Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Table of Contents

Section Page

Introduction.....................................................................................................................................1

Role of the ISMICC.................................................................................................................... 2

The 2017 ISMICC Report to Congress ...................................................................................... 4

ISMICC Vision Statement..........................................................................................................5

Recommendations From the Non-Federal Members Summary (See Chapter 4 for Full 

Recommendations)..............................................................................................................5

Focus 1: Strengthen Federal Coordination to Improve Care..............................................5

Focus 2: Access and Engagement: Make It Easier to Get Good Care.................................5

Focus 3: Treatment and Recovery: Close the Gap Between What Works and What Is 

Offered ........................................................................................................................... 6

Focus 4: Increase Opportunities for Diversion and Improve Care for People With 

SMI and SED Involved in the Criminal and Juvenile Justice Systems ........................ 7

Focus 5: Develop Finance Strategies to Increase Availability and Affordability of Care. 7

References.................................................................................................................................. 9

Chapter 1: The Current Needs of Americans With Serious Mental Illnesses and Serious 

Emotional Disturbances.................................................................................................................11

Serious Mental Illnesses ...........................................................................................................11
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Table of Contents (continued)

Section Page

Serious Emotional Disturbances............................................................................................ 20

References................................................................................................................................ 30

Chapter 2: Improving Practice Related to Serious Mental Illness and Serious 

Emotional Disturbances................................................................................................................41

Federal Presentations.............................................................................................................. 40

National Institute of Mental Health: Support of Advances to Address 

Challenges of SMI and SED ........................................................................................ 42

Substance Abuse and Mental Health Services Administration: Support of

Advances to Address Challenges of SMI and SED..................................................... 44

Department of Veterans Affairs: Support of Advances to Address Challenges 

of SMI and SED ........................................................................................................... 46

Department of Justice: Support of Advances to Address Challenges of SMI and SED..47

Non-Federal Stakeholder Presentations................................................................................. 51

Challenges and Opportunities in Improving Children’s Mental Health Care................ 51

Key Advances in the Clinical Care of People With SMI and SED ...................................52

Disparities and Closing the Treatment Gap .................................................................... 54

The Challenges and Opportunities for Improving the System That Supports 

the Care of People With SMI and SED........................................................................55
Interdepartmental

Serious Mental Illness

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The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Areas to Be Explored by the ISMICC.................................................................................57

Chapter 3: Setting the Stage for Evaluation of Federal Programs Related to SMI and SED......61

Direct and Indirect Levers of Federal Influence.....................................................................63

The ISMICC Role in Evaluating Federal Programs and Enhancing 

Coordination to Improve Outcomes................................................................................ 66

What Is Known to Date About Federal Programs................................................................. 69

Future Work of the ISMICC to Evaluate Federal Programs.................................................. 76

Chapter 4: Recommendations From Non-Federal ISMICC Members........................................77

Full Recommendations........................................................................................................... 78

Focus 1: Strengthen Federal Coordination to Improve Care........................................... 78

Focus 2: Access and Engagement: Make It Easier to Get Good Care...............................81

Focus 3: Treatment and Recovery: Close the Gap Between What Works and What Is 

Offered............................................................................................................................... 84

Focus 4: Increase Opportunities for Diversion and Improve Care for People 

With SMI and SED Involved in the Criminal and Juvenile Justice Systems.................. 87

Focus 5: Develop Finance Strategies to Increase Availability and Affordability 

of Care................................................................................................................................ 90
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Table of Contents (continued)

Appendices Page

A Members ............................................................................................................................ 94

B Glossary of Terms Used in Report...................................................................................104

Tables

1.1. Populations Receiving Select Evidence-Based Practices in Selected State 

Mental Health Systems in 2016.......................................................................................... 15

1.2. Weighted Data From 2016 National Survey of Children’s Health ...................................22

2.1. Areas for the ISMICC to Explore During Future Meetings ............................................. 58

3.1. Federal Programs Related to SMI and SED Programs That Can Support People 

With SMI and SED............................................................................................................ 70

