President's New Freedom
Achieving the Promise: Transforming Mental Health Care in America
Goal 1: Americans Understand that Mental Health Is Essential to Overall Health
1.1 Advance and implement a national campaign to reduce the stigma of seeking care and a national strategy for suicide prevention.
1.2 Address mental health with the same urgency as physical health.
Understanding the Goal
Many People with Mental Illnesses Go Untreated
Too many Americans are unaware that mental illnesses can be treated and recovery is possible. In fact, a wide array of effective mental health services and treatments is available to allow children and adults to be vital contributors to their communities. Yet, too many people remain unserved, and the consequences can be shattering. Some people end up addicted to drugs or alcohol, on the streets and homeless, or in jail, prison, or juvenile detention facilities.
The World Health Organization (WHO) identified mental illnesses as the leading causes of disability worldwide. (See Figure 1.1.) This groundbreaking study found that mental illnesses (including depression, bipolar disorder, and schizophrenia) account for nearly 25% of all disability across major industrialized countries.12
As the President indicated in his speech announcing the Commission (Albuquerque, New Mexico, April 29, 2002),
"Our country must make a commitment: Americans with mental illness deserve our understanding, and they deserve excellent care. They deserve a health system that treats their illness with the same urgency as a physical illness."
Unfortunately, several obstacles to achieving this goal remain. For example, stigma frequently surrounds mental illnesses, prompting many people to hide their symptoms and avoid treatment. Sadly, only 1 out of 2 people with a serious form of mental illness seeks treatment for the disorder.2-4
Figure 1.1. Causes of Disability*
United States, Canada and Western Europe, 2000
* Causes of disability for all ages combined. Measures of disability are based on the number of years of "healthy" life lost with less than full health (i.e., YLD: years lost due to disability) for each incidence of disease, illness, or condition. All data shown add up to 100%.
Stigma Impedes People from Getting the Care They Need
Stigma is a pervasive barrier to understanding the gravity of mental illnesses and the importance of mental health. For instance, 61% of Americans think that people with schizophrenia are likely to be dangerous to others.17 However, in reality, these individuals are rarely violent. If they are violent, the violence is usually tied to substance abuse.18
Stigma is a pervasive barrier to understanding the gravity of mental illnesses and the importance of mental health.
Some people may not recognize or correctly identify their symptoms of mental illness; when they do recognize them, they may be reluctant to seek care because of stigma.19; 20 Stigma is particularly pronounced among older adults, ethnic and racial minorities, and residents of rural areas.1
Suicide Presents Serious Challenges
Suicide is a serious public health challenge that has not received the attention and degree of national priority it deserves. Many Americans are unaware of suicide's toll and its global impact. It is the leading cause of violent deaths worldwide, outnumbering homicide or war-related deaths.13 (See Figure 1.2.)
Suicide Is the Leading Cause of Violent Deaths Worldwide
In the U.S., suicide claims approximately 30,000 lives each year. Overall, suicide was the 11th leading cause of death among Americans in 2000.21 In 1999, more than 152,000 hospital admissions and more than 700,000 visits to hospital emergency rooms were for self-harming behaviors.22 The vast majority of all people who die by suicide have a mental illness - often undiagnosed or untreated.21
Suicide was also the fourth leading cause of death among youth aged 10-14, third among those between 15 and 24, second among 25- to 34-year olds, and fourth among those 35-44 years in 1999.23 The rate of suicide is highest among older men, compared with all other age groups. But alarmingly, the rate of teen suicide (for those from ages 15 to 19) has tripled since the 1950s.21
Better Coordination Is Needed Between Mental Health Care and Primary Health Care
Research demonstrates that mental health is key to overall physical health.24-26 Therefore, improving services for individuals with mental illnesses requires paying close attention to how mental health care and general medical care interact. While mental health and physical health are clearly connected, a chasm exists between the mental health care and general health care systems in financing and practice. Primary care providers may lack the necessary time, training, or resources to provide appropriate treatment for mental health problems.
Mental health is key to overall physical health.
Mental disorders frequently co-exist with other medical disorders. For example, a number of studies have shown that adults with common medical disorders have high rates of depression and anxiety.27-29 Depression is also common in people with coronary heart disease and other cardiac illnesses. This situation is especially dangerous because depression increases the risk of dying from heart disease by as much as three-fold.30; 31 Depression impairs self-care and adherence to treatments for chronic medical illnesses.32 Similarly, people with both diabetes and depression have a greater likelihood of experiencing a greater number of diabetes complications compared to those without depression.33
Mental Health Financing Poses Challenges
Insurance plans that place greater restrictions on treating mental illnesses than on other illnesses prevent some individuals from getting the care that would dramatically improve their lives. Mental health benefits have traditionally been more limited than other medical benefits.
The Commission strongly supports the President's call for Federal legislation to provide full parity between insurance coverage for mental health care and for physical health care.
States have relied on the Medicaid program to support their mental health systems. As a result, Medicaid is now the largest payer of mental health services in the country.
