President Bush Announces New Freedom Initiative, Proposes Mental Health Commission

On February 1 President George W. Bush announced the New Freedom Initiative, a broad plan to provide $5 billion over five years to help Americans with disabilities become better integrated into communities and workplaces. As part of the initiative, the President has also proposed the creation of a National Commission on Mental Health to find ways of better coordinating the activities of several federal agencies that oversee mental health policies, funding, and programs.

A foreword to the initiative notes that more than 54 million Americans—20 percent of the population—have disabilities. About half of these individuals have a severe disability that affects their ability to see, hear, walk, or perform other ordinary activities. In addition, more than 25 million family members provide care to people with disabilities. One in five adults with disabilities have not graduated from high school, compared with less than one in ten adults without disabilities. National graduation rates for students who receive special education and related services have stagnated at 27 percent for the past three years, while rates are around 75 percent for students who do not rely on special education.

The foreword also provides statistics on poverty and unemployment. In 1997 more than a third of adults with disabilities lived in a household with an annual income of less than $15,000, compared with only 12 percent of those without disabilities. Unemployment rates for working-age adults with disabilities have hovered around 70 percent for more than 12 years. Seventy-one percent of people without disabilities own homes, but fewer than 10 percent of those with disabilities do. Rates of ownership and use of computers and Internet access for people with disabilities are half those of people without disabilities.

The President's attention to disability issues early in his administration was praised by mental health advocacy groups, including the National Mental Health Association and the National Alliance for the Mentally Ill. Both groups cited the President's promise to sign an executive order to enforce the Supreme Court's 1999 ruling in Olmstead v. L.C. and E.W. The ruling held that the Americans With Disabilities Act (ADA) provides people who have mental disabilities the right to community care rather than institutional care (see Psychiatric Services, October 1999, page 1271). Advocates have pointed out that many states are far from ready for a shift to home- and community-based services, and most have been slow to implement the provisions of the Olmstead ruling. The New Freedom Initiative states that the executive order will support "the most integrated community-based settings for individuals with disabilities, in accordance with the Olmstead decision."

The proposed National Commission on Mental Health "will study and make recommendations for improving America's mental health service delivery system, including making recommendations on the availability and delivery of new treatments and technologies for individuals with severe mental illness."

The New Freedom Initiative has three key components: increasing access to assistive technologies, expanding educational and work opportunities, and promoting full access to community life.

To develop and increase access to assistive technologies for people with disabilities, the initiative will fund more research and better coordinate the federal effort in prioritizing needs for assistive technology in the disability community. Funding will also be increased for low-interest loan programs to enable persons with disabilities to purchase assistive technologies.

To expand educational opportunities, the initiative provides more funds for the Individuals With Disabilities Education Act (IDEA) to help communities meet the special needs of students with disabilities. States that establish a comprehensive reading program for students, including those with disabilities, from preschool through second grade will be eligible for special grants.

To increase job opportunities, the initiative seeks to expand telecommuting by providing federal matching funds to states to guarantee low-interest loans to individuals with disabilities for purchasing computers and other equipment necessary to work from home. In addition, legislation will be proposed to make a company's contribution of a computer and Internet access for home use by an employee with a disability a tax-free benefit. As part of the initiative, President Bush also promises swift implementation of the "ticket to work" law, which allows Americans with disabilities to choose their own support services and maintain their health benefits when they return to work.

To achieve full ADA enforcement in the workplace, the initiative provides technical assistance to promote ADA compliance and to help small businesses hire more people with disabilities. Funding will also be provided for ten pilot programs that use innovative approaches to develop transportation plans to serve people with disabilities.

In promoting full access to community life, the third major component of the initiative, increased homeownership for people with disabilities is a primary goal. According to the initiative, the Bush administration will ensure implementation of the American Homeownership and Economic Opportunity Act of 2000, which permits Section 8 rental subsidy recipients with disabilities to use up to a year's worth of vouchers to finance the down payment on a home.

The full text of the New Freedom Initiative can be downloaded from the White House Web site at www. whitehouse.gov.

