America’s Mental Health Crisis: NAMI Medical Director Dr. Ken Duckworth on Expanding Screening and Telehealth Services to Meet Demand

Ken Duckworth

[Music]

Margaret Flinter : Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter , a show where we speak to the top thought leaders
in health innovation , health policy , care delivery and the great minds ,
who are shaping the health c are of the future. This week Mark and
Margaret speak with Dr. Ken Duckworth, Medical Director for NAMI,
t he Nation al Alliance for Mental Illness, t he nation ’ s largest grassroots
organization seeking to improve the lives of the millions of Americans
dealing with mental illness. He talks about the anxiety and depression
epidemic, especially among teens, the need to democratize
depression screening, diagnostic tools , and the need to expand the
use T elehealth to fill the clinician gap.

Lori Robertson also chec ks in , Managing Editor of FactCheck.org , look s
at misstatements spoken about health policy in the public domain ,
separating the fake from the facts . W e end with a bright idea , that ’ s
improving health and well - being in everyday lives. If you have
comments , e - mail us at [email protected] or find us on Facebook ,
Twitter , iTunes, or wherever you listen to p odcast s, and you can also
hear us by asking Alexa to play the program Conversations on Health
Care .

Now , stay tuned for our interview with Dr. Ken Duckworth of NAMI on
Conversations on Health Care .

Mark Masselli : We're speaking today with Dr. Ken Duckworth, M edical D irector for
N AMI, the Nati onal Alliance on Mental Illness, nation's largest
grassroots mental health org anization dedicated to improving lives for
the millions of Americans affected by mental illness. Dr. Duckworth
was the M edical Director and A cting Commissioner of M ental H ealth
in Massachusetts. He's an assistant professor at Harvard Medical
School and an adjunct clinical assistant professor at Boston University
School of Public Health. Dr. Duckworth, welcome to Conversations on
H ealth C are.

Dr. Ken Duckworth : Thank you for having me .

Mark Masselli: Ken , o bviously, I think all of our listeners know that we have a mental
health crisis in the country and anxiety, depression , suicide are on the
rise among our nation's youth. All of this is further complicated by the
devastated opiate crisis , and I wonder if you could talk with our
listeners about this growing h ealth crisis and what do you believe is
behind the rise in mental health issues in our nation, especially among
our nation's youth ?

Dr. Ken Duckworth: I f you look at the CDC ’s work on the rise in adolescent suic ide from
2007 to 2017, t hat corresponds prett y well with the development of
social media, which is a potential bullying effect. It also corresponds

Ken Duckworth

with the rise in school shootings and the resultant school shooting
drills that are now omnipresent. Also the black box warning on
antidepressants came o ut in 2003. Fewer antidepressants are being
written for teenagers. M odern life is complicated , a nd I think if you've
ever had a kid go through the college admissions crisis , y ou can see
kids feel the pressure in a way that , I went to my local state school at
the University of Michigan, I just showed up a t school. A completely
different mindset in every way . Y oung adults do report mo re anxiety
and more depression a nd it may also be because this generation is
more open to discussing these vulnerabilit ies. I t’ s the willingness to
talk about it, which is a great advantage that this generations bring
into the equation.

Margaret Flinter : W e often think, well, if people have health insurance, that's
something that gets them access to care , but it k ind of turns out that ;
one, there may not be a clinician available ; and t w o , we've seen a
trend towards behavioral health providers not taking insurance , and
t hen , we still haven't gotten to parity . S peak to that and how these
things make it challenging for patients to get the help t hey need ?

Dr. Ken Duckworth: Yeah, NAMI advocated very intensely to get m ental h ealth p arity and
it has shown an increase in accessibility and availability , and a ttit udes
have improved towards help seeking. There has been no
corresponding public health response to create more practitioners,
more psychiatrists. There are millions of people right now , who didn't
get the Medicaid expansion in their S tate. The people who have the
Medicaid expansion are doing better per person than the S tates that
don 't have the Medicaid expansion. Many psychiatrists are choosing
not to take insurance. My experience here in Massachusetts is that
masters level clinicians are very happy to take insurances, and so , we
have more people getting assessments and evaluations a nd being
seen by licensed mental health counselors. What I would encourage
people to do is , work with their health plan. The health plan has an
obligation to give you the help you've paid for. I think that's a secret
that people don't really know.