Studies show that 20% to 25% of services for non-elderly adult users of mental health are funded only by Medicaid. Between 7% and 13% of Medicaid enrollees are mental health service users. By 1997, Medicaid spent more than $14 billion that accounted for 20% of all mental health spending and 36% of all public mental health spending in the United States.15; 34; 35 (See Figure 1.3.) Although States have used Medicaid as a primary source of funding, missed opportunities exist because States are often uncertain about:
How to cover evidence-based practices,
Which services may be covered under the traditional State plan,
Which services are allowable under waiver, and
How to use Medicaid funds seamlessly with other private sources.
Distribution of Public and Private Mental Health Expenditures, 1997
Also, many older adults and disabled individuals may rely on Medicare for their health care. However, in this program, coverage is an issue - with the most obvious example being the lack of a prescription drug benefit. As important as Medicaid and Medicare have been, they have not always grown along with the dramatic improvements in health care, such as prescription drugs, preventive care, and coordination of care. Action is needed now to remedy this problem.
Services and Funding Are Fragmented Across Several Programs
To add to the problem, services and funding are fragmented across different programs. Increasingly, multiple programs with disparate objectives and requirements finance services and supports for those with mental illnesses including:
State and local general fund appropriations,
Social Security (Social Security Income/ Social Security and Disability Income payments),
Temporary Assistance for Needy Families (TANF),
Juvenile justice and criminal justice,
Child welfare, and
Federal block grants.
While each program provides essential assistance, together they create a financing approach that is complex, fragmented, and inconsistent in its coverage.
Financing Sources Can Be Restrictive
The current system of mental health care must rely on many sources of financing. Too many of those funding streams are tightly restricted in how they can be used or for whom. Providing access to effective treatments and services that are easy to navigate and that use flexible funding streams is crucial to transforming mental health care in America.
Providing access to effective treatments and services that are easy to navigate and that use flexible funding streams is crucial to transforming mental health care in America.
Currently, eligibility requirements for receiving services or supports and reimbursement policies vary widely, and States must rely on waivers to provide treatments and supports that Federal standards deem optional. If the mental health care system is to be responsive to the unique needs of consumers, then it must be flexible enough to accommodate each person. Our treatment systems should be able to serve consumers who are uninsured or who need a service that isn't covered by their insurer. Steps must be taken to improve the flexibility and accountability of financing in both private insurance and public programs.
Achieving the Goal
1.1 Advance and implement a national campaign to reduce the stigma of seeking care and a national strategy for suicide prevention.
Public Education Activities Can Help Encourage People to Seek Treatment
Research findings support the connection between good mental health and overall personal health.24-26 Increasing public understanding that mental health is an essential and an integral part of overall health can lead to improved services, more balanced policy decisions, and a healthier Nation.
Increasing public understanding about mental health and mental illnesses requires action at every level of government and in the private sector. The first step is to reduce the stigma surrounding mental illnesses, using targeted public education activities that are designed to provide the public with factual information about mental illnesses and to suggest strategies for enhancing mental health, much like anti-smoking campaigns promote physical health.
Research shows that the most effective way to reduce stigma is through personal contact with someone with a mental illness.36 The U.S. Department of Health and Human Services (HHS) has incorporated this research finding into its new campaign targeted to men, Real Men. Real Depression. Through compelling personal stories told through television, video, the Internet, and print media, the campaign encourages men to recognize depression and its impact on their work, home, and community life. For America to move forward in addressing the seriousness of mental health issues, the public must understand that these mental conditions are illnesses that can be reliably diagnosed and effectively treated.
Research shows that the most effective way to reduce stigma is through personal contact with someone with a mental illness.
Targeted public education can increase awareness about the effectiveness of mental health services and can encourage people to seek treatment, thus reducing the stigma and discrimination associated with mental illnesses. Eliminating stigma will also help reduce the isolation of these individuals from society.
Media-oriented and other types of mental health awareness campaigns can inform the public about where and how to obtain help. Collaboration between the public and private sectors and close coordination with consumers and other stakeholders is encouraged to reduce the possibility of sending mixed messages or duplicated messages to the public.
Campaigns should use a multi-faceted approach that includes various public education strategies, as well as direct, consumer-to-target audience, interpersonal contact methods, such as dialog meetings and speakers' bureaus. The campaigns should also address and promote the themes of recovery and the positive societal contributions that people with mental illnesses make, correcting the misperceptions associated with these illnesses.
By increasing the public's understanding that mental illnesses are treatable and recovery is possible, stigma and discrimination will be reduced for people with mental illnesses.
The Commission recommends that the Substance Abuse and Mental Health Services Administration (SAMHSA) and National Institutes of Health (NIH) take the lead to coordinate and develop targeted public education initiatives to increase understanding of mental illnesses and to encourage help-seeking behaviors. By increasing the public's understanding that mental illnesses are treatable and recovery is possible, stigma and discrimination will be reduced for people with mental illnesses. In addition, this change of attitude is important because screening and identifying mental illnesses are of little value unless the person with the problem is willing to accept the care that may be offered.
