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A question of access? Mental health and gun violence

As President Obama faces opposition from gun rights advocates over his recent proposals to combat gun violence, the challenge he faces of fixing flaws in the mental health care system may prove just as difficult a battle.

Mr. Obama outlined plans aimed at preventing mass shootings and reducing broader gun violence in the United States last week, while signing 23 executive actions that did not require Congressional approval. Alongside proposed changes to gun laws including universal background checks, a stronger ban on assault weapons and new restrictions on ammunition and magazines, mental health emerged as a core feature of the president's plan to prevent further tragedies like the Dec. 14 shooting in Newtown, Conn.

The executive actions related to mental health included:

  • A letter to health care providers clarifying that no federal law prohibits them from reporting threats of violence to law enforcement authorities
  • Incentives for schools to hire school resource officers
  • A letter to state health officials clarifying the scope of mental health services that Medicaid plans must cover
  • Finalization of regulations clarifying essential health benefits and parity requirements within health insurance exchanges
  • A commitment to finalizing mental health parity regulations
  • The launch of a national dialogue led by the departments of Health and Human Services and Education on mental health
  • A Presidential Memorandum directing the Centers for Disease Control to research the causes and prevention of gun violence
  • Clarification that the new health care law does not prohibit doctors from asking their patients about guns in their homes

Noting that it was the first of its kind to focus on mental health since 2007 -- and long overdue -- Iowa Sen. Tom Harkin chaired a hearing of the Senate Health, Education, Labor and Pensions Committee Thursday.

Harkin laid out that while Newtown has brought the issue to the forefront of discussion, mental illness only accounts for a small proportion of violent crimes.

Experts estimate only a small percentage of violent crimes -- less than 5 percent -- are caused by mentally ill people.

"People with mental illness are much more likely to be the victims of violent crimes than perpetrators of violence," said Harkin, who called mental health care's shortcomings a public health problem.

A common theme throughout the hearing was to avoid stigmatizing people with mental illness while discussing gun violence and problems facing mental health care.

Pamela S. Hyde, administrator for the government's Substance Abuse and Mental Health Services Administration (SAMHSA) laid out the scope of the mental health care problem during the hearing (video at left). Of the 45 million U.S. adults suffering from mental illness, only 38.5 percent receive the treatment they need, she said. For children, only one in five receive necessary treatment for diagnosable mental disorders. Despite showing symptoms, many children and adults experience significant delays getting into treatment. Hyde argues that if the system shifts to a focus on early intervention, more people can be helped.

"Cost, access and recognition of the problems are the primary reason this treatment is not received. However it doesn't have to be this way," said Hyde. "For most of these conditions, prevention works, treatment is effective and people do in fact recover."

Mental health care spending has been dramatically cut in recent years. A 2011 report from the National Alliance on Mental Health that looked at state-by-state mental health budgets reported $1.6 billion in state funding cuts from 2009 through 2012. Medicaid cuts at this time also negatively affected mental health care, the report showed. States are mulling increases in funding in light of the Newtown shooting.

And the health care system may only become more burdened in the near future: A July 2012 study by the Institute of Medicine, an advisory medical organization to the government, found an aging baby boomer population could cause a mental health care crisis by 2030, when the number of U.S. seniors is expected to double and necessary resources will be woefully lacking.

Dr. Jeffrey Lieberman, chairman of psychiatry at Columbia University Medical Center in New York City, told CBS News senior correspondent John Miller in December that mental health care is a societal problem because the U.S. has not taken on the treatment of mental illness as effectively as it could.

"I think mental health is a big issue," Lieberman said at the time. "It's definitely related to the frequency of these seemingly senseless and wanton killings that occur. And the way it relates is that unfortunately, individuals who have specific forms of mental illness, if untreated, can be more prone to act in a way which is socially destructive and results in harm or killing like we saw happen."

Lieberman said a person who needs treatment for mental illness often faces barriers such as insurance coverage and accessibility to care, in addition to stigma -- while people getting treated for a disease like cancer face fewer "disincentives" to getting the best care.

Following the president's announcement, Lieberman told that the new proposals are "on the right track" in terms of addressing issues in the mental health system, but much work remains to clarify how these actions will be implemented.

