Bipolar4LifeSupport

When a person chooses suicide, it’s hard to accept that choice.

Comedian and award-winning actor Robin Williams apparently made that choice earlier this morning. Robin Williams has long suspected to be a sufferer of either depression or bipolar disorder. Bipolar disorder is a mental illness where the person fluctuates between episodes of extreme energy, focus and productivity (mania) and severe depression. Apparently, he was in one of the episodes of depression when he took his own life.

We mourn his loss.

The coroner said that Williams’ death was “a suicide due to asphyxia, but a comprehensive investigation must be completed before a final determination is made.”

Williams had long struggled with addiction and mental illness. ¹ “Do I perform sometimes in a manic style? Yes,” Williams told Terry Gross on the “Fresh Air” NPR radio show in 2006. “Am I manic all the time? No. Do I get sad? Oh yeah. Does it hit me hard? Oh yeah.”²

According to news accounts:

“Robin Williams passed away this morning,” said Mara Buxbaum, president of [Williams’] PR firm. “He has been battling severe depression of late. This is a tragic and sudden loss. The family respectfully asks for their privacy as they grieve during this very difficult time.”

His wife, Susan Schneider, issued a brief statement: “This morning, I lost my husband and my best friend, while the world lost one of its most beloved artists and beautiful human beings. I am utterly heartbroken,” she said.

Suicide is an insidious choice due to the lies that depression tells us. When a person is suffering from severe depression, as apparently Williams was, it can tell that person, “Hey, you’d be better off dead. Life isn’t going to get any better.”

And sadly, sometimes people listen. Even brilliant, accomplished individuals such as Robin Williams.

Williams is best known as a comedian who made his name first in stand-up, then in TV on the hit show Mork & Mindy, and later with movies such as Mrs. Doubtfire, Dead Poets Society, Awakenings, and Good Will Hunting, where he won an Oscar for his role as a therapist.

Bipolar disorder is a mental disorder that is most-commonly treated through a combination of psychotherapy andmedications. People who limit their treatment or stop taking medications may be at higher risk for the symptoms associated with bipolar disorder, such as mania or depression. Most people with bipolar disorder need lifelong treatment for the concern, as there is no cure for it.

Some people with bipolar disorder feel that the medications commonly prescribed for the disorder make them feel like they’re “living in a fog,” or that all their emotions lack any sort of depth. For these kinds of reasons, some people choose not to keep taking medications to treat the disorder.

Suicide is a common symptom of severe, clinical depression. When properly treated, the feelings of suicide often remit as the depression lifts. But even under treatment, sometimes people choose to take their own life.

While we may never understand why someone who enjoyed so much family and success as Robin Williams did might take their own life, we can appreciate the body of work he left behind. He lit up many people’s lives with his humor, infectious energy, and poignant roles.

Robin Williams will be missed.

Editorial note: We acknowledge Williams himself has never stated, to our knowledge, that he had been formally diagnosed with bipolar disorder or depression. Yet given his behaviors and symptoms, it seems far more likely he suffered from bipolar disorder — of which depression is a very significant component. News accounts saying he suffered from depression don’t appear to be substantiated by Williams’ own statements on the issue.

8/12/2014 2:30pm Update: The Marin County Coroner’s office has now stated that Williams was seeking treatment for depression.

If you are feeling suicidal, please read this first. Then if you’re in the U.S., call 800-273-TALK, or one of these numbers here for international readers (choose your country from the drop-down list). Suicide is a temporary feeling that signals untreated or under-treated depressive symptoms. There is help — and hope.

Related articles

• Goodbye Mr. Williams
• Morning Robin Williams: The Tragedy of Suicide
• Robin Williams: A Devastating Loss
• RIP Robin Williams
• Oh Captain My Captain – SHAZBAT – Robin Williams 1951 to 2014

When we think of people with clinical depression, we think of individuals who are overtly sad — a permanent frown etched onto their face. We think of people who can’t get out of bed and have a hard time working and performing tasks. People who look exhausted and disheveled. People who are withdrawn and isolate themselves.

Sometimes this is accurate. Sometimes, this is how depression manifests.

But other times, the face of depression is actually that of a happy person. A person who’s put-together and appears to be perfectly fine on the outside. He (or she) might excel at his job and be especially productive. He might go out regularly and be active in his community.

However, on the inside, he’s drowning.

This is called “smiling depression.”

“Individuals appear happy to others, literally smiling, while they experience depressive symptoms,” said Dean Parker, Ph.D, a Dix Hills, NY, psychologist who specializes in mood disorders. Smiling depression isn’t a diagnosis that you’ll find in the DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders, fifth edition), he said. Rather, it’s a term psychotherapists use.

“You could call it ‘high-functioning depression,’” said Melanie A. Greenberg, Ph.D, a psychologist who specializes in managing mood in Marin County, Calif., and penned the forthcoming book, The Stress-Proof Brain: Master Your Emotional Response to Stress Using Mindfulness and Neuroplasticity.

People with smiling depression may experience different symptoms, she said. They “may feel disconnected from their lives or from other people and [be] unable to enjoy their usual life activities.”

While they don’t show it, they still feel a persistent sadness, Parker said. This sadness might stem from an unfulfilling career, a faltering relationship, or a general lack of meaning in their life, he said.

