BY: ROD HOCHMAN, MD
The Substance Abuse And Mental Health Epidemic
Illustration by: Roy Scott
In 1999, the Institute of Medicine published To Err is Human: Building a Safer Health System, a groundbreaking investigation that opened our eyes to the alarming rates of patients killed each year due to preventable medical errors. Three years later, the institute followed up with an even more explosive and comprehensive set of findings, titled Crossing the Quality Chasm: A New Health System for the 21st Century.
The reports were a major topic of conversation in every health care circle at the time. In fact, for years all we did was talk about them, almost as if we were admiring the problem and patting ourselves on the back for acknowledging it. There were pockets of improvements and best practices here and there. But by and large, we weren't collectively taking consistent, actionable steps across the country to safeguard our patients from harm, and after the initial excitement died down, it was as if we closed the reports and put them away on a shelf.
The reports might have stayed there, collecting dust, had it not been for the 100,000 Lives campaign led by the Institute for Healthcare Improvement in Cambridge, Massachusetts. Anyone who has worked in health care for more than a decade will remember this initiative that aimed to reduce patient deaths and harm due to preventable medical errors by 100,000 lives in 18 months.
The campaign, launched about 10 years ago, established a platform and inspired clinicians from coast to coast to adopt a standard set of best practices for keeping patients safe. Although health care still has a way to go to eliminate harmful errors, the initiative achieved its goal and sparked a passion for safety and quality that continues to propel us today.
ACTION AND TRANSFORMATION
The reason I bring it up in this context is because the 100,000 Lives campaign is a brilliant example of how to ignite a transformational movement in health care. And that's exactly what we need at this moment as we find ourselves facing another severe national crisis: the mental illness and substance abuse epidemic. We all are aware of the problem and have talked about it endlessly. But we can no longer afford to just talk. Too many lives are at risk. It's time for real action.
The statistics are staggering. One recent report estimates that in 2016, as many as 65,000 Americans died of a drug overdose.1 That's the highest rate ever. That's more Americans than were killed in the Vietnam War.
Depression is the leading cause of disability worldwide and is a major contributor to the global disease burden.2 At its worst, depression can lead to suicide, which is the second leading cause of death in the United States for people between the ages of 15 and 29 years.3 And we are painfully aware that 20 U.S. veterans kill themselves every day.4
Too many people in our communities — including our own family members, neighbors, friends and co-workers — are not getting the help they need when they are at their most vulnerable points in life. It's estimated that 67 percent of adults cannot get access to adequate mental health and support services.
How many more people need to suffer and die before we develop a comprehensive support system to help one another? It will require nothing short of social transformation, which is why I believe we can learn from the 100,000 Lives playbook and apply similar strategies to solving the crisis at hand.
DESTIGMATIZE, PERSONALIZE
A critical first step is eliminating the stigma around mental illness. One of the most powerful tactics deployed by the 100,000 Lives campaign was putting a face and name to the statistics to help us connect with individuals behind the numbers. I recall many national meetings in which Donald M. Berwick, MD, MPP, the Institute for Healthcare Improvement's former president and CEO who spearheaded the campaign, would share the stories of people killed by preventable medical errors. We all followed suit at local levels, sharing stories of people in our own hospitals who died when they shouldn't have. We reflected on their names, ages and hobbies, emphasizing that these were individuals whose lives were cut short, who had families that loved them and who still had so much to give to the world. Their stories spurred us to do everything possible to prevent the same errors from happening to anyone else.
The 100,000 Lives campaign also made it safe for clinicians to talk openly about their own mistakes, which opened the door to identifying gaps in the system so that we could fix them. For a long time in health care, we felt the pressure of being perfect. We were not encouraged to express our concerns or question someone in higher authority. The 100,000 Lives campaign made it acceptable — in fact, expected — to speak up if you believe a patient is inadvertently being put in harm's way.
Imagine if we created the same openness around mental health and addiction? Our society often equates such issues with weakness, making people reluctant to come forward when they need help. I recently spoke with Maureen Bisognano, president emerita and senior fellow with the Institute for Healthcare Improvement. She was another major figure in the 100,000 Lives campaign — she became actively involved in mental health after her nephew died of a drug overdose.
Bisognano said she was proud to see that her nephew's widow included the phrase "died after suffering a drug addiction" in his obituary. In the U.S., we often are taught to keep these types of struggles quiet and not share them outside of the family. But listing the cause of death allowed other people in the community to acknowledge addiction in their own families and to see they are not alone, that there are others facing the same issues.
In the health care ministry, we also need to look within our own organizations and address the pressure and stress on our health care workforce. The intense physical, intellectual and emotional demands of caring for patients ultimately take a toll and can manifest in terms of high burnout rates, anxiety and depression. We have expected clinicians to just "suck it up," and we have not provided outlets and resources for them so they can talk about the trauma of the life-and-death situations they deal with every day. Health care workers are a source of healing for our communities, so we, in turn, need to support their healing and wholeness by helping them build resilience and maintain joy and meaning in their work.
EMBARRASSING OTHERS INTO ACTION
The 100,000 Lives campaign moved all of us into the action phase of preventing harmful errors. The Institute for Healthcare Improvement challenged every hospital and clinician in the country to join in the campaign to save lives, and it gave us a playbook for how to do it. With a clear sense of urgency, a common objective and a pathway forward, none of us had an excuse to not be part of the solution. We all joined the cause, met the initial goal and continue to carry the torch to this day.
