Mental Health, United States, 2004: Index

Ted Lutterman
National Association of State Mental Health Program Directors Research Institute, Inc.

Introduction

In 2002, President George W. Bush appointed a 15-member Commission to examine the mental health system in the United States. The charge to the President’s New Freedom Commission on Mental Health was to undertake an in-depth review of the public/private mental health system and make recommendations on steps to achieve an effective mental health system in the United States. This 15-member Commission with its seven ex-officio Federal participants spent a year examining all aspects of the U.S. mental health delivery system. The Commission used public hearings, site visits, written and oral testimony from experts, and comments and concerns received through the Internet. After 6 months, an interim report to the President stated that “the system was in shambles” and identified substantial fragmentation as a barrier to access to care for children, adults, and older adults. Analysis of all the reports and findings seemed to suggest that the only way to create an effective and efficient mental health system was to fundamentally transform the system, not merely make minor changes to the existing system.

State Mental Health Agencies (SMHAs) Are Making Substantial Progress Toward Achieving the Major Goals of the Commission

Findings

In order to achieve this fundamental transformation, the Commission developed a plan that included six goals and 19 recommendations. It was the Commission’s belief that these recommendations needed to be seen in totality since they were interrelated. The overarching principles in the findings emphasized that the mental health system needed to be equivalent to the public health system, with better access for all, equity in treatment and funding, and a reduction of stigma. Findings suggested that too often the mental health system was built around a delivery and payment system instead of the needs of mental health service recipients and their families, resulting in frequently unsatisfactory outcomes. Further findings pointed to the public mental health system’s failure to employ evidence-based practices or the newest technologies and confirmed that a person’s race, ethnicity, or geographical location could compromise his or her access to services. The Commission’s findings and recommendations pointed out the benefits of early detection and the need for community-based services and supports, as opposed to a crisis-oriented system that often responds only years after the first appearance of symptoms.

The report’s six goals were broad-based, visionary expressions of what a transformed mental health system would look like. Its 19 supporting recommendations were drafted to apply to almost anyone with a stake in the public system, whether at the local, State, or Federal level. The Commission appears to have wanted to change perceptions about mental health service delivery almost as much as it did certain practices. In the 2 years since the report, the Commission’s work has had an impact on the thinking and the language of many involved with publicly funded mental health services. In particular, the concept that “recovery is possible” and the recommendation of a “consumer- and family-driven” system have captured considerable attention.

For practical application of the recommendations (table 11.1), the Commission looked to the Federal Government for leadership but to local and State governments and advocacy at all levels for the energy to ensure transformation of mental health service delivery in the Nation. The recommendation most clearly targeted to the Federal Government was recommendation 2.3: Align relevant Federal programs to improve access and accountability for mental health services. Under the direction of the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Mental Health Services, Federal agencies have inventoried programs that impact the delivery of mental health services. A workgroup of Federal agency representatives meets regularly to examine ways to ensure consistency in the government’s approach to meeting the needs of consumers and families affected by mental illness and mental health disorders.

In reality, the States can most readily act to implement the Commission’s recommendations. Indeed, the most concrete recommendation of the Commission was the creation of a comprehensive mental health plan in each State. The Commission saw the comprehensive State mental health plan as knitting together the disparate elements that in most States contribute to the sense of fragmentation highlighted in the Commission’s Interim Report. The Commission envisioned several purposes behind developing a comprehensive plan in each State. A comprehensive plan would promote partnerships between State agencies and among the broad range of stakeholders in the system. It would help to ensure more coordinated use of existing resources. Most important, it would enable stakeholders to assess the strengths and weakness of the existing array of services and provide a framework for creating a robust set of relationships and developing the full range of services contemplated by the Commission.

While some of the Commission’s goals were oriented toward action by the Federal Government, many are actionable by State governments and specifically by State mental health authorities (SMHAs)—the lead agencies on mental health services in each State. SMHAs are responsible for developing comprehensive mental health systems and serve as the Nation’s safety net for the provision of mental health services to adults with serious mental illnesses and children with serious emotional disturbances. Collectively, the SMHAs serve 6 million individuals with mental illnesses each year (CMHS, 2004) and expend $26 billion (National Association of State Mental Health Program Directors Research Institute, Inc., 2005) each year to pay for these mental health services.

