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President's New Freedom
Commission on Mental Health

Sec. 6 (a) Interim Report. Within 6 months from the date of this order, an interim report shall describe the extent of unmet needs and barriers to care within the mental health system, and provide examples of community-based care models with success in coordination of services and providing desired outcomes.

"My experience was very positive. ...I feel that my recovery from depression was due to the provider's flexibility in services."

-Ohio parent with depression

"Mental illness is an equal opportunity disease. Yet we are the expendable ones. If you are poor and female and minority - I'm African American ... the system isn't operating as it should."

-Hikmah Gardiner, Older Adult Consumers Mental Health Alliance, Mental Health Assoc. of Southeastern Pennsylvania

"Stigma leads to isolation, and discourages people from seeking the treatment they need."

-President George W. Bush, April 28, 2002

Exhibit 1
Barriers to Care Within the Mental Health System

    - Fragmentation and Gaps in Care-for Children
    - Fragmentation and Gaps in Care-for Adults with Serious Mental Illness
    - High Unemployment and Disability for People with Serious Mental Illness
    - Older Adults With Mental Illnesses Are Not Receiving Care
    - Mental Health and Suicide Prevention Are Not Yet National Priorities

"When I turned 18, I lost all my services."

-Student from Chicago

"When my son first became ill we were totally adrift ... help from the `system' was difficult to obtain ... he was unable to remember appointments. Confidentiality was given as the reason why we, as his parents, could not be advised of date and time for appointments. Therefore, he did not receive needed help. Any other illness would have been treated quite differently. When he was released from a hospital, local wrap-around services were almost impossible to obtain. Case management was fragmented, case managers seemed to have no training ... some really tried and cared, but they soon burned out and left ..."

-Parents from Ohio

"No one should be needing to play hide and seek to locate appropriate mental health treatment while watching a relative deteriorate. After one year, we have not found one resource to help us coordinate mental health is a full time job for me to coordinate all the appointments with psychiatrists, counselors, blood work, social services, and special education ...We hope that our 1992 van will weather the winter without major work."

-Parent from Wisconsin

Box 1
Example of Intervening Early to Prevent Mental Health Problems

- Program: Nurse-Family Partnership
- Goal: To improve pregnancy outcomes by helping mothers to adopt healthy behavior, to improve child health and development, to reduce child abuse and neglect, and to improve families' economic self-sufficiency.

- Features: A nurse visits the homes of high-risk women beginning in pregnancy and continuing for the first year of children's lives. The nurse adheres to visit-by-visit protocols to help women adopt healthy behaviors and to responsibly care for their child. In many States, Nurse-Family Partnership programs are funded as special projects or via state appropriations.

- Outcomes: For mothers: 80% reduction in abuse of their children, 25% reduction in maternal substance abuse, and 83% increase in employment. For children (15 years later): 54-69% reduction in arrests and convictions, less risky behavior, and fewer school suspensions and destructive behaviors. This is the only prevention trial in the field with a randomized, controlled design and 15 years of follow-up. The program began in rural New York 20 years ago, and its benefits have been replicated in Denver and in minority populations in Memphis (Olds et al., 1997; Olds et al., 1998; Kitzman, 2000).

- Biggest Challenge: To preserve the program's core features as it grows nationwide. The key feature is a trained nurse, rather than a para-professional, who visits homes. A randomized, controlled trial found para-professionals to be ineffective (Olds et al., 2002).

- How Other Organizations Can Adopt: Modify requirements of federal programs, where indicated, to facilitate adoption of this effective, cost-effective model.

- Contact Point: Dr. David Olds, University of Colorado

- Sites: 270 communities in 23 states

Box 2
Example of School-Based Mental Health Program
- Program: Dallas School-based Youth and Family Centers

- Goal: To establish the first comprehensive school-based program in mental health care in the 12th largest school system in the Nation. The program overcomes stigma and inadequate access to care.
- Features: Integrates physical and mental health care at nine locations. The mental health component features partnerships with parents and family, treatment (typically 6 sessions), and follow-up with teachers. Trains school nurses, counselors, and principals to identify problems and make changes in the classroom tailored to each child's needs. Annually serves 3,000 mostly poor, Hispanic, and African American children and families.

- Outcomes: Improvements in attendance, discipline referrals, and teacher evaluation of child performance (Jennings et al., 2000). Preliminary evidence reveals improvement in children's standardized test scores in relation to national and local norms.