Figures

1. Estimates and Unmet Needs of Persons With Serious Mental Illnesses and Serious 

Emotional Disturbances ......................................................................................................1

1.1. Past Year Serious Mental Illness (SMI) Among Adults Age 18 or Older in the United 

States, by Gender, Race/Ethnicity, Age Group: 2016 ........................................................ 12

1.2. Past Year Substance Use Disorder (SUD) and Serious Mental Illness (SMI) Among 

Adults Age 18 or Older: 2016.............................................................................................. 13

1.3. Receipt of Mental Health Services in the Past Year Among Adults Age 18 or Older With 

Serious Mental Illness (SMI): Percentages, 2016..............................................................14
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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1.4. Receipt of Mental Health Care and Specialty Substance Use Treatment in the Past 

Year Among Adults Age 18 or Older Who Had Past Year Serious Mental Illness and 

Substance Use Disorders: Percentages, 2016 ....................................................................14

1.5. Past Year Major Depressive Episode Among Adolescents Ages 12 to 17 in the United 

States, by Race/Ethnicity: 2016..........................................................................................22

1.6. Past Year Substance Use Disorder (SUD) and Major Depressive Episode (MDE) 

Among Youth Ages 12 to 17: 2016 .......................................................................................23

1.7. Past Year Treatment for Depression Among Adolescents Ages 12 to 17 With Major 

Depressive Episodes in the United States: 2016 .............................................................. 26

3.1. Government and Private Funding Sources for Mental Health (MH) and Substance 

Use Disorder (SUD) Treatment........................................................................................ 62
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Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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1

Introduction

In 2003, the President’s New Freedom Commission on Mental Health concluded that America’s 

mental health service delivery system was in shambles. The Commission’s final report stated that 

“for too many Americans with mental illnesses, the mental health services and supports they need 

remain fragmented, disconnected and often inadequate, frustrating the opportunity for recovery.” 

A number of the recommendations of the President’s New Freedom Commission on Mental 

Health were not implemented or have only been partially realized. Since then, quality of life has 

not fundamentally changed for adults with serious mental illnesses (SMI) and children and youth 

with serious emotional disturbances (SED) and their families in the United States (Figure 1). 

Figure 1. Estimates and Unmet Needs of Persons With Serious Mental Illnesses and 

Serious Emotional Disturbances

4.2%

Percentage of the adult population, age 18 

and over, living with SMI in the past year1

Nearly one in four

adults with SMI lived below the 

poverty line in the past year 4

The suicide rate for 

individuals with mood 

disorders such as 

depression or bipolar 

disorder is 25 times higher 

than among the general population6

One in ten youths in SAMHSA’s Children's Mental Health Initiative 

had attempted suicide prior to receiving services2

Approximate number of 

persons with SMI admitted 

annually to U.S. jails 2 million 3

Only about one in three

people with mental 

illness in jails or prisons 

is currently receiving 

any treatment 5

The Health Care System Has Failed to Address the Needs of Persons 

With Serious Mental Illnesses (SMI) and Serious Emotional Disturbances (SED)

Percentage of youth

under age 18 with SED7

7% to12%

Sources

1 CBHSQ, 2017a

2 CMHS/SAMHSA, 2016

3 Steadman et al., 2009

4 CBHSQ, 2017b

5 SAMHSA, 2015

6 HHS, 2012

7 Ibid.
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Poor social supports, unemployment, comorbid 

medical problems, and addiction challenges abound. 

We have continued to defer to law enforcement 

services, criminal justice systems, hospital services, 

public education systems, and homeless services as 

the primary solutions, overtaxing these services and 

systems while contributing to poor outcomes such as 

unnecessary incarceration and long waits in hospital 

emergency departments. Failure to succeed in school 

or to access higher education, housing, or employment 

remain all too common. Tragically, people with SMI and 

SED die of suicide at extremely high rates, and in rare 

circumstances violence has led to unspeakable pain for 

families and our communities. 