Most SMHAs have embraced the Commission’s report and recommendations as a road map for their own efforts to improve the quality of their mental health systems and to guide their transformation activities. After the Commission released its final report, the SMHAs, through the National Association of State Mental Health Program Directors (NASMHPD), collectively endorsed the goals in an official policy statement (NASMHPD, 2003).

To help States initiate development of comprehensive plans, the Federal Government invited applications for Mental Health Transformation State Incentive Grants (MHT-SIG). Administered by CMHS, this grant program requires Governors’ offices to oversee planning and system development through creation of Transformation Working Groups whose members and chairs they appoint. The MHT-SIG program places a premium on collaboration, with a clear goal in mind: “The intended outcome of Comprehensive State Mental Health Plans is to encourage States and localities to develop a comprehensive strategy to respond to the needs and preferences of consumers or families…. The final result should be an extensive and coordinated State system of services and supports that work to foster consumer independence and their ability to live, work, learn, and participate fully in their communities” (New Freedom Commission on Mental Health, 2003, p. 44).

As focused as the MHT-SIG program may be on advancing the specific goals of the Commission report, it will not immediately bring resources to all States. Some States wishing to move forward with a transformation agenda have begun developing their comprehensive State plans without benefit of these Federal grants. That many States have started down this road independent of Federal funding demonstrates the broad consensus that new, more comprehensive approaches to mental health service delivery are needed.

As SMHAs have embraced the Commission’s principles and goals and begun to fundamentally retool their mental health systems based on principles of recovery, client and family-centered services, and emphasis on coordinated services in the community, they have encountered the critical issue of collection and appropriate use of data. SMHAs realize the importance of information and data in both program development and in delivery of quality services. Therefore, SMHAs must make conscientious decisions to view data and information as a product that should be readily available, proactive, and transparent. The Commission believed that data could no longer be seen as an afterthought or an irritating burden of “completing the paperwork”; rather, data must be an integral and powerful part of system transformation. Since the release of the Commission’s report, the States have made a concerted effort to collect and disseminate data to help support and illuminate the report’s six goals.

The National Association of State Mental Health Program Directors Research Institute, Inc. (NRI) and NASMHPD have been working with the States to document their work to transform their systems and implement the Commission’s goals. The information being compiled by NRI through its CMHS-supported State Profiles System is publicly accessible to help States and advocates transforming systems.

State Profiling System

NRI maintains several databases about SMHAs. The SMHA Profiling System, funded under a contract from CMHS, provides a central database of information describing the organization, funding, operation, services, policies, statutes, and consumers of SMHAs. This database describes each SMHA’s organization and structure, service systems, eligible populations, emerging policy issues, number of consumers served, fiscal resources, consumer issues, information management structures, and the research and evaluation it conducts. Questions within each component are designed to address specific needs of SMHA managers and others interested in public mental health systems, and to support decision making, policy analysis, research, and evaluation.

An advisory group consisting of SMHA commissioners, planners, researchers, consumers, and Federal officials guides the Profiles content. The advisory group meets annually to review results of prior Profiles cycles, discuss and identify emergent issues facing the States, and develop priority questions and areas for the next cycle. The Profiles contents are selected to meet the following uses by States and others:

The Profiles Advisory Group recommended that information about SMHAs was needed in the following 11 broad content areas that form the basis of the State Profiling System.

New Freedom Commission on Mental Health (NFC): Focuses on the State activities related to the six goals for transforming mental health systems from the President’s New Freedom Commission Report. These goals are the focus of major systems change in many States and by Federal agencies.

Organization and Structure Component: Contains information on the location and general functions of the SMHA within the context of State government, including the organizational location of the SMHA within State government and of other State agencies under the same umbrella; to whom the SMHA commissioner/director is accountable; responsibility for a variety of mental health services, including State mental hospitals, community mental health programs, and forensic programs; ways in which community-based mental health services are funded; and the role of cities and/or counties.

Policy Component: Contains information on priority clients and mandates for core services; other service system requirements, standards, and future directions; activities relating to downsizing, closing, or consolidating State mental hospitals; privatizing components of the public mental health system; and major legal issues involving the SMHA.

Client Component: Contains aggregated data characterizing individuals served by the SMHA in State mental hospitals and community-based programs.

