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President's Commission Recommends Transforming Mental Health System

Cover of Achieving the Promise: Transforming Mental Health Care in America, Final Report, July 2003 President George W. Bush's New Freedom Commission on Mental Health issued its final report, Achieving the Promise: Transforming Mental Health Care in America, as part of a week-long recognition in July of the anniversary of the Americans with Disabilities Act. The product of a year of study, the report finds that the Nation's mental health care system is beyond simple repair.

Building on research, expert testimony, and input from over 2,300 consumers of mental health services, family members, service providers, and others, the report concludes that "traditional reform measures are not enough. . . ." Instead, it recommends a wholesale transformation that involves consumers and providers, policymakers at all levels of government, and both the public and the private sectors.

Commission Chair Michael F. Hogan, Ph.D., Director of the Ohio Department of Mental Health, declared, "The time has long passed for yet another piecemeal approach to mental health reform. For too many Americans with mental illnesses, mental health services and supports they need are disconnected and often inadequate. The Commission has found that the time has come for a fundamental transformation of the Nation's approach to mental health care."

He added, "This report provides the President with a roadmap for that transformation. The destination is recovery. We ask consumers, family members, service providers, other members of the mental health community, and all Americans to join us on that journey."

The Commission finds that the current system is unintentionally focused on managing the disabilities associated with mental illness rather than promoting recovery, and that this limited approach is due to fragmentation in the provision of services, gaps in care, and uneven quality of services. These systems problems frustrate the work of many dedicated staff, and make it much harder for people with mental illness and their families to access needed care. Instead, the Commission recommends a focus on promoting recovery and building resilience—the ability to withstand stresses and life challenges.

The approach recommended by the Commission will move toward full community participation for children and youth, adults, and older Americans with mental illnesses—instead of school failure, institutionalization, long-term disability, and homelessness. The Commission presents the President with six goals and a series of specific recommendations for Federal agencies, states, communities, and providers nationwide. Working through both the public and private sectors, the recommendations would achieve the needed transformation in care and put limited resources to their best use.

Commission goals underscore the urgency and magnitude of the proposed changes. The Commission believes that Americans must come to understand that mental health is integral to their overall health, and recommends that mental illnesses be addressed with the same urgency as other medical problems. The stigma attached to mental illness, which discourages people from seeking care, must be eliminated.

The Commission finds that transforming mental health care demands a shift toward consumer- and family-driven services. Consumers' needs and preferences, not bureaucratic requirements, must drive the services they receive. To achieve that goal, the Commission recommends changing Federal programs, upgrading state responsibility for planning effective services, and placing consumers and their families at the center of service decisions.

Members of minority groups and people in rural areas, the Commission finds, have less access to care and often receive services that are not responsive to their needs. As a result, the burden of mental illness is heavier for these individuals. The Commission urges a commitment to services that are "culturally competent"—acceptable to and effective for people of varied backgrounds.

The Commission's review finds that too often, mental illness is detected late not early. As a result, services frequently focus on living with disability, not the better outcomes associated with effective early intervention. Therefore, the Commission recommends a dynamic shift in care, moving toward a model that emphasizes early intervention and disability prevention. The report notes that, "early detection, assessment, and linkage with treatment and supports can prevent mental health problems from compounding and poor life outcomes from accumulating."

Achieving this goal will require greater engagement and education of first-line health care providers (e.g., primary care practitioners) and a greater focus on mental health care in institutions such as schools, child welfare programs, and the criminal and juvenile justice systems. The goal is integrated care that can screen, identify, and respond to problems early. The Commission also notes that a majority of adults—even those with the most serious mental illness—want to work, but they are held back by poor access to effective job supports, incentives to remain on disability status, and employment discrimination.

The Commission finds that effective services and supports validated by research find their way into practice too slowly. It calls for a more effective process to make evidence-based practices the bedrock of service delivery. This will require that payers of mental health care reimburse such practices, and that universities and professional groups support training and continuing education in research-validated interventions. Acknowledging significant progress in research on mental illnesses, the panel urges the elimination of the 15- to 20-year lag between the discovery of effective treatments and their wide use in routine patient care. It highlights the need for accelerated and relevant research to promote recovery and, ultimately, to cure and prevent mental illnesses.

The Commission recommends that the mental health system move more effectively to harness the power of communications and computer technology to improve access to information and care, and to improve quality and accountability. With strong protections for privacy, these technologies can improve care in rural areas, help prevent medical errors, and reduce paperwork.

Throughout the report, the Commission identifies private and public sector model programs that provide examples of how aspects of mental health care have been transformed in selected communities.

These examples of innovation—across America, across the age span, and addressing many needs—illuminate how dramatic change is possible, and serve as beacons for the broader improvements recommended by the Commission.

Responding to the release of the report, U.S. Health and Human Services (HHS) Secretary Tommy G. Thompson said, "Under the leadership of Charles G. Curie, the Administrator of our Substance Abuse and Mental Health Services Administration, HHS will conduct a thorough review and assessment of the recommendations in this report. This work will be important not only in improving our service to those with mental illness and their families, but also as part of our commitment to make every segment of the Nation's health care system work better and work together for all Americans."

Mr. Curie added, "It is SAMHSA's honor to have been asked by Secretary Thompson to undertake the Administration's first review and response to this historic document. The report reminds us that mental illness is a treatable illness and that recovery is possible. As a compassionate Nation, we cannot afford to lose the opportunity to offer hope to those people fighting for their lives to obtain and sustain recovery."

The President's New Freedom Commission on Mental Health was established by Executive Order 13263 on April 29, 2002 (See SAMHSA News, Volume X, Numbers 2, 3 and 4). The Commission's work has been an essential part of the President's commitment—embodied in the New Freedom Initiative—to eliminate inequality for Americans with disabilities. With presentation of the report to the President, the charge to the Commission has been fulfilled.

Additional information about the Commission and both its interim report and final report are available online at www.MentalHealthCommission.gov. Print copies of the Commission's final report can be obtained by contacting SAMHSA's National Mental Health Information Center at P.O. Box 42490, Washington, DC 20015. Telephone: 1 (800) 789-2647 or 1 (866) 889-2647 (TTY). Or, visit www.mentalhealth.samhsa.gov.

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