Negative attitudes and discrimination remain a painful 

part of every setting, including school, work, and health care, preventing children, youth, 

and adults with serious mental health conditions from being embraced and valued in their 

communities. When individuals and their families don’t seek help because of negative attitudes 

and discrimination, they don’t access services and supports that could improve their situations, 

and this prevents them from exercising their legal rights under the Americans with Disabilities 

Act and the Individuals with Disabilities Education Act.

Role of the ISMICC 

The 21st Century Cures Act (Public Law 114-255) authorizes the Interdepartmental Serious Mental 

Illness Coordinating Committee (ISMICC) to enhance coordination across federal agencies to 

improve service access and delivery of care for people with SMI and SED and their families.

The ISMICC is charged to: 

• Report on advances in research on SMI and SED related to prevention, diagnosis, 

intervention, treatment and recovery, and access to services and supports;

• Evaluate the effect federal programs related to SMI and SED have on public health, 

including outcomes across a number of important dimensions; and

• Make specific recommendations for actions that federal departments can take to better 

coordinate the administration of mental health services for adults with SMI or children 

with SED.

“My adult son has cycled 13 times through 

mental hospitals over a 3-year period. He is 

taking his medications but continues to have 

psychotic thoughts not based in reality, and is 

greatly disabled by them. What has transpired 

since the closing of psychiatric care facilities 

is a travesty: incarceration, multiple cycles 

through hospitals or ERs, and homelessness, 

and often deaths. Without access to adequate 

care, many family members are caught in impossible situations, become distraught, or give 

up entirely. We need a federal standard and 

community solutions to provide care for highly 

disabled, mentally ill people like my son.”

— Marilyn (submitted through public comments to 

the ISMICC)
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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The ISMICC is chaired by Dr. Elinore F. McCance-Katz, Assistant Secretary for Mental Health 

and Substance Use. This position brings a new level of authority, experience, and expertise to 

the coordination of efforts at the Department of Health and Human Services (HHS) to address 

the needs of people with SMI and SED. Dr. McCance-Katz and other federal members on the 

Committee will work across HHS and the federal government so Americans with SMI and SED are 

able to improve their lives and have access to the highest possible standard of care—care that is 

deeply informed by our knowledge of science and medicine.

The ISMICC is a historic chance to address 

SMI and SED across federal departments 

and the systems that they represent. 

Each of the eight departments supports 

programs that address the needs of people 

with SMI and SED. Their collaboration 

will be informed and strengthened by the 

participation of non-federal members, 

including national experts on health 

care research, mental health providers, 

advocates, and people with mental health 

conditions and their families and caregivers. 

The ISMICC is currently authorized through 

2022, at which time the Secretary of HHS 

will submit a recommendation to Congress 

about whether to extend the ISMICC.

The non-federal ISMICC members have firsthand experience with the mental health service 

system, and knowledge of what barriers exist for people who are seeking help. Moreover, the nonfederal members bring on-the-ground solutions and innovative ideas that can promote change 

and improve lives, in partnership with the federal members.

Together, ISMICC members bring the experience needed to develop a better understanding of 

what is working and what needs to be changed within the current systems of care. (See Appendix 

A for the full ISMICC membership.) This cross-sector, public-private partnership provides a 

unique opportunity to share and generate solutions not previously considered or implemented. 

By strengthening federal interdepartmental leadership and coordination, we can change federal 

policy to improve the availability and quality of care for people served. Improvement will 

come not just through the provision of more health care services, but through a more holistic 

approach—a true continuum of care that makes sense for each unique person. We seek to build a 

system where treatment and services work and individuals with SMI and SED can recover and live 

happier, healthier, more productive, and more connected lives. 