Services Component: Describes the nature of the service system supported by each SMHA in three broad areas. (1) SMHA service system issues include the types of services offered by the SMHA in State hospitals and community programs, the definitions of these services, linkages of services among institutions and communities, and the role of different services within the SMHA’s desired service system. (2) Linkages to other State services systems include information about the linkages between the SMHA mental health system and other State agencies that provide services for individuals with mental illness. (3) Information on the implementation of various evidence-based practices by SMHAs is a new focus in this component.

Forensic Component: Contains information about the organization and delivery of services to forensic clients by the SMHA and the relationship of the SMHA to the criminal justice systems in each State.

Workforce Component: Staffing levels of State-operated and State-funded mental health services provider organizations; minority workforce issues; client to staff ratios; recruitment, training, and retention of staff; salary levels; and workers’ compensation.

Financial Component: Includes the forms and information necessary to complete the annual SMHA-controlled Revenues and Expenditures Study plus information about the resources available to the SMHAs and the States to fund the delivery of mental health services.

Managed Behavioral Health Care: The use of managed care to deliver public mental health services, the roles of Medicaid waivers, and how traditional SMHA-funded providers interact with managed care organizations.

Research and Evaluation Component: Organizational locus of the research and evaluation functions and their funding and staffing levels.

Information Management Component: Current status of the information management function and its development over time. The component provides for a systematic compilation of the organizational placement of information management functions, the level of integration of these functions, and their funding and staffing.

To minimize the response burden on SMHAs, the following criteria were developed to determine what information should be maintained in the Profiling System:

The key new area in the latest cycle of the profiles is a focus on the New Freedom Commission’s six goals for transforming mental health. The Profiles have compiled information on the activities of SMHAs to implement major portions of each of the six goals. Individual State responses to the Profiles are available on NRI’s Web site at www.nri-inc.org. On the Profiles Web site, users can access State responses by keyword, by State, and by special topical reports.

The Profiles System’s databases from 1996 to the present are accessible online and include both quantitative data (such as mental health services data and SMHA revenues and expenditures data) and qualitative information (such as policies and administrative practices). Data from every State, the District of Columbia, and Guam depicting their systems in 1996, 1999, 2001, 2002, and 2004, as well as topical reports for each year, are accessible via NRI’s Web site.

National Activities to Implement the Commission’s Goals

The Commission’s report has provided a rallying point for considerable activity in the mental health community. Not only has it created a road map for the CMHS and its sister Federal agencies, it has simultaneously provided a standard for State-initiated activity, and it has given the notably fractious mental health advocacy community a set of principles on which many key organizations can agree.

As the only Federal agency solely focused on the provision of mental health services, CMHS was tasked with implementing the Commission’s recommendations at the Federal level. For CMHS, this has meant the initiation of several new activities. CMHS and its director have developed an inventory of mental health services supported by all Federal agencies. Working from that inventory, they have attempted to identify both gaps and redundancies in service delivery. CMHS has taken responsibility for convening a working group composed of representatives from a wide array of Federal agencies, and that working group has continued to meet on a regular basis since the Commission report was delivered.

To provide more effective leadership on its transformation agenda, CMHS also has undertaken an internal reorganization effort. In part, this realignment is meant to signal a shift from “business as usual” to a posture that will ensure the agency’s ability to keep up the momentum created by the Commission report.

Most publicly, CMHS has been tasked and funded by Congress to develop a program of Mental Health Transformation State Incentive Grants (MHT-SIG) for which States, territories, and federally recognized tribes could apply. The MHT-SIG was funded in the Federal budget for FY 2005, and it is anticipated that the program will continue to be a centerpiece of CMHS efforts for at least 5 years. In the first year there is enough funding (approximately $18.5 million) for six to eight grantees to receive $2 to $3 million each. It is expected that two to three new grantees will be added in FY 2006.

The purpose of the MHT-SIG is to enable States, territories, and tribes to plan for and develop infrastructure that will enable them to create the Comprehensive State Mental Health Plans recommended by the Commission. The MHT-SIG asks States to create Mental Health Transformation Working Groups chaired by appointees answerable directly to the office of the Governor or, in the case of territories or tribes, the entity’s designated chief executive. The idea is that it will take the attention of the chief executive to bring the disparate players in the mental health field to the table with the purpose of coordinating mental health service delivery in that jurisdiction. In their applications for the grants, States were asked to demonstrate the degree to which appropriate parties already were collaborating and working toward development of a comprehensive State plan, as well as to lay out in detail how a grant award would help them move forward with the planning process.

