Morning Zen Guest Blog Post ~ Dennis D. Embry, Ph.D.

So many people, including Congressman Murphy, are saying things like, “my son, daughter or spouse would have been saved by the Murphy Bill.” Having lost my parents and brother to the complications of mental illness and addictions, I can empathize with that. Perhaps that is why I became a first-rate psychologist and first-rate scientist for preventing mental, emotional, and behavioral disorders. Mr. Murphy believes so much in his bill that he’s commented that it would have stopped Adam Lanza (CT), James Holmes (CO) and Jared Laughner (AZ) in my hometown of Tucson. We will consider the good intentions in light of sense, science, and dollars.

Sense and Good Intentions
The bill contains honorable and hopeful aspirations, yet that evokes a quote from Thomas Edison that merits mindfulness: “A good intention, with a bad approach, often leads to a poor result.” So here is the Murphy bill, full of good intentions. When you consider the sense, science, and dollars, the bill will almost certainly lead to a bad result. 

With both successes and failures in results of major policy projects under my belt by co-writing two bills with good intentions, one worked well, and the other was sinkhole that swallowed money with mixed effects. A first principle of trying to do a good is to own and measure the possibility of failure, and own failure when it happens. This is why I am a scientist who demands that the results good or bad or in-between be published. That is wise when thinking about the future of our children and society.

In politics, however, errors and failures get buried and obscured, regardless of political party. How many political leaders in America have gone before cameras, saying? “My policies failed.” How many political leaders have demanded that their pet peeve policy and legislation be subjected to a rigorous scientifically valid evaluation, and sanctioned the publication of results if it failed? Perhaps the advocates of the Murphy Bill might want to read the web page of the Coalition for Evidenced-Base Practices in DC:

• …the Coalition [a nonprofit, nonpartisan organization} seeks to increase government effectiveness through the use of rigorous evidence about what works. In the field of medicine, public policies based on scientifically-rigorous evidence have produced extraordinary advances in health over the past 50 years. By contrast, in most areas of social policy – such as education, poverty reduction, and crime prevention – government programs often are implemented with little regard to evidence, costing billions of dollars yet failing to address critical social problems.

Sense and Science
Section 2 of the revised Murphy bill states, “The term ‘‘evidence-based’’ means the conscientious, systematic, explicit, and judicious appraisal and use of external, current, reliable, and valid research findings as the basis for making decisions about the effectiveness and efficacy of a program, intervention, or treatment.”

Only one practice is actually named in the revised Murphy bill—assisted outpatient treatment—out of a treasure trove of better evidence-based practices that could be deployed and should be deployed to save our country from the growing tragic epidemic of mental illnesses documented by several Institute of Medicine Reports [1, 2].

The single strategy proposed in the Murphy Bill does not meet the Top-Tier or Near Top Tier criteria of the Coalition for Evidence-Based Practices, nor meets the standards of Cochrane Review—another independent arbiter of evidence-based practices in medicine and psychiatry. Here’s what the Cochrane Review says about the golden boy that is supposed to prevent all the terrible events across America, including my city of Tucson:

• …no significant difference in service use, social functioning or quality of life compared with standard voluntary care. People receiving CCT were, however, less likely to be victims of violent or non-violent crime. It is unclear whether this benefit is due to the intensity of treatment or its compulsory nature. Short periods of conditional leave may be as effective (or non-effective) as formal compulsory treatment in the community. Evaluation of a wide range of outcomes should be considered when this legislation is introduced. However, conclusions are based on three relatively small trials, with high or unclear risk of blinding bias, and evidence we rated as low to medium quality.

We helped the Treatment Advocacy Center to get AOT on the National Registry of Evidence-Based Practices (NREPP), with the clear caution that the science was not strong and that the strategy required much more research, given there were alternative practices that had more robust, scientifically-proven results. The AOT research scores are on the low side for a submission, with an overall of 2.5 out of 4.

How does that compare to some well-studied strategies for serious mental illnesses like Dialectic Behavioral Therapy? DBT ratings range from 3.2-to-3.7 out of 4, and DBT has been widely scaled and evaluated.  Similarly, NIDA’s vast investment on testing prize contingency management for treating very serious addictions (which happens a lot with folks with serious mental illnesses) has research ratings of 3.4 to 3.6 out of 4. Betting the nation’s future on research score of 2.5 is like placing a bet on a pair of cards at Vegas; the House or entropy in the case of policy will likely win. How do I know that?  Well for one, my colleagues and I have taken a bunch of good quality prevention and intervention strategies to scale (including whole states and provinces) in the United States and other countries, with successes and challenges. In all three cases, these strategies have much better research scores, and still there were challenges—even-though one of those achieved population-level effects using federally collected data across states. Indeed, there is a whole level of experimental research on these issues called, Implementation Science.

The “evaluations” outlined in the bill are weak, and don’t meet any reasonable standards of finding out scientifically if the bill achieves the advertised purposes of averting future Newtown’s, Aurora’s, or Tucson’s—let alone making sure no parent or family has to wait for a psychiatric bed for seriously mentally ill loved one, as hyped to pass the bill. None of my colleagues with the proven, published studies for evaluating such large-scale prevention, intervention, or treatment practices and policies have been invited to testify or consult, and the bill really doesn’t factor in such talent in the advisory boards. Is it possible to design a sensible scientific strategy to evaluate this massive experiment with the Nation’s Mental Health? Absolutely. I can rattle of practical ways in minutes, but what will Congress do if this governmental reorganization fails?

Let us be sensible: there is absolutely no high-quality, well-controlled peer-reviewed scientific publications that remotely suggest the Murphy Bill would have, or will stop future horrific events that happened in Newtown (CT), Aurora (CO), or Tucson (AZ). That’s simply good intentions. That said, the bill’s opponent often equally tout their good intentions, with similar emotional appeals and weak evidence.

