Mental health care in America is often inadequate and needs "fundamental transformation," a presidential commission reported yesterday.The commission described the present system as a "patchwork relic" of disjointed state and federal agencies that frequently stepped in the way of people who were seeking care instead of helping them. The panel said each state should draw up plans to treat the mentally ill.
The report called for a more streamlined system strongly focused on early diagnosis and treatment in patients' own communities, a high expectation of recovery and methods for helping people with mental illnesses find work and housing.
One proposed means of early diagnosis would use questionnaires to screen high-school students, with parental permission, for signs of mental or emotional disturbance, with follow-up testing and treatment for those who need it.
The report did not recommend increased spending on mental health, but called for a more coordinated and efficient use of the money available now.
The commission also said mental health should be addressed with the same urgency as physical health, with equivalent insurance coverage. Currently, many plans put tighter limits treating mental illness than for physical ailments, and President Bush has asked Congress to pass "mental health parity" legislation, requiring equal coverage.
About 5 to 7 percent of American adults have serious mental illnesses, according to the report, and 5 to 9 percent of children suffer serious emotional disturbances.
The report was prepared by the President's New Freedom Commission on Mental Health, a 22-member group that Mr. Bush formed in April 2002. The commissioners included psychologists and psychiatrists, as well as administrators from state and federal agencies. In 86 pages, they discussed the failings of the current system and described six major goals for transformation.
Advocacy groups for the mentally ill praised the report.
"I think it brings us out of the dark ages," said Richard Birkel, national executive director of the National Alliance for the Mentally Ill. "The goals and standards they have set are good ones. Get people into treatment early, have high expectations of recovery. This is the opposite of what we have now. This really envisions a very modern health care system in mental health."
The main shortcoming of the report, Mr. Birkel said, is "limitations in terms of actual next steps, a clear road map for how we get there."
But, he added: "I'm not surprised by these limitations. Otherwise it would have been a five-year report. They had less than a year to finish this. For a one-year report, it's remarkable."
Bill Emmet, a project director at the National Association of State Mental Health Program Directors, said: "We think it's a once-in-a-generation opportunity to assess the mental health system in this country, and the report comes through with recommendations that, if implemented, will change the direction of mental health services in this country. I think the `if implemented' is the critical caveat."
Mr. Emmet said the details of instituting the changes were not really the goal of the report.
"I think," he said, "it's up to us as advocates, and up to our champions in Congress, to move from this platform to the nitty-gritty."
Dr. Marcia Goin, president of the America Psychiatric Association, said that the report gave an honest portrayal of "the mental health system in a shambles." Dr. Goin said many mentally ill people became lost in the system and wound up living on the streets or, if they lack needed medication, in jail for petty crimes. The report notes that 30,000 Americans a year commit suicide, many with undiagnosed or untreated mental illnesses. Attempted suicides lead to hundreds of thousands of hospital visits a year.
"It's a horrendous system across the country," Dr. Goin said.
She noted that the commission worked under the assumption that financing for mental health programs would not increase.
"But the reality is that there needs to be a big structural change," Dr. Goin added. "And you can't do that without funding."
The value of the report, she said, is that advocacy groups can use it to back their statements when they ask state legislatures and other agencies to pay for treatment.
Officials and others expect direction on reaching the goals from the Substance Abuse and Mental Health Services Administration, a $3.2 billion-a-year agency in the Health and Human Services Department.
The director of the agency, Charles G. Curie, said, "We'll conduct now a thorough review and assessment of the report and begin to outline a clear action plan."
"I anticipate an action plan within just a matter of two to three months," he said.
Mr. Curie said his agency had been working with other agencies on translating research findings into treatment more quickly and eliminate the current 15- to 20-year lag.
Mr. Birkel's group also issued a report yesterday that he called a companion piece to the commission report. His group's report was based on a survey of more than 3,400 people with serious mental illnesses and their families. Most, 86 percent, were from 18 to 54 years old.
The survey found that two-thirds were unemployed and that more than half relied on public programs. Some said they wanted to work, but had been offered just positions that did not provide insurance for mental health. If they take the positions, they lose government coverage.
In the last year, nearly half had been hospitalized, 40 percent had sought emergency care for their mental problems and 44 percent had been arrested or detained by the police.
Mr. Birkel said of the commission's report: "Was it a good report? That depends on what happens in the next six months to a year. If it works as well as we hope to stimulate action, then it will be a great report. If it's a snapshot of a system in shambles in 2003 and nothing happens, it will be a terrible report."
The report is at www .MentalHealthCommission.gov. Prints can be obtained by calling (800) 662-4357 or (TTD) (800) 228-0427.
Copyright 2003 The New York Times Company