The New Freedom Commission's Report To Shape Mental Health Policy in Years Ahead

When the President's New Freedom Commission on Mental Health released its final report in July, it issued a document that is likely to shape the nation's mental health care policies for decades. The Commission's charge was to study inadequacies in the current mental health care system and make specific recommendations for addressing these problems without increasing government spending.

After more than a year of coast-to-coast hearings and meetings, the panel released a roadmap that calls for a fundamental transformation of the delivery of mental health care. That transformation rests on two principles:

• Services and treatments must be consumer- and family-centered, designed to give meaningful choices in terms of treatment options and providers.
• Care must focus on increasing the consumer's ability to cope with life's challenges, emphasizing recovery and resilience, rather than just managing symptoms.

"The Nation must replace unnecessary institutional care with efficient, effective community services that people can count on," the report stated. "It needs to integrate programs that are fragmented across levels of government and among many agencies."

While the report targeted public sector mental health care, its impact could be widespread. If the U.S. Department of Health and Human Services (HHS) uses the document to reshape Medicaid policy, for instance, the report's influence will likely extend to private health care plans as well. It is widely acknowledged that Medicaid policy has a major impact on local systems of care that extends beyond the public sector.

The report emphasized a recovery model that would offer options in treatment, housing and employment and other supports to help people with serious mental illness take charge of their lives.

It defined recovery as "the process in which people are able to live, work, learn, and participate fully in their communities." Recovery can mean living a fulfilling life despite a disability or having a reduction or complete remission of symptoms.

The HHS is now conducting an assessment of the report and looking at the model programs that the final report uses as examples of best practices. "Our aim will be to identify ways in which the best elements of these models can be brought to scale nationwide," HHS Secretary Tommy G. Thompson said in a press release.

In 1997--the latest year for comparable data--the United States spent $71 billion on mental health care out of a total health care budget of more than $1 trillion, according to the report. The public sector paid for 57% of mental health care, compared to the public sector's 4% share of general health care expenditures. Mental health care spending did not keep pace with general health care spending between 1987 and 1997, primarily due to drops in private sector spending as a result of managed care and cutbacks in hospital expenditures.

The American Psychiatric Association released its own blueprint for the nation's mental health care system in April titled "A Vision for the Mental Health System." The APA's plan called for an investment in mental health care services that is equivalent to the level of disability caused by mental disorders, an end to behavioral health carveouts, and better integration between psychiatry and primary care. The report was released in the hopes of influencing the Commission's work.

While the report from the New Freedom Commission emphasized recovery and rehabilitation, the APA task force emphasized the role of medical professionals in shaping the nation's mental health care system. The APA blueprint stressed the need for expert diagnosis, an individualized treatment plan, continuity of care and a meaningful physician-patient relationship.

When the Commission released their final report, APA President Marcia K. Goin, M.D., voiced support: "The report describes barriers to the delivery of effective mental health care and provides examples of community-based care models that enable people with mental illnesses to live, work, learn and participate more fully in their communities."

Goin also stated that the APA "believes that a treatment approach based on a biomedical and public health perspective is a forward-looking conceptual foundation for a rational mental health system." Such a conceptual framework ought to include the "global burden of disease" model used by the World Health Organization (WHO) and World Bank to measure the impact of a given disability.

The WHO model--which uses disability-adjusted life years or years of life lost and years living with a disability--offers a way to compare the resources necessary to treat psychiatric disorders in relation to the impact of other medical conditions. The measure showed that mental disorders account for 20% of the total disease burden in the United States. Only 5.7% of health care expenditures go toward the treatment of these disorders.

Overall, mental health trade associations and advocacy groups came out in support of the Commission's final report. The Campaign for Mental Health Reform--a group founded by the Judge David L. Bazelon Center for Mental Health Law, National Alliance for the Mentally Ill (NAMI), National Association of State Mental Health Program Directors and National Mental Health Association--called on the U.S. Congress and the president to act on the report's recommendations.

"Policymakers have a choice," Robert Bernstein, executive director of the Bazelon Center for Mental Health Law, said in a press release. "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."