- Biggest Challenge: To sustain financial and organizational support of collaborative partners in spite of resistance to change or jurisdictional barriers. Program's $3.5 million funding comes from the school district and an additional $1.5 million from Parkland Hospital.

- How Other Organizations Can Adopt: Recognize the importance of children's mental health for school success. Rethink how state and Federal funding streams can be more efficiently partnered and utilized by school systems to deliver these services.

- Contact Point: Jenni Jennings, Dallas Independent School District

- Sites: Dallas and Fort Worth, Texas

"This is an ordinary miracle."

-Bruce Kamradt, Director, Wraparound Milwaukee

Box 4
Example of Integrated Services for Homeless Adults With Serious Mental Illness

- Program: AB-34 Projects - Named after California Legislation of 2000
- Goal: To "do whatever it takes" to meet the needs of homeless persons with serious mental illness, whether on the street, under a bridge, or in jail.

- Features: Outreach (often by formerly homeless people), comprehensive services, 24/7 availability, partnerships with community providers, and real-time evaluation. Flexible funding, not driven by eligibility requirements.

- Outcomes: 66% decrease in number of days of psychiatric hospitalization, 82% decrease in days of incarceration, and 80% fewer days of homelessness (Figures 3 & 4).

- Biggest Challenge: To change the culture, attitudes, and values around treating difficult populations with different strategies. Traditional services and providers tend to want to continue "business as usual" and follow funding streams rather than integrate services or share responsibility.

- How Other Organizations Can Adopt: Change infrastructure to integrate services. This concept is a different way of doing business and requires linkage to a broader array of services, not just mental health.

- Contact Point: Dr. Stephen W. Mayberg, Director, California Dept. of Mental Health

- Sites: 38 California counties

Box 5
Example of Quality Care for Serious Mental Illness

- Program: TMAP - Texas Medication Algorithm Project
- Goal: To ensure quality care for serious mental illness through the development, application, and evaluation of medication algorithms. An algorithm is a step-by-step procedure, in the form of a flow chart, to help clinicians deliver quality care via the best choice of medications and brief assessment of whether they work. The target population is serious and chronically ill people served by public programs.

- Features: Development of algorithms by research physicians, as well as development of consumer education materials and other tools for treating serious mental illness. 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 and tested the benefits; the program's latest phases are to be implemented everywhere in the state of Texas.

- Outcomes: The algorithm package, implemented by Texas, was more effective than treatment-as-usual for depression, bipolar disorder, and schizophrenia (Rush, 2000; Rush, 2001). It reduced symptoms, side effects, and improved functioning. The package's benefit for reducing incarceration is being studied.

- 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.

- Contact Point: Dr. John Rush, Prof. of Psychiatry, Univ. of Texas Southwestern Medical Center, Dr. Steve Shon, Medical Director of the Texas Department of Mental Health and Mental Retardation; Dr. M. Lynn Crismon, University of Texas at Austin

- Sites: States of Texas, Nevada, Ohio, Pennsylvania, South Carolina, New Mexico; Atlanta and Athens, Ga.; Louisville, Kentucky; Washington D.C.; San Diego County; and private sector in Denver, Colorado

"ACCESS took 7,200 chronically homeless, seriously mentally ill, addicted persons off the streets in this country and gave them back their lives."

-ACCESS Program Director of West Philadelphia, May 2001

"... I cannot emphasize enough how important the ability to work in a real job has been to [my daughter's] self-esteem and therefore to her continued stability."

-Mother of a woman with bipolar disorder

Box 6
Example of Program for Homeless Adults with Serious Mental Illness

- Program: ACCESS-Access To Community Care And Effective Services And Supports
- Goal: To demonstrate that the most vulnerable Americans-homeless people with serious mental illness-can be served through fresh approaches that bring together five distinct service sectors: mental health, drug and alcohol, housing, benefits and entitlements, and medical treatment.

- Features: Outreach, often by formerly homeless people in recovery, to bring services to where homeless people are: on the street, in missions, soup kitchens, shelters, and drop-in centers. Provides them with intensive case management through the highly regarded Assertive Community Treatment. Permits each community, with stakeholder input, to develop its own innovative ways to coordinate services.

- Outcomes: Over 5 years, the pooled findings from more than 7,000 homeless people reveal significant improvements in housing, income, and quality of life, and significant reductions in symptoms and substance use (Randolph et al., 2002).

- Biggest Challenge: To coordinate services across five independent service sectors and to recognize that homeless people do not readily come to traditional settings for services.

- How Other Organizations Can Adopt: Develop innovative ways to deliver services and coordinate existing services for homeless people with mental illness.

