The National Alliance on Mental Illness (NAMI) has issued a report card on the public mental health system for adults, giving the nation a grade of D. The detailed state-by-state survey is the second that NAMI has conducted since the President's New Freedom Commission on Mental Health characterized the system as being "in shambles" in 2003. Although 14 states improved their grade since NAMI's 2006 report card, 12 fell backward. Oklahoma improved the most, rising from a D to a B, and South Carolina fell the farthest, from a B to a D. The grades for 23 states remained the same.

The survey of state mental health agencies was conducted in August 2008, before the full effects of the recession were felt, and the report's release comes at a time when state budget cuts are threatening programs and services. "Mental health care in America is in crisis," said NAMI executive director Michael J. Fitzpatrick in a statement accompanying the report. "Even states that have worked hard to build life-saving, recovery-oriented systems of care stand to see their progress wiped out."

The report card gives each state an overall grade, which is based on its grades in four categories: health promotion and measurement of key services (25% of grade), financing and core treatment and recovery services (45%), consumer and family empowerment (15%), and community integration and social inclusion of consumers (15%). No state earned an overall A. In fact, out of the 200 category grades—four for each of the 50 states—there was only one A: for Connecticut in the category of consumer and family empowerment. Six states had an overall grade of B (Connecticut, Maine, Maryland, Massachusetts, New York, and Oklahoma), and there were 18 Cs, 21 Ds, and six Fs (Arkansas, Kentucky, Mississippi, South Dakota [the only state that did not participate in the survey], West Virginia, and Wyoming).

An alarming finding of the survey is that, on average, state systems serve just over one-fourth (27.9%) of all adults with serious mental illnesses, ranging from less than 15% served in Vermont to more than 55% in New York. In addition, assertive community treatment, which the report calls a "linchpin of a comprehensive system of care," reaches very few consumers. Although some researchers have called for enough ACT to serve 50% of people with serious mental illnesses, the report notes that there is no consensus on how much ACT communities should have and that communities with greater resources would need less. However, even with a much more conservative goal of 15%, no state comes anywhere close. Only six states—Colorado, Connecticut, Hawaii, Michigan, Rhode Island, and Wisconsin—and the District of Columbia reported having enough ACT services in place to reach 15 out of every 1,000 people with serious mental illness. Thirteen states reported that only three of every 1,000 adults with serious mental illness receive ACT, and five states reported no ACT at all.

The bulk of the 180-page Grading the States 2009 consists of two-page report cards for each state that detail the findings in both narrative and graphic formats. Boxes in each narrative highlight innovations, urgent needs, and consumer and family comments. Chapter 3 takes a broader look and examines major findings in each of the four categories, highlighting innovative practices in states with top grades in each category. For example, five states—Arizona, California, Connecticut, Hawaii, and Massachusetts—have "exemplary cultural competence plans and activities." California requires all county programs to identify groups facing significant disparities, develop comprehensive cultural competence plans, and report annually on progress. However, a troubling finding is that of the ten states with the largest proportion of individuals from racial-ethnic minority groups (39% or more of the population), only three have made significant inroads in becoming more culturally competent and the other seven "urgently need to improve."

The 12-page survey instrument, with 49 detailed questions assessing performance in the four categories, is reproduced in an appendix. States' detailed responses to the survey were weighted to reflect the relative importance of each measure and supplemented with data from research findings, comments on state programs and services from more than 13,000 respondents to a NAMI Web survey, and information from lawsuits and federal investigations. The full report, along with an interactive map, a discussion board, and a list of ways to become involved in advocacy activities, is available on the NAMI Web site at www.nami.org/grades09.

Throughout the report are compelling black-and-white portraits from Fine Line, a portfolio of photographs by Michael Nye, who spent four years photographing and recording the stories of people living with mental illnesses. To view the photographs and hear excerpts of the stories, visit www.michaelnye.org.