Speaking with Former Surgeon General David Satcher, a Leader in Mental Health

During his tenure (1998 – 2002), former Surgeon General Dr. David Satcher tackled many issues that had not been previously discussed, including access to care for minorities, sexual health, obesity and mental health. Today Dr. Satcher is the director of the Satcher Health Leadership Institute at Morehouse School of Medicine, which was established in 2006 and addresses many of his core issues that he focused on while surgeon general. The mission of the institute is to develop a diverse group of public health leaders, instill and encourage leadership strategies and shape policies and practices toward the reduction and ultimate elimination of disparities in health, with a focus on neglected diseases and underserved communities.

In December 1999, Dr. Satcher issued Mental Health: A Report of the Surgeon General, the first ever surgeon general’s report on mental health. The report called attention to the importance of addressing the mental health concerns that face the country. Although new research has been conducted and new developments have been made in the treatment and management of mental illness, the report continues to reflect several core principles underlying NAMI’s goals, including the importance of neuroscience and neurochemistry. It confirms that mental illness is treatable and while there is no single definition or way to measure recovery, with the help of family and the health care parity ruling, recovery is possible.

Dr. Satcher also issued three other reports on the topic, including Mental Health: Culture, Race and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon Generalin August 2001. While the first report made clear that there is hope for recovery from mental illness, this report noted that certain communities face additional challenges, including less access to mental health services, poorer quality of services and a decreased likelihood of reaching out for services, all of which make recovery more difficult. Culture and society play integral roles in mental health and understanding those specific factors can improve outcomes.

The two other reports were The Surgeon General’s Call to Action to Prevent Suicide, published in 1999, and Report of the Surgeon General’s Conference on Children’s Mental Health, published in 2000.

Nearly 15 years after the publishing of the first report, progress has been made but much work still needs to be done. Dr. Satcher recently spoke with NAMI about mental health issues facing the country today, how the Affordable Care Act can improve access to mental health care and how he developed his passion for fixing the mental health system.

Your landmark report was issued nearly 15 years ago but still has a lasting impact today. Is there a need for a second report?

I hope that the next surgeon general will issue a follow-up report but we have made some progress, however. Our major recommendation was parity of access to mental health services. In 2008, President Bush, with the support of Congress, signed legislation (the Paul Welstone and Pete Domenici Mental Health Parity and Addiction Equity Act) for parity of access to mental health services. The Affordable Care Act went even further and said that all insurance companies have to include services to mental health and substance abuse.

We currently have the best opportunity possible to move forward in providing access but we need to keep pushing forward. More research needs to be done on how integrating mental health and primary care improves access and how it removes stigma. Those are the kind of questions that we need to keep asking. And of course, we need to keep doing more research on the brain. President Obama has set aside $100 million dollars to look more closely at the brain to allow researchers to find new ways to treat illnesses—that’s a start but more needs to be done.

As the nation turns it focus onto the importance of early intervention and the prevention of violent tragedies, how do we get communities around the country to focus on these issues and develop solutions that result in lasting change?

When I was surgeon general the Columbine High School shooting took place; mental health seemed to be an issue then, as it does now. What happened after Columbine was that the White House and Congress requested a report from the surgeon general on youth violence; the American people were up in arms. They acted rapidly but by the time our report was complete, things had returned to “normal.” This is what generally happens after every mass shooting. People are upset for a little while, but then they forget it. You try to make some changes, whether it has to with access to weapons or access to healthcare, but then the country seems to let it go.

The Affordable Care Act moves us dramatically forward in regards to access to mental health services. But as a rule, we forget about the tragedy and we move on. I think what we have to do is to develop a strategy that really keeps this issue on the minds of people in this country and those who represent them in Washington, D.C.
We had a series of mental health forums when I first returned to Morehouse. People were anxious to talk about mental health; they are still the best attended forums that we’ve had. The community wants to know more but they don’t want it to be limited to TV reports on tragedies. They really want to be able to ask questions of people who are out there on the front lines trying to improve the mental health system.

The system that we currently have seems to wait for these tragedies to happen. What steps can we take to implement more preventative strategies?

I would say three things. I would start first with community and education. I think that we need some aggressive approaches to that, like we have with smoking and health. We have educated the American people in all sorts of ways about the harmful effects of smoking and in the process we have decreased the number of people smoking from 50 percent to less than 20 percent. That’s not good enough, but it’s dramatic progress. We have not had that education about mental health. And I think we have to. Mental health is about all of us, it’s about those with serious problems but it’s also about you and me and how we deal with our own mental health. We defined mental health in the report as the successful performance of mental functions such that one can be productive in his or her life. It is the ability to develop and maintain fulfilling relationships with other people.

Mental health is the ability to adapt to change and deal with adversity. Those were the four components we listed in the definition: productive activities, fulfilling relationships, adapting to change in one’s life and finally, dealing with adversity.

I think we also have to change the way healthcare system views mental health. Here at the Morehouse School of Medicine we now have relationships with 10 community health centers where we are implementing the integration of mental health in primary care. I believe we have to get to the point where we see mental health as a part of overall health and well-being. Routinely, we are not taught to do that; we do not look at the brain. I think we need to get primary care providers to see their responsibility here. And then we have to build teams between primary care providers and mental health specialists. Primary care is a team sport and now we have to integrate mental health into that because people with mental illness, particularly severe mental illness, have life expectancies 25 years less than the general population.

The second thing is that in the health care system we must send the right message that does not feed stigma. We must send the message that just as things go wrong with the heart, the lungs and the kidneys, they go wrong with the brain. They always have, they always will. The only question is how we will deal with it.