Swift Action Is Needed to Prevent Suicide
The urgent need for action on suicide prevention is the subject of a number of recent reports and congressional resolutions. For example, just last year the Institute of Medicine (IOM) underscored suicide prevention as a significant public health problem with the publication Reducing Suicide: A National Imperative.21
As another example, through its pioneering program on suicide prevention, the U.S. Air Force works to reverse deep-seated attitudes in the military that seeking help should be avoided and is shameful. (See Figure 1.4.) The program helps the target audience - in this case Air Force personnel - recognize that it takes courage to confront life's stresses and that taking steps to do so is "career-enhancing."
In addition, the National Strategy for Suicide Prevention (NSSP) was developed and launched through the combined work of advocates, clinicians, researchers, and survivors around the Nation.37 It is the first attempt in the United States to prevent suicide through such a coordinated approach. The NSSP lays out a suicide prevention framework for action and guides development of an array of services and programs. It requires involving a variety of organizations and individuals and emphasizes coordinating resources and delivering culturally appropriate services at all levels of a public-private partnership. This promising blueprint for change is poised to guide the Nation toward a brighter future for suicide prevention.
The Commission urges swiftly implementing and enhancing the NSSP to serve as a blueprint for communities and all levels of government. Within the public education component of this initiative, the messages should encourage the target audiences to seek help for mental health problems and to understand that suicide is preventable. Public education efforts should also be targeted to distinct and often hard-to-reach populations, such as ethnic and racial minorities, older men, and adolescents.
Figure 1.4. Model Program: Suicide Prevention and Changing Attitudes About Mental Health Care
Air Force Initiative to Prevent Suicide
To reduce the alarming rate of suicide. Between 1990 and 1994, one in every four deaths among active duty U.S. Air Force personnel was from suicide. After unintentional injuries, suicide was the second leading cause of death in the Air Force.
In 1996, the Air Force Chief of Staff initiated a community-wide approach to prevent suicide through hard-hitting messages to all active duty personnel. The messages recognized the courage of those confronting life's stresses and encouraged them to seek help from mental health clinics - actions that were once regarded as career hindering, but were now deemed "career-enhancing." Other features of the program: education and training, improved surveillance, critical incident stress management, and integrated delivery systems of care.
From 1994 to 1998, the suicide rate dropped from 16.4 to 9.4 suicides per 100,000. By 2002, the overall decline from 1994 was about 50%. Researchers also found significant declines in violent crime, family violence, and deaths that resulted from unintentional injuries.38 Air Force leaders have emphasized community-wide involvement in every aspect of the project.
Sustaining the enthusiasm by service providers as the program has become more established.
How other organizations can adopt
The program can be transferred to any community that has identified leaders and organization, especially other military services, large corporations, police forces, firefighters, schools, and universities.
All U.S. Air Force locations throughout the world
Further, the Commission recommends forming a national level public-private partnership to advance the goals and objectives of the NSSP that proposes local projects in every State. This public-private partnership would emphasize building voluntary coalitions to address suicide prevention in communities and would include local leaders, business and school personnel, and representatives of the faith community.
1.2 Address mental health with the same urgency as physical health.
Recognize the Connection Between Mental Health and Physical Health
Health care and other human service systems should treat adults with serious mental illnesses and children with serious emotional disturbances with the same dignity, urgency, and quality of care that is given to people with any other form of illness. Doing so can contribute greatly to reducing stigma while encouraging people in need to seek help.
Good mental health improves the quality of life for people with serious physical illnesses and may contribute to longer life in general. When considering older adults who have general medical illnesses - such as heart disease, stroke, cancer, and arthritis - about 25% also have depression.39-44 Depression is associated with a shortened life expectancy.30; 31
The Commission recommends reviewing existing scientific literature and initiating new studies to examine the impact of mental health and mental illnesses on physical illnesses and health. It is anticipated that reviewing the current scientific knowledge in this critical area will contribute significantly to identifying new research priorities. New studies should focus on innovative and effective ways to enhance the balance between mental and physical health. These studies should also support using best practices to improve quality of life, provide effective treatment, and enhance cost-effectiveness.
Good mental health improves the quality of life for people with serious physical illnesses and may contribute to longer life in general.
Address Unique Needs of Mental Health Financing
As future opportunities emerge to transform health care in America, mental health care must be considered part of the reform necessary to achieve optimal health benefits for the American public.
The Commission recommends including issues of critical importance for mental health service delivery as part of the national dialog on health care reform. The two largest Federal health care programs - Medicare and Medicaid - as well as private insurance programs must address the delivery of mental health care. Any effort to strengthen or improve the Medicare and Medicaid programs should offer beneficiaries options to effectively use the most up-to-date treatments and services. Critical issues to be addressed include:
Prescription drug coverage,
Accessibility of services,
Affordability of services,
Clarification of coordination of benefits between the Medicare and Medicaid programs,
Support for evidenced-based services and supports,
Support for self-direction,
Choice of health care services and resources, and
Outcomes and accountability.
To be effective and comprehensive, mental health care must rely on many sources of financing. Flexible, accountable financing that pays for treatments and services that work and result in recovery is an essential aspect of transforming mental health care in America.