safety, ineffectiveness, and poor quality of U.S. health care overall have previously received substantial attention among the health care community, the lay press, and the public at large as a result of two IOM reports—To Err Is Human: Building a Safer Health System (IOM, 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001). These reports have played a key role in focusing national attention on problems in the quality of the nation’s health care, while garnering consensus on strategies for achieving significant quality improve-

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

ments. Both reports underscore that the vast majority of problems in the quality of health care are not the result of poorly motivated, uncaring, or unintelligent health care personnel but instead result from numerous barriers to high-quality health care imposed by the delivery systems in which clinicians work. Some of these barriers occur at the level of the patient’s interaction with the clinician (e.g., not having sufficient time during the patient visit to talk with the clinician); some at the level of interactions among different clinicians serving the patient (e.g., poor communication, collaboration, and coordination of care); some within the organization in which care is delivered (e.g., poor decision support for clinicians); and some in the environment external to the delivery of care (e.g., the arenas of policy, payment, and regulation) (Berwick, 2002).

Crossing the Quality Chasm speaks to all of these barriers to quality health care15 and has gained considerable traction in the health care community since its publication. As the subject of more than 50 peer-reviewed articles in the medical literature and hundreds of lay publications and coverage in other media, it has attracted the attention of many health care leaders. In the M/SU sector, the American College of Mental Health Administration (ACMHA), for example, focused on the report at its 2002 summit meeting of leaders from public and private behavioral health care systems. Summit meeting participants reached strong consensus that the Quality Chasm framework is immediately relevant and applicable to the concerns of behavioral health systems of care and policy. Attendees also endorsed the IOM paradigm as a strategic planning blueprint for the redesign of the behavioral health care system. However, because the Quality Chasm report did not separately address the unique characteristics of health care for mental and substance-use conditions (e.g., the use of coercion into treatment; the delivery of care through non-health care sectors, such as schools), attendees also agreed on the need to develop a strategy for applying the framework and recommendations of the Quality Chasm to address the unique characteristics of M/SU health care (ACMHA, undated).

15  

Crossing the Quality Chasm identifies four different levels for intervening in the delivery of health care: (1) the experience of patients; (2) the functioning of small units of care delivery (“microsystems”), such as surgical teams or nursing units; (3) the functioning of organizations that house the microsystems; and (4) the environment of policy, payment, regulation, accreditation, and similar external factors that shape the context in which health care organizations deliver care. Whereas To Err Is Human speaks mainly to the fourth level, Crossing the Quality Chasm addresses primarily the first and second levels—how the experiences of patients and the work of microsystems of care, such as health care teams, nursing units, or individual health care workers delivering care to patients, should be changed (Berwick, 2002). Both of these reports direct less attention to the third level above—the organizations that house the microsystems.

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

As a result of ACMHA leadership, there was a convergence of support from many sectors for adapting the Quality Chasm framework to M/SU health care. With support from the Annie E. Casey Foundation, the CIGNA Foundation, the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, The Robert Wood Johnson Foundation, SAMHSA within the U.S. Department of Health and Human Services, and the Veterans Health Administration of the U.S. Department of Veterans Affairs, the IOM was given the following charge:

Crossing the Quality Chasm: A New Health System for the 21st Century identified six dimensions in which the United States health system functions at far lower levels than it should (i.e., safety, effectiveness, patient-centeredness, timeliness, efficiency and equity) and concluded that the current health care system in is in need of fundamental change. The IOM is to explore the implications of that conclusion for the field of mental health and addictive disorders, and identify the barriers and facilitators to achieving significant improvements along all six of these dimensions. The committee will examine both environmental factors such as payment, benefits coverage and regulatory issues, as well as health care organization and delivery issues. Based on a review of the evidence, the committee will develop an “agenda for change.”

To carry out this charge, in 2004 the IOM convened a multidisciplinary committee of experts in mental, substance-use, and general health care; public- and private-sector M/SU health care delivery; primary care; consumer issues; integration of service; ethics; economics; Medicaid; racial and ethnic disparities in care; veterans’ health and health care; child M/SU health care; geriatrics; informatics; and systems engineering (see Appendix A for the biographical sketches of committee members). This report is the result of their efforts.