Mark Mas selli: Well, that's great. L et me just share another secret that the
C ommunity H ealth C enter M ovement is a place where there is a fully
integrated medical, dental and behavioral health team waiting for
you , whether you're coming in the door for dental o r c oming in for
medical, that PHQ - 9 is being done , understanding your mental health
status. We've got to educate people to make sure they understand it
just like they understand their blood pressure score. NAMI is
partnering with Google to attempt to do a muc h br oader access for
the population . I wonder if you could talk about this online screening
to really democratize mental health and depression screening ?

Dr. Ken Duckworth: Yeah, the PHQ - 9 is the P atient H ealth Q uestionnaire - 9 . It is universally

Ken Duckworth

accepted a s a great metric for the potential for depression. There are
nine areas each of those is rated zero to three. 27 is an extremely high
score. W alking around with five is probably , not something that needs
intervention, but you might want to look at how's yo ur self care,
how's your sleep, how's your exercise . A score of 15 is an indication
that you should see your primary care doctor or find a clinician to get
an assessment. T hese tools need to be democratized , because there
simply aren't enough practitioner s who will sit with you as you go
through your PH Q - 9 . I f you can find a good clinician, it's t he best case
scenario . W e have half t he counties in America have no p sychiatry at
all . T he idea that you could structure your own self understanding
around your d epression. B efore I go on my vacation, honey, my PHQ -
9 score i s 20. We have to stop at CVS, get my meds and set an
appointment for the day I come back to see my therapist. J ust people
do this to blood pressure every day. PHQ - 9 is a kind of outcome
metric i n the depressio n field . I think if people have this vulnerability,
it's useful for them to have self knowledge.

Margaret Flinter : Ken, I wonder if we could talk a little bit about stigma in mental
health . I think traditionally people had a lot of concerns about
p otential reprisals in the workplace or in school. Y ou were just
recently in an hour - long special segment on the CBS morning show ,
you were talking about stigma and how to address it. You said that
young people may be way less afraid of stigma, but w e're concerned
about everybody. H ow are you addressing stigma, which is a real
barrier to people getting the help that they need ?

Dr. Ken Duckworth: C ouple of programs that I think are pretty cool. One is , E nding T he
S ilence, which was invented by one N AMI chapter , a nd this is given
middle school students and high school students across America. T his
is people in recovery discussing their journey. It’s a big barrier breaker
to have somebody who looks like you or talks like you or thin k s like
you that you ca n ide ntify with. L iterature is pretty strong that when
you meet people who have a mental health vulnerability, your
attitudes tend to improve. T he program , E nding T he S ilence , is getting
people with real life experience in the junior and high schools . I n o ur
own voice as a program, any business, any community health center,
which are a jewel in our A merican h ealth s ystem, community mental
health and community health centers are really valuable resources.
Y ou could have a person or two with lived experience come and help
the staff think about their attitudes. I think these are good examples
that we have put together that's rooted in the science. I mean, 0.5
million people have seen these -- each of these programs . I gave a talk
in M idl and, New Jersey , and bec ause they've had a problem with
adolescent suicide, which is a common problem , t he local N AMI
chapter was asked to involve themselves in the school district and do
E nding T he S ilence workshops. T hat's a great example of responding
to a real time problem.

Ken Duckworth

M ark Masselli: We're speaking today with Dr. Ken Duckworth, Medical D irector for
N AMI, the National Alliance for Mental I llness, the nation's largest
grassroots mental health organization, dedicated to improving the
lives of millions of Americans affected b y mental illness. Ken, I was
struck when you said that half the counties in the United States don't
have access to psychiatry . P erhaps that's one of the reasons that
we're seeing th is incredible proliferation of T elehealth interventions
in the space . I t se ems that the evidence supports the T elehea lth visit
is effective as an in - person visit. Y et we're still such a long way f rom
the widespread adoption of T elehealth protocol . I’m wondering what
NAMI is considered in terms of its strategy on try ing to cultiva te more
of those T elehealth partnerships?

