New Freedom Commission Report: The Commission's Report and Its Implications for Psychiatry

It is tragic to witness the crushing, relentless erosion of resources available for the care of persons with severe mental illnesses. Hospital closures, cost cutting in outpatient clinics, crowded emergency departments, an increase in homelessness, and an increase in the number of people with mental illnesses in jails and prisons have followed serial budget cuts.

Would a President's Commission charged to study the mental health delivery system in the United States and to make recommendations that would "enable adults with serious mental illnesses and children with serious emotional disturbance to live, work, learn, and participate fully in their communities" really tell it like it is? It did. The New Freedom Commission's interim report stated that the mental health delivery system is fragmented and in disarray, leading to homelessness, school failure, and incarceration. The final report repeats that the mental health system is "in shambles" and fragmented and further describes the system as in need of complete restructuring.

The Commission's report cites many of the real problems with which we struggle. Stigma impedes people from getting the care they need. The increasing incidence of suicide presents serious challenges. Insurance plans place greater restrictions on treating mental illnesses than on treating other illnesses. We need legislatively mandated parity. Better coordination between mental health care and primary health care and better public education are also needed. We need mental health financing for prescription drug coverage, accessibility and affordability of services, and support for evidenced-based services and supports. The Commission's report recognizes the connection between mental health and physical health and describes the complicated funding that characterizes mental health care.

Some of the Commission's recommendations parallel the principles articulated in the American Psychiatric Association's Vision for the Mental Health System (1). The Commission's report advocates that treatments be driven by the needs of persons with mental illness and that treatments and services should focus not just on managing symptoms but on increasing patients' ability to successfully cope with life's challenges, on facilitating recovery, and on building resilience. Built around patients' needs, the system must be convenient and close to seamless. These recommendations of the Commission resonate with the principles articulated in APA's Vision for the Mental Health System that mental health care should be patient and family centered, community based, culturally sensitive, and easily accessible without discriminatory administrative or financial barriers or obstacles.

However, it is important not to lose sight of the very first item in APA's Vision for the Mental Health System: "Every American with psychiatric symptoms has the right to a comprehensive and an accurate diagnosis which leads to an appropriate, individualized plan of treatment." In the midst of a commitment to outreach and integration with communities, we must not lose sight of how important it is for each person with psychiatric symptoms to have the benefit of an accurate diagnosis.

The Commission's report is accurate in its description of the complex mental health system that overwhelms many patients and the complicated funding system that presents many roadblocks. However, we should proceed with caution regarding the following statement in the report: "In partnership with their health care providers, consumers and families will play a larger role in managing the funding for their services, treatments, and supports. Placing financial support increasingly under the management of consumers and families will enhance their choices. By allowing funding to follow consumers, incentives will shift toward a system of learning, self-monitoring, and accountability. This program design will give people a vested economic interest in using resources wisely to obtain and sustain recovery."

Serious problems may arise in making this approach work effectively. Patients and families, who are often overwhelmed with many other practical daily pressures, may not be in the best position to accurately sift out the most efficacious way to spend available treatment dollars. In an effort to encourage independence, we must be careful not to abandon our extensive experience and our responsibility to patients.

It is unfortunate that the report does not draw greater attention to the current crisis in availability of acute care psychiatric hospital beds. Only one small section near the end of the report addresses this issue. It is true that wherever and whenever possible it is best for patients to be treated in the community. Rehabilitation, integration into the community, and support provided by recovery groups are all important to long-term care. But the ongoing flood of psychiatric hospital closures across the country is having a profound effect on emergency rooms, families, and communities. When a person with diabetes is in crisis with metabolic acidosis, he or she needs to be hospitalized and stabilized. In the same way, acutely ill psychiatric patients need to be hospitalized and stabilized before they can benefit from resources in the community and recovery programs.

Stabilization does not always proceed as rapidly as reflected in insurance benefits that specify the number of "allowable days" of hospitalization. In planning for responsible mental health care, it is crucial to ensure a level of care that will provide safety, stabilize patients with medications and support, develop rapport, and provide a connection from the hospital to the community so that the patient will follow through with the needed treatment. Studies have shown that one of the most dangerous times for suicide completion is immediately after discharge from the hospital. Patients are often lost to follow-up when connections are not successfully made between inpatient and outpatient care. Any successful treatment plan should provide for a strong connection between inpatient treatment and reentry into the community.

It is encouraging to see that the Commission recognizes the distressing role that has been handed, by default, to the criminal justice system. The report states that "as a shrinking public health care system limits access to services, many poor and racial or ethnic minority youth with serious emotional disorders fall through the cracks into the juvenile justice system. People with serious mental illnesses who come into contact with the criminal justice system are often poor, uninsured, disproportionately members of minority groups, homeless, and living with co-occurring substance abuse and mental disorders." As the report affirms, too often the criminal justice system unnecessarily becomes a primary source of mental health care. The Commission recommends diversion to avoid criminalization and extended incarceration of nonviolent adult and juvenile offenders with mental illness. Reentry into society is even more difficult after incarceration.

Additional funding is essential to achieve the transformed system described in the report. Among the model programs cited in the report is California's AB34. The program began in 1999 when Governor Gray Davis provided $10 million authorizing pilot programs in three counties for comprehensive services targeting homeless persons who are at imminent risk of being incarcerated. The success of the pilot programs served as a strong impetus for continued funding. Consequently, in 2000 nearly $55 million was allocated annually over three years to support similar programs in 24 cities. The programs are reported to have led to a 66 percent decrease in the number of days of psychiatric hospitalization, an 82 percent decrease in the number of days of incarceration, and an 80 percent decrease in the number of days of homelessness. The programs target a difficult population characterized by severe and persistent mental illness, homelessness, and, usually, co-occurring substance use disorders.

This sort of intervention is welcomed by the law enforcement community as well as by chambers of commerce. Such programs provide an essential array of services and reach out to a difficult patient population. Success? Yes. But a successful program, which may result in long-term cost savings along with treatment success, needs initial funding and sustained support. California's AB34 program is relatively small—currently it reaches 5,200 of the 50,000 homeless persons in California. However, $55 million a year is needed to sustain this program.

As this issue of Psychiatric Services goes to press, the Campaign for Mental Health is being launched in California to support section AB34 of the Mental Health Services Act and expand the pilot programs. The campaign hopes to garner the needed funds by a 1 percent income tax on each million dollars earned by state residents who earn more than $1 million a year.

The President's New Freedom Commission has done splendid work in examining the current state of mental health delivery systems in our nation in 2002-2003. The American Psychiatric Association and other organizational advocates for mental health treatment will be able to benefit from its comprehensive and honest acknowledgment of the problems. Following on the work of the Carter Commission and former Surgeon General Satcher's mental health reports, the Commission has performed an exceedingly important function. The Surgeon General's reports reflected on the difficulty of improving conditions without long-range planning. Too often budgets are written and implemented by individuals who, given the vicissitudes of the political arena, are not certain whether they are long-term or short-term players. Those with fiscal and humane responsibilities must take a long-term view regardless of their future prospects. The Commission's report helps to focus attention in that direction.