FIG1State health planners have
encountered numerous obstacles during the early stages of mental health system
transformation efforts, including funding shortfalls and resistance from some
Sy Saeed, M.D., discusses efforts to transform state mental health
Credit: David Hathcox
Mental health transformation—the top-to-bottom reform of the nation's
service delivery system called for by the President's New Freedom Commission
on Mental Health four years ago—is in the early stages of a multiyear
effort to create pilot plans in several states to overhaul their public and
private mental health systems. The effort aims to replace the nation's
patchwork mental health system with a cohesive approach that emphasizes the
possibility of recovery.
Officials from some of the nine states that have received five-year federal
Mental Health Transformation grants reported their progress at APA's annual
meeting in May in San Diego.
Consumer health groups have voiced opposition to some of the mental health
transformation plans under development, in part, because the plans attempt to
refocus state resources across the spectrum of mental illnesses. The approach,
which follows commission recommendations, is required for grant recipients.
Some groups that represent patients with serious mental illnesses and their
families have long pushed to get states to focus more resources specifically
on those conditions, panelists reported.
Complaints from groups representing patients with severe mental illness and
their families, for example, recently led the new Maryland governor to replace
the state official leading the transformation-planning effort over concerns
that this individual had insufficient expertise in programs and services for
those with serious mental illness.
Maryland sought to overcome tension with some consumer groups by including
them from the early stages of mental health transformation planning, which is
in its second year, according to Brian Hepburn, M.D., executive director of
the Maryland Mental Hygiene Administration.
"They're not there to give you after-thoughts but to help from the
beginning," Hepburn said of the advocates.
L. Mark Russakoff, M.D., chair of APA's Committee on Psychiatric
Administration and Management, said state officials in New York provided
opportunities for patient groups who were not involved from the beginning of
the planning process to ask questions and provide comments later.
Consumer groups are also frustrated by the five-year time frame for mental
health transformation efforts, maintaining that the long development time
ensures that systemic changes will not be implemented, even in the first
states to attempt this, for several additional years.
Planners also have had to address concerns of some consumer groups that all
of the state initiatives plan to devote equal funding and resources to
recovery models and to evidence-based practices. The New Freedom Commission
placed equal emphasis on the two approaches, although they are very different
and diverge in some areas. Some patient groups regard evidence-based practices
as almost a "right-wing conspiracy" because they run counter to
the recovery model's emphasis on phenomenological ex periences and t he
autonomous rights of those in recovery, according to Sy Saeed, M.D., chair of
the Department of Psychiatric Medicine at the Brody School of Medicine of East
He traced the reduced emphasis on only using therapeutic approaches based
on placebo-cont rolled, double-blind, prospective research to federal reports
that have illustrated the "huge gaps in what we know about these
[mental] illnesses and how to treat them." He emphasized increased
dialogue with patients to make them aware of the available treatment
Conversely, the other challenge for transformation planners is how to get
health care clinicians to implement practice guidelines as part of their
everyday work, Saeed said. Systemic change is required, he said, to overcome
pervasive reluctance among clinicians to use guidelines and new research.
Health care planners also have encountered resistance to the transformation
plans from some clinicians, who are concerned that the model's emphasis on
consumer-directed care will result in patients and their families telling
trained professionals how to provide care.
"There is a certain amount of resistance, but we're working through
that," Hepburn said, about health care providers in Maryland.
Some health professionals also have criticized the lack of changes in
distributing state and federal funding more evenly to support research on all
types of mental illness and not focusing in particular on serious mental
Yet another concern state officials have grappled with is how to move
low-income patients into a recovery model of care, which can result in a loss
of their entitlement benefits.
Hepburn explained that the planning efforts in Maryland have focused on
ways to overcome the impact of the lack of health insurance on access to
mental health services. That lack of access has led to a situation in which 28
percent of patients who come to emergency rooms need mental health care.
The hard reality of financial limits arise in every health care system
undertaking transformation planning.
The process's emphasis on community rather than institutional care is a
laudable goal, but it doesn't work without a spectrum of supports, including
housing and employment, said Lydia Weisser, D.O., clinical director of
Mississippi State Hospital, who until recently participated in Georgia's
Limited resources have affected Georgia's effort most recently by causing
transformation planning efforts to be suspended while all seven of the state's
psychiatric hospitals prepare for an unscheduled Joint Commission audit.
State officials in Maryland worry that once planning has been completed the
legislature may not fund the range of initiatives identified, Hepburn
said. That concern was reinforced by the loss of recent savings at psychiatric
hospitals. State officials had planned to shift those savings to
community-based programs but the legislature required a 2 percent
across-the-board cut that wiped out those transferable funds.
The ongoing f unding shortfalls in every state are exacerbated by the
increased expectations of patients and the public that mental health systems
will provide comprehensive and timely care. Criminal-justice officials add to
these demands by describing ever-larger proportions of their populations as
mentally ill and demanding that already underfunded mental health programs
assume responsibility for care of prisoners. ▪