On July 22, 2003, the White House released the final report of the President's New Freedom Commission on Mental Health. Just over a year earlier, President Bush had established the Commission, charging it with the formidable task of conducting "a comprehensive study of the United States mental health service delivery system…and advis[ing] the President on methods of improving the system." The final report cites pervasive fragmentation and disorganization in the current system and calls for a "fundamental transformation of the Nation's approach to mental health care."
This special section of Psychiatric Services presents an overview of the New Freedom Commission's report, along with the perspectives of key stakeholder groups representing consumers and their families, state mental health authorities, and clinicians, as well as comments from the chief executive officer of a managed behavioral health company. Individuals in these organizations are in a position to be affected by, as well as to effect, changes in the U.S. mental health care system.
The section begins with an overview of the report by Michael F. Hogan, Ph.D., chair of the Commission and director of the Ohio Department of Mental Health. Dr. Hogan provides a valuable summary of the Commission's recommendations and discusses the historical, political, and legal contexts in which they were developed. He points out that having Presidential attention focused on mental health care presents an important opportunity for advocates and consumers, and he describes some of the challenges that will likely be encountered in turning the recommendations into policy. Dr. Hogan notes that the changes called for in the report must occur not only from the "top down," through the efforts of federal agencies such as the Substance Abuse and Mental Health Services Administration, but also from the "bottom up," through work at the state and community levels by people who deliver and receive mental health care.
The remainder of the special section presents comments from several key groups on the report and its recommendations. The first contribution is from the Campaign for Mental Health Reform, a new partnership that was developed in response to the creation of the President's Commission. This group represents an alliance of leading mental health advocacy organizations who have joined together to work toward common policy goals, including those outlined in the Commission's report. The formation of this group not only furthers but also embodies a major theme of the New Freedom Commission's report—the need to reduce fragmentation and to focus systematically on addressing the needs of consumers.
After the campaign's statement are brief comments from the directors of the four founding organizations, who provide their individual perspectives on the Commission's report. Robert Glover, Ph.D., director of the National Association of State Mental Health Program Directors, highlights the critical role that state organizations can play as agents of reform and progress. Writing for the National Alliance for the Mentally Ill (NAMI), Executive Director Richard Birkel, Ph.D., describes NAMI's ongoing and planned activities to achieve the Commission's goals and to create a recovery-focused system for consumers and families. Michael Faenza, M.S.S.W., president and chief executive officer of the National Mental Health Association, calls for a "national conversation" that includes not only mental health advocates but also the general public. Robert Bernstein, Ph.D., director of the Bazelon Center for Mental Health Law, praises the Commission's emphasis on recovery, which is defined in the report as "the process in which people are able to live, work, learn, and participate fully in their communities."
Finally, provocative commentaries from leaders in clinical psychiatry and managed behavioral health care are presented. Marcia Kraft Goin, M.D., Ph.D., president of the American Psychiatric Association, supports the report's major conclusions but also expresses some concerns. Although she praises the Commission for "tell[ing] it like it is," she calls for greater attention to the shortage of acute care hospital beds and worries that developing the sorts of innovative programs described in the report requires both "initial funding and sustained support." Saul Feldman, Ph.D., chief executive officer of United Behavioral Health, criticizes the lack of recommendations for new funding, citing "formidable restrictions" placed on the Commission. Managed behavioral health care, he argues, can function effectively only in an environment that has sufficient housing for patients, an adequate psychiatric workforce, and consistent regulations across different states.
The conclusion of Dr. Hogan's overview asks the question that explicitly or implicitly underlies all of the commentaries: "Will the Commission's work make a difference?" Answering this question is not simply an exercise in predicting the future. It is a challenge to readers to ensure that the Commission's report does make a difference. Creating the transformation called for in the report will require coordinated, sustained effort by federal, state, and local governments; by national advocacy organizations; and, ultimately, from all of us who care about the mental health system and the people it serves.
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 high-quality care that is culturally competent
• Improve access to high-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 by 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 to and coordination of care
• Develop and implement integrated electronic health record and personal health information systems
Dr. Druss holds the Rosalynn Carter Chair in Mental Health in the Rollins School of Public Health at Emory University, 1518 Clifton Road, Atlanta, Georgia 30322 (e-mail, firstname.lastname@example.org). Dr. Goldman is professor of psychiatry at the University of Maryland School of Medicine in Baltimore. He served as a consultant to the Commission.