Although some improvements have been made in the mental health care that
states offer, a recent report from the National Alliance on Mental Illness
(NAMI) found that overall psychiatric care in the United States remains caught
in the "stranglehold" of rising demand and limited resources.
NAMI conducted a nationwide grading of the states in 2008 and 2009 and
released its findings in a "report card" on March 11. The
organization reported that there has been little systemic improvement in the
mental health care system since its last look at the states that was released
in 2006 (Psychiatric News, April 21, 2006).
"Overall this shows that the President's New Freedom Commission's
call for fundamental transformation was not heard," said psychiatrist
and NAMI President Anand Pandya, M.D., in an interview with Psychiatric
The report assessed the nation's public mental health care system for
adults and found that the national average grade is a disappointing"
D," just as it was in 2006. The report card was based on both
state-government surveys of available services and computer searches of the
availability of information and treatment services in each state, conducted in
2008 and early 2009.
The findings, based on 65 specific criteria such as access to medicine,
housing, and family education, led NAMI to the conclusion that services had
actually degraded in 12 states over the last three years.
"Even states that made progress are, because of the [economic]
downturn, at risk of losing ground," said Pandya, who cited reform
efforts of the Virginia public mental health system following the April 2007
killing of 32 students and faculty at Virginia Tech by a student with serious
mental illness who later killed himself. However, the recession has led
Virginia's legislature to provide little of the funding needed to enact the
The impact of the ongoing recession on mental health services was echoed by
Michael Fitzpatrick, executive director of NAMI, who noted that state budget
cuts are coming at precisely the time when the need for psychiatric care is
spiking due to the economic stress that is spreading in the general
population, particularly that caused by growing unemployment.
Cutting back on mental health services funding is part of "a vicious
cycle that can lead to ruin," Fitzpatrick said. "States need to
move forward, not retreat."
Robert Feder, M.D., an APA Assembly representative from the New Hampshire
Psychiatric Society, said budget cuts in his state have resulted in the loss
of housing for people with mental illness and psychiatrist positions at
community mental health centers. The result of funding cuts has been a
reduction in the overall mental health care available in New Hampshire, which
received a "C" grade.
"My fear is that people who are not getting the help they need in the
mental health system are going to end up in the prison system," Feder
said. "So I don't know if the state is going to end up saving any
Marcia Goin, M.D., Ph.D., vice chair of APA's Council on Advocacy and
Public Policy and a former APA president, said the low grades in the report
will not surprise anyone who works in the public health care sector.
The grades "reflect what we see," said Goin, a psychiatrist in
California, which received a "C."
Not all states have joined the cost-cutting trend at the expense of their
NAMI grades. Among the highest scoring states were Connecticut, Maine,
Maryland, Massachusetts, New York, and Oklahoma, which all received a"
B." Oklahoma also was among the most improved, moving from a"
D" in 2006. No state earned an "A."
The lowest-scoring states were Arkansas, Kentucky, Mississippi, South
Dakota, West Virginia, and Wyoming, all of which received failing grades.
Among the specific shortcomings identified in the report was the lack in
most states of public health insurance plans that meet the needs of people
with serious psychiatric illness. States also frequently fail to provide
adequate amounts of "lynchpin" services, such as integrated
substance abuse and mental health services along with hospital-based care when
Few states have invested in or even developed plans for long-term housing
for people with serious mental illness.
The almost total lack of supportive housing for people with mental illness
in Illinois is a "huge problem," said Joan Anzia, M.D., a member
of the APA Council on Advocacy and Public Policy. The state, which received a"
D" grade, eliminated four community psychiatric outpatient
clinics over the last six months and plans further cuts this year.
Among improvements since the 2006 report, NAMI found that states are more
likely to offer effective diversion programs to people with psychiatric
illness from the criminal-justice system, but such programs are often
implemented by county governments without effective state leadership, the
report pointed out.
Other findings include a widespread "information gap" in many
states, where few data are collected by either federal or state mental health
administrators regarding the performance and effectiveness of the state
The authors criticized the federal Substance Abuse and Mental Health
Services Administration in particular for failure to provide adequate
leadership in the development of uniform standards for collecting state,
county, and local data.
"The problem starts at the federal level," said Ron Honberg,
director of policy and legal affairs at NAMI. "We need leadership from
the federal government like never before."
Among the steps needed to improve care, according to the report, is
increased public funding for mental health care services through"
modest" tax increases and dedicated trusts. Systemwide
improvements have been limited by the continuing lack of treatment and
effectiveness data through standardized collection within and across states.
Specifically, the authors called for better reporting on evidence-based mental
health treatment practices and tracking waiting times in emergency rooms.
Psychiatrists likely are already aware of many of the shortcomings of the
state mental health systems within which they work, including the lack of
patient-centered care, Pandya said. However, he hoped that the report will
provide more comprehensive information on the needs of each state that
psychiatrists can use to advocate for improvements where they live and