Individuals with smiling depression might still feel anxious, angry, overwhelmed and irritable, and have trouble sleeping, Greenberg said. They might experience feelings of hopelessness, dread and fear, which, again, remain suppressed and unseen by others, Parker said.

Greenberg speculates that men, successful professionals, and stay-at-home moms—who try to be “supermom”—are especially prone to smiling depression (though she’s not aware of specific research). “It may come on following a significant loss that hasn’t been mourned or that threatens their self-image of strength and independence. These individuals may have grown up in families that focused on external success and discouraged the expression of vulnerable emotions.”

Individuals with smiling depression might have grown up poor and are now more successful, she said. They might have grown up in families with alcoholism. They might yearn to be perfect.

Smiling depression tends to go undiagnosed, Parker said, because people deny or suppress their feelings and symptoms. They might not even know they’re depressed. Or they “keep a stiff upper lip, moving forward as if they are not struggling.”

They might not want to burden others or appear weak, Greenberg said. Again, “they may value a self-image as strong and capable, so they push their sad and anxious feelings aside and try not to show them to others.”

For instance, Greenberg worked with John (not his real name), a successful manager at a large company. He was a strong performer and well-liked by his colleagues. He had an active social life. He was a great dad to his three young kids. He made time to coach his son’s soccer team. He cooked dinner during the week and repaired the house on the weekends.

However, on the inside, John was drowning. He had recently lost his father, and experienced a major disappointment at work. His wife, who struggles with chronic fatigue, was emotionally and physically distant. He couldn’t sleep. He felt like he was going through the motions without actually enjoying his life. He felt shame about his work situation. He felt angry with his wife, even though he understood that she was struggling with an illness. He worried often about their finances.

In therapy John struggled with connecting to his feelings of loss, shame and helplessness. He was very much invested in viewing himself as strong and self-reliant. Slowly, he and Greenberg explored his feelings and assumptions about strength. They worked on being more honest with John’s wife. They worked on letting go of the belief that he had to do everything.

“After about 9 months of therapy, he was more able to understand and accept his own feelings and needs. [He felt] more comfortable in communicating them and taking action to address them. The depression lifted and he felt happier and more engaged in life.”

Not addressing your depression can be dangerous. According to Greenberg, you might not realize how hopeless you feel or get the help and support you really need. Your seemingly strong and competent exterior also isn’t sustainable over the long term. Worst of all, untreated depression ups your risk for suicide.

So if you’re struggling or you sense that something isn’t right, seek professional help. Doing so is the opposite of weakness: It takes real strength to admit there’s an issue and to work on solving it. Plus, it means that you’ll feel better. You’ll find relief and reconnect to yourself, to your loved ones, and to your life—which is genuinely something to smile about.

I keep going back to this quote by Vivian Greene when it comes to learning how to live with my chronic illness: “Life isn’t about waiting for the storm to pass… It’s about learning to dance in the rain.”

In fact, every morning I drink out of a mug with that quote on it to remind myself of Vivian’s wisdom: IT’S NOT ABOUT GETTING TO THE OTHER SIDE. With chronic illness, the important exercise is to get out the rain boots and start stomping in the puddles — to not let the downpour stop you from living.

Going into the second decade of living with a host of conditions — retractable depression, inflammatory bowel disease (IBD), hypothyroidism, pituitary tumor, aortic valve regurgitation, Raynaud’s disease, and connective tissue issues — one of the bigger mistakes I keep making is hanging on to the promise that if I do everything “right,” I will be freed from all symptoms for the rest of my life. If I follow the right diet that won’t aggravate my Crohn’s disease or cause brain inflammation that makes me depressed; if I exercise in such a way that doesn’t raise my cortisol and further deplete my adrenals (like running can) or wipe out my good gut bacteria (likeswimming in chlorine can); if I practice mindfulness instead of cuss and reduce my stress…if I do all these things, I will be fixed!

One day this past summer I was especially discouraged because, having returned home from a family vacation very depressed and anxious, I realized I couldn’t practice my health regimen perfectly every day for the rest of my life. There would be times I wouldn’t be able to make it to yoga, and my sleep would be compromised. Fresh kale wouldn’t always be in the fridge. I should expect lots of more evenings out when a waiter sets a basket of hot fries or tortilla chips right in front of me, or my daughter can’t finish her hot fudge sundae and my willpower wilts.

“We won’t always get it right,” a friend reminded me when I told her I caved to the fries and was therefore depressed. “And even if we did manage to do it all perfectly, would it ‘cure’ us? We have a chronic illness that will occasionally (hopefully less and less) rear its ugly head into our lives no matter how hard we try!”

This was true. I tend to forget about the word “chronic.”

I get persuaded into thinking by the dozens of self-help books I read each year that I have the power to fix every symptom of every condition I have with the right supplement or relaxation technique or food combination. And if I can’t? Then I’m not trying hard enough and have given up.