As the committee’s charge and expertise indicate, the scope of this study was large, encompassing both public and private sectors, children and adults, and health care for mental and substance-use problems and illnesses. In particular, addressing health care for both mental and substance-use conditions in a single report was challenging; major public-and private-sector initiatives and reports have nearly always addressed only one or the other (DHHS, 1999; New Freedom Commission on Mental Health, 2003). Nonetheless, the committee found this dual focus to be appropriate and invaluable to its analysis of the evidence and formulation of policy recommendations, given the interconnected nature of these conditions and the resulting need for coordinated policy and care delivery. Indeed, the committee believes that in future initiatives to improve the quality of M/SU health care, expertise in health care for both mental and substance-use conditions should always be at the table.

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

SCOPE OF THE STUDY

At the beginning of its deliberations, the committee identified several issues that it decided should be excluded from this study to best focus its efforts. The special considerations involved in delivering care in rural areas consistent with the Quality Chasm recommendations are addressed in a separate IOM report (IOM, 2005), and thus are not addressed here. Similarly, a separate study on emergency care was under way at the same time as this study. Readers are directed to the reports of the IOM Committee on the Future of Emergency Care in the U.S. Health System, which will include discussion of the impact of M/SU illnesses on emergency departments and the quality of M/SU health care these facilities provide. Moreover, although touched on briefly in this report, difficulties in achieving diversity in the health care workforce and addressing disparities in health care likewise have been the subject two recent IOM reports (IOM, 2003, 2004). Also, because of the committee’s expansive charge, it was not able to attend to the unique issues related to dementia and the mental health care needs of older adults in long-term care facilities; the committee calls attention to the need for further study and resources focused on this population. Finally, Crossing the Quality Chasm sets forth a “patient-centered, treatment-focused” approach to improving individual health care, as opposed to a “population-centered, prevention-focused” approach to improving public health. The committee recognizes that much work is needed to apply public health interventions to M/SU problems and illnesses and briefly touches on a few of these issues in this report. However, resource limitations and the scope of the committee’s charge and expertise made it infeasible to address more fully this very important aspect of improving M/SU health care.

ORGANIZATION OF THE REPORT

In carrying out its charge, the committee focused on those characteristics of M/SU health care that distinguish it from non-M/SU health care (what is referred to throughout this report as “general” health care). These characteristics are briefly described in Chapter 2, along with the Quality Chasm framework. The report then examines how the Quality Chasm framework can be applied to achieve high-quality M/SU care, focusing first on patient-centered care (Chapter 3) and then on safe and effective care (Chapter 4). Approaches to implementing the Quality Chasm rule of coordinating health care across general, mental, and substance-use health conditions are discussed in Chapter 5. Chapter 6 mirrors the original Quality Chasm report by addressing the application of information technology to facilitate changes needed to improve the quality of care. This report also parallels the Quality Chasm report by reviewing in a separate chapter

Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×

(Chapter 7) changes needed in the M/SU health care workforce to implement the committee’s recommendations. New approaches to purchasing M/SU health care to create incentives for these changes are discussed in Chapter 8. Finally, Chapter 9 identifies areas in need of additional research. Appendix A contains further discussion of the Quality Chasm aims and rules and the organization of this report.

The report also contains overarching recommendations (in Chapter 2) as well as more specific recommendations for quality improvement. These latter recommendations, organized topically in Chapters 39, are collected and grouped according to the entities charged with their implementation in a series of tables at the end of Chapter 9.

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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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Suggested Citation:"1 The Quality Chasm in Health Care for Mental and Substance-Use Conditions." Institute of Medicine. 2006. Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: The National Academies Press. doi: 10.17226/11470.
×
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×
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Each year, more than 33 million Americans receive health care for mental or substance-use conditions, or both. Together, mental and substance-use illnesses are the leading cause of death and disability for women, the highest for men ages 15-44, and the second highest for all men. Effective treatments exist, but services are frequently fragmented and, as with general health care, there are barriers that prevent many from receiving these treatments as designed or at all. The consequences of this are serious—for these individuals and their families; their employers and the workforce; for the nation's economy; as well as the education, welfare, and justice systems. Improving the Quality of Health Care for Mental and Substance-Use Conditions examines the distinctive characteristics of health care for mental and substance-use conditions, including payment, benefit coverage, and regulatory issues, as well as health care organization and delivery issues. This new volume in the Quality Chasm series puts forth an agenda for improving the quality of this care based on this analysis. Patients and their families, primary health care providers, specialty mental health and substance-use treatment providers, health care organizations, health plans, purchasers of group health care, and all involved in health care for mental and substance–use conditions will benefit from this guide to achieving better care.

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