A Survey of Mental Health Leaders One Year After the President's New Freedom Commission Report

In April 2002 President Bush announced the creation of the President's New Freedom Commission on Mental Health, the goal of which was to "recommend improvements to enable adults with serious mental illness and children with serious emotional disturbances to live, work, learn, and participate fully in their communities" (1). On July 22, 2003, the Bush administration released the commission's final report (2). The commission identified six major goals: building greater understanding among Americans that mental health is essential to overall health; placing consumers of mental health services at the center of their care; eliminating disparities in the delivery of mental health care services; making early screening, assessment, and referral to mental health services common practice; delivering excellent mental health care and accelerating research; and exploiting available information technology to improve access to and coordination of mental health care (3,4).

Although a number of initiatives were created in response to the commission's report (4,5), little information has been gathered about how the mental health community has responded. The Rosalynn Carter Symposium on Mental Health Policy brings together mental health leaders and organizations each year to discuss a mental health policy topic of national importance (6). The focus of the 2003 symposium was the President's New Freedom Commission and how the commission's recommendations can be implemented to transform the mental health system (1). Symposium participants (N=194) were affiliated with local, state, and national government agencies (41 participants, or 21 percent of all attendees), professional organizations (46 participants, or 24 percent), nonprofit organizations (11 participants, or 6 percent), family and consumer advocacy groups (27 participants, or 14 percent), service provision (22 participants, or 11 percent), research and educational institutions (28 participants, or 14 percent), the media (11 participants, or 6 percent), and others (eight participants, or 4 percent).

After the symposium, The Carter Center's mental health program conducted an online survey to gain insight into the symposium participants' perceptions of the impact on their organizations of the New Freedom Commission and its recommendations. The results provide a useful perspective on how a group of national opinion leaders has responded to the commission and its recommendations.

Methods

In June 2004 an invitation to participate in an anonymous online survey was sent to all 194 individuals who attended the symposium. The survey included three categories of questions. In the first set, respondents were asked to identify which of the six goals listed in the commission's report they personally considered to be the most important for transformation and which goal they considered to be the most relevant and feasible for their organization. In the second set of questions, respondents were asked whether the behavior of their organization had changed in response to the President's New Freedom Commission and whether they considered their organization to be currently aligned with the commission in general as well as with each of the six goals. In the third set, respondents were asked to identify in what respects the commission's report influenced their organization's behavior as well as which facilitators and barriers for successful implementation were encountered by their organization.

Results

A total of 68 symposium attendees responded to the survey. The respondents were affiliated with government agencies (19 respondents, or 28 percent of all respondents), professional organizations (12 respondents, or 18 percent), nonprofit organizations (four respondents, or 6 percent), family and consumer advocacy groups (ten respondents, or 15 percent), service provision (three respondents, or 4 percent), research and educational institutions (12 respondents, or 18 percent), the media (four respondents, or 6 percent), and other (four respondents, or 6 percent). With the exception of a relatively low response rate in the clinical provider category, the respondents were representative of the symposium attendees overall.

Among the six goals identified by the President's New Freedom Commission, a plurality of respondents (40 percent) endorsed "Americans understand that mental health is essential to overall health" as most important for transforming mental health care in the United States (Table 1). However, most respondents highlighted another goal, "Excellent mental health care is delivered and research is accelerated," as the most relevant to their individual organizations (32 percent). Respondents highlighted several goals as being feasible for their organization to accomplish (24 percent for "Americans understand that mental health is essential to overall health," "Mental health care is consumer and family driven," and "Excellent mental health care is delivered and research is accelerated" respectively).

A total of 41 percent of participants (28 respondents) believed that their organization's behavior had changed in response to the commission's report, and 46 percent (31 respondents) believed that their organization was currently aligned with its goals. Respondents saw the greatest progress in improving mental health delivery and research, the elimination of disparities, and the use of technology (Table 1). The report most commonly influenced organizations' behaviors through facilitating informal discussions among colleagues (50 respondents, or 74 percent), encouraging partnerships with external organizations (39 respondents, or 57 percent), and influencing internal planning (35 respondents, or 51 percent).

The factors most consistently identified as contributing to successful implementation of the recommendations of the New Freedom Commission were willingness to change within the organization (17 respondents, or 25 percent), partnerships with community agencies (13 respondents, or 19 percent), and availability of public funding (nine respondents, or 13 percent). The most common barriers cited were financial constraints (29 respondents, or 43 percent), other competing priorities within the organization (26 respondents, or 38 percent), and lack of local political support (19 respondents, or 28 percent).

Discussion

This results of this survey suggest that the President's New Freedom Commission has had a substantial impact on the organizations represented at the 19th annual Rosalynn Carter Symposium on Mental Health Policy. Nearly half of respondents reported that at least one change had been made in their organization in response to the commission's report. In particular, the report seems to have had the most influence by stimulating internal communication and by facilitating collaborations with outside organizations.

However, the specific findings on successes and challenges suggest areas for ongoing efforts to transform mental health care. For example, a majority of respondents identified "Americans understand that mental health is essential to overall health" as most important for transformation, but only about 25 percent of the respondents considered this goal as a relevant and feasible one for their organization. This discrepancy suggests that this first goal, which is so critical to transformation called for in the New Freedom Commission's report, cannot be accomplished by mental health policy makers alone. Making mental health essential to overall health requires efforts to reach out to general health policy makers, health providers, and the general public.

The single largest barrier to successful implementation of the commission's recommendations reported by respondents was the presence of financial constraints. The commission was explicitly charged with making recommendations that did not require any new governmental expenditures. This survey's findings support concerns raised by some advocates about achieving the commission's goals in the absence of new funding (7,8,9).

Although participants in the symposium are selected to represent a range of influential stakeholder groups, we recognize that they do not reflect a random sample of mental health policy makers in the United States. The relatively low response rate limited our ability to break down the findings across subgroups of attendees or to conduct bivariate analyses. In spite of its exploratory rather than definitive nature, the survey provides a first structured look at how policy makers view the impact of the New Freedom Commission and its recommendations.

Conclusions

This survey provides a first glimpse at how the President's New Freedom Commission has influenced mental health organizations in the United States. The previous presidential commission report, conducted a quarter of a century ago, provided advocates with an important tool for fostering change within and beyond their organizations (10). The results of this survey suggest that the current report may similarly serve as a catalyst for transformation in the coming years.

Ms. von Esenwein and Dr. Druss are affiliated with the department of health policy and management of Emory University in Atlanta. Dr. Bornemann, Ms. Ellingson, Ms. Palpant, and Ms. Randolph are with the mental health program of The Carter Center in Atlanta. Send correspondence to Ms. von Esenwein at Emory University, Rollins School of Public Health, 1518 Clifton Road, N.E., Room 646, Atlanta, Georgia 30322 (e-mail, [email protected]).

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