Part of the campaign's genius was getting every health care organization involved. That same sense of collaboration is what we need now to solve the mental health and substance abuse crisis. One major difference, though, is that in addition to health care organizations, we need every segment of society to be part of the solution, from the schools and the criminal justice system to churches, businesses, social service agencies and veterans' groups.
By the time someone shows up in an emergency room with a mental health or addiction issue, that individual already has suffered a great deal of emotional and personal pain without enough early support or intervention. That is why we need to get upstream and bring the assets of entire communities to bear so we can help one another in the earliest possible stages.
The Well Being Trust is a national foundation based in Oakland, California, that aims to do exactly that. It is working to bring diverse organizations together to advance the mental, emotional and spiritual health and well-being of communities across the country. Providence St. Joseph Health established the foundation in 2012 with an initial seed investment of $100 million and has invited other organizations to join the cause.
The foundation is infusing the 100,000 Lives campaign's bold thinking into its mental health efforts. Bringing her experience from the Institute for Healthcare Improvement, Bisognano serves as the advisory council chair for the Well Being Trust. She has been instrumental in helping the foundation get organized so that we can identify the most effective set of actions that will have the biggest impacts in our communities.
Bisognano is working closely with Tyler Norris, MDiv, the foundation's chief executive. Prior to joining the Well Being Trust, Norris was vice president for Total Health at Kaiser Permanente in Oakland, California, where he worked with large community institutions to apply all operational assets to impact the economic, social and environmental determinants of health.
Under their leadership, the Well Being Trust is engaging organizations across sectors to:
- Eliminate the stigma of mental illness and ease access to care
- Build resilience in children, teens, families and seniors
- Reduce suffering from depression, anxiety and social isolation
- Curtail substance abuse
- Create hope for people with serious and persistent mental illness
- Grow healthy, equitable communities that support human flourishing5
The foundation has announced its first slate of grants, which include:
- A collaboration with the Institute for Healthcare Improvement to support patients who come to emergency departments in need of mental health care and substance abuse treatment
- A partnership with the Trust for America's Health to develop federal and state policy recommendations for a variety of mental health issues, but especially for substance misuse and suicide
- A grant to the California Mental Health and Wellness Initiative, an effort sponsored by the state of California to focus on better integrating behavioral health services across the full spectrum of care, from hospitals and clinics to schools, churches, community centers and the social services
ENGAGING OUR YOUTH
I have believed for a long time that our young people offer refreshing, valuable perspective, and I think one of the smartest things Bisognano and Berwick did prior to creating the 100,000 Lives campaign was to get advice from their kids about how to develop a national initiative to reduce medical errors. Both of them had children at the time who were working for political campaigns, and the first question their kids asked was, "How many lives do you want to save and by when?" In other words, their kids forced them to realize that "some" is not a number and "soon" is not a time, and it resulted in creating a clear campaign objective of saving 100,000 lives in a year and a half.
I think it's wonderful that the Well Being Trust also is turning to youth for answers. The foundation is partnering with sports figures, musicians, "YouTubers," popular bloggers and radio networks that can lend their voices to the movement and help reach young people. Athletes and hip-hop artists, for example, often have kept quiet about their mental health issues because they are perceived as weaknesses. But in partnership with the Well Being Trust, some of them have shared their stories about the pressures they face and how they have coped. It's all part of a campaign to create dialogue and inspire young people who may be facing their own challenges. The campaign uses the social media hash tags #BeWell and #BeHeard to invite young people to share their own experiences and create community.
Every great social movement begins with community, and that's what it will take to solve the nation's mental health and substance abuse crisis. As we saw with the 100,000 Lives campaign, it is possible to ignite a movement that can be a catalyst for dramatic transformation. Together, we can inspire hope, healing, wellness and inclusion for everyone.
ROD HOCHMAN is president and CEO of Providence St. Joseph Health based in Renton, Washington.
NOTES
- National Institute on Drug Abuse, "Overdose Death Rates." www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.
- World Health Organization, "Depression," Fact Sheet, February 2017. www.who.int/mediacentre/factsheets/fs369/en/
- World Health Organization, "Suicide," Fact Sheet, August 2017.
- www.who.int/mediacentre/factsheets/fs398/en/
- U.S. Department of Veteran Affairs, Office of Mental Health and Suicide Prevention, Suicide among Veterans and Other Americans, 2001-2014, updated August 2017. www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf
- Rod Hochman, "Initiatives — Mental Health: Well Being Trust," blog entry. www.rodhochmanmd.org/initiatives.
Rod Hochman, MD, is calling for a transformational industrywide change in health care to address the national crises of substance abuse and mental illness. He contends that the problems have been properly identified and discussed sufficiently, and that now is the time for strategic action. - Hochman uses the 100,000 Lives campaign, led by the Institute for Health Care Improvement 10 years ago, as an example of how to craft specific and actionable goals for a national change in the care of people with mental illnesses and substance abuse disorders. Do you think the 100,000 Lives campaign still provides a realistic model?
- What new challenges to a national initiative have surfaced in the last 10 years? What new opportunities might exist now with the use of social media for storytelling and information sharing?
- Does your ministry have policies and practices in place to reduce the stigmas of mental illness and substance use disorder? What are they?
- In your community, what actions are in place to improve access to mental health services? What partnerships could be forged to further improve access?
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