The Interim Report Condensed To Six Bullet Points

Last April, President Bush put together a Commission, "The President's New Freedom Commission On Mental Health" to study the state of mental health care in America, to identify faults and problems in the health care delivery system, and to recommend remedies that could fix these problems. Six months into their one year mission, the Commission has released their interim report. The gist of this report is that the mental health care delivery system is badly broken and needs major reform and overhaul if it is to reasonably address the severe problem of untreated mental illness. Unfortunately, we'll have to wait another six months to find out how the commission thinks things can be fixed.

The report is available on the web at http://www.nami.org/Template.cfm?Section=New_Freedom_Commission&Template=/ContentManagement/ContentDisplay.cfm&ContentID=28321. Because the report is more than four pages long, and because I'm a firm believer that long documents can often be adequately summarized in a page or two of condensed text - I hereby present to you my condensed version of the Interim Report. I've taken the liberty of illustrating my summary with quotes from the report, and have bolded what I think are important statements.

1) The commission thinks that America's mental health care delivery system is really messed up.

"The commission is united in the belief that the mental health service delivery system needs dramatic reform. It is becoming clear that the mental health services system does not adequately treat millions of people who need care. .... The system is fragmented and in disarray - not from lack of commitment and skill of those who deliver care, but from underlying structural, financing and organizational problems. Many of the problems are due to the "layering on" of multiple well intentioned programs without overall direction, coordination or consistency.The system's failings lead to unnecessary and costly disability, homelessness, school failure and incarceration."

2) This is a real problem that should not be disregarded or brushed aside, because mental illness affects so many Americans in a devastating way, creating serious economic and social consequences for individuals, families, towns, cities, states, and the country as a whole. People are getting hurt and money is being wasted.

"Mental Illness is shockingly common, affecting almost every American family - directly or indirectly. It can strike a child, a brother, a grandparent, or a coworker. It can strike someone of any background - white, African-American, Asian-American, Pacific Islander, Hispanic American, or Native American. It can strike at any stage of life, from childhood to old age. No community is unaffected, no school or workplace untouched."

"... when compared with other diseases (such as cancer and heart disease), mental illness ranks first in terms of causing disability in the United States, Canada and Western Europe, according to a study by the world health organization. This groundbreaking study found that mental illness (including depression, bipolar disorder and schizophrenia) accounts for 25% of all disability across major industrialized countries." ---- and this is without counting alcohol and substance abuse disorders as mental illnesses. Substance abuse is responsible for about 12% of disability claims - so in combination, mental illnesses and substance abuse disorders would account for 37% of all disability - the largest cause by a mile (kilometer?) of all disability cases.

Because appropriate care is difficult to obtain, persons with serious mental illnesses often end up being served by institutions not suited to care for their needs (e.g., "nursing homes, jails and homeless shelters"). "The rates of serious mental illness among incarcerated persons are about 3 to 4 times those of the general US population".

3) We, as a nation, are capable of providing adequate care. We already have the technologies and the means to treat mental illness effectively. We also now know that mental illnesses are real illnesses (just like physical illnesses), and not just moral weaknesses.

"There are many effective treatments for mental illness, according to the landmark 1999 report, Mental Health, A Report Of The Surgeon General. With effective treatment, services, and the support of families friends and communities, the possibility of recovery is no longer elusive."

4) And yet - because our health care delivery system is so messed up, disorganized, and under-funded, and because of prejudicial societal attitudes- more than half the people who need mental help are not receiving it.

"About one out of every two people who need mental health care do not receive it" due to "unavailable" or "inadequate" care.

"Many people are reluctant to seek care because of the shame our society attaches to mental illness."

"For ethnic and racial minorities, the rate of treatment is even lower than that for the general population, and the quality of care is poorer. After thorough study of the problem, the Surgeon General's report concluded that minorities, in comparison to whites, bear a greater burden from unmet mental health needs and thus suffer a greater loss to their overall health and productivity"

Specifically, the commission names several issues that prevent or inhibit efficient mental health care from being available, including that the health care system is administered by a literal patchwork of different programs and agencies which cannot provide coordinated care, that there is inadequate funding made available for treating and managing mental health care, and that as a society, we still tend to stigmatize and discriminate against persons with mental illness, further exacerbating the problem by shaming people into not seeking needed care, and by making it difficult for mentally ill people to maintain employment or to be adequately insured. While the interim report doesn't specifically mention that health insurance companies typically do not provide 'parity' payments for mental illnesses vs. physical ones (physical illnesses are allowed to be claimed more often, and are reimbursed at a much higher rate than mental illnesses), the failure for insurance companies to provide parity is another example of the societal discrimination that they do mention.

5) The commission identified five problems creating barriers that preventing people from receiving care:

• Fragmentation And Gaps In Care - For Children
  

  There are too many different programs serving children, they are too specialized, and there is little communication amongst them. There is no easily accessible and accurate map for where to locate these different programs. The paperwork is staggering. Many programs are under-funded or overwhelmed and cannot efficiently do their jobs.

