Mental Health First Aid Act : A Policy Analysis

Mental health is a critical part of overall wellness. Only 17% of United States adults are in a state of optimal mental health. Depression is the most common type of mental illness. Likewise, Major Depressive Disorder (MDD) is common in childhood and adolescence and is associated with functional impairment and suicide. Among teenagers and young adults, suicide was the second leading cause of death in 2013. Adolescents in foster care have considerably more psychiatric symptoms than their other counterparts. Mental health problems are also associated with gun violence. The purpose of this policy analysis paper is to emphasize the importance of different proposed bills and implemented policies for improving mental health outcomes. Several efforts have been made in the past to improve mental health care in the United States. The Affordable Care Act (ACA) provided opportunities for expanded access to behavioral health care and established mental health and substance abuse care as essential coverage. The Mental Health First Aid Act (MHFAA) was a bill introduced in Congress in order to improve awareness, identification, and ability to appropriately respond to the needs of persons experiencing symptoms of mental disorders. The goal of this act is to provide mental health first aid training to first responders. Mental health stigma is a significant barrier to participation in mental health care. Mental health first aid training can play a significant role in building community awareness and reducing stigma. Primary care providers can also play significant roles in early identification and establishment of care coordination of mental illnesses. The positive parenting programs that motivate parents to come and discuss their family issues without any fear or shame are advantageous in improving positive outcomes. Also, policies in reducing the scarcity of the mental health providers in all states and counties should be considered. Citation: Bhatta S (2018) Mental Health First Aid Act: A Policy Analysis. J Psychiatry Depress Anxiety 4: 013.


Introduction
"Mental health is a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to contribute to his or her community" [1]. Mental illness is defined as "collectively all diagnosable mental disorders" or "health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning". (U.S. Department of Health and Human Services, cited in CDC, 2013). However, it is estimated that about 17% of U.S. adults are in a state of optimal mental health [2]. Depression is the most common type of mental illness. About 6.7% of U.S. adults experienced a Major Depressive Disorder (MDD) in the past 12 months [2]. Women are more affected by MDD than men in their lifetime [2]. Other common mental health disorders are anxiety disorders, bipolar disorder, schizophrenia, frequent mental distress, and Alzheimer's disease [2].
According to the CDC, the percentage of adults with serious psychological distress in the past 30 days was 3.6%. The number of outpatient visits including physician's offices, hospital outpatient, and emergency departments with mental disorders as primary diagnosis in 2009-2010 was 63.3 million. According to 2014 data, the number of deaths due to suicide was 42,773 and suicide deaths per 100,000 population was 13. According to Cohen & Zammitti [3], from the national health interview survey early release program 2012-September 2015, in the first 9 months of 2015, 24% of adults with serious psychological distress and 6.1% of those without serious psychological distress had not received needed medical care due to cost.