For example, I just finished the book The Hormone Cure by Sara Gottfried, MD, an excellent resource for women who are cursed by hormonal issues in the throes of perimenopause and menopause. She promises she can boost your energy, renew your sex drive, and restore your sleep with her natural protocols. A Harvard-trained gynecologist and nationally recognized yoga teacher, she is a pioneer in treating the root causes of hormonal issues, and I admire her work very much. However, I started to feel bad about myself on page 295 of her book when she refers to the kind of “learned helplessness” that Martin Seligman, PhD, of the University of Pennsylvania writes about in his book Authentic Happiness, and other works, the tendency to “behave helplessly and fail to respond to opportunities for better circumstances.” Dr. Gottfried writes:

Here’s a secret: I observe that women in my practice with learned helplessness have a far more difficult time achieving the hormone cure. Please answer this question honestly: Do you have the pattern of learned helplessness? Do you feel you lack the power to change your eating, exercise, and other health habits? In contrast, women who understand the many positive consequences of their lifestyle reset — such as cutting out sugar and flour, and walking most days of the week — achieve the hormone cure much more rapidly and sustain it. The most successful women in my practice also recognize that the locus of control is internal — they understand they have the power to change, and cultivate hope and accountability about meeting their health challenges.

Now I’m all about finding new ways to treat various conditions, by researching and exploring and inquiring with others, and readjusting and then learning some more. That’s why I average one self-help book a week, and I’ve made a hobby out of evaluating different studies. However, I also know that therein lies my weakness, as is the case with other people I know who battle chronic illness. Because when I’ve incorporated all the data being processed by my brain, and implemented suggestions from all my doctors and literature, and am on medication combination No. 45, and making kale smoothies every morning, and going to therapy every week, and doing Bikram yoga — and I can’t get well, or don’t get well — or slip and eat a basket of fries, I beat myself up like I have just committed three of each of the seven deadly sins. Actually, four of “sloth.”

Trying too hard — perhaps the opposite of learned helplessness — is the very source of my suffering.

But it’s hard to exercise self-compassion and know when enough is enough when you have people like Arnold Schwarzenegger and other celebrity types saying things like, “Learned helplessness is the giving-up reaction, the quitting response that follows from the belief that whatever you do doesn’t matter.” In our results-oriented culture, it’s all about pushing yourself beyond your limits, because “life begins at the end of your comfort zone” (Neale Donald Walsch).

Yes, there are times to push yourself like Schwarzenegger does.

And there are times to throw out the word “cure.”

It’s the first step of all 12-step support programs, where you admit powerlessness in a gesture of exhilarated defeat.

As a result, you can experience profound peace.

I remember one such moment in the summer of 2014 when I gave up on a cure for my retractable depression. I had been experiencing loud death thoughts for about five years despite trying numerous medication combinations and sessions ofpsychotherapy. I then decided to embrace the holistic route: making profound changes to my diet, trying new supplements, and participating in a course on mindfulness meditation at the local hospital. However, four months and lots of bills later, I wasn’t any better. (The diet changes did make a difference later on, but they took a good nine months.)

One June afternoon, I panicked when I realized I might not ever experience a reprieve from the death thoughts.

Like, EVER.

A man in the depression forum I had just started suggested I read Toni Bernhard’s book, How to Be Sick — and learn how to live “around” my symptoms instead of putting so much energy into trying to make them disappear. A few paragraphs into her book, I felt profound relief. A former law professor and dean, Bernhard contracted a mysterious viral infection on a trip to Paris in 2001 and has had flu-like symptoms ever since. Many days she is confined to her bed, and yet her life is full of meaning. In her new book, How to Live Well With Chronic Pain and Illness, she writes:

Many people think it’s their fault when they become chronically ill. They see it as a personal failing on their part. We live in a culture that reinforces this view by bombarding us with messages about how, if we’d just eat this food or engage in that exercise, we need never worry about our health. For many years, I thought that the skillful response to my illness was to mount a militant battle against it. All I got for my efforts was intense mental suffering — on top of the physical suffering I was already experiencing.

The pivotal moment for me came when I realized that, although I couldn’t force my body to get better, I could heal my mind. From that moment, I began the process of learning (to reference the title of my first book), “how to be sick,” by which I mean how to develop skills for living gracefully and purposefully despite the limitations imposed by chronic illness…If there’s no escaping our measure of disappointment and sorrow, then the path to peace and well-being must lie in learning to open our hearts and minds to embrace whatever life is serving at the moment. This is a mindfulness practice — mindfulness infused with compassion for ourselves.

I consider Toni my coach and inspiration when it comes to living gracefully within my limits. From her, and from other companions with infuriating health conditions, I have learned that life isn’t about waiting for the storm to pass. It’s not about fixing every symptom so that you can go to a dinner party without anxiety or help your daughter with her homework without abdominal pain. Life with chronic illness is about dancing in the messy wetness, accepting the perspiration of the universe for what it is, and — with the right umbrella and guidance and support from others who have been there — doing an elegant jig in the moment.

Sometimes by allowing yourself to have fun catching a raindrop in your mouth, you can forget about your symptoms.

And you can be set free.