The MHT-SIG and, indeed, the work of the Commission both built on considerable activity already taking place in many States. While the Commission introduced the concept of mental health system transformation and placed particular emphasis on development of a statewide mental health plan, policy makers in a number of States had already concluded that the system was in need of repair. Starting in 1999 in no fewer than 13 States, commissions or task forces had been convened by the Governor, legislature, or a State oversight agency to study the mental health system and make recommendations for its reform.

The trend of State-level reform has continued since the Commission issued its report. Whether initiated by SMHAs or through actions of the Governor, major efforts to improve mental health service delivery are under way in most States. In some instances, a close examination of mental health service delivery was prompted by the State budget crises that crested in 2003; in others, the effort resulted from recognition that other State systems, especially corrections, were bearing a burden resulting from the failures of the mental health system.

The Commission report also spurred unusual advocacy activity at the national level. In recognition of the opportunity presented by the Commission’s work, 16 national associations and advocacy organizations came together to develop a robust Federal policy agenda and a strategy for implementing it. Creating the Campaign for Mental Health Reform,¹ the groups demonstrated an ability to collaborate rarely seen in the past in the mental health advocacy community. Creation of the campaign showed the degree to which advocates were invested in the central themes of the Commission report, as well as their conviction that “business as usual” would not result in changes in Federal policy that would ensure adoption of the Commission’s recommendations. The campaign partners embraced the Commission report as a platform on which to continue to build as mental health transformation efforts gathered steam. The campaign provided considerable advocacy in support of the MHT-SIG program as well as the Mentally Ill Offender Treatment and Crime Reduction Act, which created a grant program within the Department of Justice for the diversion and reintegration of persons with mental illness who come into contact with the criminal justice system. The campaign’s collaborative approach signaled to the broader field and to policy makers that the transformation agenda has found acceptance among the mental health system’s stakeholders and, more important, that they are willing to set aside their differences to work on its behalf.

State Activities to Implement the Commission Goals

As described above, the 2004 cycle of NRI’s State Profiling System was redesigned to compile information from the SMHAs about their activities related to each of the six goals. The State responses to each of the goals are listed below.

Goal 1: Americans Understand Mental Health Is Essential to Overall Health Care

The Commission’s first goal is to reduce the stigma and discrimination related to mental illnesses and increase the public’s understanding of mental illnesses. With the elimination of stigma and a better understanding of the fundamental role of mental health to overall health care, the public will seek care earlier and more often.

Fundamental to increased access is providing better information to Americans about mental illness and better recognition of mental illnesses among primary care providers. SMHAs are traditionally specialty systems that focus their attention on the provision of mental health (and often other disability services). However, many States are now actively working across State governments to increase the recognition and treatment of mental illnesses. For example, 71 percent of SMHAs (32 of 45 States reporting) are collaborating with their State health department and/or Medicaid agency to increase the recognition and treatment of persons with mental illness by primary care providers. These initiatives include providing psychiatric consultation (three States), and providing training and education to primary care providers (seven States).

In addition to efforts to get primary care workers to accurately identify and treat mental illnesses, more than half the States are working with primary care systems to improve the quality of physical health care treatment for individuals with mental illness. Several studies have recently found that the physical conditions of persons with mental illnesses are often not adequately addressed, and that major medical conditions are often not treated (Cradock-O’Leary, Young, Yano, Wang, & Lee, 2002). More than half (56 percent) of SMHAs are working with primary care providers to improve the physical health treatment of persons with mental illnesses (Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Kentucky, Louisiana, Massachusetts, Maryland, Missouri, Montana, New Jersey, Nevada, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Texas, West Virginia).

A second area of focus by more than half the SMHAs is the development of public awareness and information efforts. Sixty percent of SMHAs (27 of 45) have public information campaigns to promote better understandings of the role of mental health in overall health (Arizona, Colorado (adult), District of Columbia, Florida, Hawaii, Indiana, Kentucky, Louisiana, Massachusetts, Maryland, Montana, North Carolina, New Jersey, New Mexico, Nevada, New York, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Texas, Vermont, West Virginia, Wyoming).

