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President's New Freedom
Commission on Mental Health

Achieving the Promise: Transforming Mental Health Care in America

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


    5.1 Accelerate research to promote recovery and resilience, and ultimately to cure and prevent mental illnesses.

    5.2 Advance evidence-based practices using dissemination and demonstration projects and create a public-private partnership to guide their implementation.

    5.3 Improve and expand the workforce providing evidence-based mental health services and supports.

    5.4 Develop the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care.

Understanding the Goal

The Delay Is Too Long Before Research Reaches Practice

Too Few Benefit from Available Treatment

Effective, state-of-the-art treatments vital for quality care and recovery are now available for most serious mental illnesses and serious emotional disorders.18 Yet these new effective practices are not being used to benefit countless people with mental illnesses. The mental health field has developed evidence-based practices (EBPs) - a range of treatments and services whose effectiveness is well documented. A partial list of EBPs includes:

    Evidence-based practice
    (EBP) is defined by the Institute of Medicine as - the integration of best-researched evidence and clinical expertise with patient values.9

    Emerging best practices - treatments and services that are promising but less thoroughly documented than evidence-based practices.

Along with EBPs, the mental health field has also developed promising but less thoroughly documented emerging best practices, such as:

Despite this range of effective, state-of-the-art treatments and best practices, many interventions and supports do not reach the people who need them because of:

The Texas Medication Algorithm Project illustrates an evidence-based practice that results in better consumer outcomes, including reduced symptoms, fewer and less severe side effects, and improved functioning.166-168 (See Figure 5.1.) However, too few consumers benefit from this practice because it is not widely used.

Figure 5-1. Model Program: Quality Medications Care for Serious Mental Illnesses


Texas Medication Algorithm Project (TMAP)


To ensure quality care for people with serious mental illnesses by developing, applying, and evaluating medication algorithms. An algorithm is a step-by-step procedure in the form of a flow chart to help clinicians deliver quality care through the best choice of medications and brief assessment of their effectiveness. The target population is people with serious mental illnesses served by public programs.


Development of algorithms as well as development of consumer education materials and other tools for treating serious mental illnesses. Public sector-university collaboration with support of stakeholders, education and technical assistance, and administrative supports to serve the most medically complex patients. Early phases of the project developed the algorithms and tested the benefits of their use; the program's latest phases focus on implementing TMAP in mental health treatment settings throughout the State.


The algorithm package implemented by Texas was more effective than treatment-as-usual for depression, bipolar disorder and schizophrenia. It reduced symptoms, side effects and improved functioning.166-168 The package's benefit for reducing incarceration is being studied. In addition, medication algorithms have been developed for treating children with depression or attention deficit hyperactivity disorder (AD/HD). TMAP algorithms have also been adapted to treat adult consumers who have co-occurring mental and substance use disorders.

Biggest Challenge

To ensure that the entire algorithm package - patient education, frequent medical visits, medication availability, and consultation - is properly implemented in other States and localities.

How other organizations can adopt

Conduct an active planning process, including meetings with stakeholders, to examine what organizational changes are needed to make the algorithm work best.


Texas; Nevada; Ohio; Pennsylvania; South Carolina; New Mexico; Atlanta and Athens, GA; Louisville, Kentucky; Washington, D.C.; San Diego County, CA; and private sector in Denver, Colorado.

Reimbursement Policies Do Not Foster Converting Research to Practice

Serious Workforce Problems Exist

Four Areas Have Not Been Studied Enough

The knowledge base in the mental health system is lacking sufficient information in at least four areas:

Disparities in Mental Health Research

While many types of disparities exist in mental health care, American Indians, Alaskan Natives, African Americans, Asian Americans, Pacific Islanders, and Hispanic Americans bear a disproportionately high burden of disability from mental health disorders, not because of greater prevalence or severity of illnesses in these populations, but because they receive less care and poorer quality of care.1 Similarly, these groups are significantly under-represented in mental health research and mental health service delivery.1 (See Goal 3 for a related discussion.)

Long-term Use of Medications

Breakthroughs in developing the next generation of medications provide hope for treatment and recovery from mental illnesses. The discovery of effective treatments using medications currently on the market is also encouraging. However, since these medications are treatments and not cures, some individuals with chronic illnesses, including children, are expected to use these medications over an extended period of time. Knowledge of the clinical and economic effects of these medications is limited because systematically evaluating the maintenance use of medications is not required for FDA approval. Consequently, long-term effects have not been well studied for many psychotropic medications.

