COMMISSION REPORTS TO THE PRESIDENT
"MENTAL HEALTH SYSTEM IS IN DISARRAY"
MH commission issues searing indictment of nation’s system
Mental Health Weekly November 4, 2002
Taking the first major step in its mission to evaluate and then provide
recommendations for systemwide improvements in this nation’s mental health
system, the President’s New Freedom Commission on Mental Health holds nothing
back in decrying the current system as fragmented and in disarray in its
interim report released last week.
The interim report, the result of months of public hearings with stakeholders
from across the spectrum, is the first step for the commission. The report
focuses on problems in the current system across five areas, and highlights
community-based programs that have been successful in each of the five areas
and that serve as rays of hope in an otherwise dismal outlook on the current
system.
President Bush also has charged the commission with making recommendations for
improving the system. If the interim report offers any guide, the
recommendations, due next April, could be quite provocative. Among the more
intriguing conclusions in the interim report are the importance of finding
employment for people with serious mental illness and breaking the cycle of
dependence that the current system promotes, citing parallels to the former
welfare system.
The Interim Report to the President is the most significant report on mental
health since the release of Mental Health: A Report of the Surgeon General
toward the end of 1999 (see MHW, Dec. 20, 1999). While the Surgeon General’s
report offered an extensive overview of the biological nature of mental
disorders and the current state of treatment and research, and has been
critical to reducing stigma and bringing increased mainstream medical
acceptance to mental illness, that report did not offer broad policy
recommendations.
While the Surgeon General’s report acted as a rallying call for treatment, the
interim report takes a critical look at where improvements are needed and sets
the foundation for broad policy recommendations.
The critical tone is set in the report’s cover letter to President Bush.
Commission chairman Michael Hogan, Ph.D., writes, “Our review for this interim
report leads us to the united belief that America’s mental health service
delivery system is in shambles.”
Hogan goes on to write in the cover letter that the system is incapable of
efficiently delivering and financing effective treatments. He points to the
fragmentation of the existing system among agencies, programs and levels of
government.
“There are so many programs operating under such different rules that it is
often impossible for families and consumers to find the care that they
urgently need,” wrote Hogan in the cover letter.
The report points out that the system is in disarray not from a lack of
commitment or skill among those who deliver care, but from underlying
structural, financing and organizational problems. The report states that many
of the problems are due to the “layering on” of multiple, well-intentioned
programs without overall direction, coordination or consistency.
Citing various studies, the report estimates the prevalence of mental health
among U.S. adults at 5 to 7 percent, with 5 to 9 percent of children having a
serious emotional disturbance.
Referring to a World Health Organization (WHO) survey in 2001, the report
states that by far, mental illness is the leading cause of disability. The
report states that one out of two people who need mental health treatment do
not receive it.
The five barriers
The report identifies five barriers that needlessly impede access to mental
health services. They are: fragmentation and gaps in care for children;
fragmentation and gaps in care for adults; high unemployment and disability
for people with serious mental illness; older adults not receiving care; and
mental health and suicide prevention not being a national priority.
The report describes a mental health system with varying missions, settings
and financing. It states that the $80 billion that is financed annually for
mental health services could come from one of many sources — Medicare,
Medicaid, a state agency, a local agency, a foundation or private insurance,
each with a different set of rules.
The reasons for the fragmentation of the system date to the 1950s, when
patients were moved from institutions to community-based care, the report
states. The unintended consequence of this reform movement, the report states,
was to scatter responsibility across levels of government and multiple
agencies. New programs created to fill gaps added to the complexity and
fragmentation.
Compounding the problem, the report states, is that most federal resources are
within larger programs, such as Medicaid and Medicare, housing programs and
vocational rehabilitation services that are not tailored to the requirements
of good mental health care.
The report states that while many mental health providers are dedicated and
make valuable contributions despite the system’s disorganization, no one is
ultimately responsible while consumers and families struggle to find care.
The result is that there are hundreds of thousands of individuals with serious
mental illness in settings that are not designed to meet their needs, the
report states — in nursing homes, jails and homeless shelters. “Something is
terribly wrong, terribly amiss with the mental health system,” the report
states.
According to the report, the system is even more fragmented for children, with
even more uncoordinated funding streams and differing eligibility
requirements. It is again the unintended consequence of good intentions: There
are more programs in existence for children. The problems are
disproportionately worse for children from ethnic and racial minority groups,
the report states.
Among adults, the report states that about 25 percent of homeless persons have
a serious mental illness and, for the most part, do not receive any treatment.
Adults ages 65 and older are reluctant to seek care from “Something is
terribly wrong, terribly amiss with the mental health system.”
The Commission report states that most people suffering depression symptoms do
not go to see a mental health professional, mostly for stigma reasons. They
feel more comfortable going to their primary care doctor, the report states,
and are more likely to describe physical symptoms rather than feelings of
depression.
The report states that primary care physicians may see an older person’s
suffering as a part of aging rather than an underlying mental illness.
The report states that the nation’s failure to prioritize mental health is a
national tragedy, pointing to the 30,000 lives that are lost annually to
suicide.