Today, Hillary Clinton announced her comprehensive plan to support Americans living with mental health problems and illnesses—by integrating our healthcare systems and finally putting the treatment of mental health on par with that of physical health. Nearly a fifth of all adults in the United States, more than 40 million people, are coping with a mental health problem.[1] Close to 14 million people live with a serious mental illness such as schizophrenia or bipolar disorder.[2] Moreover, many of these individuals have additional complicating life circumstances, such as drug or alcohol addiction, homelessness, or involvement with the criminal justice system.[3] Veterans are in acute need of mental health care, with close to 20% of those returning from the Iraq and Afghanistan wars experiencing post-traumatic stress or depression.[4] And the problem is not limited to adults: an estimated 17 million children in the United States experience mental health problems,[5] as do one in four college students.[6]

Americans with mental health conditions and their families need our support. The economic impact of mental illness is enormous –at nearly $200 billion per year nationwide in lost earnings[7] —and the human cost is worse. Too many Americans are being left to face mental health problems on their own, and too many individuals are dying prematurely from associated health conditions. We must do better. To date in this campaign, Hillary set out policies that will direct support to individuals with mental health problems and their families—including a detailed agenda to support military service members and veterans, an initiative to end America’s epidemic of drug and alcohol addiction, and a robust caregivers’ agenda. Today, she is building on those proposals with a comprehensive agenda on mental health. Hillary’s plan will:

• Promote early diagnosis and intervention, including launching a national initiative for suicide prevention.
• Integrate our nation’s mental and physical health care systems so that health care delivery focuses on the “whole person,” and significantly enhance community-based treatment
• Improve criminal justice outcomes by training law enforcement officers in crisis intervention, and prioritizing treatment over jail for non-violent, low-level offenders.
• Enforce mental health parity to the full extent of the law.
• Improve access to housing and job opportunities.
• Invest in brain and behavioral research and developing safe and effective treatments.

As a down-payment on this agenda, Hillary will convene a White House Conference on Mental Health during her first year as President. Her goal is that within her time in office, Americans will no longer separate mental health from physical health when it comes to access to care or quality of treatment. The next generation must grow up knowing that mental health is a key component of overall health and there is no shame, stigma, or barriers to seeking out care.

Early Diagnosis and Intervention

Most mental health conditions have their origins in childhood and adolescence. But today, two-thirds of children with mental health problems receive no treatment at all,[8] and children in high-risk groups – such as those in juvenile justice settings, in the child-welfare system, or whose mothers experienced depression during or after pregnancy – are particularly underserved. The consequences of delayed and inadequate treatment for children and young adults with mental health problems play out over decades. For instance, adolescents with serious mental illness are about three times more likely to drop out of school and twice as likely to face a premature death as are their cohorts who do not face such problems. Hillary is committed to expanding early diagnosis and treatment of mental health conditions, and preventing them when possible. As president, she will:

• Increase public awareness and take action to address maternal depression, infant mental health, and trauma and stress in the lives of young children. Hillary will ensure that the public health and early education communities receive needed information and action steps to address maternal depression, infant mental health, and trauma and stress. New studies show that as many as 1 in 5 women develop symptoms of depression, anxiety, or mental health disorders in the year after giving birth.[9] The U.S. Preventive Services Task Force now recommends that women be screened for depression during pregnancy and after giving birth. We also know that infant mental health depends on children forming close and secure relationships with the adults in their lives, and that too many children are growing in environments that cause them to experience trauma or develop stress. Hillary will build on innovative state Medicaid practices to increase screenings for maternal depression, infant mental health, and toxic stress, with the goal of these screenings becoming standard practice in Medicaid

• Scale up efforts to help pediatric practices and schools support children facing behavioral problems. Hillary believes we must redouble our efforts around early screening and intervention – and that means training pediatricians, teachers, school counselors, and other service providers throughout the public health system, to identify mental health problems at an early age and recommend appropriate support. There are many promising state and local programs aimed at early detection and intervention of mental health problems, such as Positive Parenting Program, Nurse Family Partnership, Typical or Troubled Program, Mental Health First Aid, Incredible Years, and Massachusetts’ Child Psychiatry Access Project (MCPAP).[10]Hillary will fund promising programs like these by increasing the set-aside in the Mental Health Block Grant for early intervention from 5% to 10% of the annual budget, and she will move this from set-aside funding to a stand-alone program.

• Help providers share information and best practices. People experience mental illness in a variety of ways, with symptoms often differing even with the same illness. The Early Psychosis Intervention Network (EPINET) is a platform at the National Institute of Mental Health, which serves as a centralized source of information, data, and best practices to providers and clinicians who treat psychosis. Hillary will support EPINET and other efforts like it that enable mental health practitioners to share information, and she will build on what works.

• Ensure that college students have access to mental health services. Mental health and well-being are integral to campus success. Hillary will encourage every college to put in place preventive services, comprehensive treatment and coverage of services, and an interdisciplinary team (including but not limited to school leadership, faculty, students, and personnel from counseling, health services, student affairs, and the office supporting students with disabilities) to oversee the campus’s mental health policies and programming. Hillary will also strengthen support for under-resourced schools that serve a disproportionate number of low- and middle-income students and communities of color, and she will help those schools improve coordination of care with local clinical providers.

Federal Support for Suicide Prevention

Suicides, which are usually fueled by mental illness, are rising among numerous population groups, from adolescents and college students[11] to veterans[12] and older adults.[13] The overall rate of suicide increased by 24 percent between 1999 and 2014, and is now at its highest level in 30 years.[14] Over 40,000 Americans die of suicide every year, making it the tenth-leading cause of death nationally.[15] As the former director of NIMH, Dr. Tom Insel, often notes, suicides have 11 victims: the person who dies, and at least 10 people close to them who will never be the same. Hillary believes that suicide is a critical issue that she will prioritize as president. She will:

• Create a national initiative around suicide prevention across the lifespan that is headed by the Surgeon General: As president, Hillary will move toward the goal of “Zero Suicide” that has been promoted by the Department of Health and Human Services. She will direct all relevant federal agencies, including HHS, the VA, and the Department of Education, to research and develop plans for suicide prevention in their respective settings, and create a cross-government initiative headed by the Surgeon General to coordinate these efforts. She will also launch a citizen input and feedback mechanism, to enable outside groups to comment on agency recommendations, and explore how we can harness technology to reach out to people who need support.