The Commission found that stigma related to mental illnesses remains a major impediment to many people seeking mental health treatment: 33 SMHAs (73 percent) report they have public health information campaigns designed to combat stigma with mental illnesses (Alaska, Arkansas, Arizona, California, Colorado, Connecticut, District of Columbia, Delaware, Florida, Hawaii, Idaho, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Maryland, Missouri, Montana, North Carolina, North Dakota, New Jersey, Nevada, New York, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Texas, Utah, Vermont, Wyoming).

Ensuring that private health insurance coverage addresses the needs of persons to receive mental health services is an additional component of ensuring access to services. Although there is no national legislation requiring “parity” in mental health coverage with physical health services, four States report that their State insurance laws mandate mental health insurance benefits, and in 19 these insurance benefits include parity in benefits with physical health care. Eleven States limit benefits to specific mental disorders, four report that parity laws cover all mental health service, and nine have benefits that include both mental health and substance abuse services.

Goal 2: Mental Health Care Is Consumer and Family Driven

The Commission promulgated the objective that all mental health care should be recovery oriented and organized and driven by consumer and family needs, and that every consumer should have an individualized plan of care. SMHAs are already working to achieve these goals through a number of activities (table 11.2).

Recovery Orientation: Every one of the 45 reporting SMHAs has adopted a mission statement or policy about the potential of consumers to recover from their illnesses and is seeking to reorient the mental health system to be more recovery oriented.

SMHA recovery initiatives include drafting recovery mission statements, changing the array of services funded by the SMHA, working with consumers and families to promote recovery concepts, and moving toward evidence-based practices.

Individualized Treatment Plans: SMHAs are taking action to reduce this fragmentation and to move their systems to reflect the desires of mental health consumers to recover and direct their own care. Ninety-five percent of SMHAs (39 States) have initiatives to ensure that every consumer receives an individualized, person-centered treatment plan that meets his or her unique needs. To monitor the development and implementation of these individualized treatment plans, 29 SMHAs receive information on individualized treatment plans from community mental health providers.

SMHAs involve consumers and family members in the SMHA’s policymaking, quality assurance, and research and evaluation activities. The Profiles compiled information on the types of involvement that SMHAs have for consumers and family members (table 11.3).

The Commission identified as a major problem with the provision of comprehensive consumer-directed mental health services the fact that the provision of services is fragmented among many different funding and service delivery systems. As a result, the provision of care is often driven more by eligibility and funding considerations than by the desires and needs of families and consumers of mental health services. Consumers often are subject to multiple eligibility determinations to receive services, and the services they receive may be determined more by what funding sources will pay for than by what the consumer actually needs or wants.

Over half the SMHAs (24 of 25) are developing a comprehensive State mental health plan that spans multiple State government agencies and addresses the mental health services and essential supports provided by State agencies other than the SMHA. All SMHAs (46) include representatives of other State government agencies in the SMHA’s mental health planning council.

Most SMHAs are working with other major State government agencies to reduce fragmentation in mental health services and improve access to services (table 11.4): 39 States are working with housing, 39 with Medicaid, 37 with juvenile justice, and 37 with corrections.

Persons with mental illness often need more than just mental health services in order to live productive lives in the community. As a result, many SMHAs are working with consumers to provide vocational and housing supports to assist them in their recovery. Finding decent and affordable housing is a major issue for most SMHAs. SMHAs identified the following major barriers to addressing consumer housing needs:

Most SMHAs (65 percent) have a housing plan (a delineated set of strategies to address the housing needs of persons with mental illness). There are housing specialists/coordinators responsible for increasing affordable housing opportunities for persons with serious mental illnesses within the SMHA in 32 States, within the State housing agency in 11 States, and within both agencies in nine States. In 38 States, the SMHA supports or collaborates with community development corporations or local housing authorities. In 26 States, the local mental health authority works with these local housing authorities.

SMHAs have established working interagency relationships with the other major State agencies responsible for the development of housing: 90 percent (35 States) with the State housing finance agency, 31 States with the State department of housing/community development, 25 with the State affordable housing coalition, and 38 with the State coalition for homeless persons.

A major problem identified by the Commission regarding the provision of mental health service to children was that too many parents have to relinquish the custody of their children to the State government so their children can receive publicly funded mental health services. The Commission called for policy changes to eliminate the need for parents to relinquish custody of their children in order for them to receive services. States have already been working to ensure this change: Twenty-eight SMHAs have laws or policies designed to keep parents from having to relinquish custody of children in this situation (Alaska, Alabama, Arizona, Colorado, Connecticut, District of Columbia, Delaware, Florida, Georgia, Illinois, Indiana, Kansas, Massachusetts, Maryland, Maine, Minnesota, Missouri, North Dakota, New Jersey, New Mexico, Nevada, New York, Ohio, Pennsylvania, South Carolina, Texas, Utah, Vermont).

