President's Commission Calls Mental Health Care System 'A Maze'

Charged with improving America's mental health care delivery system, President Bush's commission has found what many health care professionals and patients have known for some time: The system is in shambles and, according to the commission, "is incapable of efficiently delivering and financing effective treatments."

Created by Bush in April, The President's New Freedom Commission on Mental Health issued an interim report in October to a complete lack of attention by the news media. A final report, including recommendations, is due in April 2003.

In his transmittal letter to the president, Commission Chair Michael F. Hogan, M.D., suggested that a lack of a coherent approach to mental illness and substance abuse, coupled with a lack of coordination among existing programs, stymies health professionals in providing care to the estimated "5-7 percent of adults [who] in a given year, have a serious mental illness."

Hogan noted:

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. The efforts of countless skilled and caring professionals are frustrated by the system's fragmentation. As a result, too many Americans suffer needless disability, and millions of dollars are spent unproductively in a dysfunctional service system that cannot deliver the treatments that work so well.

Elaborating on this theme, the report pointed out, "Many of the problems are due to the 'layering on' of multiple, well-intentioned programs without overall direction, coordination, or consistency."

Despite its sweeping indictment of the delivery system, the commission report came under fire from the mental health care establishment. In a press statement, Michael M. Faenza, president and CEO of the National Mental Health Association (NMHA), agreed with the commission's call for dramatic reform of the system but added, "We urge the commission to focus as well on the broad range of unmet mental health needs not addressed specifically in the report."

"The commission has unreasonably limited its examination of the United States mental health service-delivery system to advise President Bush on budget-neutral methods to improve the system," Paul S. Appelbaum, M.D., president of the American Psychiatric Association, said in a statement. "The nationwide lack of adequate care for people with mental illness goes beyond the problem of state funding and affects patients in the private sector. It requires a broad societal response."

Both the APA and NMHA called on the U.S. Congress to pass parity legislation immediately. "The interim report fails to address a fundamental problem with the mental health system today--equal access to insurance coverage for mental health treatment," Appelbaum said.

"We urge the commission to end our patchwork national policy on the coverage of treatment for mental illness," Appelbaum added. "The APA hopes any final commission report will provide real solutions to fix the current fragmented mental health delivery system, address the critical need to pass mental health parity legislation, provide adequate funding in the public health system, and increase the supply of psychiatrists in underserved areas."

Despite the criticisms, the interim report amounts to a scathing denunciation of the existing health care system, while singling out individual programs that show positive results.

"The Commission has found creative, community-based programs that begin to circumvent the barriers," the report stated. "These programs carry a track record of success in achieving desired outcomes. Our review indicates that the best results are often achieved despite--not because of--financing systems and bureaucracies that often create fragmentation instead of focus and reward dependency instead of recovery."

Underscoring the extent of the mental health care crisis in the United States, the commission found that approximately 5% to 9% of children--a similar percentage to the affected adult population--have a serious emotional disturbance, as defined by federal regulations.

"The annual prevalence figures translate into millions of adults and children disabled by mental illness," the commission stated, quoting a 2001 World Health Organization study. "The disability toll can be quantified in a way that cannot be ignored: when compared to all other diseases [such as cancer and heart disease], mental illness ranks first in terms of causing disability in the United States, Canada, and Western Europe."

Yet, the commission found, "About one out of every two people who needs mental health treatment does 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 identified what it called five barriers that needlessly impede access to care within the mental health system. Those barriers are:

Fragmentation and gaps in care for childrenFragmentation and gaps in care for adults with serious mental illnessHigh unemployment and disability for people with serious mental illnessOlder adults with mental illness are not receiving careMental health and suicide prevention are not yet national priorities

Underlying many of these barriers is the issue of public attitudes. "The stigma of mental illness is also a major barrier to treatment," the report stated. "Many people are reluctant to seek care because of the shame our society attaches to mental illness. Societal stigma leads to ridicule, ostracism, and inexcusable discrimination in housing and employment. Stigma is often internalized by individuals with mental illness, leading to hopelessness, lower self-esteem, and isolation. Even more tragically, stigma deprives them of the social support they need to recover."

The report claimed that fragmentation in the mental health care system leads to waste and squandering of at least $80 billion in annual expenditures for treatment of mental illness. This is in part because of the large number of separate public agencies and private insurance programs that aim to provide care. "Each funding source has its own complex, sometimes contradictory, set of rules. Taken as a whole, the system is supposed to function in a coordinated manner; it is supposed to deliver the best possible treatments, services, and supports--but it often falls short."

For the estimated 3 million adults with both mental illness and a substance use disorder, the barriers to care are even more daunting. "Mental illness is often treated in one setting... while substance abuse treatment is often given in another... The rules governing eligibility for care often vary across those settings. And the rules governing payment vary, too, depending on which funding sources apply." Adolescents face even another challenge because their benefits may be lost as they enter adulthood.

Federal health programs, such as Medicare and Medicaid, pay for much of the care for the mentally ill, but these mainstream programs "are not tailored to the requirements of good mental health care."

"The reality is that the mental health system looks more like a maze than a coordinated system of care," the report said.

The report also pointed to unemployment as a major problem for individuals with mental illness. "Many of them want to work and report they could work with modest assistance. Instead, our Nation's largest 'program' for people with mental illness is disability payments Our mental health, rehabilitation, and disability programs unintentionally trap millions of individuals--who want to work--into expensive, long-term dependency."

While much of the report criticized the existing system, it also highlighted model programs in a number of areas that show positive outcomes for the populations they serve. However, there are few, if any, mechanisms for translating locally successful model programs into broad, national initiatives. "Federal programs should be structured to support proven effective models as the standard approach, not as the alternative, which requires local ingenuity."

Among the programs the report cited:

Nurse-Family Partnerships, which are aimed at reducing child abuse and neglect. This program provides nurses who visit high-risk women regularly during their pregnancies and during the first year of their children's lives in order to help women adopt healthy behaviors and responsibly care for their children. In areas where the program has been implemented, it has demonstrated an 80% reduction in abuse of the children of affected mothers, a 25% reduction in maternal substance abuse and an 83% increase in employment. Children who have been followed for 15 years in the program show a 54% to 69% reduction in arrests and convictions, less risky behavior and fewer school suspensions.A school-based mental health treatment program in Dallas that includes partnerships with parents and family members, treatment, and follow-up. In addition, school nurses, teachers and principals are trained to identify problems and make changes that are tailored to children's needs in classrooms. Wraparound Milwaukee, which is a public agency that coordinates a crisis team, provider network, family advocacy and access to 80 different services. The program has shown substantial improvements in juvenile arrests and convictions at a cost that is "almost 40 percent lower than the cost of traditional approaches that emphasize residential treatment."The AB-34 Projects in California (named after the 2000 state assembly measure that created the program), which aim to provide integrated services to homeless adults with serious mental illness. The AB-34 projects have resulted in a 66% decrease in the number of days of psychiatric hospitalization, an 82% decrease in days of incarceration and 80% fewer days of homelessness.U.S. Air Force adopted a program aimed at reducing suicide rates in the ranks. According to the report, the Air Force Chief of Staff began issuing statements to officers and enlisted men encouraging them to seek help from mental healthclinics. The program also involved increased training and education, critical-incident stress management, and integrated delivery of care. Between 1994 and 1998, the suicide rate dropped from 16.4 suicides to 9.4 suicides per 100,000 personnel. By 2002, the overall decline from 1994 was about 50%.

While these and other programs show substantial promise for improving the nation's mental health, the report found:

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 treatment tailored to their needs, to support, and to services in each of 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.