After a year of intensive study, a commission appointed by President Bush has concluded that the delivery of mental health care in America needs to be fundamentally transformed and that the transformation should rest on two principles—a focus on recovery rather than symptom management and an orientation to the needs of consumers and families rather than to the requirements of bureaucracies.
Achieving the Promise: Transforming Mental Health Care in America, which was submitted to the White House in May by the President's New Freedom Commission on Mental Health and released in late July, has been widely praised by clinicians, service providers, advocates, and consumers. Commission Chair Michael F. Hogan, Ph.D., called the report a roadmap for a new approach to mental health care. "The destination is recovery," he said. "We ask consumers, family members, service providers, other members of the mental health community and all Americans to join us on that journey."
The commission was established in April 2002 and charged with studying both the public and the private sectors of the mental health system and recommending methods to improve the care of adults with serious mental illness and children with serious emotional disturbances so that they can fully participate in community life. The commission based its 105-page report on research, expert testimony, and input from more than 2,300 consumers, family members, service providers, and others. The report calls the current system "a patchwork relic—the result of disjointed reforms and policies" that cannot be fixed by traditional reform measures.
To achieve a fundamental transformation, six broad goals must be met. Along with the goals the report presents a series of specific recommendations for achieving them (see box on this page). In addition, the report identifies model programs that have already transformed aspects of mental health care related to the six goals.
The President's New Freedom Commission: Goals and Recommendations for a Transformed Mental Health System
Goal 1: Americans understand that mental health is essential to overall health.
Implement a national campaign to reduce stigma and prevent suicide.
• Address mental health with the same urgency as physical health.
Goal 2: Mental health care is consumer and family driven.
• Develop an individualized plan of care for every adult with a serious mental illness and child with a serious emotional disturbance.
• Involve consumers and families fully in orienting the system toward recovery.
• Align federal programs to improve access and accountability.
• Create a comprehensive state mental health plan.
• Protect and enhance the rights of people with mental illnesses.
Goal 3: Disparities in mental health services are eliminated.
• Improve access to quality care that is culturally competent.
• Improve access to quality care in rural and geographically remote areas.
Goal 4: Early mental health screening, assessment, and referral are common practice.
• Promote the mental health of young children.
• Improve and expand school mental health programs.
• Screen for co-occurring mental and substance use disorders and link with integrated treatment.
• Screen for mental disorders in primary care, across the life span, and link with treatment and supports.
Goal 5: Excellent mental health care is delivered and research is accelerated.
• Accelerate research to promote recovery and resilience, and ultimately to cure and prevent mental illnesses.
• Advance evidence-based practices using dissemination and demonstration projects and create a public-private partnership to guide their implementation.
• Improve and expand the workforce providing evidence-based services and supports.
• Develop knowledge in four areas: mental health disparities, long-term effects of medications, trauma, and acute care.
Goal 6: Technology is used to access mental health care and information.
• Use technology to improve access and coordination of care.
• Develop and implement integrated electronic health record and personal health information systems.
Because the commission was directed to find "budget-neutral" solutions to existing problems, the report does not recommend spending any new money. All states are directed to develop a plan for collaboration among federal, state, and local agencies to address the full range of treatment and support programs that consumers and families need. According to the report, in exchange for the accountability reflected in their state plans, "states will have the flexibility to combine federal, state, and local resources in creative, innovative, and more efficient ways, overcoming the bureaucratic boundaries between health care, employment supports, housing, and the criminal justice systems."
Despite mental health advocates' enthusiastic welcome of the report and the unprecedented level of consensus about its conclusions and recommendations, many have objected to its budget-neutral stance, pointing out that a true transformation cannot be realized without additional federal funds. Marcia K. Goin, M.D., president of the American Psychiatric Association, noted that financing for mental health care is in a "perilous state" and that "the lack of adequate care for people with mental illness has gone beyond the problem of state funding and affects patients in the private sector."
For many in the mental health field, the New Freedom Commission has evoked memories of President Carter's Commission on Mental Health, whose 1978 report resulted in the Mental Health Systems Act of 1980. The act was effectively repealed in 1981 by the incoming Reagan administration, but not before its provisions resulted in a national plan to greatly increase federal support for persons with severe mental illness. In a March 2003 interview with APA's Psychiatric News, Gary Tischler, M.D., who was the Carter commission's study director, noted that the national plan's emphasis on federal-state partnerships, planning and accountability, and the integration of mental health and other health services led to important changes in the government's approach to mental health services during the 1980s. The national plan provided a rallying point for advocates and a roadmap for incremental change.
Two words used throughout the New Freedom Commission's report are "recovery" and "resilience." As defined in the report, recovery "refers to the process in which people are able to live, work, learn, and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life despite a disability. For others, recovery implies the reduction or complete remission of symptoms. Science has shown that having hope plays an integral role in an individual's recovery." About the concept of resilience, the report states: "Resilience means the personal and community qualities that enable us to rebound from adversity, trauma, tragedy, threats, or other stresses—and to go on with life with a sense of mastery, competence, and hope. We now understand from research that resilience is fostered by a positive childhood and includes positive individual traits, such as optimism, good problem-solving skills, and treatments. Closely-knit communities and neighborhoods are also resilient, providing supports for their members."
The report is available on the New Freedom Commission's Web site at www.mentalhealthcommission.gov. Free copies can be ordered by calling the National Mental Health Information Center at 800-789-2647.
Three reports examine financing of services: The Substance Abuse and Mental Health Services Administration (SAMHSA) has released three reports that examine public- and private-sector financing of mental health services. The Provision of Mental Health Services in Managed Care Organizations provides an update on the provision of services under managed care and examines services for privately insured individuals. Medical Necessity in Private Health Plans: Implications for Behavioral Health Care addresses how the term "medical necessity" is defined. The report reviews the literature and the legal cases that have challenged insurer decisions. Medicaid Financing of State and County Psychiatric Hospitals addresses the lack of information about the nature and scope of Medicaid support for individuals in psychiatric institutions. The study identifies potential sources of Medicaid funds paid on behalf of public psychiatric hospitals and provides an estimate of the amount of such funds in 2001. All three reports are available on the SAMHSA Web site at www.mental health.samhsa.gov. To order, call the National Mental Health Information Center at 800-789-2647.
Autism research and awareness initiatives: The National Institutes of Health (NIH) has awarded grants to support six new research centers to investigate the biomedical and behavioral aspects of autism. The grants are part of an initiative called STAART (Studies to Advance Autism Research and Treatment), which began by funding two centers last year. NIH expects to provide $65 million over five years to the eight centers. The 2003 grants were awarded to the University of Washington; the University of California, Los Angeles; Boston University; the University of Rochester; Kennedy Krieger Institute; and Mt. Sinai Medical School. In 2002 centers at the University of North Carolina, Chapel Hill, and Yale University received funds. This effort is paralleled by an initiative launched by the Centers for Disease Control and Prevention and the Autism Society of America that is aimed at raising awareness of the importance of early screening and intervention for autism. The campaign will educate parents, day care providers, teachers, and others about their role in monitoring developmental progress. More information is available at www.cdc.gov/ncbddd/dd/ddautism.htm.