Youth Violence: A Report of the Surgeon General

For a decade, beginning in 1983, lethal youth violence in the United States reached epidemic proportions. Since peaking in 1993, the number of homicide arrests among young people has dropped dramatically, largely because of the declining use of firearms. By 1999 arrest rates for most violent crimes had fallen below 1983 levels. However, arrest rates for aggravated assault remain almost 70 percent higher than they were in 1983, and the self-reported proportion of young people involved in nonfatal violence has not dropped from the peak years of the epidemic.

These numbers are contained in Youth Violence: A Report by the Surgeon General, which was released in January. The report summarizes the latest research on this national problem. It focuses on national trends; developmental dynamics; risk factors; prevention and intervention; and possible courses of action for policy makers, the justice system, researchers, and the general public.

The report, published by the Department of Health and Human Services, was a collaborative effort by the Centers for Disease Control and Prevention; the National Institutes of Health and its component, the National Institute of Mental Health; and the Substance Abuse and Mental Health Services Administration. It is based on the most recent findings of major long-term research projects supported by these three agencies. The projects involve nationally representative samples of the nation's youth and are designed both to monitor the health status of young Americans and to identify factors that can be shown to carry some likelihood of jeopardizing health.

Several findings are of particular interest to mental health professionals. For example, age at onset of violent behavior was found to be associated with outcome. Youths who become violent before age 13 are more likely to commit more—and more serious—crimes for a longer time. Most youth violence, however, begins in adolescence and ends with the transition into adulthood. Interestingly, most highly aggressive children and children with behavioral disorders do not become serious violent offenders, whereas substantial numbers of serious violent offenders emerge in adolescence without warning signs in childhood. These patterns have important implications for prevention and intervention.

The report also found an association between youth violence and the age at which children are exposed to different risk factors. The strongest risk factors during childhood are involvement in serious but not necessarily violent criminal behavior, substance use—which is a much stronger risk factor at age nine than at age 14—being male, physical aggressiveness, low family socioeconomic status or poverty, and having antisocial parents. During adolescence the strongest risk factors are weak ties to conventional peers, ties to antisocial or delinquent peers, belonging to a gang, and involvement in other criminal acts. Despite these associations, the report noted that no single risk factor or combination of factors can predict violence with unerring accuracy.

Identifying and understanding the factors that protect children from involvement in violent behavior is potentially as important as identifying and understanding the factors that place them at risk. Among several proposed protective factors, the report notes that only two have been found to buffer the effects of exposure to specific risk factors for violence: an intolerant attitude by a youth toward deviance, including violence, and commitment to school.

The report points out that hundreds of well-intentioned programs aimed at preventing youth violence have sprung up in communities and schools across the country, but their effectiveness is mostly unstudied and undocumented. At the time of the report, nearly half of the most thoroughly evaluated programs had been proved ineffective, and several actually had negative effects. The report also notes that many programs that have effective strategies are ineffective because the quality of implementation is poor.

Nevertheless, the most important conclusion of the report, according to its authors, is that an array of intervention programs with well-documented effectiveness in preventing youth violence is now in place. The report highlights 27 specific programs that are not only effective but cost-effective as well. Most highly effective programs combine components that address individual risks and environmental conditions, particularly building individual skills and competencies, providing parent effectiveness training, improving the social climate of the school, and helping youths change their type and level of involvement in peer groups.

The full report is available online at www.surgeongeneral.gov. On April 1 it will be available from the U.S. Government Printing Office (http://book store.gpo.gov).

News Briefs

A second medical decade: Congress has declared a second "medical decade." The first was the Decade of the Brain in the 1990s, which stimulated significant progress in research on and public awareness of mental illness. The second medical decade began on January 1, 2001, when President Clinton signed into law a bill providing for the Decade of Pain Control and Research. In enacting this legislation, government authorities noted that because pain control lacks a significant constituency at the federal level, it has suffered from a lack of investment in research, education, and treatment.

