FIG2 Michele Reid, M.D., was ebullient when asked about the prospects for reform of Michigan's mental health system.FIG1

"October 25 was one of those perfect days I'll remember forever," she said. On that day members of the Michigan Mental Health Commission submitted their report and recommendations to Gov. Jennifer Granholm (D).

"The governor greeted each of us by name, thanked us for our work, and instructed Janet Olszewski, director of Michigan's Department of Community Health, to come up within 90 days with a list of recommendations that could be implemented immediately and a timeline for other actions."

Reid, who is medical director of the Detroit-Wayne County Community Mental Health Agency, was a member of the commission. Other psychiatrists on the commission were Thomas Carli, M.D., and Rajiv Tandon, M.D.

Granholm appointed the 33-member commission on December 15, 2003, with the charge "to recommend sweeping changes in both the delivery of services and effectiveness of Michigan's mental health network."

At the group's opening session, Granholm said that the system is" broken."

During the next 10 months, hundreds of people testified at public hearings and submitted comments to the commission's Web site. The views of psychiatrists were represented by the three members on the commission and by other members of the Michigan Psychiatric Society (MPS) who participated in work groups about specific issues or testified before the commission.

Tandon said, "I found the proceedings arduous, intellectually stimulating, and incredibly informative." He was a professor of psychiatry at the University of Michigan at the time of his appointment. During the work of the commission, Tandon became chief of psychiatry for Florida's Department of Children and Families and commuted to Michigan for meetings.

The experience with the commission proved "incredibly valuable" to what he is doing now, he said.

Reid said that MPS Executive Director Kathleen Gross kept the members well-supplied with background information from APA. APA's "A Vision for the Mental Health System" was a key source document cited by the commission.

Carli said, "The psychiatrists played an important role in bringing the medical perspective to the deliberations of the commission."

Carli is a clinical associate professor of psychiatry at the University of Michigan and director of medical and disease management at the University of Michigan Health System.

The commission came up with hundreds of recommendations that support the achievement of seven goals (see box).

Both Carli and Reid mentioned a recommendation for strengthening the role of the state's medical director for mental health as being particularly important to psychiatry.

The recommendation is to "strengthen the role of the current Michigan Department of Community Health Medical director so that s/he becomes the leader in the development of evidence-based practices in the mental health system." The recommendation describes specific actions to implement those practices.

Reid mentioned the commission's emphasis on consumerism as being" very important."

"Consumer and family members should be involved in the design and delivery of services," she said. "It's the only way to go."

She also cited the importance of recommendations about suicide prevention and reducing stigma.

Carli said that psychiatrists reminded the commission that treatment of mental illness often necessitates managing a chronic illness. "We discussed whether or not that concept conflicts with a focus on the recovery model and decided that the two are not incompatible," he added.

The report analyzes the impact of the "Medicaidization" of mental health services. Prior to 1999, the state legislature funded community mental health services through one line item that did not depend on a patient's eligibility for Medicaid benefits. Since then, community mental health dollars have been split into Medicaid and non-Medicaid lines, with a federal prohibition against using any of the former to benefit a non-Medicaid recipient.

Medicaid does not cover many people with serious mental illness or emotional disturbance because eligibility requires meeting a restrictive definition of disability and restrictive income requirements, according to the report.

The result is fewer resources for screening, early intervention, or treatment of persons whose conditions are of moderate or mild severity and who are not Medicaid-eligible.

Some of those people will deteriorate, resulting in additional direct or indirect costs to the state.

The report also presents data that show that the amount the state is spending on mental health from its general fund is declining, when adjusted for inflation.

Commission members noted that Michigan had once been a national leader in the development of Assertive Community Treatment programming, person-centered planning policies and family-center practice, creating clubhouse programs, and offering wraparound service delivery.

"The erosion of state funding and other policy support in the past decade, however, has contributed to serious gaps in both availability and quality of essential services...."

The commission recommended "funding streams dedicated to public mental health services and treatment."

The commission also noted that public testimony showed that people do not want to see services taken out of their local settings.

Carli said that there was considerable discussion about balancing the assets and deficits of regional administration and delivery of community mental health services with those of administration and delivery at the county level.

The aim is to capture the financial savings of regional administration while maintaining local delivery.

The problem is complicated by the fact that there is significant variation in funding and administrative costs among counties.

The report concluded with a statement that echoes findings of the President's New Freedom Commission on Mental Health in 2003.

"The unintended result of several factors and policies that were well meaning but not always far-sighted has been a state/community mental health system that is uncoordinated and fragmented, with few real quality controls and dispersed accountability."

About the work of the commission, Carli said, "The outcome was good, but the process was tough." The commission was large and included" every possible constituency," which led to difficulties in coming up with a genuine redesign of the system. "The recommendations represent a lot of good incremental steps," he said.

Tandon said, "It was an honest, open, and inclusive process and we were able to pull everything together at the end to come up with a strong report."

Reid and Carli both commented that Granholm has a strong commitment to improving the state's mental health system.

The two psychiatrists will be working with other advocates in a coalition to monitor progress on the recommendations.

A press release on and the final report of the Michigan Mental Health Commission are posted online at<www.michigan.gov/gov/0,1607,7-168--104835--,00.html>.▪