Let us be equally sensible, forced treatment has horror stories—which I know first hand as a family member and clinician. Just letting very troubled patients decide to seek treatment has equally horrific stories. Both shades of grey are abundant in the press. 

The recommended best implementation of AOT I visited in Hamilton, OH was exemplary as promised but is not presently scalable in the county let alone the nation or state of Ohio to handle all the potential patients who need it. You can read my report about this terrific exemplar in a previous posting on the CMHNetwork website.

I get and honor the good intentions of both Congressman Murphy and his detractors. The revised bill cannot achieve the hoped-for goals when it pivots on a weak strategy and is not crafted based on good science of prevention, intervention, treatment or their implementation. Our current policies and practices are not working, as well documented by the rise in morbidity and mortality from neuropsychiatric disorders in the United States by diverse sources [1-13].

One thing absolutely missing from testimony and the bill is a serious discussion the prevention of mental illnesses long before events in Newtown, Aurora, and Tucson. In 1994, when the Institute of Medicine reviewed the evidence, there was a hint of possibility but no solid science. In 2009, the Institute of Medicine revisited that issue after the publication of hundreds of well-designed randomized, longitudinal trials that concretely proved it was possible to prevent such serious problems.

Sense and Dollars
The promise of the bill cannot be practically achieved, when it only appropriates a fraction of the funds spent in New York to achieve its statewide results with AOT. To achieve the result in New York across the United States would require $4 billion in new treatment money. And if all the money from the mental health block grant (about $480 million) each year were diverted just to patients with first-episode psychosis (for which there is both good prevention and treatment research) that would be only about $900 per patient for the 500,000 cases per year—not even one night for a psych bed. Further, the bill lacks a credible way to scientifically evaluate the outcomes of this vast “policy experiment” with the minds of our most fragile citizens. I speak this caution from both successes and utter failure of my own good intentions trying to better lives with science, dollars, and policy.

There are better ways to achieve the good intentions of all the parties, with better sense, science, and dollar value. I wish we could have that adult discussion: millions of lives hang in the balance.

 *   *    *   *   *    *   *   *

Dennis Embry, President/Senior Scientist at PAXIS Institute – Dennis D. Embry is a prominent prevention scientist in the United States and Canada, trained as clinician and developmental and child psychologist. He is president/senior scientist at PAXIS Institute in Tucson and co-investigator at Johns Hopkins University and the Manitoba Centre for Health Policy. His work and that of colleagues cited in 2009 the Institute of Medicine Report on The Prevention of Mental, Emotional, and Behavioral Disorders Among Young People. Clinically his work has focused on children and adults with serious mental illnesses. He was responsible for drafting of the letter signed by  23 scientists, who collectively represent scores of randomized prevention trials of mental illnesses published in leading scientific journals. In March 2014, his work and the work of several signatories was featured in a Prime-TV special on the Canadian Broadcast Corporation on the prevention of mental illnesses among children—which have become epidemic in North America. Dr. Embry serves on the Children’s Mental Health Network Advisory Council. 

References
1. O’Connell, M.E., T. Boat, and K.E. Warner, eds. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth and Young Adults: Research Advances and Promising Interventions. 2009, Institute of Medicine; National Research Council: Washington, DC. 576.

2. Woolf, S.H. and L. Aron, U.S. Health in International Perspective: Shorter Lives, Poorer Health, in Board on Population Health and Public Health Practice, Division of Behavioral and Social Sciences and Education, R.M. Martinez, Editor. 2013, The National Research Council and Institute of Medicine: Washington, DC.

3. Soni, A., The Five Most Costly Children’s Conditions, 2011: Estimates for U.S. Civilian Noninstitutionalized Children, Ages 0-17, A.f.H.R.a. Quality, Editor. 2014, Agency for Healthcare Research and Quality: Washington, DC.

4. Merikangas, K.R., et al., Comorbidity of Physical and Mental Disorders in the Neurodevelopmental Genomics Cohort Study. Pediatrics, 2015.

5. Kessler, R.C., et al., Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Arch Gen Psychiatry, 2012. 69(4): p. 372-80.

6. Patton, G.C., et al., Health of the world’s adolescents: a synthesis of internationally comparable data. The Lancet, 2012. 379(9826): p. 1665-1675.

7. Thomas, J.R., Panel looks to tackle skyrocketing special education costs, in The CT Mirror. 2012, The Connecticut News Project, Inc: Hartford, CT.

8. Copeland, W., et al., Cumulative Prevalence of Psychiatric Disorders by Young Adulthood: A Prospective Cohort Analysis From the Great Smoky Mountains Study. Journal of the American Academy of Child and Adolescent Psychiatry, 2011. 50(3): p. 252-261.

9. Twenge, J.M., et al., Birth cohort increases in psychopathology among young Americans, 1938-2007: A cross-temporal meta-analysis of the MMPI. Clin Psychol Rev, 2010. 30(2): p. 145-54.

10. Smith, J.P. and G.C. Smith, Long-term economic costs of psychological problems during childhood. Soc Sci Med, 2010. 71(1): p. 110-5.

11. Merikangas, K.R., et al., Prevalence and treatment of mental disorders among US children in the 2001-2004 NHANES. Pediatrics, 2010. 125(1): p. 75-81.

12. Mathews, A.W., So Young and So Many Pills: More than 25% of Kids and Teens in the U.S. Take Prescriptions on a Regular Basis, in Wall Street Journal. 2010, The News Corporation: New York.

13. McMichael, W.H., Most U.S. youths unfit to serve, data show, in Army Times. 2009: Washington, DC.