  "The Commission has heard from families whose children could not get an accurate diagnosis for years and for whom the maze of "helping" programs is 'opaque'..."

 

• Fragmentation And Gaps In Care - For Adults With Serious Mental Illnesses

  The same fragmentation of care problems that plagues service delivery for kids is at work for adults with serious mental illnesses (schizophrenia, bipolar disorder, severe depression). There is little coordination amongst programs, they are hard to locate and pin down (especially for cognitively compromised individuals!), and they are underfunded and overwhelmed. The result is that many people with serious illnesses end up on the street or in jail.

  ...Less than 40 percent of those with serious mental illness receive stable treatment. An estimated 25 percent of homeless persons have a serious mental disorder and, for the most part, do not receive any treatment. Among those who are"chronically homeless," the prevalence of mental illness is even higher.

 

• High Unemployment And Disability For People With Serious Mental Illnesses

Mentally ill people who do not receive adequate treatment are at a very high risk of becoming unemployed. The costs of providing disability payments (both economically, and in terms of self-esteem) are higher than what it would cost to provide adequate treatment and support.

"Our review finds a shocking 90 percent unemployment rate among adults with serious mental illness-the worst level of employment of any group of people with disabilities. Strikingly, surveys show that many of them want to work and report that they could work with modest assistance. Instead, our Nation's largest "program" for people with mental illness is disability payments".

 

• Older Adults With Serious Mental Illnesses Are Not Receiving Care

  Screening programs to identify Depression and other mental illnesses in elderly populations are inadequate, and access to care for those who are identified is also inadequate. Results include increased disability and even suicide.

  "Older men have the highest rates of suicide in the Nation."

   

• Mental Health And Suicide Prevention Are Not Yet National Priorities

  America has largely failed to take suicide prevention seriously. As a result:

  "Over 30,000 lives are lost annually to this largely preventable public health problem. About ninety percent of those who take their life have a mental disorder. Many have not had the care in the months before their death that would help them to affirm life."

6) For each of their five identified problems, the Commissioners briefly describe creative and successful ways that some states and organizations have developed to manage each problem. For example, a Nurse-Family Partnership program is described wherein a registered nurse is funded to visit high-risk expectant mothers beginning in pregnancy and continuing for the first year of life, teaching these women how to responsibly care for their child. In another program, mentally ill persons are helped to find employment by a specialized counselor who helps them with the job search process, and who provides ongoing work-related counseling. As described, the results of this later program were encouraging, with 60-80% of participants finding and maintaining work. The Commission's message is clear. It is indeed possible to do a much better job treating and supporting mentally ill persons than we are currently doing. However, accomplishing this will require a radical, almost ecologically minded, rethinking of how services are coordinated and funded.

Tune in six months from now to see what "bold" proposals these brave commissioners come up with to address this most complex and difficult set of problems. And then hang around to see if anyone in power ever actually implements any of these recommendations.

Impressions

Any mental health care worker will tell you that they've known for years and years that the mental health care system in America is in crisis. This report is not for us health care workers, however, but rather to raise the general public's awareness of these issues, and hopefully to serve as a basis for the government to act upon for the better. I expected the report to conclude that the funding and availability of care situations were in shambles. What I did not expect (and what was really nice to see!) was the way that mental illnesses were described in an environmental perspective, including not just the biological and psychological aspects of illness, but also the social and economic consequences of illness. It is not really enough to treat a brain illness in isolation if the course of the illness has also crippled a patient's social and occupational functioning. Effective solutions to mental health care delivery must address homelessness, crime (and the lack of adequate mental health treatment in jail), broken relationships, unemployment, and discrimination in addition to biology and dysfunctional thinking patterns. It is just a fact that treatment of mental illness must address afflicted people holistically - considering their biology and psychology, and also their access to social support and a decent place to live, and even their spirituality - if it is to be optimally successful. I'm glad to see this principle recognized in this Interim Report.

What will the fate of this report be? Will it actually lead to anything, or will it just be a bunch of bits on a computer or a few scraps of paper - a bit of sound and fury with an important story to tell that no one takes seriously. I firmly believe that people in the government want to help fix this situation, but I don't quite see how it will ultimately be politically expedient for powerful politicians like President Bush to do anything about this particular health crisis. Political decisions just don't get made for sound humanitarian or economic reasons. There doesn't appear to be enough of a special interest power base pushing for reform here to really make a difference. And there are many rich special interests (the health insurance companies for one) arrayed against truly reforming our very broken system. I'd be surprised and very pleased if President Bush actually does anything with this mental health project of his. It sounds awfully good so far, but I won't be counting on these chickens until they are hatched.

What do you think?

• Link to the Interim Report