• Encourage evidence-based suicide prevention and mental health programs in high schools. In 2013, a survey of high school students revealed that 17 percent considered attempting suicide in the last year, with 8 percent actually attempting it. The suicide rate among American Indian/Alaska Native adolescents is even higher, at 1.5 times the national average. There are effective ways to respond. It is critical that school districts emphasize evidence-based mental health education, so that students, teachers, and school nurses are aware of the warning signs and risk factors of mental illness and how to address them. The Model School District Policy on Suicide Prevention, released by four leading mental health organizations, includes concrete recommendations that school districts can follow. Hillary will direct the Department of Education to emphasize mental health literacy in middle and high schools and will work with regional and national PTA, school counselor associations, and associations of secondary school principals to encourage school districts to adopt this model policy.

• Provide federal support for suicide prevention on college campuses. Hillary believes that every college campus should have a comprehensive strategy to prevent suicide, including counseling, training for personnel, and policies that enable students to take leave for mental health. Such multi-layered approaches have a proven track record of decreasing suicides. For instance, the Air Force launched an initiative in 1996 that brought together multiple intervention programs and reduced the suicide rate among Air Force personnel by nearly a third in under a decade. Groups such as the Jed Foundation, American Foundation for Suicide Prevention, the Suicide Prevention Resource Center, and Active Minds have created frameworks around suicide prevention tailored for colleges and universities. Hillary will dramatically increase funding for campus suicide prevention, investing up to $50 million per year to provide a pathway for the country’s nearly 5,000 colleges – whether private or public, two-year or four-year – to implement these frameworks on behalf of students.

• Partner with colleges and researchers to ensure that students of color and LGBT students are receiving adequate mental health coverage. Evidence suggests that the psychological needs of students of color are disproportionately unmet, impeding their ability to adapt to college life. LGBT students face added burdens as well, with gay youth being four times more likely than their straight peers to attempt suicide. Hillary will direct the Departments of Education and Health and Human Services to work with universities, researchers and community programs to determine how best to meet and respond to the challenges these students face and to provide specialized counseling.

Integrate our Healthcare Systems and Expand Community-Based Treatment

Demand for mental health services far outpaces supply, and our health care system lacks the treatment infrastructure and behavioral health workforce necessary to provide adequate care. Of adults experiencing any mental illness today, nearly 60% are untreated. Of those with a serious condition, 40% are untreated.[16] We need to close the treatment gap, and ensure that there is no wrong door to access care. Hillary’s plan will:

• Foster integration between the medical and behavioral health care systems (including mental health and addiction services), so that high-quality treatment for behavioral health is widely available in general health care settings. The responsibility for mental health care and substance use disorders is increasingly falling on general care providers. One study finds that today, over a third of patients with mental disorders who use the health care system are treated by primary care providers.[17] While some primary care providers offer excellent care, many do not receive dedicated training in treating mental illnesses. In addition, the medical and behavioral health care systems are highly segmented—to the point that when a patient has both conditions, providers have trouble collaborating and jointly managing the patient’s treatment plan. Hillary believes we should break down the barriers between medical and behavioral health care, and move the system so that it focuses on the whole person. System integration could yield $26-$48 billion in savings annually to the health care system, with $7-$10 billion coming from Medicaid alone.[18] That is why Hillary will:

• Expand reimbursement systems for collaborative care models in Medicare and Medicaid. Collaborative care is a model of integrated care that treats mental health and substance use conditions in primary care settings. A team of health care professionals work together to coordinate the patient’s services, including a primary care doctor, a care manager, and a behavioral health specialist. These integrative approaches not only produce better medical outcomes and patient satisfaction, they also result in significant savings to the health care system. Hillary will expand reimbursement structures in Medicare and Medicaid for collaborative care by tasking the Center for Medicare and Medicaid Innovation to create and implement new such payment models. She will also issue recommendations on best practices for private plans.

• Promote the use of health information technology to foster coordination of care. Hillary will adjust payment systems in Medicare, Medicaid, and under the Public Health Service Act, to allow for reimbursement of tele-psychiatry and other telehealth services delivered through primary care and hospital settings.

• Promote the use of peer support specialists. Peer support specialists have been shown to provide needed, cost-effective services for individuals with mental health conditions and addiction. Hillary will support initiatives to include peers in clinical care teams in primary care settings, mental health specialty care settings, hospitals, and Accountable Care Organizations. She will encourage all 50 states to reimburse peer services in state Medicaid programs, which 30 states do currently, and continue providing the Consumer and Consumer Supporter Technical Assistance Center grants.

• Encourage states to allow same-day billing. Many state Medicaid programs prohibit payments for mental health services and primary care services furnished to the same individual on the same day. This results in unnecessary obstacles to care and segmentation of health care practices. Hillary will issue best practices guidance to states, encouraging them to lift this restriction.