Federal Department and Agency Representation 

on the ISMICC 

• Secretary of the Department of Health and Human Services

• Assistant Secretary for Mental Health and Substance Use

• Attorney General, Department of Justice

• Secretary of the Department of Veterans Affairs 

• Secretary of the Department of Defense

• Secretary of the Department of Housing and Urban 

Development

• Secretary of the Department of Education

• Secretary of the Department of Labor

• Administrator of the Centers for Medicare & Medicaid 

Services

• Commissioner of the Social Security Administration
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The 2017 ISMICC Report to Congress

The work of the ISMICC is just beginning. This 2017 ISMICC Report to Congress includes 

information presented in the first ISMICC meeting in August 2017 and from ongoing dialogue 

with the ISMICC members. This report will set the stage for work by the ISMICC in the years 

ahead.

The ISMICC identified five major areas of focus 

for fulfilling the Committee’s vision. The five areas 

will guide the Committee’s work. We know that 

important treatment advances are on the horizon. 

Research is identifying new and powerful ways to 

improve the ability to diagnose and identify risk 

factors for the course of mental illnesses. Sensitive 

to emerging science, the ISMICC members plan to 

revisit this report, its charge, and the areas of focus 

periodically in the coming years.

The final ISMICC report to Congress is due 

December 2022 and will provide more complete 

information on what the ISMICC has accomplished 

and will identify future opportunities for improving 

the lives of those with SMI and SED. The ISMICC 

will develop interim reports and other documents as needed to further the progress of the 

Committee’s work.

The ISMICC will serve as a model for cross-sector coordination and will promote partnerships to 

address the needs of people with SMI and SED and their families and caregivers. We anticipate 

that the work of the ISMICC will stimulate change across federal and non-federal sectors. Federal 

efforts will help build new relationships and partnerships across public sectors, agencies, and 

levels of government. A commitment to coordinate and collaborate at the federal, state, tribal, 

county, and local levels will lead to systems that are easy to navigate, appropriate, and tailored to 

the individual needs of each person and their family and caregivers. 

Five ISMICC Areas of Focus

1. Strengthen federal coordination to improve 

care

2. Access and engagement: Make it easier to get 

good care

3. Treatment and recovery: Close the gap 

between what works and what is offered

4. Increase opportunities for diversion and 

improve care for people with SMI and SED 

involved in the criminal and juvenile justice 

systems

5. Develop finance strategies to increase 

availability and affordability of care
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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ISMICC Vision Statement

Federal interdepartmental leadership, with genuine collaboration and shared accountability of 

all federal agencies, and in partnership with all levels of government and other stakeholders, 

supports a mental health system that successfully addresses the needs of all individuals living 

with SMI or SED and their families and caregivers, effectively supporting their progress to achieve 

healthy lives characterized by autonomy, pride, self-worth, hope, dignity, and meaning.

Recommendations From the Non-Federal Members Summary1

(See Chapter 4 for Full Recommendations)

Focus 1: Strengthen Federal Coordination to Improve Care

1.1. Improve ongoing interdepartmental coordination under the guidance of the Assistant 

Secretary for Mental Health and Substance Use.

1.2. Develop and implement an interdepartmental strategic plan to improve the lives of people 

with SMI and SED and their families. 

1.3. Create a comprehensive inventory of federal activities that affect the provision of services 

for people with SMI and SED.

1.4. Harmonize and improve policies to support federal coordination.

1.5. Evaluate the federal approach to serving people with SMI and SED.

1.6. Use data to improve quality of care and outcomes.

1.7. Ensure that quality measurement efforts include mental health.

1.8. Improve national linkage of data to improve services.

Focus 2: Access and Engagement: Make It Easier to Get Good Care

2.1. Define and implement a national standard for crisis care.

1 These recommendations reflect the views of the non-federal ISMICC members. Federal members were consulted regarding 

factual concerns and federal processes, but the final list of recommendations are the product of the non-federal members. These 

recommendations do not represent federal policy, and the federal departments represented on the ISMICC have not reviewed 

the recommendations to determine what role they could play in the future activities of the departments. The recommendations 

should not be interpreted as recommendations from the federal government.

 
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2.2. Develop a continuum of care that includes adequate psychiatric bed capacity and 

community-based alternatives to hospitalization.