Mental illness in children and adolescents
Despite the recent consideration to children's mental health issues and improved ability to diagnose and treat mental health problems, the rate of treatment in childhood psychiatry has been a continued challenge. The low rate of childhood diagnosis of mental disorders is due to lack of knowledge, stigma associated with mental illness, concerns about increasing use of psychotropic medications, and the cost [4]. Mental health stigma is a significant barrier to care seeking. Many people do not know that help is available, and they often need encouragement to seek help. A mental health first aid trained person can direct to patients to appropriate care by educating and providing empathy to those who are not seeking care due to self-internalizing stigma. Lack of appropriate diagnosis of mental health disorders in children and adolescents leads increased risk for suicide.
Suicide was the second leading cause of death in 2013 among teenagers and young adults [5]. In 2012-2013, young adult males aged 18-24 years were more likely to commit suicide than young adult females. MDD is common in childhood and adolescence and is associated with functional impairment and suicide. Approximately 8% of adolescents were depressed within the past year [6]. According to Hudson & Nandy [7], in the U.S, nearly 26,000 youth age out from Several efforts have been made in the past to improve mental health care in the United States. The Affordable Care Act (ACA) provided opportunities for expanded access to behavioral health care and established mental health and substance abuse care as essential coverage. The Mental Health First Aid Act (MHFAA) was a bill introduced in Congress in order to improve awareness, identification, and ability to appropriately respond to the needs of persons experiencing symptoms of mental disorders. The goal of this act is to provide mental health first aid training to first responders. Mental health stigma is a significant barrier to participation in mental health care. Mental health first aid training can play a significant role in building community awareness and reducing stigma. Primary care providers can also play significant roles in early identification and establishment of care coordination of mental illnesses. The positive parenting programs that motivate parents to come and discuss their family issues without any fear or shame are advantageous in improving positive outcomes. Also, policies in reducing the scarcity of the mental health providers in all states and counties should be considered. the child welfare system annually. These youth are at risk for substance abuse, poverty and severe mental illness.
Adolescents in foster care have considerably more psychiatric symptoms than adolescents without foster care including suicidal ideation, alcohol abuse, and substance abuse [8]. Data has identified that there is a higher proportion of drug abuse in youth with history of foster care than those without foster care history. Once former foster care youth become homeless, they might not have access to comprehensive mental health services; as a result, they self-medicate with methamphetamine [7].
According to Jonas, Gu & Albertorio-Diaz [9], the data from national health and nutrition examination survey, approximately 6.0% of adolescents aged 12-19 years reported psychotropic drug use in the past month. The use of antidepressants (3.2%) and attention deficit hyperactive disorder drugs (3.2%) was highest. Children and adolescents with mental health disorders are often encountered in primary care for healthcare services [6]. Primary care providers can facilitate early identification of mental health disorders, initiate early treatment, and refer patients to appropriate services as necessary.

Mental illness related gun violence
The study by Ilgen, Zivin, McCammon, & Valenstein [10] examined the association between mental disorders, prior suicidality, and access to gun safety in the U.S. The result of the study showed that individuals with lifetime mental disorders were more likely than those without mental disorders to have access to a gun. In 2004, more than 29,500 deaths involved due to gun violence; 57% of those were attributed to suicide. One of the case control studies has shown that individuals who commit suicide are more likely to have access to guns [11]. Older adults with suicidal ideation and depression were equally more likely to own a gun at home compared to those without psychiatric problems [12].
Gun violence is common in the United States. Most gun violence is committed by youth and young adults. According to whitehouse. gov (n.d.) [13], on January 8, 2011, six people were killed, and 13 people were injured in a Tucson grocery store parking lot, in Arizona. On July 20, 2012, an armed man killed 12 people in a movie theater in Aurora, Colorado and wounded 58 people. Similarly, on December 14, 2012, a man killed 20 first graders along with 6 other staff members at Sandy Hook Elementary School. Likewise, 49 people were killed in Orlando gay bar shooting incident. Similarly, 59 people died in the sad incident that recently happened in Las Vegas [14]. The tragic incidents indicate that the efforts need to be made to control gun violence related consequences (Table 1).

Previous Efforts to Improve Mental Health Care
Former president obama's plan against gun violence On January 16, 2013, former president Obama put forward a specific plan to protect American children and communities by reducing gun violence. President Obama's plan was focused on keeping guns out of dangerous hands by strict background checks, banning military style assault weapons, making schools safer by promoting nurturing environments, and increasing access to mental health services. The President's plan was to put up to 1,000 more school resource officers and counselors in schools to assist in improving safety. The president's plan also included providing mental health first aid training to teachers and other adults who interact with youth to detect and respond to mental illnesses in a timely manner. Furthermore, the plan proposed $50 million to train 5,000 more social workers, psychologists, counselors, and other mental health providers serving young people in our community [13].

Proposed bills related to mental health care
Mental Health Reform Act: S. 2680: It is a mental health reform act of 2016 sponsored by Senator Lamar Alexander (R-TN). The bill was introduced on March 15, 2016 and it is the leading mental health reform bill in the Senate. The S. 2680 builds upon agreement provisions included in S. 1945, the Mental Health Reform Act of 2015, introduced by Senator Cassidy and Murphy, and S. 1893, the Mental Health Awareness and Improvement Act of 2015, which was sponsored by Senator Alexander and Murray [15]. The Mental Health Reform Act of 2016 plan to strengthen leadership and accountability for federal mental health programs. It also ensures that the programs facilitate the development and incorporation of the most up-to-date approaches to treat mental health conditions. It also supports states and communities to improve mental health care, promotes access to mental health care, and improves mental health parity protections [16].