• Support the creation of high-quality, comprehensive community health centers in every state. A 2014 law established a demonstration program in eight states, under which new benefits would be available to health centers certified by the federal government as Certified Community Behavioral Health Clinics (CCBHCs). To be a CCBHC, a clinic must provide a range of physical and mental health services, including emergency psychiatric care, treatment for mental health and substance use disorders, and peer support. In return, the clinic can receive reimbursement at rates similar to those received by federally-qualified health centers. Hillary will invest $5 billion over the next ten years to scale up this demonstration project and help bring it to every state in America. This will vastly expand community-based treatment, by enabling thousands of health centers across the country (i.e., FQHCs, CMHCs, etc.) to upgrade to an integrated center.

• Launch a nationwide strategy to address the shortage of mental health providers. The United States is already experiencing shortages in its mental health workforce, and those shortages are projected to worsen in the coming years. For example, there are only 8,300 practicing child and adolescent psychiatrists today, which is one provider per 38,000 children.[19] Moreover, there is an increasing need for mental health professionals to be trained in cultural competency, so that they can deliver effective care to different populations. Hillary will launch a national strategy to bolster our mental health workforce, pulling together the Substance Abuse and Mental Health Services Administration, Health Resources and Services Administration, Center for Medicare and Medicaid Services, Indian Health Service, Department of Education, and public and private partners. This cross-governmental initiative will aim to: recruit more persons into the mental health fields; expand resources for mental health training, from loan forgiveness programs, to scholarships, to grants for training programs and additional GME funding; disseminate telehealth systems so that providers can reach underserved populations remotely; and expand culturally competent care.[20]

Improve Outcomes in the Criminal Justice System

Today, our criminal justice system is increasingly becoming the “front line” of engagement with individuals with mental health problems. Law enforcement officers routinely have to intervene or respond to unfolding situations that involve individuals with mental illness. As many as 1 in every 10 police encounters may be with individuals with some type of mental health problem.[21] And our county jails today house more individuals with mental illness than our state and local psychiatric hospitals.[22] Hillary believes that while greater investments in prevention and community-based treatment for behavioral healthcare will minimize these encounters with the criminal justice system, there are also specific steps we should take to improve outcomes for those individuals who do end up interfacing with law enforcement. She will:

• Dedicate new resources to help train law enforcement officers in responding to encounters involving persons with mental illness, and increase support for law enforcement partnerships with mental health professionals.Even though an increasing number of police encounters or use-of-force incidents involve people with mental health problems, law enforcement officers receive minimal training in how to handle such situations. According to one study, the average police officer receives only 8 hours of training for crisis intervention, which is far below the recommended amount.[23] Hillary will ensure adequate evidence-based training for law enforcement on crisis intervention and referral to treatment, so that officers can properly and safely respond to individuals with mental illness during their efforts to enforce the law.

• Prioritize treatment over punishment for low-level, non-violent offenders with mental illnesses. Over half of prison and jail inmates today have a mental health problem, and up to 65% of the correctional population meets the medical criteria for addiction. Many of these individuals are first-time or nonviolent offenders, whose prospects for recovery and reentry would be far enhanced were they to participate in diversionary programs rather than serve time in jail. Hillary will increase investments in local programs such as specialized courts, drug courts, and veterans’ treatment courts, which send people to treatment and rehab instead of the criminal justice system. She will also direct the Attorney General to issue guidance to federal prosecutors, instructing them to prioritize treatment over incarceration for low-level, non-violent offenders. Finally, she will work to strengthen mental health services for incarcerated individuals and ensure continuity of care so that they get the treatment they need.

Enforcing Mental Health Parity

The Mental Health Parity and Addiction Equity Act of 2008, which Hillary proudly co-sponsored, requires that mental health benefits under group health plans be equal to benefits for other medical conditions. The Affordable Care Act built on this important law by requiring that insurance plans offered in the individual and small group markets offer mental health coverage as an essential health benefit. But while the right laws are on the books, they are too often ignored or not enforced. Millions of Americans still get turned away when seeking treatment for mental illness, even when the interventions are well-established and evidence-based. A recent report published by the National Alliance on Mental Illness suggested that a patient seeking mental health services is twice as likely to be denied coverage by a private insurer as a patient seeking general medical care.[24] As part of her commitment to fully enforcing the mental health parity law, Hillary will:

• Launch randomized audits to detect parity violations, and increase federal enforcement.Hillary will ensure that the Departments of Labor and HHS have the authority they need to conduct randomized audits of insurers, to determine whether they are complying with the parity law. She will direct both agencies to bring appropriate enforcement actions against insurers, and to make their enforcement actions more transparent so that the general public is more aware when insurers violate the law.

• Enforce disclosure requirements so that insurers cannot conceal their practices for denying mental health care.The parity legislation provided the Departments of Labor and HHS the power to demand key information from insurers on the medical management decisions they use to deny care for behavioral health care. This information is essential for the government and patients to be able to identify and prove parity violations. Hillary will direct the DOL and HHS to fully enforce the disclosure requirements—requiring that plans specifically disclose how their non-quantitative treatment limitations comply with the parity law—and she will work to ensure that public insurers are subject to the same transparency.

• Strengthen federal monitoring of health insurer compliance with network adequacy requirements. The list of providers that health insurers give to beneficiaries should adequately reflect the providers who are in-network and provide care to patients with that insurance. Hillary will ensure that insurers provide up-to-date lists on mental health provider networks, so patients know where to get care.

