Two Reports Point Government To More Effective MH System

Better coordination and more federal action could transform the nation's fragmented system of mental health care, according to two major reports, one issued by the U.S. government and the other by a coalition of national mental health organizations.

“The federal government is aligning its resources so that people will have the opportunity for recovery,” said Charles G. Curie, M.A., administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), at a press conference last month at the Capitol in Washington, D.C.

“We must send a message that mental illness is an illness and not a scandal,” said Curie. “Recovery should be an expectation, not an exception.”

SAMHSA's report is titled “Transforming Mental Health in America. The Federal Action Agenda: First Steps.” Just a few days later, the Campaign for Mental Health Reform (CMHR), a coalition of 16 national mental health advocacy organizations, including APA, set out its own list of goals in a 32-page report titled “Emergency Response: A Roadmap for Federal Action on America's Mental Health Crisis.”

“The proof of these reports will appear if things actually change in the real world of care and support for people with mental illness,” said APA President Steven Sharfstein, M.D., in an interview.

SAMHSA's agenda is an outgrowth of the 2003 report of President Bush's New Freedom Commission on Mental Health, titled “Achieving the Promise: Transforming Mental Health Care in America” (Psychiatric News, August 15, 2003). The agenda was developed in discussion with six cabinet departments—Health and Human Services, Education, Justice, Labor, Housing and Urban Development, and Veterans Affairs—and the Social Security Administration.

“The Action Agenda is not a quick fix,” Curie emphasized.“ It's a living document to transform mental health care and hold the federal government accountable.”

Following the guidelines for the New Freedom Commission, which required that initiatives have no impact on federal budgets, the Action Agenda proposes coordination of ideas but requests no new funding.

“The underlying assumption is of budget neutrality, but strategic use of new funds to make changes could make a big difference,” said Sharfstein.

According to the SAMHSA report, the role of the federal government should be to lead and to facilitate change in mental health care at the federal, state, and local levels as well as in the private sector. The Action Agenda lists 31 separate items covering clinical outcomes, community models of care, cost-effectiveness, and dissemination of research (see box).

Observers said the agenda appeared belatedly but praised its intent.

“Advocates were nervous and dismayed at the time it took to get the Action Agenda cleared for release, but we are pleased with its breadth and depth,” Michael Hogan, Ph.D., director of the Ohio Department of Mental Health and chair of the New Freedom Commission on Mental Health, said in an interview with Psychiatric News.

The next step for the federal government is to set up an executive steering committee from all the concerned departments to plan “ongoing stewardship... to guide the collaborative work of mental health system transformation...,” in its words.

“The Action Agenda is really an inventory of what all federal agencies are doing now and how they have pledged to act together in an agreed way,” said A. Kathryn Power, M.Ed., director of SAMHSA's Center for Mental Health Services, in an interview. “It's the first step—that's all it is. I hope we can convene the steering committee by the end of the year.”

“The steering committee creates a high-level, organized body on mental illness that has been strikingly absent in the federal government,” said Hogan. “I am pleased to see the involvement of the Labor Department, Veterans Affairs, and Social Security.”

He noted that the Social Security Administration wasn't even represented on the New Freedom Commission, but that rules for its Social Security Disability Insurance and Supplemental Security Income programs affect how people with disabilities can work their way out of poverty.

Termed a “roadmap” for federal action, the CMHR's document calls for new legislation to ensure mental health parity in insurance coverage, allow families with mentally ill children and incomes up to 250 percent of the federal poverty line to buy into Medicaid, end discrimination in Medicare, and fund the diversion of mentally ill people who have committed nonviolent crimes into treatment rather than prison (see box).

“The Action Agenda is focused on what the federal government bureaucracy can do, while the CMHR report addresses what Congress still needs to do,” said Hogan. “Having the two appear within days of each other leaves me hoping we're moving toward a critical mass.”

“The roadmap,” Sharfstein commented, “provides a constructive set of doable steps that would improve opportunities for persons with mental illness to receive effective treatment and support.”

Representing APA at the CMHR report's unveiling at the Capitol in Washington, D.C., were James H. Scully Jr., M.D., APA medical director; Eugene Cassel, J.D., director of APA's Division of Advocacy; and Jessica Mikulski, a communications specialist in APA's Office of Communications and Public Affairs.

“APA's involvement in the campaign,” Hogan told Psychiatric News, “is very important because it brings professional credibility to CMHR.”

A bipartisan group of senators and representatives spoke at the CMHR press conference. While both Democrats and Republicans have supported many mental health bills, some were passed without sufficient funding being authorized, said Sen. Mike DeWine (R-Ohio). DeWine recalled his days as a county prosecutor, when jail was the only option for mentally ill offenders. Fully funding the Mentally Ill Offender Treatment and Crime Reduction Act of 2004 would offer alternatives to prison for mentally ill persons who commit nonviolent crimes, he said.

Opposition to mandating better mental health benefits in private plans has come largely from corporations, which fear adding to already high health care costs, explained Sen. Edward Kennedy (D-Mass.).

“If people faced the reality of the statistics, there would be no difficulty in passing parity legislation,” said Rep. Patrick Kennedy (D-R.I.), the senator's son. “The American people don't understand the extent of mental illness, so we're dealing with the symptoms of the problem—overcrowded jails, family separations, depressed senior citizens trapped in their apartments.”

The biggest challenge is Medicaid funding, said Rep. Kennedy. Funding for mental health services will probably be the first to be cut, especially if there is a shift to block grants.

“The Action Agenda and the CMHR roadmap were complementary documents and together can serve to bring about needed changes to the country's mental health system,” said CMHR Director Charles S. Konigsberg, J.D. “We look forward to sitting down with SAMHSA to develop a common agenda.”

SAMHSA's Action Agenda is posted at<www.samhsa.gov/Federalactionagenda/NFC_TOC.aspx>. The CMHR's roadmap is posted at<www.mhreform.org/emergency/index.htm>.▪