In 1977 President Jimmy Carter signed an executive order establishing the President’s Commission on Mental Health. An important impetus for the commission was the interest of First Lady Rosalynn Carter, who had worked to transform Georgia’s state mental health system into a community-based approach.
A year later, after public hearings and development of a series of special reports, the commission issued a four-volume report and a set of recommendations (see box).
President Carter’s legislative response to the report was the Mental Health Systems Act (MHSA), which he submitted to Congress in 1979.
After a series of negotiations among various interest groups and between the House of Representatives and the Senate, the MHSA passed and was signed in 1980.
In 1981 newly elected President Reagan signed the Omnibus Budget Reconciliation Act, which effectively repealed the MHSA and instead provided for block grants to the states for mental health services.
Now, 25 years after the commission’s report, President Bush’s New Freedom Commission is preparing to issue its report and recommendations about mental health services in May.
To help understand the potential impact of that report and how its effect might be maximized, Psychiatric News arranged a conversation between Gary Tischler, M.D., and APA Vice President Steven Sharfstein, M.D.
Tischler, who had been a professor of psychiatry at Yale University School of Medicine, was the Carter Commission’s study director. Sharfstein, who was then acting director of the Division of Mental Health Service Programs at the National Institute of Mental Health, was a consultant to the commission.
One of the most important results, said Tischler, was the development of a broad-based coalition of organizations concerned with mental health issues.
"Before the commission," he said, "it was like the Tower of Babel, with advocates talking past each other."
The visible and sustained support of Rosalynn Carter for the work of the commission helped to bring the issue of mental illness "out of the closet."
"Problems were talked about with a new level of openness," Tischler said.
Rosalynn Carter and Tom Bryant, commission chair, continued to support mental health issues after the official end of the commission’s work through their involvement with the Public Committee on Mental Health, a nonprofit organization that resulted from the alliances the commission encouraged.
Specific legislative and other governmental initiatives can be traced to the commission’s work, despite the fact that the MHSA was "substantially repealed" in 1981 by President Reagan.
In 1986 Congress passed the Protection and Advocacy for Individuals With Mental Illness Act (PL 99-318), which had been one of the sections of the MHSA.
In 1980 the U.S. Surgeon General, Julius B. Richmond, M.D., issued the National Plan for the Chronically Mentally Ill, which echoed many of the commission recommendations and helped create a community-based safety net for people who had been released from psychiatric hospitals.
The National Institute of Mental Health (NIMH) established the Prevention Research Branch to serve as a focal point of effort to promote new ideas and programs and also undertook initiatives, such as the promotion of case management techniques, that the commission had recommended.
Tischler said, "Themes in the Mental Health Systems Act also had an impact on how the government came to approach mental health services. The legislation emphasized federal-state partnerships, planning and accountability, and the integration of mental and other health services."
Sharfstein noted that the work of the Carter Commission and other initiatives have resulted in a "more responsive service system."
The commission recommended "rebuilding our mental health research capacity over the next 10 years." Sharfstein called attention to the "remarkable advances" in research that have produced better medications and increased knowledge about effective treatments.
"Treatment works," Sharfstein said, and the result is greater demand for services. "The paradox, however, is that resources have not kept up with increased demand, leading to even larger gaps between perceived need and availability of services."
In 1978, according to the Carter Commission, 12 percent of general health expenditures were directed to mental health. The most recent national data, for 1997, indicate that only 7.8 percent of personal and governmental health spending was for mental health and addiction treatment.
The New Freedom Commission is scheduled to issue its report in May, when the country’s attention likely will be diverted by war and budget deficits.
Sharfstein said, "There’s always a foreign policy crisis. There’s always a budget crisis. They don’t excuse inaction."
He pointed out that the country was focused on the hostages in Iran when the Carter Commission issued its recommendations.
Tischler said that psychiatrists and other mental health advocates should remember the importance of building a broad-based coalition to take advantage of the opportunities associated with the report.
"We can’t focus only on issues that are important to the guild. We must emphasize our role as caregivers and as advocates for resources to bring treatment to people who need it."
Sharfstein specifically urged advocacy for parity because passage of a "meaningful bill" would result in increased access and would also legitimize the idea that mental health treatment should be regarded as equally important as treatment for other kinds of health problems.
There likely will be supplemental reports issued in conjunction with the main report and its recommendations.
"Those reports will contain what we can call ‘seeds’ for action," he said. "They will germinate if a coalition focuses attention on them and develops strategies to push for their implementation." ▪