• A Question of Resources

The Commission's work and the attention given to mental health care issues by the White House are positive, Steven S. Sharfstein, M.D., APA vice president, told Psychiatric Times. Sharfstein was also chair of the APA task force that wrote the APA's blueprint on the mental health care system.

Speaking as a psychiatrist and as president and CEO of Maryland-based Sheppard Pratt Health System, Sharfstein said, "To argue that there are enough resources in the system, which is implicit in the report, and not to say that we need more resources, is wrong."

We need to advocate and articulate a greater devotion of society's resources in the care and treatment of the mentally ill," Sharfstein added. "And they missed an opportunity to advocate for that."

The resource issue includes advocating a larger share of the private insurance premium devoted to mental health care and more equitable treatment under Medicare, which charges a 50% co-pay for mental health treatment versus 20% for other health care services.

The Commission's report relied on the statistics presented by the U.S. Surgeon General and other federal sources in citing the incidence of mental illness: in any given year, 5% to 7% of adults have a serious mental illness and 5% to 9% of children have a serious emotional disturbance.

It also pointed out that mental illness is the leading cause of disability in the United States, Canada and Western Europe. A 2002 report by WHO stated that suicide causes more deaths every year worldwide than does homicide or war.

The Commission identified six goals for transforming the U.S. mental health care system (Table).

"Far too often, treatments and services that are based on rigorous clinical research languish for years rather than being used effectively at the earliest opportunity," the report stated.

The solution is to use research to develop evidence-based practices for the prevention and treatment of mental illness and to put these discoveries immediately into practice. The report stated, "Translating research into practice will include adequate training for frontline providers and professionals, resulting in a workforce that is equipped to use the latest breakthroughs in modern medicine. Research discoveries will become routinely available at the community level."

The existing knowledge base lacks information on at least four key areas of mental health care and delivery:

• Disparities in mental health care for minorities.
• The long-term effects of psychotropic medications.
• The impact and treatment of trauma.
• Treatment gaps and clinical standards in acute care.

On the technology front, the Commission recommended developing an integrated electronic health record and personal health information system.

• Involuntary Treatment

According to Sharfstein, the report does not do justice to individuals in the most dire straits in society. It emphasized choice, "but there are a large number of individuals who aren't able to choose." That population includes people who are homeless and those who have been incarcerated.

The treatment these people need has to be provided with due process, in order to protect civil liberties, but with a compassionate understanding that certain people need treatment and not punishment. Sharfstein added, "If they don't want treatment, that doesn't mean they shouldn't get treatment."

The issue of involuntary commitment, especially outpatient commitment, has proven to be a divisive one within the mental health care community. Consumers and other mental health care advocates oppose coercive means of bringing people into treatment.

Sharfstein, who prefers the term "compassionate coercion," said that involuntary or assisted treatment is sometimes necessary, especially with people who have schizophrenia. "Sometimes you need to go in and compassionately treat them against their will," he said. "And that is not reflected in this report."

In general, involuntary commitment is a result of inadequate crisis planning, Marty Raaymakers, chair of the NAMI Consumer Council, told PT.

Involuntary commitment results from people who are not in the system or are in the system but are not being treated adequately, explained Raaymakers, who also serves as chair of the Recipients Rights Advisory Committee for the Michigan Department of Community Health. In general, these people need more treatment over a longer period of time than the system is able to give them.

In addition to supporting choice over forced treatment, the report also made an important statement regarding the use of seclusion and restraint, Raaymakers said. "Seclusion and restraint will be used only as safety interventions of last resort, not as treatment interventions," the report stated.

Michigan has been engaged in person-centered planning for years, according to Raaymakers. Consumers write their own treatment plans, using the essential lifestyle-planning model. That approach has helped make the state's system of local mental health care systems significantly better than they were five years ago.

Michigan's Medicaid waiver program, like other public sector mental health care programs around the country, has its share of problems. "It's hard to provide care in a community," Raaymakers explained. "It's easy to provide care in an institution." The trade-off has been that more people have their lives now than they did before the local system switched to a consumer-focused approach.