Since 1986, the Protection and Advocacy for Individuals With Mental Illness (PAIMI) Act has provided federal funds for state protection and advocacy systems. A primary mission of these systems is to investigate reported incidents of abuse, neglect, and civil rights violations of persons with mental illness who live in institutions. Although the law requires states to submit annual reports that include the total numbers of complaints of each type reported to them, to our knowledge the variability of these complaints among states has not been examined.

To explore this issue, we used U.S. Census Bureau population data to generate population-based estimates of the number of complaints of each type per 100,000 residents in 1997 for the United States and for each state and the District of Columbia.

Our analyses indicated that nationwide, state protection and advocacy systems received an average of 9.03 complaints per 100,000 residents—3.04 reports of abuse, 3.05 of neglect, and 2.94 of civil rights violations.

Estimates of complaint rates across the 50 states and the District of Columbia varied widely. F1 presents the average population-based complaint rates for the states by quintiles. The first quintile comprises the states with the lowest rates and the fifth quintile the states with the highest rates. The data for each quintile reflect the average rates of complaints of each type for the states in that quintile.

The average complaint rates varied dramatically by quintile. The average rate in the lowest quintile was 3.22 complaints per 100,000 residents, and the rate in the highest quintile was 30.82 per 100,000. Similar variations were observed by type of complaint.

Possible reasons for these variations include differences among states in funding, staffing expertise, intensity or accuracy of outreach and reporting, and thresholds for what constitutes abuse, neglect, or a civil rights violation. Unfortunately, limitations in the available data do not permit further exploration of these factors.

Calculations using the number of persons with mental illness in institutions as the denominator might yield different complaint rates and thus different relative rankings among states, but estimates of this population are not reliable in all states.

A more thorough understanding of the variability among state protection and advocacy systems may help in improving quality of care for persons with mental illness.

Dr. Hennessy is senior health policy analyst and Dr. Hijjazi is social science research analyst in the office of the assistant secretary for planning and evaluation of the U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 442E, Washington, D.C. 20201 (e-mail, kevin.hennessy@hhs.gov). Dr. Green-Hennessy is assistant professor of psychology at Loyola College in Maryland in Baltimore. Harold A. Pincus, M.D., and Terri L. Tanielian, M.A., are editors of this column.