• Create a simple process for patients, families, and providers to report parity violations and improve federal-state coordination on parity enforcement. Hillary will direct the Departments of Labor and HHS to issue clear, easy-to-follow guidance on where to report parity complaints, and to publish data on complaints the agencies received and how they responded. She will also ensure that patients and families are aware of consumer hotlines that they can call to understand their rights under the parity law, and navigate the complaint and appeals processes. Finally, she will direct officials to work with the National Association of Insurance Commissioners as well as state leaders, patient advocates, and other key stakeholders to set milestones and hold one another accountable to improve parity enforcement across-the-board.

Housing and Job Opportunities

Hillary supports a full range of housing and employment support for individuals with mental health problems, to help them lead independent and productive lives. As president, Hillary will:

• Expand community-based housing opportunities for individuals with mental illness and other disabilities. Hillary will launch a joint initiative among the Departments of Housing and Urban Development (HUD), Health and Human Services, and Agriculture to create supportive housing opportunities for thousands of people with mental illnesses and disabilities, who currently reside in or are at risk of entering institutional settings. As the Supreme Court held in the Olmstead decision, individuals with mental or physical disabilities should not be segregated in institutional settings when community-based services can be accommodated. Hillary’s new program will provide dedicated Housing Choice Vouchers and other critical assistance to individuals with mental illnesses or disabilities, enabling such persons to live independently while paying no more than 30% of their adjusted monthly income in housing costs. Public housing authorities will administer the new housing subsidies, while HUD will work with HHS and USDA as well as state mental health agencies to identify qualifying  individuals. Hillary will dedicate an average of $100 million to this initiative per year over the next ten years. This funding builds on her stated commitment to expand support for community-based housing through the HUD Section 811 program, authorized by the Supportive Housing Investment Act of 2010.

• Expand employment opportunities for people with mental illness. Research has shown that supported employment helps people with mental illness avoid hospitalization, while also giving them the opportunity to earn money and contribute to society. The employment rate for people with serious mental illness is below 20 percent, even though many of these adults want to work and more than half could succeed with appropriate job supports.[25] Hillary will work with private employers and state and local mental health authorities to share best practices around hiring and retaining individuals with mental health problems, and in adopting supported employment programs. That includes expanding HHS’s “Transforming Lives Through Supported Employment” program, which already assists states and communities in providing supported jobs to people with mental illness. Another area of focus will be encouraging employment for individuals with mental illness within the mental health sector itself, including as peer support specialists and recovery coaches.

• Expand protection and advocacy support for people with mental health conditions. Hillary will support and expand funding for the Protection and Advocacy for Individuals with Mental Illness (PAIMI) Program to ensure advocacy services for individuals with mental health conditions. These services make a critical difference for those who need reasonable accommodations for housing, employment, and other support and services.

Brain and Behavioral Science Research

We are still in the early stages of unraveling the mysteries of human brain development and behavior. Hillary believes we need a pioneering, multi-sector effort to transform our knowledge of this field—from mapping the human brain to generating new insights into what drives our behavior to investing in clinical and services research to understand the interventions that work best and how to deliver them to patients. Combining neurobiological research with behavioral, clinical, and services research will help us develop new therapies to help patients today while laying the foundation for future breakthroughs. Through it all, Hillary believes we must ensure that the resulting data and insights are widely available to researchers. As president, Hillary will:

• Significantly increase research into brain and behavioral science research. As part of a broad new investment in medical research, Hillary will provide new funding for the National Institutes of Health; build on cross-collaborative basic research efforts like the BRAIN initiative; scale up critical investments in clinical, behavioral, and services research; and integrate research portfolios with pioneering work on conditions like PTSD and traumatic brain injury already underway at DoD, the VA, and HHS. Together, these efforts will transform the landscape of funding for brain and behavioral research, and improve clinicians’ ability to detect and treat mental illness at the earliest stages.

• Develop new links with the private and non-profit sectors. Hillary will work with her biomedical research team to forge new links with the private and nonprofit sectors. In addition to the NIH, pioneering work in these fields is taking place at foundation-funded centers, academic institutions, and private firms. As she scales up investments in brain and behavioral research, Hillary will ensure that federal government efforts are aligned with those of other sectors to ensure that progress occurs as quickly as possible.

• Commit to brain and behavioral science research based on open data. Hillary understands that we must not only improve funding of brain and behavioral research but ensure that findings are widely shared. Beyond promoting research partnerships across sectors, Hillary believes that the way we fund research must change to fully embrace open science and data. The open science principles put forth by One Mind offer a useful guide, and the success of the Human Connectome Project serves as an important model. Hillary will work with leaders in the research community to structure grants in a way that promotes timely access to results for all researchers while preserving patient privacy.

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Hillary is committed to delivering on the above agenda and to ensuring that mental health is treated like the national priority it already is. As a down-payment on her agenda, Hillary will convene a White House Conference on Mental Health within her first year in office, to highlight the issue, identify successful interventions, and discuss barriers that must be removed to improve today’s system.

Hillary has also laid out policies that offer additional support to individuals with mental health problems and their families, beyond today’s announcement. Earlier this year, she released a robust Caregivers Agenda, to support family members and workers who care for individuals with health conditions, including mental illness. She also set out a $10 billion Initiative to Combat America’s Deadly Epidemic of Drug and Alcohol Addiction, which provides incentives to every state to dramatically expand its prevention and treatment programs for substance use disorders. And she has released a detailed Veterans Agenda that outlines a robust plan for tackling the issues facing veterans, our service members, and their families, including expanding access to mental health care and treatment, ending the epidemic of veteran suicide, and reducing homelessness.

