Better coordination and more federal action could transform the nation's
fragmented system of mental health care, according to two major reports, one
issued by the U.S. government and the other by a coalition of national mental
"The federal government is aligning its resources so that people will
have the opportunity for recovery," said Charles G. Curie, M.A.,
administrator of the Substance Abuse and Mental Health Services Administration
(SAMHSA), at a press conference last month at the Capitol in Washington,
"We must send a message that mental illness is an illness and not a
scandal," said Curie. "Recovery should be an expectation, not an
SAMHSA's report is titled "Transforming Mental Health in America. The
Federal Action Agenda: First Steps." Just a few days later, the Campaign
for Mental Health Reform (CMHR), a coalition of 16 national mental health
advocacy organizations, including APA, set out its own list of goals in a
32-page report titled "Emergency Response: A Roadmap for Federal Action
on America's Mental Health Crisis."
"The proof of these reports will appear if things actually change in
the real world of care and support for people with mental illness," said
APA President Steven Sharfstein, M.D., in an interview.
SAMHSA's agenda is an outgrowth of the 2003 report of President Bush's New
Freedom Commission on Mental Health, titled "Achieving the Promise:
Transforming Mental Health Care in America" (Psychiatric News,
August 15, 2003). The agenda was developed in discussion with six cabinet
departments—Health and Human Services, Education, Justice, Labor,
Housing and Urban Development, and Veterans Affairs—and the Social
"The Action Agenda is not a quick fix," Curie emphasized."
It's a living document to transform mental health care and hold the
federal government accountable."
Following the guidelines for the New Freedom Commission, which required
that initiatives have no impact on federal budgets, the Action Agenda proposes
coordination of ideas but requests no new funding.
"The underlying assumption is of budget neutrality, but strategic use
of new funds to make changes could make a big difference," said
According to the SAMHSA report, the role of the federal government should
be to lead and to facilitate change in mental health care at the federal,
state, and local levels as well as in the private sector. The Action Agenda
lists 31 separate items covering clinical outcomes, community models of care,
cost-effectiveness, and dissemination of research
Observers said the agenda appeared belatedly but praised its intent.
"Advocates were nervous and dismayed at the time it took to get the
Action Agenda cleared for release, but we are pleased with its breadth and
depth," Michael Hogan, Ph.D., director of the Ohio Department of Mental
Health and chair of the New Freedom Commission on Mental Health, said in an
interview with Psychiatric News.
The next step for the federal government is to set up an executive steering
committee from all the concerned departments to plan "ongoing
stewardship... to guide the collaborative work of mental health system
transformation...," in its words.
"The Action Agenda is really an inventory of what all federal
agencies are doing now and how they have pledged to act together in an agreed
way," said A. Kathryn Power, M.Ed., director of SAMHSA's Center for
Mental Health Services, in an interview. "It's the first
step—that's all it is. I hope we can convene the steering committee by
the end of the year."
"The steering committee creates a high-level, organized body on
mental illness that has been strikingly absent in the federal
government," said Hogan. "I am pleased to see the involvement of
the Labor Department, Veterans Affairs, and Social Security."
He noted that the Social Security Administration wasn't even represented on
the New Freedom Commission, but that rules for its Social Security Disability
Insurance and Supplemental Security Income programs affect how people with
disabilities can work their way out of poverty.
Termed a "roadmap" for federal action, the CMHR's document
calls for new legislation to ensure mental health parity in insurance
coverage, allow families with mentally ill children and incomes up to 250
percent of the federal poverty line to buy into Medicaid, end discrimination
in Medicare, and fund the diversion of mentally ill people who have committed
nonviolent crimes into treatment rather than prison
"The Action Agenda is focused on what the federal government
bureaucracy can do, while the CMHR report addresses what Congress still needs
to do," said Hogan. "Having the two appear within days of each
other leaves me hoping we're moving toward a critical mass."
"The roadmap," Sharfstein commented, "provides a
constructive set of doable steps that would improve opportunities for persons
with mental illness to receive effective treatment and support."
Representing APA at the CMHR report's unveiling at the Capitol in
Washington, D.C., were James H. Scully Jr., M.D., APA medical director; Eugene
Cassel, J.D., director of APA's Division of Advocacy; and Jessica Mikulski, a
communications specialist in APA's Office of Communications and Public
"APA's involvement in the campaign," Hogan told Psychiatric
News, "is very important because it brings professional credibility
A bipartisan group of senators and representatives spoke at the CMHR press
conference. While both Democrats and Republicans have supported many mental
health bills, some were passed without sufficient funding being authorized,
said Sen. Mike DeWine (R-Ohio). DeWine recalled his days as a county
prosecutor, when jail was the only option for mentally ill offenders. Fully
funding the Mentally Ill Offender Treatment and Crime Reduction Act of 2004
would offer alternatives to prison for mentally ill persons who commit
nonviolent crimes, he said.
Opposition to mandating better mental health benefits in private plans has
come largely from corporations, which fear adding to already high health care
costs, explained Sen. Edward Kennedy (D-Mass.).
"If people faced the reality of the statistics, there would be no
difficulty in passing parity legislation," said Rep. Patrick Kennedy
(D-R.I.), the senator's son. "The American people don't understand the
extent of mental illness, so we're dealing with the symptoms of the
problem—overcrowded jails, family separations, depressed senior citizens
trapped in their apartments."
The biggest challenge is Medicaid funding, said Rep. Kennedy. Funding for
mental health services will probably be the first to be cut, especially if
there is a shift to block grants.
"The Action Agenda and the CMHR roadmap were complementary documents
and together can serve to bring about needed changes to the country's mental
health system," said CMHR Director Charles S. Konigsberg, J.D. "We
look forward to sitting down with SAMHSA to develop a common