What should the mental health system look like in the 21st century? What are the values that guide advocacy for a genuine, responsive mental health system? A task force called together by the American Psychiatric Association (APA) has used these questions to articulate a vision for the mental health system—a system judged to be "in shambles" by a similar group appointed by President Bush.
APA's blueprint for reform and rebuilding—A Vision for the Mental Health System—was unveiled in April in anticipation of the final report of the President's New Freedom Commission on Mental Health, which was scheduled for submission to President Bush in May and quick release thereafter. At press time neither the commission nor the White House had issued further statements about the status of the final report. The commission released an interim report last October (available at www.mentalhealthcommission.gov).
In releasing the APA statement, Steven S. Sharfstein, M.D., chair of the eight-member task force, said that "2003 is a watershed year for mental health because for the first time in more than 30 years, a presidential commission is focusing on the crisis, and the U.S. Congress is seriously considering a law to equalize insurance coverage for mental illness and other mental conditions." The task force hopes that the commission's report will include the 12 critical principles articulated in the statement, said Dr. Sharfstein (see box).
The 12 Principles of A Vision for the Mental Health System
1. Every American with psychiatric symptoms has the right to a comprehensive evaluation and an accurate diagnosis leading to an individualized treatment plan.
2. Mental health care should be patient and family centered, community based, culturally sensitive, and easily accessible.
3. Mental health care should be readily available for patients of all ages, with particular attention to the special needs of children, adolescents, and the elderly. Unmet needs of ethnic and racial minorities require urgent attention.
4. Access to mental health care should be provided across numerous settings, including the workplace, schools, and correctional facilities, with an emphasis on early recognition and treatment.
5. Patients deserve to be treated with respect. When they are clinically able, they are entitled to choose their physician or community-based agency and to make decisions about their care.
6. Patients deserve to receive care in the least restrictive setting that encourages maximum independence with access to a full continuum of clinical services.
7. Mental health care should be fully integrated with the treatment of substance abuse disorders and with primary care and other general medical services.
8. Support must expand for research into etiology and prevention and into the ongoing development of safe and effective interventions.
9. Efforts must be intensified to overcome stigma through enhanced public understanding and awareness.
10. Health benefits, access to effective services, and utilization management must be the same for mental illnesses as for other medical illnesses, preferably funded by integrated financing systems. Although states provide the public safety net, the federal government and private-sector employers must also support an increased investment in the mental health of Americans.
11. Funding for care should be commensurate with the level of disability caused by a psychiatric illness.
12. More resources should be devoted to treatment and to training an adequate supply of psychiatrists, especially child psychiatrists, to meet current and future needs.
The vision statement calls for a "genuine" mental health system, which it describes as "more than the asylum movement of the 19th century or the community mental health centers in the mid-20th century or the more recent debacle of excessive utilization management that has forced patients prematurely out of hospital settings, split psychotherapy from psychopharmacology, separated primary care and specialty care, and focused on cost savings to the detriment of the physician-patient relationship."
The task force statement addresses nine areas. For example, in the area of payments and costs, the task force goes beyond calling for parity—a central theme of the statement—to point out that "it is an unrealistic expectation that any changes in the funding of the mental health system should be 'budget neutral.'" The budget for dealing with psychiatric illness should be interpreted broadly and must consider the cost offsets in the health care, welfare, and criminal justice systems that would be achieved by devoting more funds to diagnosis and treatment.
The vision statement describes mandatory outpatient treatment as "a useful tool and a preventive intervention" that should be part of any "humane and comprehensive" system and points out that 40 states and the District of Columbia have commitment statutes that permit this treatment approach.
A "rational mental health system" should incorporate the global burden of disease model jointly developed by the World Health Organization and the World Bank, according to the task force statement. The major strength of the model is its effort to quantify the level of disability across medical, surgical, and psychiatric illnesses by using disability-adjusted life years (DALYs), which provides an evidence-based approach to reformulating budgetary priorities. In the United States, mental disorders account for 20 percent of the burden of disease, whereas only 5 to 7 percent of all health expenditures are directed toward treatment of these disorders.
The eight-page vision statement can be downloaded from APA's Web site at www.psych.org.
Child welfare directors in 19 states and juvenile justice officials in 30 counties who responded to a survey by the U.S. General Accounting Office (GAO) estimated that in fiscal year 2001, parents inappropriately placed more than 12,700 children in the child welfare or juvenile justice systems so that the children could receive mental health services. The number of such placements nationwide is likely to be much higher, because many state child welfare directors did not provide data to the GAO—including the five states with the largest child populations—and coverage of county juvenile justice officials was limited. Neither system was designed to serve children who have not been abused or neglected or who have not committed a delinquent act.
According to state officials, reasons for parents' relinquishing custody of their children to obtain care include limitations of both public and private health insurance, inadequate supplies of mental health services, limited availability of services through mental health agencies and schools, and difficulties meeting eligibility rules for services.
Although no agency tracks these children or maintains data on their characteristics, the report found that most are male and adolescent and that many have multiple problems and exhibit behaviors that threaten their safety and that of others. The GAO investigators also found that despite guidance issued by the various federal agencies that have responsibilities for serving children with mental illness, misunderstandings among state and local officials about the roles of these agencies pose additional challenges to parents seeking mental health services for their children.
State laws addressing the ability of parents to place children in child welfare systems vary across states, the report notes. Eleven states allow parents voluntary placement in order to gain access to mental health services for as long as necessary without relinquishing custody. State laws prohibit such placements in eight states and the District of Columbia. Laws in the remaining states are generally silent in this area, according to the report.
Few strategies have been developed specifically to prevent inappropriate health-related placements. The report notes that state and local practices have focused on three main areas: finding new ways to reduce costs or fund services, consolidating services in a single location, and expanding community mental health services and supporting families. The effectiveness of many practices is unknown, because programs are typically implemented on a small scale in one location or with a small target group.
The 66-page report, Child Welfare and Juvenile Justice: Federal Agencies Could Play a Stronger Role in Helping States Reduce the Number of Children Placed Solely to Obtain Mental Health Services (GAO-03-397) is available on the GAO Web site at www.gao.gov.
The National Institute of Mental Health (NIMH) has launched the first national campaign to raise awareness of depression among men. "Real Men. Real Depression" features the personal stories of men who live with depression: a New York City firefighter, a national diving champion, a retired Air Force sergeant, a lawyer, a publisher, and a college student. In a series of public service announcements (PSAs), these real men—not actors—tell their stories about depression and how it affects their lives. The primary message of the PSAs is that it takes courage to seek help for depression.
An estimated six million men suffer from depression each year. Men die by suicide at four times the rate of women, even though depression affects twice as many women as men. Research has shown that compared with women, men talk differently—or don't talk—about the symptoms of this serious medical condition and are less likely to seek treatment.
At a press briefing to launch the campaign, Thomas R. Insel, M.D., director of NIMH, explained that the campaign aims to give a "face" to depression, to show men what it looks like. Men may not recognize their irritability, sleep problems, loss of interest in work or hobbies, and withdrawal as signs of depression, with the result that they do not seek treatment.
More information about the campaign and about depression can be obtained by calling the campaign's toll-free number, 866-227-6464, or by visiting www.nimh.nih.gov.