Long-term effects have not been studied well enough for many psychotropic medications.

The Impact of Trauma

Stressful life events or the manifestation of mental illnesses can upset the balance most adults seek in life, resulting in distress and dysfunction. Severe or life-threatening traumatic events experienced in childhood or adulthood sometimes lead to emotional and behavioral reactions that jeopardize mental health. The likelihood of developing post-traumatic stress disorder (PTSD) is related to pre-trauma vulnerability, magnitude of the event, preparedness for the event, and the quality of care after the event.172

Urban and Native American youth are more likely to be exposed to violence,173 while women are twice as likely to develop PTSD after they are exposed to life-threatening trauma.174 The mental health field lacks sufficient information about dealing with trauma and its effects on different populations. Also, few treatments specifically for adult survivors of childhood abuse have been studied in randomized controlled trials.175

Achieving the Goal


5.1 Accelerate research to promote recovery and resilience, and ultimately to cure and prevent mental illnesses.

Speed Research on Treatment and Recovery


5.2 Advance evidence-based practices using dissemination and demonstration projects and create a public-private partnership to guide their implementation.

Bridge the Gap Between Science and Service

The Commission recommends that the Department of Health and Human Services provide leadership to evaluate implementing evidence-based interventions through dissemination projects. The Federal government should initiate and sustain a public-private partnership, with involvement and support from private foundations, advocacy groups, and professional organizations. The goal of this partnership would be to:

The partnership should comprise all stakeholders including providers, consumers, and families. It should guide and oversee many activities that are currently scattered throughout the public and private sectors, thus eliminating inefficient duplication and encouraging collaboration on potentially beneficial issues. This leadership is needed to bridge the gap between science and service.

The Commission encourages continuing and expanding the collaboration between NIH and SAMHSA to conduct rigorous peer-reviewed research. They should use both quantitative and qualitative research methods to increase our knowledge about the most effective means of disseminating and promoting evidenced-based practices. These HHS agencies have already begun a formal "science to services" process to further develop and expand evidenced-based practices in the field. They have jointly funded a grant program for State mental health agencies to begin developing the infrastructure to conduct research alongside dissemination efforts. The process should be part of a comprehensive strategy moving from science to service and from the field back to science.

To promote efficient and cost-effective practices for improved consumer outcomes, the field needs more rigorous studies of EBP dissemination efforts. One such effort is ongoing. National Institute of Mental Health and SAMHSA are collaborating to support a study on implementing the Family Critical Time Intervention Model with homeless families and their children. (See Figure 5.2.)

The Commission concludes that national leadership must overcome the fragmentation and blurring of responsibility for translating the science of mental health into clinical practice.

Toward this end, mental health field must expand its efforts to develop and test new treatments and practices, to promote awareness of and improve training in evidence-based practices, and to better finance those practices.

Figure 5-2. Model Program: Critical Time Intervention with Homeless Families


Family Critical Time Intervention model (FCTI). The program is jointly funded by NIMH and the Center for Mental Health Services/Center for Substance Abuse Treatment Homeless Families Program.


To apply effective, time-limited, and intensive intervention strategies to provide mental health and substance abuse treatment, trauma recovery, housing, support, and family preservation services to homeless mothers with mental illnesses and substance use disorders who are caring for their dependent children.


The Critical Time Intervention model (CTI) was developed in New York City as a program to increase housing stability for persons with severe mental illnesses and long-term histories of homelessness. Its principle components are rapid placement in transitional housing, fidelity to a Critical Time Intervention CTI model for families (i.e., provision of an intensive, 9-month case management intervention, with mental health and substance use treatments), a focused team approach to service delivery, with the aim of reducing homelessness, and brokering and monitoring the appropriate support arrangements to ensure continuity of care.


Data indicate that mothers in this group tend to be poorly educated, have meager work histories, and face multiple medical, mental health, and substance use problems. Their children's lives have lacked stability in terms of housing, education, and periods of separation from their mothers. African-American and Latina women were over-represented in study sites in proportions greater than the national average for homeless populations. (An NIMH-funded study of this project is ongoing; additional outcomes will be available at its conclusion.)