Goal 3: Disparities in Mental Health Services Are Eliminated

The Commission found that minority populations are underserved and “that the mental health system has not kept pace with the diverse needs of racial and ethnic minorities, often underserving or inappropriately serving them” (New Freedom Commission on Mental Health, 2003). SMHAs report taking many steps to address the needs of ethnic and minority populations, as well as rural and geographically remote persons with mental illnesses.

Seventy-eight percent (36 of 46) of SMHAs have initiatives to increase access to mental health services in rural and geographically remote areas. And 42 percent (18 of 43) have initiatives to recruit and train mental health professionals to work in rural and remote areas. Seventy-four percent (35 of 47) of SMHAs have initiatives to provide transportation for mental health clients so they can access needed mental health services.

One of the first steps essential to the provision of culturally appropriate services to ethnic and cultural minorities is identifying the needs of these consumers and planning to develop the appropriate mental health services and staff training to meet these needs. A NASMHPD task force has been working on cultural competence issues for several years. The task force has developed a self-assessment instrument for SMHAs and mental health programs to use in moving their cultural competence planning and implementation forward (NASMHPD, 2004).

The State Profiles found that 78 percent of SMHAs (28 of 42) have a cultural competence plan.

Having a mental health services workforce that understands and can provide culturally competent mental health services is an important step to reduce disparities. Many SMHAs are undertaking initiatives to recruit and train minority mental health workers into the public mental health system. Twenty-one SMHAs have initiatives to recruit and train members of minority groups, ethnic groups, or other special populations for work in State-funded mental health programs: Ten have staff recruitment initiatives for blacks/African Americans, seven for Hispanics, six for Asians, five for Native Americans, and four for Pacific Islanders.

In addition to efforts to recruit more minorities into the public mental health system, SMHAs are fostering initiatives to increase the training they provide to minorities in their system: Eight SMHAs have staff training initiatives for blacks/African Americans, six for Hispanics, eight for Asians, six for Native Americans, and seven for Pacific Islanders.

A significant problem for SMHAs in providing quality mental health services is a universal shortage of mental health staff. Of SMHAs reporting 44 of 45 are currently experiencing shortages of mental health staff. Psychiatrists and registered nurses were the professional disciplines for which the largest numbers of SMHAs reported shortages (figure 11.6).

Many (29) SMHAs report they have initiatives to address these staffing shortages: Twenty-four SMHAs are working with universities to increase the training of future staff and increase recruitment into the public sector, 19 are increasing salaries paid in the SMHA system, 17 are providing training at mental h ealth providers, and 14 are providing recruitment bonuses or other financial incentives.

Goal 4: Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice

The Commission report found that “emerging research indicates that intervening early can interrupt the negative course of some mental illnesses and may, in some cases, lessen long-term disability” (New Freedom Commission on Mental Health, 2003, p. 57). As a result, the Commission called for a major increase in the early identification of mental health problems and for making mental health screening and assessment part of routine practice in health care. SMHAs are undertaking a number of efforts to meet these goals.

Thirty-nine of 50 SMHAs (78 percent) have initiatives for the early detection of mental health problems: 39 States for children, 17 for adults, and 17 for older adults (figure 11.7). Thirty-three SMHAs (67 percent) operate or fund prevention/early intervention programs for children, 16 operate or fund such programs for adults, and 10 operate or fund them for elderly persons. Thirty-four of 44 SMHAs (82 percent) work with schools to expand and improve mental health services for children.

Persons with co-occurring mental illnesses and substance abuse disorders often experience difficulty having both of their illnesses appropriately recognized and treated. Thirty-seven of 46 SMHAs (80 percent) require or work with mental health providers to screen for co-occurring mental health and substance abuse disorders. Thirty-one SMHAs operate or fund separate specialized treatment programs for persons with co-occurring mental health and substance abuse disorders.

Twenty-eight of 47 SMHAs (60 percent) require or work with mental health providers to screen for histories of trauma in persons served in the public mental health system.