Medicaid expansion under Affordable Care Act (ACA):
The patient protection and ACA of 2010 gives states the option of extending Medicaid coverage to uninsured adults younger than 65 years whose family income is below 138% of the federal poverty level defined by the US Department of Health and Human Services. Twenty Seven states are currently expanding Medicaid under ACA. Adults with untreated serious mental illness are often poor, uninsured, or enrolled in Medicaid [17]. The provision of ACA provides opportunities for expanded access to behavioral health care and establishes mental health and substance abuse care as essential coverage.

Mental Health Parity and Addiction Equity Act of 2008:
It provides access to mental health and substance abuse services without limitations than those of medical and surgical insured services. Prior to mental health parity legislation, there were major flaws on public health insurance coverage of mental health services. It was extremely difficult to get enrolled in the insurance due to its strict requirements. The division of Medicaid funding between the federal government and states also contributed to difficulties in getting access to mental health services coverage. The mental health coverage under Medicaid was not consistent and uniform across the country [18].

Introduction to proposed legislation mental health first aid act
A bipartisan group of senators introduced the Mental Health First Aid Act (MHFAA) of 2015 (S. 711/ H.R. 1877). The bill was introduced on April 16, 2015 [19]. This bill was passed in the House on September 26, 2016 and it has gone to senate for next consideration [20]. This act authorized $20 million in grants to organizations to fund mental health first aid training programs around the country. The mental health first aid training prepares trainees in recognizing the symptoms of common mental illnesses and substance use disorders, responding to a person in crisis, and initiating referrals to mental health and substance abuse resources in a timely manner [21]. The training session is 8 hours long and it uses role play and simulation to demonstrate how to assess a mental health crisis, select interventions, and provide initial help. Thus far, nearly 350,000 people have been trained in mental health first aid in America [21]. According to National Council for Behavioral Health, since 2014, congress has provided annual appropriation of $15 million in funding for mental health first aid trainings around the country. About $4 million is also allocated for Veteran's mental health first aid training.
According to the national counil.org (n.d.) [22], in 2008, the National Council, the Maryland Department of Health and Mental Hygiene, and the Missouri Department of Mental Health brought mental health first aid to the United States. The goal of the program was to make mental health first aid as common as Cardiopulmonary Resuscitation (CPR) in 10 years. In the 2013-2014 legislative session, 21 states passed legislation or introduced executed programs related to mental health first aid.
According to the national counil.org (n.d) [22], the target mental health first aid trainees are law enforcement officers, juvenile detention officers, teachers, school counselors, education administrators, social workers, child welfare personnel, and foster caregivers. One of the goals this training is to reduce gun violence by educating people and law enforcement personnel, especially those who interact with children and youth. According to Clay [23], initial evaluation of the mental health first aid training have shown that the program effectively reduces stigma, increases knowledge of mental illness, and boosts confidence in responding appropriately to emergency mental health crisis.
Originally, the mental health first aid training was developed in Australia in 2001, which is now adopted in the United States and other countries around the world. President Obama has included mental health first aid in his plan to reduce gun violence by training school teachers and other adults who interact with youth [23]. Initial evaluation has shown that the program successfully reduces stigma and improves knowledge about mental illness and also prepares trainees appropriately respond to crisis [23]. According to Jorm [24], four randomized controlled trials have been carried out comparing the course with wait-list controls. These trials have found that mental health first aid training has brought improvement in knowledge, confidence in providing help, helping behavior, and stigmatizing attitude.