Biggest challenge

The CTI model for families challenges the assumption that homeless mothers with children who are have mental health or substance use disorders require confinement and extended stays in congregate shelter living before they can independently manage their own households. This can be addressed by acquiring buy-in from collaborators and involved agencies, acquiring needed housing resources, evaluating the project with respect to model fidelity, and attaining ongoing involvement of practice innovators to establish thoughtful compromises within local contexts.

How other organizations can adopt

The program is transferable to any community that can align resources needed for housing and conduct relevant training for providers in a CTI model for families. (A manual to guide program replication will be available at the conclusion of the current study.)


Westchester County, NY

For additional information


Change Reimbursement Policies to More Fully Support EBPs

The Commission urges the Centers for Medicare and Medicaid Services (CMS) to provide technical assistance to States on how to effectively finance EBPs. This technical assistance should address financing strategies for:

  • Family psycho-education,
  • Integrated care of co-occurring mental and substance use disorders,
  • Personal illness management,
  • Supported employment,
  • Assertive community treatment, and
  • Medication management.165

In addition, the Commission urges CMS to continue to clarify and simplify the waiver process and other administrative processes to facilitate States' using waivers to develop evidence-based practices.

Successfully transforming the mental health system, hinges, in part, on better balancing fiscal resources to support using proven, evidence-based practices.

The Commission notes the particular difficulty of engaging consumers in any type of treatment or support services - including EBPs - after they are released from public institutions, such as hospitals, residential treatment centers, jails, or prisons. For many of these individuals, losing disability benefits when they leave these facilities represents a major barrier to engagement. During extended stays in these institutions, consumers may lose their enrollment, lose their eligibility, or have their eligibility suspended from various disability income programs and from Medicaid or Medicare. When this occurs because rules and regulations have not been properly applied, it reflects confusion or misunderstanding of the rules and regulations. The Commission encourages CMS to collaborate with the Social Security Administration (SSA), the Veterans Administration (VA), and other relevant Federal agencies to clarify existing policy on reinstating disability benefit eligibility - and to explore changing existing policy, as needed. This is critical to facilitate following-up and engaging individuals in treatment and services after they are discharged from public institutions.

The Commission urges SAMHSA to work with CMS to facilitate collaboration between State Mental Health Authorities and Single State Medicaid Agencies.


5.3 Improve and expand the workforce providing evidence-based mental health services and supports.

Address the Workforce Crisis in Mental Health Care

Every mental health education and training program in the Nation should voluntarily assess the extent to which it:

HHS must partner with State agencies that are responsible for the mental health care of children and adults to develop model, portable curricula to train direct care staff in the Nation's public-sector systems. In the case of service systems for children and families, these curricula must recognize and accommodate a variety of settings and providers, such as social service agencies, schools, and primary care settings.

Some curricula must target individuals who do not have graduate training. Others should be focused on students in graduate training programs or in-service professionals, such as psychologists, psychiatrists, social workers and psychiatric nurses. All training curricula should clearly reflect the perspectives of consumers and families.

In addition, graduate and continuing education programs must train more mental health professionals in effective evidence-based and emerging best practices. The field must move what we know into what we do. This transformation may require special attention from administrators and policy-makers, as well as from accrediting, licensing, and professional organizations, that have enormous influence on shaping health and mental health workforce education.

The Commission recommends that HHS refine its approach to technology transfer in mental health to ensure that:

Graduate and continuing education programs must train more mental health professionals in effective evidence-based and emerging best practices.


5.4 Develop the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care.

To transform the mental health system, the Commission has identified and highlighted the critical policy areas of:

Research in these understudied areas is essential to ultimately improve the quality of mental health treatments and services.

Study Disparities for Minorities in Mental Health

To address this discrepancy, the Commission recommends conducting studies to inform policy decisions and develop a comprehensive research program for minority mental health. In particular, the Commission urges HHS to further study:

To close the gap that exists in the quality and access of care, the Commission also encourages researchers and grant-makers to focus on the impact of cultural competence on mental health treatment outcomes. Services research should focus on eliminating disparities in access to quality care among racial and ethnic groups.

Study the Effects of Long-term Medication Use

Examine the Effects of Trauma

Address the Problems of Acute Care

The Commission recommends that HHS take the lead in:


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