FIG1What would you do with $1.5 billion in new funding? That's the enviable challenge California mental health programs have faced each year since 2005 when the state began to collect and distribute a new tax on individuals with annual income over $1 million earmarked for improving mental health services. The funds bolster the $4.7 billion the state already allots to mental health care.

The California Mental Health Services Act was approved by voters in 2004. Its initial implementation has emphasized care for residents with serious mental illness and expanded treatment options for homeless residents. Most programs are operated by counties.

"The public asked that this serve people with serious mental illness and the homeless, so most of the funding is for full-service partnerships to provide all other attendant services around homelessness and mental illness," said Rachel Guerrero, director of the Office of Multicultural Services in the California Department of Mental Health, about programs that provide housing and job-placement assistance to homeless people. She provided an update on the act at APA's 2007 annual meeting in San Diego in May.

California mental health officials expressed amazement that they finally have sufficient funding to provide not only more treatment services, but also prevention and early intervention services.

Funding from the act allows mental health programs to treat early symptoms of mental illness, instead of having to wait for people to develop severe symptoms, said Robbin Huff-Musgrove, Ph.D., cultural competency officer for San Bernardino County, Calif.

She pointed out that people with little or no income live under tremendous amounts of stress, which research has shown can affect physical as well as mental health. Health officials have focused much of their initial efforts for low-income residents on providing treatment through community health centers.

The state's prevention-focused framework also aims to bolster mental health screening by primary care providers. This goal follows research suggesting that greater improvement in detecting mental illness may come through expanding the number of physicians who are aware they need to look for mental illness, instead of just improving the abilities of some clinicians to detect such conditions.

Another primary goal of the increased funding is stepped up mental health care among minority groups that have traditionally had little such care or among whom deep suspicions of psychiatric care exist.

The California program targets minority groups, in part, said Katherine Ruiz-Mellott, M.D., because members of minority communities were found to be more likely to present at primary care providers with somatic conditions than with mental health ones. This can frustrate primary care physicians because physical health problems are often symptomatic of untreated psychiatric illness.

To increase screening and treatment among minorities, health officials have funded several new programs with the new tax money, including interpreters in communities where English is not a primary language. They also have begun efforts to get more young members of these communities to go into the mental health field, to provide the most culturally knowledgeable resource for those groups. Health officials also have conducted outreach to underserved communities to find out how they can provide better care.

Evidence-based mental health research has not been "normed" on multicultural communities and that can have "disastrous" consequences, Guerrero said. She noted that the mental health field has little experience developing culturally specific approaches.

California mental health officials have used much of the new funding to establish trust with communities through small group meetings in an effort to overcome the distrust many have for a health care system they feel has long ignored them.

"A lot of communities have mistrust in the system, and it took a long time to get some of them to talk to us," said Sergio Aguilar-Gaxiola, M.D., Ph.D., director of the Center for Reducing Health Disparities at the University of California, Davis, School of Medicine.

Once a relationship has been established in underserved communities, health officials have used the new tax money to fund a variety of programs, including training for community-based organizations that can provide mental health services, hiring outreach workers who know the community, and establishing after-school activities. ▪