Dr. Ken Duckworth: T eleh ealth is the same quality as in - person treatment. The American
Psychiatric Association has really reviewed this entire literature. The
question is , how do you incent practitioners and indivi duals to receive
care through this vehicle ? This doesn't create more mental health
practitioners, but it might use them more efficient ly . You can see
people during snowstorms , I happen to live in Boston , there's
efficiency there. Another idea to deal with the supply - demand
mismatch is the idea of bringing peers into the equation, someone
who has well managed their fill in the blank bipolar disorder,
schizophrenia, opiate use disorder . T hey can offer something to the
treatment equation , it is a powerful piec e of the future, I think.
P ractitioners weren't trained on this for the most part. Well, we'd
have to think of ways to incent them with loan repayment or some
other ideas, and we have to make sure that people are getting trained
in this model. N AMI is conn ected to a major medical school in Iowa
that is working wi th primary care clinicians. T elehealth is one of the
many things that we're trying to do , so that when th ere are patients
present with mental health vulnerabilities, which is about a third to a
half of primary care work that they're aware of a free resource that
they can utilize.

Margaret Flinter : I want to get back to something Mark referenced and you second ed it
around the community health center model a nd there's a lot of
wonderful things in our o pinion about that , b ut it's also true in the VA,
it's true in Kaiser, that where you have fully integrated primary care
and behavioral health, you eliminate a whole set of barriers right off
the bat. W e have felt the need to take that to the next level of
recognizing that unless we train the next generation to this model and
in this model, we can't expect that the next generation is going to be
prepared to practice and le ad an integrated model of care a nd you're
teaching at some of the finest institutions i n the country. What are
you seeing about the uptake of training in an integrated model as a
fundamental strategy ? T hen , what the leaders in p sychiatry and
b ehavioral h ealth are thinking about this as a critical element of
training the next generation?

Ken Duckworth

Dr. Ken Duckworth: Yes, this is an important challenge. I was the M edical Director of the
Massachusetts M ental H ealth center for eight years, and the Brigham
and Women's Hospital was 250 yards away , b ut that was a big 250
yards.

Margaret Flinter: A bsolutely .

D r. Ken Duckworth: D ifferent record system, different culture. I think there's cultural and
historical challenges here. What you're doing is great, hosting people
for warm handoffs is probably your gold standard. I think the hope is
with global payment mode ls on the commercial side that people will
recognize that the people who consume a lot of resources require
integrated care. What I ha d been disappointed by is the new
collaborative care codes, which have a very strong evidence base that
you don't have to co - locate , because people will frequently say it's
expensive to co - locate social workers, psychologists, psychiatrists .
C ollaborative care codes has a very strong evidence base and the idea
with that, let's take the PHQ - 9 , which we already talked about, th e
idea as a practitioner in the field in a different office than a primary
care doctor is following the same patient with the same metric , with a
Case M anager connecting the two. You can imagine in some rural
areas, it's going to be difficult to get co - loc ation, s o the collaborative
care model, I think, like T elehealth , represents a future state , but we
haven't created the culture or the momentum to make that happen.
W hat you're doing by posting practitioners in primary care, I think
would be the optimal ou tcome.

Mark Masselli: Now, l et's just take a moment to talk about the policy landscape. Lots
of activity going on in Iowa in terms of the primaries about what
might be the best health care coverage model . A s we look in our
rearview mirror, we see good news , which was the Affordable Care
Act passed and 20 million Americans got coverage to be able to seek
mental health and substance abuse treatment i n a way that hadn't
happened before. W e're hearing a lot in terms of Medicare for all and
other elements of a m odified Affordable Care Act. We have the
Mental Health Parity Act, which passed in 2008. I'd be interested in
your thoughts about the larger policy conversations going on , b ut I
also want you to talk about anything at the state level that might be
happenin g best practices at businesses. Is there any exemplar out
there that people could look to?