FDA approves new antipsychotic: The U.S. Food and Drug Administration has approved ziprasidone, a novel antipsychotic medication for treatment of schizophrenia. The drug, developed by Pfizer, is a serotonin and dopamine antagonist for treatment of positive and negative symptoms of the disorder. The 45,000-patient worldwide clinical trials program for ziprasidone was the largest ever conducted for an antipsychotic agent before the drug's introduction. Among chronic, stable inpatients, ziprasidone was shown to be effective in delaying the time to and rate of relapse.

Mental disorders and uninsured hospital stays: A study by the U.S. Agency for Healthcare Research and Quality (AHRQ) has shown that hospital stays for mental disorders are second only to childbirth in the number of uninsured hospital stays. About 135,000 hospital stays a year for treatment of depression and mental disorders related to substance abuse are not covered by either private or public insurance programs, such as Medicare or Medicaid. Nearly 23 percent of all stays for treatment of drug-related mental disorders, 19 percent of alcohol-related stays, and 8 percent of stays for treatment of depression are uninsured. Five percent of all childbirth hospital stays—191,000 births—are not covered. For more information, visit the AHRQ Web site at www. ahrq.gov/data/hcup/factbk.1.

Advocate guides from NMHA: Three new publications from the National Mental Health Association (NMHA) are designed to help providers, consumers, family members, and mental health and disability advocates understand and advocate for comprehensive state mental health services. The publications address state employment incentives, access to psychotropic drugs, and the needs of children eligible for the State Children's Health Insurance Program. Best and Worst Practices in State Children's Health Insurance Programs: An Analysis of Contracts, Requests for Proposals, and Amendments is geared to state agencies attempting to improve outreach to and management of children. Ready to Work: Enacting State Employment Incentives provides advocates with an understanding of new work incentives available to states and strategies for advocacy coalitions. It offers guidelines for those interested in helping consumers who are ready for work but fear losing their Medicaid benefits. Penny-Wise and Pound-Foolish: Restricting Access to Psychotropic Medications defines obstacles and describes strategies to combat some states' practice of restrictions on newer medications. To obtain these publications, contact NMHA's resource center at 800-969-6642.

Increased market share for managed behavioral health programs: Between 1999 and 2000, enrollment in managed behavioral health programs and employee assistance programs rose more than 14 percent, to 220 million, according to a report on market share among the top ten managed behavioral health care firms issued by Open Minds, a research and consulting firm. Between 1993 and 2000, the total number of enrollees in these programs rose 155 percent. Of an estimated 250 million Americans with health insurance, about 170 million (68 percent) are enrolled in some type of managed behavioral health program. Enrollment in employee assistance programs rose to 66.5 million people in 2000, an increase of 245 percent since 1994. In the past year alone, enrollment in such programs rose by 13 percent. Magellan, with a 33 percent market share, continues to dominate the market. The other two vendors in the top three were ValueOptions and United Behavioral Health. The report is available from Open Minds for $195. Contact Vicki Arentz at 877-350-6463.

National treatment directory: A guide containing information on thousands of substance abuse treatment programs has been released by the Substance Abuse and Mental Health Services Administration (SAMHSA). The National Directory of Drug and Alcohol Abuse Treatment Programs (2000), which is organized by state, is a nationwide inventory of public and private treatment programs at the federal, state, and local levels. The programs listed are licensed, certified, or otherwise approved by substance abuse agencies in each state. The directory complements SAMHSA's Web-based Substance Abuse Treatment Facility Locator service (http:// findtreatment. samhsa.gov). A free copy of the directory can be obtained by calling the National Clearinghouse for Alcohol and Drug Information at 800-729-6686.

Educational video on schizophrenia: The National Mental Health Association (NMHA), with support from Janssen Pharmaceutica, is releasing an educational video on schizophrenia, "Lives in Progress: People With Schizophrenia Today." The target audience for the video is consumers—especially newly diagnosed individuals—and their families. The video focuses on the full lives enjoyed by many people with schizophrenia because of treatment breakthroughs and psychosocial programs. Five copies of the tape will be sent to each of NMHA's 340 affiliates. For information about obtaining the video, call the NMHA resource center at 800-969-6642 or contact a local NMHA affiliate.