Hillary Clinton’s Record

The comprehensive mental health agenda Hillary released today builds on her record of fighting for better services for Americans with mental illnesses. In the U.S. Senate, she co-sponsored the Campus Care and Counseling Act, which established critical mental health support and early suicide prevention for college students across the country. She supported a $500 million increase in mental health care for veterans, co-sponsored the Joshua Omvig Veterans Suicide Prevention Act, and worked across the aisle to make sure their mental health needs would not be forgotten in policy recommendations to the Department of Veterans Affairs. And she strongly supported the enactment of mental health parity laws, which have helped ensure that millions of Americans with mental illness do not lose access to the services that they need because of financial restrictions or arbitrary treatment limits. This record reflects Hillary’s strong belief that mental illness must be treated no differently from other medical conditions and her commitment to the needs of Americans and their families coping with mental illness.

We have to address the mental health crisis in America and end the stigma and shame associated with treatment.

I believe that together we can make sure that the next generation gets quality mental health care—without shame, without stigma, without barriers. And that we can do so much more to help people right here and now.

Hillary, August 29, 2016

More than 40 million adults in America—nearly 1 in 5—and 17 million children are coping with a mental health problem. Too many individuals are being left to deal with these issues on their own, and many face complicating life circumstances like drug and alcohol addiction, homelessness, incarceration, or chronic health conditions.

These Americans and their families need our support. Hillary Clinton strongly believes we have to bring mental and behavioral health care on par with physical health care—and end the shame and stigma associated with treatment. To that end, she has announced a comprehensive mental health agenda that will:

• Promote early diagnosis and intervention. The majority of Americans living with lifelong mental health illnesses show signs of distress at an early age, and yet few are treated. As president, Hillary will increase public awareness and action to address maternal depression, infant mental health, and trauma and stress in the lives of young children. She will scale up funding for programs through which pediatricians and schools seek to identify and support children facing behavioral problems. And she will encourage colleges and universities to provide comprehensive mental health services.
• Launch a national initiative for suicide prevention. America is facing the highest suicide rate in 30 years—and it’s becoming increasingly prevalent among adolescents, college students, veterans, and older adults. As president, Hillary will create a national, cross-governmental suicide prevention initiative to be led by the surgeon general and involve all relevant agencies, from HHS to the VA to USDA. She’ll provide federal support for suicide prevention programs in high schools and on college campuses, and she’ll work to ensure schools are meeting the mental health needs of all students—particularly LGBT students and students of color.
• Integrate our nation’s mental and physical health care systems so that health care delivery focuses on the “whole person” and expand community-based treatment.Hillary will work to foster better integration of our health care systems so that high-quality behavioral care—for mental health problems and as well as addiction—is available in general health care settings. She’ll launch a national strategy to increase the number of mental health providers. And she will support the creation of top grade, comprehensive community health centers in every state where behavioral care is available.
• Prioritize treatment over jail for low-level, nonviolent offenders and help train law enforcement officers in responding to conflicts involving persons with mental illness. Hillary will increase investments in local programs, such as specialized courts, drug courts, and veterans’ treatment courts, which emphasize treatment and rehabilitation over incarceration. She will also direct the attorney general to issue guidance to federal prosecutors, instructing them to prioritize treatment over incarceration for low-level, nonviolent offenders. And she will ensure adequate training for law enforcement on crisis intervention so that officers can properly and safely respond to individuals with mental illness.
• Enforce mental health parity to the full extent of the law. The Mental Health Parity and Addiction Equity Act of 2008, which Hillary proudly co-sponsored, requires group health plans to provide the same level of benefits for mental health as other medical conditions. Despite the law, too many Americans seeking mental health treatment still get turned away. Hillary will strengthen federal monitoring to make sure insurers are complying with the mental health parity law—and she’ll make it easier for patients to file a complaint when their rights are violated.
• Improve access to housing and job opportunities. Hillary will launch a joint initiative among HUD, HHS, and USDA to expand community-based housing opportunities for individuals with mental illness and other disabilities. She’ll work with private employers and state and local mental health authorities to expand job opportunities for Americans with mental health issues. And she’ll increase support for the Protection and Advocacy for Individuals with Mental Illness (PAIMI) program.
• Invest in brain behavioral science research. As part of a broad new investment in scientific research, Hillary will provide new federal funding for research into brain development and human behavior, promote research partnerships across sectors, and ensure data is widely shared.

Read the fact sheet.

Hillary’s plan builds on a long record of fighting for better services for Americans with mental illnesses:

• In the U.S. Senate, she co-sponsored the Campus Care and Counseling Act, which established critical mental health support and early suicide prevention for college students across the country.
• She also supported a $500 million increase in mental health care for veterans, co-sponsored the Joshua Omvig Veterans Suicide Prevention Act, and worked across the aisle to make sure their mental health needs would be included in policy recommendations to the Department of Veterans Affairs.
• And she strongly supported the enactment of mental health parity laws, which have helped ensure that millions of Americans with mental illness do not lose access to the services that they need because of financial restrictions or arbitrary treatment limits.