Dr. Ken Duckworth: A couple things. N AMI is part of a challenge with other mental health
associations , where the so called junk health plan . T here's a plan to
underm ine the Affordable Care Act implementation by selling plans
that don't cover mental health and substance use disorder. These
plans also don't have to exclude pre existing conditions , and they can
be quite expensive for people who have these vulnerabiliti es . These
are not comprehensive. T hey are not m ental h ealth p arity friendly.

Ken Duckworth

T hat's a great e xample of a real time struggle t hat's happ ening right
now. We agree that m ental h ealth p arity was good , hasn't been fully
implemented, is not been realized , b ut it r epresents a floor. These
new health plans that are being proposed by the administration
undermine that basic floor. Medicaid expansion is a crucial thing. 27%
of people with serious mental illness have Medicaid and there are
several million people who aren 't getting access to care , because of
the expansion of Medicaid challenges in many states. I do want to
mention, are you familiar with the 988 c risis l ine legislation?

Mark Masselli: No .

Margaret Flinter : I'm not.

Dr. Ken Duckworth: Okay . T his is the idea that you call 911 if your house is on fire, but you
have to call a long number for the national suicide crisis hotline. N AMI
is supporting legislation that you should be able to pick up any phone
and call 988 and be connected directly to the national suici de hotline.
We're facing a crisis here in our country and e very barrie r you can
remove, whether it's T elehealth legislation or a simple ph one call. The
national suicide h otline is a long number right now. There is
legislation in the Senate, y our S enator in Connecticut has proposed
the standard par ity enforcement legislation, which would really
subject more institutions to a more rigorous examination. Medicare
for all -- the details in that haven't been clear to me , how that would
impact access to care. I do know that other countries seem to be able
to ensure people across the board in western countries without much
problems , in terms of having the population insured. That's our first
threshold problem is people without insur ance then have to rely on
free c ar e and seeing if they can qualify for Medicaid. O f course,
m ental health is part of health . I f you don't have the mental health
benefit, you can even begin to hope to get the care. I think there's
millions of people who could get Medicaid if Medicaid were t o
expand.

I am impressed that the opiate crisis is actively part of the presidential
conversation. I was at a talk by our G overnor , here in Massachusetts ,
Governor Charlie Baker who said that when he traveled across
Massachusetts, he couldn't get away fro m the opiate crisis. I think
that Massachusetts has seen the leveling and overdose deaths.
T here's probably many, many reasons for that, so we may be
prescribing fewer opiates, making Narcan more available. Medicaid
just added T elehealth. There is some hop e that the presidential
campaign will continue to shine a light on that national emergency,
which of course , is at the same time , a mental health crisis.

Margaret Flinter : That’s right.

Dr. Ken Duckworth: Right? I think that's a long answer there.

Ken Duckworth

Mark Mas selli: That's great. Perfect.

Dr. Ken Duckworth: L et's talk about employers. I want to shout out a couple groups that
I'm aware of in Massachusetts that are impressive. Some of the
construction industries have really taken the opiate crisis to heart.
Const ruction workers and people in the fishing industry are the two
highest risk groups . I n the commercial fishing industry , t hey now have
Narcan on every boat. I feel like that is a progressive, thoughtful,
g ame c hanging way to approach opiate overdoses. Now, obviously,
prevention is a big challenge. Physician prescribing of opiates is down
substantially. I think with the emergence of fentanyl , which is a
leading compound found in overdose deaths, that's more of a criminal
justice problem , is figuring out how t o keep fentanyl out of the supply
chain. I think the presidential conversation is going to be very
interesting, because mental health is a core American crisis now.
S uicide rates are up for virtually every demographic imaginable. The
American life span is actually shortening , because of the opiate crisis
and because of suicide. This is not happening in other first world
countries.

Margaret Flinter : We've been speaking today wi th Dr. Ken Duckworth. He's the Medical
Director of NAMI , the National Association of M ental I llness, the
largest grassroots organization, seeking to improve the lives of those
who are dealing with mental illness. You can learn more about his
important work by going to nami.org or follow them on Twitter
@ N AMIC ommunicate. Ken, we want to thank you for your vital work
in this important area of health for highlighting so many issues for our
listeners, and for joining us today on C onversations on H ealth C are .

