Appelbaum Urges Senate To Halt Piecemeal Fixes

Paul Appelbaum, M.D., looked back to the 1960s to answer key questions raised by Sen. Mike DeWine (R-Ohio) at a congressional hearing last month about recommendations of the New Freedom Commission on Mental Health.

DeWine is chair of the Subcommittee on Substance Abuse and Mental Health Services of the Health, Education, Labor, and Pensions Committee, which sponsored the hearing.

“You have said the recommendations are helpful, but they fall short of the fundamental transformation that is so clearly needed,” he said. “How do they fall short? What would it take to bring about that transformation?”

Appelbaum replied that the typical approach to mental health reform has been to target a high-visibility problem with piecemeal approaches for a short period. The government funds model programs to address an immediate crisis, but they have little long-range impact on the viability of the system as a whole.

“Five years later,” he said, “we are back in the same place or the total system has contracted.”

Appelbaum urged committee members to use a systematic approach to reform. “In the early 1960s, which was the last time we thought systematically, we came up with a good plan,” he said.

The Community Mental Health Act of 1963 divided the country into catchment areas, each of which was served by a mental health center. Residents knew where to go for mental health services. The problems of fragmentation and transitioning between services because of age were minimized or nonexistent.

“It was a terrific concept,” he said, which ultimately faltered because federal funding for mental health services was converted into a block-grant program for states and because states did not pick up an adequate share of the costs.

The most frequent note at the hearing was frustration about the likelihood of change and concern about the current plight of the mental health system.

Sen. Edward Kennedy (D-Mass.), the subcommittee’s minority chair, reminded the audience of the numerous reports, such as that of the Carter Commission in 1978, that had also identified serious problems with the mental health system.

“We’ve seen the documentation,” said Kennedy. “It’s coming down to whether or not we have the will to bring about change. Our failure to [create a viable mental health system] is one of our most serious public policy failures.”

Kennedy posed a series of questions to Stephen Mayberg, Ph.D., director of the California Department of Mental Health and a member of the New Freedom Commission on Mental Health. “What does the report tell us about what we need to change? Is it resources? Is it public policy? What are the real roadblocks? Are they entrenched interests? If it’s us, we need to know.”

Mayberg replied that fragmentation of services and uncoordinated “silos” were major problems. He urged that consumers of mental health services be given information that would empower them to access services. The New Freedom Commission has also recommended that states take a more active role in planning and promoting coordination.

Sen. Hillary Rodham Clinton (D-N.Y.) said, “My greatest fear [about the report] is that nothing will come of it. . . .We can send a lot of money to governors’ offices and tell them to get people together and show results. But five years later we will be in the same place.”

She added that past advances are being undercut in many states because of fiscal constraints and that an increasing number of people with mental illness are ending up in jails and prisons.

Clinton asked, “Is it fair to say that the 1960s and 1970s were decades of deinstitutionalization, and the 1980s and 1990s were decades of incarceration?”

In his written testimony, Appelbaum charged, “After three decades of neglect and progressive defunding, the mental health system finds itself mired in crisis.”

He presented several scenarios depicting problems of access and recommended the “integration of treatment for most mental disorders into the primary care medical system.” To address the needs of people with serious mental illness, Appelbaum urged reinvigoration of President John F. Kennedy’s vision that led to the Community Mental Health Act of 1963.

Michael M. Faenza, president and CEO of the National Mental Health Association, concurred with criticism about the mental health system, saying, “In my 30 years in the field, this is the worst time for mental health.”

Charles Curie, M.A., administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), described plans to respond to recommendations in the report and introduced Kathryn Power, M.Ed., the new director of the Center for Mental Health Services, who will lead the effort.

SAMHSA is developing a “to do list” that is built around the six goals and 19 recommendations in the report. A draft action agenda is scheduled to be completed within the next 60 days. ▪