The Commission documented that the mental health needs of older adults often are recognized or treated adequately. Fifteen of 43 SMHAs (35 percent) have a specialized plan for providing mental health services to older adults (age 65+). Eleven SMHAs offer specialized training to providers regarding older adult mental health service needs and recognition of mental illnesses. Twenty-eight SMHAs work with providers to help them recognize and treat older adults with mental health problems. Twenty-one work with community mental health providers, 22 with nursing homes, 18 with other long-term care settings, 13 with psychiatric hospitals, and eight with primary care providers.

Many persons with mental illness unfortunately fall into the criminal justice system, where their mental health needs are either unrecognized or often inadequately treated. SMHAs have undertaken a variety of initiatives to work with the criminal justice system to help divert persons with mental illness out of corrections programs and into treatment. Forty-six out of 48 (96 percent) of the States reported having at least one mental health court or other criminal justice diversion program for persons with mental illnesses (figure 11.8).

Sixty-seven percent of SMHAs (31 of 45) have at least one mental health court designed to divert persons with mental illnesses from the criminal justice system into mental health treatment. Mental health courts, which are modeled after drug courts, are special courts designed to handle criminal cases of persons with mental illnesses and divert them out of jail or prison and into treatment. These States reported on 178 courts that served 5,251 persons in 2003. Ten of the States have the courts control dedicated resources for services totaling over $1.7 million.

According to the CMHS-funded GAINS Center, “diversion” programs refer to “programs that divert individuals with serious mental illness (and often co-occurring substance use disorders) in contact with the justice system from jail and provide linkages to community-based treatment and support services. The individual thus avoids or spends a significantly reduced time period in jail and/or lockups on the current charge” (http://gainscenter.samhsa.gov/flash/default.html).

Thirty-one States have pre-booking diversion programs to help divert adults with mental illnesses into treatment. Pre-booking diversion programs aim to move people out of the criminal justice system and into treatment before formal criminal charges are made against them. Twenty-eight SMHAs have funded or otherwise promoted pre-booking programs for adults in the past 2 years. Twenty-seven SMHAs have plans to fund or otherwise promote pre-booking programs in the next fiscal year.

Twenty-seven SMHAs have post-booking, pre-adjudication programs to help divert adults with mental illnesses into treatment. These programs are designed to move persons with mental illnesses out of the criminal justice system and into community treatment after charges have been filed, but before they go to court. SMHAs have funded or otherwise promoted criminal justice diversion programs for adults in the last 2 years. Twenty-four SMHAs have plans to fund or promote any criminal justice diversion programs in the next fiscal year.

Twenty-nine of 45 SMHAs support diversion programs for youth with mental illnesses from the juvenile justice system into treatment. Nineteen SMHAs have juvenile justice diversion programs at the intake level, 17 at the adjudication level, and 15 at pre-arrest stages.
Sixty-one percent of SMHAs (27 of 44) have re-entry programs to support prisoners or jail detainees with mental illness and/or co-occurring substance abuse disorders who are returning to the community.

Goal 5: Excellent Mental Health Care Is Delivered and Research Is Accelerated

The Commission set a goal that persons with mental illnesses receive the highest quality mental health services demonstrated effective by research. One major impediment to the provision of quality mental health services is the long delay between the advances in knowledge from research to the implementation of these advances into common clinical practice. The Commission called for concerted action to accelerate research to promote recovery and resilience and to advance the use of evidence-based practices in mental health services.

Most SMHAs (76 percent) are working with academia to move research results into better mental health services. States report a number of initiatives between SMHAs and academia to accelerate the movement of research findings into practice. Examples of these initiatives include establishing “centers for excellence” to work with mental health providers, establishing joint appointments with mental health researchers and mental health policy and clinical providers, and using local academic institutions to provide training to mental health providers. In addition to activities to move research into practice, 61 percent of SMHAs have initiatives to help academia and other researchers to study mental health issues identified by the SMHA.

Ninety-two percent of SMHAs are measuring client outcome measures. The most common client outcome measures being routinely measured by SMHAs for community services are as follows (49 SMHAs -reporting):

The Commission recommended an increase in the implementation of mental health services that have been demonstrated to be effective (evidence-based practices, or EBPs). The NRI’s State Profiles System compiles information on the implementation by SMHAs of the six adult EBPs for which CMHS has developed “toolkits”, as well as for several child/adolescent services that many researchers have identified as having strong research evidence.