Citing an Institute of Medicine report, the report says that about 90 percent
of individuals who commit suicide have a mental disorder.
High unemployment
The report found a 90 percent unemployment rate among adults with serious
mental illness — the worst level of employment among any group of people with
disabilities. The report states that many of these people want to work and
could work with a modest amount of assistance.
Instead, according to the report, the nation’s largest “program” for people
with mental illness is disability payments. The report compares the situation
to that of the old welfare system — unintentionally trapping millions into
long-term dependency.
The report concludes that the nation’s mental health system is not oriented to
the most important goal of the people it serves — the hope of recovery. Many
more people could recover from mental illness if they had access to programs
tailored to their needs, the report states. State of-the art treatments are
not being transferred to the communities, according to the report, while
outdated and ineffective treatments are being actively supported.
The report concludes that barriers to care can be overcome, as illustrated by
the programs highlighted in the text. Programs need to be integrated across
fragmented governments and agencies, and capacity increased.
CMHS Consumer Affairs E-News November 1, 2002
Vol. 02-82
_________________________________________________
For Immediate Release
November 1, 2002
Mental Health System in Disarray
EXEMPLARY PROGRAMS OFFER HOPE FOR THE FUTURE
Calling the mental health system an inefficient maze of private, federal,state
and local government programs with scattered responsibility for
services that frustrates both people with mental illness and providers of
care, the President's New Freedom Commission on Mental Health Chairman Michael
F. Hogan, Ph.D., released an interim report to the President today.
Citing the need for dramatic reform at all levels of service delivery, Hogan
said, "the Commission's challenge now is to identify realistic solutions to
help people with mental illness get the quality care that research has shown
to be effective."
"Today, people diagnosed with cancer or heart disease benefit from a broad
array of effective treatments. People with mental illness deserve no less.
Undetected, untreated and poorly-treated mental disorders interrupt lives,
leading many to disability, poverty and long-term dependence." Hogan
continued. "The good news is that recovery from mental illness is a reality; a
range of safe and effective treatments, services and supports exist for men,
women and children with mental illness. We know that when mental illness is
diagnosed early and treated appropriately, quality of life is tremendously
improved. Yet, half of all people who need treatment for mental illness do not
receive it. The rate is even lower for racial and ethnic minorities and the
quality of care they receive is poorer."
In its report, the Commission identified barriers to quality care and
recovery. Some relate directly to the service delivery system itself, such as
fragmentation and gaps in care for children, adults and older adults. Others
reward dependency such as through a mix of inadequate rehabilitation, and
disincentives to work. Still others reflect a failure to make mental health a
national priority. In its next phase of work, the Commission will be
addressing ways to break down these barriers to recovery.
Hogan said, "We need to answer the question, 'Why are 90 percent of adults
with serious mental illness unemployed?' After all, studies show that a
majority want to work and can work. Instead, our Nation’s largest 'program'
for people with mental illness is the disability system. Our mental health,
rehabilitation and disability programs unintentionally trap millions of
individuals – who want to work – into expensive long-term dependency."
Hogan continued, "The barriers that keeps adults with mental illness from
productive work and children with serious emotional disturbance from school
success are a tragedy from both human and economic perspectives. Although most
adults with mental illness want to work, they are the largest and fastest
growing group of people with disabilities receiving Supplemental Security
Income (SSI) and Social Security Disability Income (SSDI) payments. An
estimated $25 billion is spent annually for this population. Many people with
mental illness find that they cannot afford to go back to work because they
would lose their Medicaid coverage and disability benefits, and despite a job,
could not afford private health insurance coverage. Too many people with
mental illness are trapped in a 'disability welfare system' that badly serves
them and needs reform. And although many children with emotional disorders are
very bright, fewer than half ever graduate from high school. Our failure to
support employment and school success is a disgrace."
To help identify what works best to break down the barriers to care for people
with mental illness, the Commission has already identified some creative,
community-based programs that blend the promise of modern science with the
compassion of skilled professionals. These exemplary programs often achieve
the best results, despite bureaucracies that frequently create fragmentation
instead of focus, and that reward dependency instead of recovery. They range
from school-based mental health care in Dallas, to home visits by trained
nurses for high-risk women during pregnancy and the first year of their
child's life, to suicide prevention by the United States Air Force, and
effective treatment for late-life depression.
"These models," Hogan said, "can inspire communities nationwide, and provide
realistic examples of how quality, coordinated care is possible for the
millions of Americans with mental illness."
Overall, the Commission's interim report found that the system is not oriented
to the single most important goal of the people it serves – the hope of
recovery. Many more individuals could recover – from even the most serious
mental illnesses – if they had access to effective treatments tailored to
their needs, to supports and to services in their communities.
State-of-the-art treatments, based on decades of scientific inquiry, are not
being transferred from research to community settings. At the same time, many
outdated and ineffective treatments are still used.
The President's New Freedom Commission on Mental Health was established by
Executive Order 13263 on April 29, 2002. The Commission's work is essential to
the President's commitment embodied in the New Freedom Initiative to eliminate
inequality for Americans with disabilities.
