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The nation’s mental health system is in a shambles and needs a major overhaul rather than incremental improvements. That’s the assessment of the New Freedom Commission on Mental Health appointed by President Bush to "study the mental health delivery system and make recommendations that would enable adults with serious mental illnesses and children with serious emotional disturbances to live, work, learn, and participate fully in their communities."
While the commission doesn’t assign specific responsibility for its recommendations and doesn’t consider funding, it is clear that state governments, many of which already are facing severe financial problems, especially in their health care programs, would be expected to step up to the plate and assume significant responsibility for rebuilding a broken mental health system.
The commission based its assessment and recommendations on a year of study and a review of research and testimony, and has concluded that for too many Americans with mental illnesses, the mental health services and supports they need remain fragmented, disconnected, and often inadequate, frustrating the opportunity for recovery. And it is that opportunity for recovery that the commission said should be the centerpiece of a coherent system. But too often, according to the commission, the system simply manages symptoms and accepts long-term disability.
What it said it found is a "patchwork relic — the result of disjointed reforms and priorities. Instead of ready access to quality care, the system presents barriers that all too often add to the burden on mental illnesses for individuals, their families, and our communities. The time has long passed for another piecemeal approach to mental health reform. Instead, the commission recommends a fundamental transformation of the nation’s approach to mental health care. This transformation must ensure that mental health services and supports actively facilitate recovery, and build resilience to face life’s challenges."
The commission estimates that in any give year, some 5% to 7% of adults and 5% to 9% of children suffer from mental illness or severe emotional disturbance. These figures translate into millions of people disabled by mental illness each year. Despite significant investments of resources that have enormously increased the scientific knowledge base and led to developing many effective treatments, many Americans don’t benefit from what has been learned.
"Far too often," the commission declared, "treatments and services that are based on rigorous clinical research languish for years rather than being used effectively at the earliest opportunity." The commission envisions a system that ensures that when a serious mental illness or emotional disturbance is first diagnosed, a health care provider, in full partnership with consumers and families, will develop an individualized plan of care for managing the illness. It said that such a partnership of personalized care means "basically choosing who, what, and how appropriate health care will be provided: choosing which mental health professionals are on the team, sharing in decision making, and having the option to agree or disagree with the treatment plan."
The commission voiced the expectation that since all treatment plans would be oriented toward recovery, the stigma surrounding mental illnesses would be reduced, reinforcing the hope of recovery for every individual with a mental illness. Successfully transforming the mental health service delivery system rests on two principles, it said. First, services and treatments must be consumer- and family-centered, geared to giving consumers real and meaningful choices about treatment options and providers, rather than being oriented to the requirements of bureaucracies. And second, care must focus on increasing consumers’ ability to successfully cope with life’s challenges, on facilitating recovery, and on building resilience, not just on managing symptoms. The commission identified six goals as the foundation for transforming the mental health system, and recommendations for meeting each of the goals, noting that the goals are intertwined and no single step can achieve the fundamental restructuring that is needed.
Generally positive reaction
By and large, the mental health community and advocacy organizations strongly supported the commission’s work and recommendations. "Mental health advocates today call on the nation’s leaders to capitalize on this historic opportunity to address the growing crisis in public mental health systems," said Robert Bernstein, executive director of Bazelon Center for Mental Health Law. "Policy-makers have a choice — they can put this report on a shelf and continue the past policies of hopelessness, or they can act on its recommendations and make recovery-focused services a priority for millions of Americans with unmet mental health needs."
National Alliance for the Mentally Ill executive director Robert Birkel said the nation "cannot wait another day, another year, or another decade for real progress. . . . Let today be the turning point. Let today begin the transformation of a broken system of care to one that provides recovery-oriented, community-based treatment and services that we know will work."
From the provider community, the American Psychiatric Association called on the president and Congress to provide real solutions to fix the current fragmented mental health delivery system, pass mental health parity legislation, and provide adequate funding in the public health system. The association called the commission report a "major step on the road to recovery of the nation’s mental health system."
Federation of Families for Children’s Mental Health executive director Barbara Huff said her group looks to the Bush administration "for a commitment to take action and support changes with necessary increased funding in order to change the way this nation serves children with mental health needs and their families."
While most organizations praised the commission’s work, cautioning that its recommendations cannot be allowed to pass without implementation, at least one advocacy organization said the commission missed the mark and ignored people with the most severe mental illnesses.
The Treatment Advocacy Center in Arlington, VA, a nonprofit organization working to eliminate barriers to timely and humane treatment of those with mental illness, said that in a desire to be politically correct the commission report "left out the people who needed them most, ignored powerful tools proven to save time and money, and reinforced harmful stereotypes about recovery and stigma. Many mental health advocates are praising the report for its assessment of the system, but we find it sad that because there is such a low bar for success with such reports, none wants to mention the important things that were omitted."
Treatment Advocacy Center president E. Fuller Torrey said the commissioners glossed over tools such as police training, mental health courts, and commitment laws, especially assisted-outpatient treatment.
"Adopting and utilizing assisted outpatient treatment is a proven way to meet the commission’s goal to disseminate and apply proven treatments to mental health care delivery," Mr. Torrey said. "The commission’s hesitancy to address this treatment mechanism is especially astonishing given the results from instituting such measures. For instance, in New York, of those placed in six months of assisted outpatient treatment, 77% fewer were hospitalized, 85% fewer experienced homelessness, 83% fewer were arrested, and 85% fewer were incarcerated."
He also challenged the commission’s lack of recommendation for eliminating the Medicaid IMD exclusion under which the federal government does not reimburse states for Medicaid-eligible people with severe mental illnesses who are in state psychiatric hospitals, although it will pay for medical and psychiatric treatment in other settings. He said the commission didn’t acknowledge that a major reason for the stigma associated with mental health patients is crimes committed by those not receiving treatment, and said the best way to reduce stigma is not through a public education campaign but rather to help people before they become a headline.
Finally, Mr. Torrey said the commission erred in promoting the notion that all of those who have a serious mental illness can recover. "The implication that failure to fully recover is because a person who is sick failed to have a strong-enough faith in recovery is akin to suggesting that happy thoughts can cure a broken leg. This perspective implies that the person with the brain disease is somehow at fault. Although the commission’s focus on full recovery is understandable and recovery for all is a laudable long-term vision, it is important to remember that recovery is not currently possible for every person who has a severe psychiatric illness."
[To see the commission report, go to: www.mentalhealthcommission.gov/reports/reports.htm. Contact Bazelon Center at (202) 467-5730; NAMI at (703) 524-7600; American Psychiatric Association at (703) 907-7300; American Psychological Association at (202) 336-5500; the Federation of Families for Children’s Mental Health at (703) 684-7710; and the Treatment Advocacy Center at (703) 294-6001.]