By getting more people with mental illness, impulse disorders and substance abuse issues into constant treatment, he said, they may be prevented from ever getting to a point where they are showing symptoms of mental illness -- and acting on violent impulses.

"Trying to say we should only do something when they get dangerous is very late in the process," said Lieberman.

Details on the president's proposals still need to be worked out, said Lieberman, who is also president-elect of the American Psychiatric Association. For example, the Mental Health Parity Act, which the president wanted to finalize in his executive actions, requires that mental health benefits are covered by insurance, similar to non-psychiatric health care benefits. However, the rules to determine what services are covered, how people become reimbursed and other stipulations have not been established, he said. The president also asked for clarification on Medicaid mental health services, which now typically covers people who have severe forms of mental illness. Lieberman argues policymakers may find that these services are not adequate, and broader services are needed.

Right now, doctors cannot provide mental health care services in what Lieberman refers to as a "financially viable way." He explains that patients seeking help for mental health may require a lot of support, not only from a doctor who may provide medication, but from therapists, case managers and social and vocational rehabilitation counselors who need to be more actively involved in the patient's lives. These team-based "multi-element treatment approaches" have been shown in studies to be effective, however these types of paid services just aren't available for people suffering from mental health problems. Meanwhile, a person with heart disease may see a cardiologist, a surgeon, a different doctor about stent management, a nutritionist for lifestyle tips, and other providers all covered by insurance.

"In mental health care it's the same thing -- you can't just see a psychiatrist and get a prescription," he said. "This is not just throwing different services at the problem, there's good evidence that these things work."

Dr. Jeffrey Swanson, a professor of psychiatry and behavioral sciences at Duke University School of Medicine, who has published several research papers on gun violence and mental health for more than a decade, agrees the current mental health system represents a complex public health problem facing the United States.

"The mental health system in the country, if you can call it that, is fragmented and grossly under-resourced," Swanson told in an email. "It needs a lot of things, and more research into how to fix it -- at a time when there are more mentally ill people incarcerated than in hospitals -- is one of the needed things," he said.

A 2011 paper by Swanson published in Psychiatric Services examines the lack of data available on firearm use against strangers, and how it is impossible to reliably predict which specific individuals would engage in the most serious acts of violence.

But even if more CDC research stemming from the president's proposals strengthens the available data pool, Swanson argues these egregious acts of violence may still be impossible to predict.

"I think more access to evidence-based treatment and less access to guns, taken together, would have an impact on gun violence, at least on the margins. But prevent mass shootings? That's hard to say," Swanson said. "Those are almost inherently unpredictable, and often perpetrated by people with no gun-disqualifying mental health or criminal record -- until it's too late. Most of the measures in the President's proposal, even if enacted and implemented perfectly, would not necessarily have prevented the shootings in Tucson, Aurora, or Newtown."

While concerns persist on how the president's proposals will be implemented, the announcement was supported by various health organizations that had previously submitted recommendations to Vice President Joe Biden's White House Task Force on Gun Violence Prevention.

"NAMI applauds the President's plan for its significant provisions to strengthen and expand mental health services," Michael Fitzpatrick, executive director of the National Alliance on Mental Illness said in a statement following the proposals. "The mental health care system has long been broken. The challenge is not to fix it, but to build it anew, focusing on early screening, diagnosis, treatment and prevention. The President's plan takes important steps toward meeting that challenge."

Dr. Dilip V. Jeste, president of the American Psychiatric Association, added in statement, "We are heartened that the Administration plans to finalize rules governing mental health parity under the 2008 Mental Health Parity and Addiction Equity Act, the Affordable Care Act, and Medicaid. "We are glad that the President has clarified that doctors are not prohibited from asking their patients about guns in their homes. The APA has consistently advocated for such a position."

The American Academy of Pediatrics also offered its support.

"In addition to addressing firearm regulations, we must improve access to quality mental health care both to help prevent violent acts and to assist victims of trauma," AAP President Dr. Thomas K. McInerny, said in a statement following the proposals. "The AAP agrees with the President that we must improve the identification of mental illnesses through increased screening, address inadequate insurance coverage and high out-of-pocket costs that create barriers to access, strengthen the overall quality of mental health access, and improve and expand the Medicaid reimbursement policy to include mental health and developmental services.

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