Every reporting SMHA is implementing at least one adult evidence-based practice (EBP), and most States are implementing multiple EBPs, with three EBPs being implemented in most States: assertive community treatment teams: 37 SMHAs; supported employment: 37 SMHAs; integrated dual diagnosis programs for persons with co-occurring mental health and substance abuse: 34 SMHAs (figure 11.9).

SMHAs are increasingly offering these EBPs throughout the State and are working to increase the training of mental health providers to deliver EBPs according to practice standards. For example:

SMHAs are using a number of initiatives to promote the adoption of EBPs across their systems (table 11.5).

Goal 6: Technology Is Used to Access Mental Health Care and Information

The Commission established a goal of increasing the use of technology to improve the quality of mental health services and to promote better information about services among consumers and family members. SMHAs are investing in technology to implement this goal:

Forty-seven percent of SMHAs (23) have implemented electronic medical records in either State hospitals or community programs (figure 11.10). Most of these initiatives are in the community (18), and 13 are in State psychiatric hospitals.

Seventeen SMHAs have implemented electronic medication ordering systems for their State psychiatric hospitals, and four States have implemented them with community mental health providers.

Eighty-one percent of SMHAs (38 of 47) promote the use of telemedicine to provide mental health services (figure 11.11). To help promote the use of telemedicine services, 10 SMHAs reimburse providers for providing these telemedicine services, and 25 State Medicaid agencies reimburse for mental health telemedicine services. In addition, three States have changed State licensure or scope-of-practice restrictions to promote and encourage the use of telemedicine.

SMHAs have many initiatives to make information about recovery, self-help services, and data on services available to consumers, family members, and advocates via the Internet:

Seventy-two percent of SMHAs (33) survey consumers to assess the extent to which services did or did not achieve the self-defined goals of recipients. Twenty-five SMHAs make these survey data public, and 23 SMHAs use these data in policy decisions.

Next Steps/Future

The Profiles information about SMHA activities related to the Commission goals demonstrates that the States have embraced the goals and challenges of the Commission report as a road map to transform their systems. States are in the midst of major changes in the way they organize, fund, and deliver mental health services.

The Profiles Technical Advisory Group met during the spring of 2005 and has refined the information compiled by the NRI related to the six goals. The NRI will be updating the Profiles information on State implementation of the Commission goals during the fall of 2005. The updated information will become available on the NRI’s Web site as of spring 2006.

The NASMHPD commissioners have committed to making information and data more accessible to consumers, family members, and advocates, to allow all interested groups to better understand systems and work toward achieving quality and appropriate mental health services for all who need them. We hope that the information contained in this chapter, as well as the State Profiles System information, can be used as instruments of transformation within State government to help drive the changes States are making. The information can be used to identify other States that have initiatives similar to those being considered in a State, and to organize and help develop technical assistance across States.

The full State Mental Health Agency Profiles database on the implementation of the six Commission goals are available via the NRI’s Web site at www.nri-inc.org. Using the Profiles Web site, interested users can search by State or by keyword to find out what each of the States are accomplishing on the specific issues described above.

References

CMHS Uniform Reporting System (2004).

3 Cradock-O’Leary, J., Young, A. S., Yano, E. M., Wang, M., & Lee, M. L. (2002) Use of general medical services by VA patients with psychiatric disorders.

National Association of State Mental Health Program Directors Research Institute, Inc. (2004). Cultural competency: Measurement as a strategy for moving knowledge into practice in state mental health systems: Final report. Alexandria, VA: Author.

National Association of State Mental Health Program Directors Research Institute, Inc. (2005). Funding sources and expenditures of state mental health agencies: Fiscal year 2003. Alexandria, VA: Author.

National Association of State Mental Health Program Directors Research Institute, Inc. (2003). Position Statement on the President’s New Freedom Commission on Mental Health. Alexandria, VA: Author.

The President’s New Freedom Commission on Mental Health. (2003). Achieving the promise: Transforming mental health care in America. Final report. DDHS Pub. No. SMA-03-3932. Rockville, MD: U.S. Department of Health and Human Services.

Note: Connecticut has two separate State agencies responsible for mental health: a child and adolescent agency and an adult agency. The counts of SMHAs shown in this report may reflect responses from both.

Chapter 11

State Mental Health Agency Implementation of The New Freedom Commission on Mental Health Goals: 2004