President's Commission Finds Fragmented System, Outdated Treatments, Incentives for Dependency

The 20-member commission appointed in April by President Bush to take a close look at mental health care in the United States has completed its initial review and has issued an interim report of its findings: "America's mental health service delivery system is in shambles. We have found that the system needs dramatic reform because it is incapable of efficiently delivering and financing effective treatments. . . . The efforts of countless skilled and caring professionals are frustrated by the system's fragmentation. As a result, too many Americans suffer needless disability, and millions of dollars are spent unproductively in a dysfunctional service system that cannot deliver the treatments that work so well." Overall, the commission found that the system is not oriented to the single most important goal of the people it serves—the hope of recovery.

The interim report is part of a year-long undertaking by the President's New Freedom Commission on Mental Health, which was charged with conducting a comprehensive study of the mental health system and advising the President on budget-neutral improvements that would enable adults with serious mental illness and children with serious emotional disturbances to participate fully in their communities. The commission has met in various cities to hear from the public, from experts in mental health care, from state authorities and program administrators, and from people with mental illness and their family members. Its recommendations will be presented in a final report in April 2003.

Succinctly—in fewer than 20 pages of text—the report identifies five "overwhelming barriers" that prevent access to effective treatments. The barriers are fragmentation and gaps in care for children, fragmentation and gaps in care for adults, high rates of unemployment and disability for people with serious mental illness, insufficient attention to older adults, and a failure to make mental health care and suicide prevention national priorities. For each barrier, the report describes one or more model programs that illuminate how services can be delivered despite these barriers and that provide evidence that "excellent care and recovery can become the norm, not the exception" (see accompanying box).

The report is also succinct in describing the scope of the problem: "Mental illness is shockingly common, affecting almost every American family—directly or indirectly." In a given year about 5 to 7 percent of adults have a serious mental illness, and from 5 to 9 percent of children have a serious emotional disturbance, according to the report. As a cause of disability in the United States, mental illness ranks above all other diseases, including cancer and heart disease. In terms of lost productivity, the annual cost to the U.S. economy amounts to $63 billion. A total of $80 billion is spent annually to finance mental health care.

Among the five barriers impeding access to treatment is the fragmentation of the service system for both adults and children. The report describes the system as "more like a maze than a coordinated system of care." It attributes many problems to the "layering on" of multiple, well-intentioned programs without overall direction, coordination, or consistency. Because the system lacks coordination, state-of-the-art treatments based on decades of research are not transferred to community settings. Instead, the commission found that many outdated and ineffective treatments are being actively supported. The report also cites the obstacles created by myriad funding sources for care, each of which has its own complex and sometimes contradictory set of rules. Overall, the commission found that instead of fostering recovery, resilience, and independence, the existing system rewards dependency.

Dependency is a critical focus in the report's discussion of another barrier to treatment: high unemployment and disability among people with serious mental illness. According to the report, people with mental illness represent the largest and fastest-growing group receiving disability payments from Supplemental Security Income and Social Security Disability Income, accounting for an estimated $25 billion annually. The report compares the present situation to the prereform welfare system. Approximately 90 percent of adults with serious mental illness are unemployed. The report decries the fact that although studies show that many of these individuals want to work, and many could work with modest assistance, the largest "program" for people with mental illness is disability payments. "Disability programs unintentionally trap millions of individuals into expensive long-term dependency, the costs of which are staggering."

The failure to make suicide prevention a national priority is another barrier cited by the report, which singles out as exemplary a program established by the U.S. Air Force in 1996 to confront the growing number of suicides in its ranks—25 percent of all deaths. The report highlights the military leadership's destigmatizing messages encouraging personnel to seek help, which have served "to change a military culture and reverse centuries of stoicism in the face of hardship." From 1994 to 2002, the program has reduced suicide by about 50 percent.

In a statement issued shortly after the report was released, Paul S. Appelbaum, M.D., president of the American Psychiatric Association, expressed concerns that the commission has unreasonably limited its examination to the public-sector system and to budget-neutral recommendations. He also noted that the report fails to address a fundamental problem with both public and private systems of care—the lack of parity in insurance coverage for mental health treatment.

The Interim Report of the President's New Freedom Commission on Mental Health is available on Web at www.mentalhealthcommission.gov.

News Briefs

2003 NAPHS directory: The National Association of Psychiatric Health Systems (NAPHS) has published its 2003 Membership Directory. The directory is designed to help clinicians, employee assistance directors, school counselors, nursing home personnel, and others who must quickly identify sources of help for individuals with psychiatric and addictive disorders. The directory lists contact information for specialty hospitals, psychiatric units in general hospitals, addiction treatment units, residential treatment centers, partial hospital programs, behavioral group practices, and outpatient centers. The directory is available from NAPHS for $35. For more information call 202-393-6700.

National suicide prevention resource center: The Substance Abuse and Mental Health Services Administration has granted funds to establish a national suicide prevention resource center. The Education Development Center in Newton, Massachusetts, will receive $2.5 million a year for three years to serve as a central source of information and technical assistance for states and communities seeking to create and evaluate suicide prevention programs. The center is part of the National Strategy for Suicide Prevention published in May 2001 under the leadership of the U.S. Surgeon General. The center will be a collaborative effort of the Education Development Center, the American Association of Suicidology, the American Foundation for Suicide Prevention, and the Suicide Prevention Advocacy Network.

New APA fellowship program in child psychiatry: The American Psychiatric Association (APA) has launched the APA/Shire Child and Adolescent Psychiatry Fellowship to promote interest among residents in child and adolescent psychiatry, an area with a shortage of psychiatrists. Four residents will be selected to participate in a two-year program. Financial support for the fellowship comes from an unrestricted educational grant from Shire Pharmaceuticals. More information is available by contacting Jane Edgerton, director of APA's office of children's affairs, by phone at 202-682-6857 or by e-mail at [email protected].

Public-private collaboration on performance measurement: The National Association of State Mental Health Program Directors (NASMHPD), the National Association of Psychiatric Health Systems (NAPHS), and the NASMHPD Research Institute have signed a teaming agreement to work on identifying performance measures that will be useful throughout the behavioral health field. The organizations have determined that there is significant congruence between measures and concepts already identified through independent performance measurement projects under way in each of the organizations. The goal of the project is to provide benchmarking information to the field and to be in a position to help shape the development of core measures. The groups are set to pilot test several agreed-upon measures. After the pilot test, data collection efforts will be expanded to include larger segments of the public and private sectors. More information is available on the Web site of the National Association of Psychiatric Health Systems at www.naphs.org.