The President tasked the Commission to recommend improvements in the U.S.
mental health service system for adults with serious mental illness and for
children with serious emotional disturbances. He requested a review of both
public and private sectors to identify policies that could be implemented by
federal, state and local governments to maximize the utility of existing
resources, to improve coordination of treatments and services, and to promote
a full life in the community for people with mental illness. The Commission's
recommendations will be presented in its final report. The document released
today responds to the legal requirement for an interim report. Additional
information about the Commission and the Interim Report are available on the
Internet at
www.MentalHealthCommission.gov.
MENTAL HEALTH COMMISSION RELEASES INTERIM REPORT
The President's New Freedom Commission on Mental Health is charged with
conducting a comprehensive study of the United States mental health service
delivery system and advising the President on methods of improving the system
to enable adults with serious mental illness and children with serious
emotional disturbances to live, work, learn and participate fully in their
communities. As part of that goal, the President's April 29 Executive Order
creating the Commission requires this interim report to describe barriers to
the delivery of effective mental health care. The report also provides
examples of community-based care models with success in coordinating services
and providing desired outcomes. The Commission will further examine these
barriers and models as it develops its final recommendations.
After several months of hearing from the public, experts in mental health care
and people with mental illness and their family members, the interim report
finds:
Mental Illness Affects Millions of Men, Women and Children. About 5-7 percent
of adults, in a given year, have a serious mental illness. "Serious mental
illness" is a term used in federal regulations for any diagnosable mental
disorder that affects work, home, or other areas of social functioning. A
similar percentage of children, about 5-9 percent, have a "serious emotional
disturbance." This term also comes from federal regulations, and it refers to
any diagnosable mental disorder, in a child under age 18, that severely
disrupts social, academic and emotional functioning. When compared to all
other diseases, such as cancer and heart disease, mental illness including
depression, bipolar disorder and schizophrenia, ranks first in terms of
causing disability in the United States.
Effective Treatments for Mental Illness Exist. A range of safe and effective
options are available to treat mental illnesses – including medications and
short term psychotherapy, and community-based supportive services. When mental
illness is diagnosed early and treated appropriately, quality of life is
tremendously improved. Quality care for children with serious emotional
disturbances can improve their social functioning, school attendance and
grades, and of equal significance, reduce severe behavioral and emotional
problems and contact with law enforcement. Quality treatment and flexible
supports for adults with a serious mental illness lead to employment and
recovery, reduced substance abuse and incarceration, and greatly improved
quality of life.
Multiple Barriers Impede Access to Effective Treatments, Services and
Supports. The array of programs that deliver or pay for treatments, services
and supports are offered by multiple levels of government and the private
sector. The varying missions, settings and financing of these health, housing,
disability and employment programs create a mental health maze instead of a
coordinated system. Navigating this maze is left to the people with the mental
illness and their families, who are least equipped to deal with the
complexities of the system. As a result it is often impossible for families
and consumers to find the care that they urgently need. Overall, one in two
people who need mental health treatment do not receive it. For ethnic and
racial minorities, the rate of treatment is even lower than that for the
general population and the quality of care is poorer.
The Commission has identified five barriers in the interim report that
needlessly impede access to care: "Fragmentation and Gaps in Care for
Children, Fragmentation and Gaps in Care for Adults, High Unemployment and
Disability for People with Serious Mental Illness, Insufficient Attention to
Older Adults, and Mental Health and Suicide Prevention are not yet National
Priorities."
Incentives Reward Dependency Instead of Recovery. Approximately 90 percent of
adults with serious mental illness are unemployed. Studies show that many of
them want to work and many can work. Instead, our nation's largest 'program'
for people with mental illness is disability payments. The situation is
similar in many ways to the pre-reform welfare system. Mental health,
rehabilitation and disability programs unintentionally trap millions of
individuals – who want to work – into expensive long-term dependency, the
costs of which are staggering. People with mental illnesses are both the
largest and fastest growing group of people with disabilities receiving
Supplemental Security Income (SSI) and Social Security Disability Income (SSDI)
disability payments. An estimated $25 billion is spent annually for this
population.
Excellent Care and Recovery Is Possible. Creative, community-based programs
that blend the promise of modern science with the compassion of skilled
professionals are breaking down the barriers to effective treatments, services
and supports. These exemplary programs often achieve the best results despite
– not because of – bureaucracies that often create fragmentation instead of
focus and reward dependency instead of recovery. They range from school-based
mental health care in Dallas; to home visits by trained nurses for high-risk
women during pregnancy and the first year of the child's life; to suicide
prevention by Air Force generals; and treatment for late-life depression in
primary care.
Overall, the Commission's interim report finds that the system is not oriented
to the single most important goal of the people it serves – the hope of
recovery. Many more individuals could recover from even the most serious
mental illnesses, if they had access to treatments tailored to their needs, to
supports and to services in their communities. State-of-the-art treatments,
based on decades of research, are not being transferred from research to
community settings. Meanwhile, many outdated and ineffective treatments are
currently being actively supported. The barriers to effective mental health
care can and must be overcome, and the Commission will continue its task of
developing ways to do so.
Additional information about the Commission and the Interim Report are
available on the Internet at
www.MentalHealthCommission.gov.
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