Dr. Ken Duckworth: It's a pleasure. Thank you for taking this topic up.

[Music]

Mark Masselli: At Conversations on Health Care , we want our audience to be truly in
the know when it comes to the facts about health care reform and
policy. Lori Robertson is an award winning journalist and M anaging
E ditor of FactCheck.org, a nonpartisan, nonp rofit consumer advocate
for voters that aim to reduce the level of deception in U.S. politics.
Lori, what have you got for us this week ?

Lori Robertson: T he Census Bureau in September released its report on health
insurance coverage in the United States in 2018. Finding that the rate
and number of the uninsured increased from 2017 to 2018, t he first
time it has found a yearly increase since the Affordable Care Act was
enacted in 2010. In 2018 , 8.5% of people were uninsured for the
entire ye ar. That's up fro m 7.9% in 2017 and it's an increase of about
1.9 million people. 67.3% of people have pri vate coverage with most
getting that co verage through their employment. T hose with
Medicaid coverage dropped 0.7 percent age points from 2017 to 2018

Ken Duckworth

to 17.9% of the po pulation. Medicare coverage went up by 0.4
percentage points , covering 17.8% of the population . T he percentage
of children without insurance went up by 0.6 percentage points. The
Census Bureau uses data from the c urrent population s urvey and the
American c ommunity s urvey making this measurement dependent on
a large amount of responses a nd that's my fa c t check for this week.
I'm Lori Robertson, M anaging E ditor of F a ctC heck.org .

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country ’ s
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you ’ d
like checked, e - mail us at chcradio.com , we ’ ll have FactCheck.org ’ s
Lori Robertson check it out for you here on Conversations on Health
Care.

[Music]

Margaret Flinter: Each week C onversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. If music
soothes the savage beast , the question they want to answer at the
s ync project is , how exactly ? T here are lots of anecdotal studies
supporting music ’ s ability to trigger memory or boost endurance or
focus. V irtually nothing is known about how music truly impacts our
physiological and neurological state. This is the question that
intrigued scientist Ketki Karanam, a Systems Biology PhD from
Harvard , who wondered , how could music be scientifically harnessed
as a powerful precision medicine tool? They formed the S ync P roject
with a c ross - section of neuroscientist s , biologists , audio engineers,
and even some rock stars like Peter Gabriel , and started by using
artificial intelligence systems to analyze existing play lists that
purports or promote relaxation induced sleep, enhanced focus , or
athletic performance.

Female: O nce we have this set of songs that our machine learning algorithms
predict to be effective for a specific activity , w e can then draw on
stud ying using these devices like your heart rate monitors , your smart
watches , the activity trackers and actually look at how effective
indeed is that song for that purpose .

Margaret Flinter : Karanam and her colleagues note that most of us self - medicate with
music already. W hy not harness this ubiquitous tool that's available to
all of u s and develop strategies and systems that might replace
pharmacological interventions with musical ones?

Female: We are literally walking around with 14 million songs in our pocket
every single day. We saw a great opportunity and really being able to
under stand how music was affecting us to measure how different
types of music to affect both our psychological health as well as a
physiology .

Ken Duckworth

Margaret Flinter: Karanam and her team see vast potential for reducing reliance on
drugs by crafting personalized musi c interventions in the
management of a variety of complex conditions such as pain
management, PTSD, even Parkinson's disease .

Female: In Parkinson's disease, patients have trouble coordinating
movements , so by playing them the right kind of music, it can b e an
external auditory support t hey have that's going to help them walk
more smoothly .

Margaret Flinter: The S ync P roject, combining computer technology and neuroscience ,
physiology and musicology to harness the he aling powers inherent in
music, n ow that i s a bright idea.

[Music]

Mark Masselli: You ’ ve been listening to Conversations on Health Care. I ’ m Mark
Masselli.

Margaret Flinter: I ’ m Margaret Flinter.

Mark Masselli: Peace and health.

Margaret Flinter: Conversations on Health Care is recorded at WESU at Wesleyan
University, streaming live at chcradio.com , iTunes, or wherever you
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