Analysis of the bill
MHFAA is a bill introduced in the Congress with the aim of improving the awareness, identification, and ability to appropriately respond to the needs of persons experiencing symptoms of a mental disorders by providing the mental health first aid training. This type of training program is necessary in improving gun violence, suicide, homicide, and improving the overall mental health of the youth, adult, and elderly in the United States. There is a gap existing in research in the U.S. related to the effectiveness of the training. Nonetheless, the randomized control trials conducted outside the U.S. show that the training is effective in improving knowledge among the trainees. A meta-analysis from fifteen different papers demonstrates that the training increases participants' knowledge regarding mental health, decreases their negative attitudes, and increases supportive behavior towards people with mental illnesses [25]. This meta-analysis concludes that training is recommended for public action. There were no studies found related to the effectiveness of training in reducing gun violence, suicide rate, and improving the rate of identification and treatment of mental illnesses. The lack of evidence on its effectiveness may be due to mental health first aid training being fairly a new program. In fact, crisis related to mental illnesses are more common than heart attacks [26]. Therefore, like CPR, having this type of skills among general population may bring beneficial outcome.

Economic burden of mental illness
Mental illnesses carry major economic burden for the patient and the country. Depression is the most burdensome mental illness worldwide. In the United States it is the leading cause of disability in people aged 15-44 years, resulting in 400 million disability days per year [27]. According to Greenberg, Fournier, Sisitsky, Pike, & Kessler [27], the economic burden due to mental illnesses including MDD, bipolar disorder, and dysthymia was estimated at $83.1 billion in 2000 in the United States. This total composed of $51.5 billion in direct workplace costs due to absenteeism from work, $26.1 billion from direct medical costs, and $5. 4 billion in suicide-related mortality costs. Considering economic burden in a country and impact faced by patients, early identification and early intervention are extremely important. Likewise, the hideous tragedies like Newtown, Sandy Hook Elementary School, the Orlando shooting, Tucson, Arizona shooting, and Las Vegas shooting show the importance of prioritizing mental health services as a comprehensive effort to make our communities safer. The mental health first aid training will make a great contribution in early identification of mental disorders and de-escalation of crisis by providing training to first responders. Although mental illness is common, it is often not recognized. Individuals with mental illness do not seek timely care due to social stigma, cost, or not identifying it as a problem. Therefore, mental health first aid training better allows us to recognize symptoms of distress and know how to connect them with appropriate healthcare providers.

Limitations for access to mental care
Costisone of factors for lack of access to mental health services in the community prior to Medicaid expansion under affordable care act. Still, uninsured individuals do not have access to mental health services due to high cost and lack of adequate mental health providers. Gaps still exist in the infrastructure to provide mental health services. According to Cummings, Wen & Druss [28], only 63% of U.S. counties have mental health facilities that provide outpatient treatment for children and adolescents; and fewer than half of counties have special programs that provide services for youth with severe emotional disturbances. The gap in infrastructure is more pronounced in rural areas due to healthcare provider shortage. Thus, policy makers should work together to make sure there is an adequate workforce to serve in rural areas through programs like supplementary training grants and loan forgiveness programs. The mental health reform act of 2016 S. 2680 was introduced in the senate with the aim of improving access. This act is in legislative limbo, if passed and enacted, it may contribute to bring positive outcomes in mental health access and parity.

Role of primary care in improving mental health outcome
Primary care is the first point of contact for patients with mental illness. They often present with somatic symptoms such as insomnia, lack of performance in work and school, weight changes, etc. Primary care providers can be the first person to evaluate, start treatment and initiate the referral. However, primary care providers are not well trained and do not feel comfortable dealing with mental illnesses. According to Olfson, Kroenke, Wang & Blanco [29], there were significant increases between 1995-1998 and 2007-2010 in the percentage of visits to primary care providers that resulted in a mental disorder diagnosis and a prescription for a psychotropic medication. This data suggest that primary care providers are playing a major role in managing mental illnesses despite less training and education in mental illnesses management. The involvement of primary care providers in the management of mental illnesses is due to lack of access to psychiatrists and cost. This evidence suggests that there should be policies and procedures in place to educate or train primary care providers in managing mental illnesses. Additionally, integration of mental health services in primary care is crucial. The mental health first aid training for primary care providers can play a vital role in early identification and treatment of mental disorders; and it should be made mandatory for them.