And the third thing is that we’ve got to continue to research. When the surgeon general first released his report on smoking, we didn’t know that secondhand smoke was harmful to your health. We didn’t know that 90 percent of the people who were addicted to tobacco became addicted before they were legally able to buy cigarettes. We then realized we had to focus on children. That’s what we have to do for mental health. We’ve got to keep doing the research and put more focus on children, where many mental health problems begin. Children in school need to hear stories about mental health and how we help people with mental illness. They need to under that it’s just like heart disease or kidney disease; you don’t blame the victim. You try to do everything to create an environment in which they can heal.

In both child and adult psychiatry, one of the problems is workforce capacity. What can be done to address the shortages in mental health professionals?

In my opinion the integration of mental health and primary care is key to addressing the workforce capacity. By combining professionals, it allows us to see more people, more easily. It also makes it more comfortable for the patient. The patient doesn’t just come with mental health problems, they come with other problems as well. By combining them, it doesn’t separate out different health problems and say, “Oh, you have to go somewhere else to get your care.”
We’ve been working a lot with community health centers, and those places can develop teams who can provide comprehensive services. For the majority of people, if you develop the right teams at these centers, more people will be seen and more appropriate care be given.

One of the issues that you’ve mentioned a few times that is an impediment to people receiving care is stigma. Have we been able to reduce the stigma of mental health in recent years?

I definitely think so. If you look at all of the things you see on TV, if you look at all of the movie stars and others who are coming out and talking about their mental health problems, you can see we’ve made progress. But it’s still not enough. When I was surgeon general, before we released the report, General Virginia Betts, who was a psychiatric nurse, and I went to New Zealand and Australia to look at their community-based mental health programs because they were outstanding. New Zealand has a large Maori population, about 15 percent of their overall population, and they have addressed the unique needs of this group in their training programs as well as in their community education. I remember speaking to groups in Australia and when people would ask questions they would begin by telling about their own troubles, saying that they had a nervous breakdown five years ago or that they been diagnosed with schizophrenia or that their brother had. That’s the kind of thing that wouldn’t happen in the U.S. for the most part. They were comfortable because it was an open discussion. That’s the direction I think our country still needs to head in, a more open discussion of mental health. 

You mentioned the ability of New Zealand to address the needs of the Maori people, a minority population. In much of your work, you’ve focused on minority and disadvantaged communities. As a supplement to the main report, you issued Mental Health: Culture, Race, and Ethnicity. Do you see progress happening or have things worsened in terms of disparities of care or lack of cultural competence?

What we said in that report, and something that surprised many people, was that was no evidence of a difference in the prevalence of mental health problems. However, there were disparities in the burden of mental health problems. And by burden we meant that minority communities often had more stigma. African Americans are about 50 percent less likely to seek outpatient treatment as whites. Asian Americans are even less likely. And then there was the trouble of accessing care, especially if they were poor.

Since the report, we’ve seen some great things happen. A lot of places have put together integrated teams. I remember visiting a program in Seattle and they were serving a community that spoke 30 different languages. The individuals they were serving were primarily Southeast Asian and what they had done that really impressed me was that they had gone into the community and worked with community organizations to identify people that could be trained to work with teams to help diagnose and treat mental health problems. They spoke the language and understood the culture. This helped lead to a tremendous increase in the number of people seeking help for mental health concerns. They started with the community. They engaged the community. They learned from the community.

Getting people to treatment is difficult. Getting them to effective treatment is even more challenging. What steps can be taken to ensure providers are trained in the most effective treatment methods?

What I think we’re beginning to see is that healthcare is a team sport. We’ve got to make sure that if a patient is seen in the emergency room or if they are seen at a community health center, they will have access to the highest quality or care that they need. On that team you have someone who can provide the highest level of care needed. They may not be there every day, but they are available and know that when they are asked to intervene they know that they are needed. They also need to help train everyone else on the team. Because again, everybody teaches and everybody learns. Unfortunately, we’re probably never going to have enough psychiatrists or clinical psychologists within the next five to 10 years. So what do we do? We change the way we play the game. We train teams, not just individuals.

You’ve been a supporter of a single-payer national health care (Medicare-style). What’s your assessment of the ACA in providing a foundation for the future?

As you note, I am a huge supporter. I think this is the biggest undertaking this country has ever had to reform our health system. Anyone who thought this was going to be easy was mistaken. I’m not making excuses for the errors that were made but in no way should we even think about turning back. The Affordable Care Act means so much to people with mental illness, to parents of children with mental illness and to the communities that have been left out of the healthcare system. Whenever I talk about the Affordable Care Act, I always remind people about the many problems that we have with our healthcare system—the problems with access, the problems with quality, that we’re not getting our money’s worth—and the Affordable Care Act will help significantly; it will improve access for over 30 million people within the next few years; it will ensure that physicians for the first time are rewarded for the quality of their work not the quantity. And of course, there is a tremendous amount of focus given to prevention and primary care.

Was there anything that stands out in your career pertaining to mental illness that pushed you to address the state of the mental health system?

It was really in medical school. I was the only black student in most of my classes at Case Western and they had a strong emphasis on mental and behavioral health. There was a young African American patient who came in who wouldn’t let anyone talk with him except for me; he was paranoid around others of a different race. They were going to give up on him, but they assigned him to me and we developed quite the relationship. I ended up doing grand rounds as a student in psychiatry based on my experience with this man. I always felt it was essential to address the needs of the whole patient. My interest grew as I continued and by the time I had gotten to the office of surgeon general, I think I already brought a lot of passion. I saw mental health similar to the way I saw race and ethnicity. I saw people being discriminated against because of their mental health status and I felt that if I had to opportunity to make a difference I was going to do it.