- Contact Point: Dr. Frances Randolph, SAMHSA

- Sites: 18 communities in nine states

Box 7
Example of Supported Employment for People with Serious Mental Illness

- Program: IPS - Individual Placement and Support
- Goal: To secure employment quickly and efficiently for people with mental illness. An alarming 90% of them are unemployed, yet most wish to be working.

- Features: An IPS employment specialist on a mental health treatment team. The employment specialist collaborates with clinicians to make sure that employment is part of the treatment plan. Then the specialist conducts assessments, rapid job searches, and provides ongoing support while the consumer is on the job.

- Outcomes: In general, 60-80% of those served by IPS obtain at least one competitive job, according to findings from three randomized controlled trials in New Hampshire, Washington, DC, and Baltimore (Drake et al., 1999). Those trials find IPS far superior to traditional programs that include prevocational training. The cost of IPS is no greater than that for traditional programs, suggesting that IPS is cost-effective.

- Biggest Challenge: To move away from traditional partial hospital programs, which are ineffective at achieving employment outcomes yet still reimbursable under Medicaid.

- How Other Organizations Can Adopt: Restructure state and federal programs to pay for evidence-based practices like IPS that help consumers achieve employment goals, rather than pay for ineffective, traditional day treatment programs that are not effective in supporting employment.

- Contact Point: Dr. Robert E. Drake, Dartmouth Medical Center

- Sites: 30 States in the United States, Canada, Hong Kong, Australia, and 6 European countries

"The US population will look like Florida very soon."

-Stephen Bartels, M.D., M.S., Dartmouth Medical School

"Suicide poses a threat to the health and well-being of our community. This is not the time to put this program on autopilot. The loss of a single airman is a loss to us all."

-General Michael Ryan, Air Force Chief of Staff, in a service-wide electronic message, 2000

Box 8
Example of Program for Treating Late-Life Depression in Primary Care

- Program: IMPACT - Improving Mood: Providing Access To Collaborative Treatment For Late Life Depression
- Goal: To recognize, treat, and prevent future relapses in older patients with major depression in primary care. About 5-10% of older patients have major depression, yet most are not properly recognized and treated. Untreated depression causes distress, disability, and, most tragically, suicide.

- Features: A multi-site clinical trial delivering depression care, in the primary care setting, to older people with major depression. Mental health professionals added to the team give older adults a choice of medications or psychotherapy. If they do not get better, a stepped up approach is offered via supervision by a psychiatrist.

- Outcomes: The study's preliminary findings are that the intervention, compared with usual care, leads to higher satisfaction with depression care and reduced prevalence and severity of symptoms, or complete remission (Unutzer, 2002).

- Biggest Challenge: To ensure that the intervention is readily adapted from the research setting into the practice setting.

- How Other Organizations Can Adopt: Be receptive to organizational changes in primary care and to finding new methods of reimbursement.

- Contact Point: Dr. Jurgen Unutzer, Principal Investigator, UCLA

- Sites: Study sites in California, Texas, Washington, North Carolina, Indiana

Box 9
Example of Suicide Prevention & Changing Attitudes about Mental Health Care

- Program: Air Force Initiative To Prevent Suicide
- Goal: To reduce the alarming rate of suicide-one in every four deaths, 1990-1994-among active duty U.S. Air Force personnel. Suicide was the second leading cause of death, after unintentional injuries, in the Air Force.

- Features: The Air Force Chief of Staff, in 1996, initiated a community-wide approach to combat suicide through hard-hitting messages to all active duty personnel. The messages recognized the courage of those confronting life stress and encouraged them to seek help from mental health clinics-moves once regarded as career-hindering, but now deemed "career-enhancing." Other features of the program: education and training, improved surveillance, critical incident stress management, and integrated delivery systems of care.

- Outcomes: From 1994 to 1998, the suicide rate dropped from 16.4 to 9.4 suicides per 100,000 (Litts et al., 2000). By 2002, the overall decline from 1994 was about 50 percent (Figure 5). The University of Rochester is also conducting an external evaluation of the program.

- Biggest Challenge: Sustaining the enthusiasm by service providers as the program has become more established.

- How Other Organizations Can Adopt: "The program's principles should be transferable to any community. Every community has leaders and the most basic elements of organization," said Dr. David Litts.

- Contact Point: Dr. David Litts, Advisor to the Surgeon General and Executive Director of the Air Force Program on Suicide Prevention (1996-1999)

- Sites: All U.S. Air Force locations throughout the world


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