Policy Recommendations
Mental health first aid training can play a significant role in building community awareness. It should not only be offered to school teachers, administrators, parents of youth, mental health counselors, law enforcement officers, foster parents, primary care staffs, etc.; but also, should be made part of mandatory training for them. The policy should be made in improving comprehensive mental health services in primary care by training or providing mandatory education and guidelines to primary care providers and mental health counselors in primary care; especially in underserved areas. Once more people are trained with mental health first aid training, it is expected that more mental illnesses will be identified; as a result, there will be more demand for mental health providers. If we do not meet the demand of mental health providers to manage common mental illnesses, we won't succeed in improving the mental health. Likewise, all schools and universities should have positive environments to access the mental health services.
Primary prevention of mental health problems should be included in any mental health related legislative plans. Several meta-analytic reviews have shown that prevention programs for children and adolescents produce significant benefits by reducing the rate of future behavioral problems [30]. Parenting can play a significant role in the prevention of certain mental illnesses such as depression, anxiety, drug abuse, etc. Creating a positive parenting program that motivates parents to come and discuss their family issues without any fear or shame may be valuable. There are programs that have been found beneficial in preventing specific mental illnesses in youth. These programs are: Child abuse prevention programs, programs designed to prevent negative consequences of divorce on parents and children, and drug abuse prevention programs [30].
Finally, mental health first aid training is still in the initial phase and more data is available to evaluate its effectiveness in long-term. The program should be improved by expanding the scope of training and using the high fidelity training methods. Primary prevention of mental disorders should be included in future legislative action. More comprehensive mental health programs should be offered in each county. All states and counties should have an adequate number of mental health providers.

Conclusion
Mental Health First Aid Act (MHFAA) was introduced by a bipartisan group of senators which was passed in the house in September 26, 2016. The aim of the program is to provide funding for mental health first aid training around the country and make mental health first aid as common as CPR. Former President Obama has incorporated this training in his plan to reduce gun violence by training key personnel who frequently interact with youth. Mental illness is a common problem worldwide, with major depressive disorder being common in children and adolescents. Foster care youth are more likely to have mental illness. Mental health stigma, cost, lack of knowledge in identifying mental illnesses, lack of mental health services related infrastructures still become the barriers of accessing mental health care in the United States. Previously, some efforts have been made to improve consequences related to unidentified mental illnesses. Those efforts are improving school safety, implementation of mental health first aid training, increasing the number of mental health providers serving young people in the community, etc. Mental Health Reform Act currently is in legislative limbo, which was introduced in the senate with the aim of improving mental health care, promote access and improve mental health parity protection. Since the introduction of this legislation, the majority of states have started first aid training but there is still a gap exists in the literature about the effectiveness of this program. Mental health first aid training seemed to be enormously essential in improving timely detection of mental illness, reduction in gun violence, suicide, and homicide related death. This type of training also may lighten the burden of cost because of early identification and starting of intervention. A strong policy is required to improve the infrastructure of mental health services in the United States. Integrating of mental health services in primary care, providing licensed professional counselors, training and educating primary care providers in managing common mental illnesses, and improving screening of depression may help to mitigate problems related to access and under identification of mental illnesses. Similarly, improving primary prevention of mental disorders outweigh the treatment or early identification. Some of the examples of primary prevention are: Creating positive parenting programs, child abuse and bullying prevention programs, programs designed to prevent negative consequences of divorce on parents and children, and drug abuse prevention programs.
In conclusion, although mental health first aid training assists in bringing positive outcome in mental illness related consequences, it alone cannot improve the current existing broad problems of American people. Further, above mentioned recommendations should be considered in order bring the positive outcome in mental health.

Limitations
One of the limitations of this article is that it did not try to investigate how President Obama's plan was implemented and what the outcomes were. There might have been other bills proposed to improve the mental healthcare which are not discussed in this paper. Due to limited focus, details about each bill are not discussed in this article; as a result, other important prospective might have been missed. This paper lacks the evidence of effectiveness of mental health first aid training in the United States. Therefore, future studies should focus on investigating its effectiveness.