2.3. Educate providers, service agencies, people with SMI and SED and their families, and 

caregivers about the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 

and other privacy laws, including 42 CFR Part 2, in the context of psychiatric care.

2.4. Reassess civil commitment standards and processes. 

2.5. Establish standardized assessments for level of care and monitoring of consumer progress.

2.6. Prioritize early identification and intervention for children, youth, and young adults.

2.7. Use telehealth and other technologies to increase access to care.

2.8. Maximize the capacity of the behavioral health workforce.

2.9. Support family members and caregivers.

2.10. Expect SMI and SED screening to occur in all primary care settings.

Focus 3: Treatment and Recovery: Close the Gap Between What Works and What Is Offered

3.1. Provide a comprehensive continuum of care for people with SMI and SED.

3.2. Make screening and early intervention among children, youth, transition-age youth, and 

young adults a national expectation.

3.3. Make coordinated specialty care for first-episode psychosis available nationwide.

3.4. Make trauma-informed, whole-person health care the expectation in all our systems of 

care for people with SMI and SED.

3.5. Implement effective systems of care for children, youth, and transition-age youth 

throughout the nation.

3.6. Make housing more readily available for people with SMI and SED.

3.7. Advance the national adoption of effective suicide prevention strategies.

3.8. Develop a priority research agenda for SED/SMI prevention, diagnosis, treatment, and 

recovery services.
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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3.9. Make integrated services readily available to people with co-occurring mental illnesses and 

substance use disorders, including medication-assisted treatment (MAT) for opioid use 

disorders.

3.10. Develop national and state capacity to disseminate and support implementation of the 

national standards for a comprehensive continuum of effective care for people with SMI 

and SED.

Focus 4: Increase Opportunities for Diversion and Improve Care for People With SMI and SED 

Involved in the Criminal and Juvenile Justice Systems

4.1. Support interventions to correspond to all stages of justice involvement. Consider all 

points included in the sequential intercept model.

4.2. Develop an integrated crisis response system to divert people with SMI and SED from the 

justice system.

4.3. Prepare and train all first responders on how to work with people with SMI and SED.

4.4. Establish and incentivize best practices for competency restoration that use communitybased evaluation and services.

4.5. Develop and sustain therapeutic justice dockets in federal, state, and local courts for any 

person with SMI or SED who becomes involved in the justice system.

4.6. Require universal screening for mental illnesses, substance use disorders, and other 

behavioral health needs of every person booked into jail.

4.7. Strictly limit or eliminate the use of solitary confinement, seclusion, restraint, or other 

forms of restrictive housing for people with SMI and SED.

4.8. Reduce barriers that impede immediate access to treatment and recovery services upon 

release from correctional facilities.

4.9. Build on efforts under the Mentally Ill Offender Treatment and Crime Reduction Act, the 

21st Century Cures Act, and other federal programs to reduce incarceration of people with 

mental illness and co-occurring substance use disorders.

Focus 5: Develop Finance Strategies to Increase Availability and Affordability of Care

5.1. Implement population health payment models in federal health benefit programs.

5.2. Adequately fund the full range of services needed by people with SMI and SED.
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5.3. Fully enforce parity to ensure that people with SMI and SED receive the mental health 

and substance abuse services they are entitled to, and that benefits are offered on terms 

comparable to those for physical illnesses.

5.4. Eliminate financing practices and policies that discriminate against behavioral health care.

5.5. Pay for psychiatric and other behavioral health services at rates equivalent to other health 

care services.

5.6. Provide reimbursement for outreach and engagement services related to mental health 

care.

5.7. Fund adequate home- and community-based services for children and youth with SED and 

adults with SMI.

5.8. Expand the Certified Community Behavioral Health Clinic (CCBHC) program nationwide.
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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References

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017a). 2016 National Survey on 

Drug Use and Health: Detailed Tables. (NSDUH 2016, Table 8.6B). Rockville, MD: Substance 

Abuse and Mental Health Services Administration. 

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017b). 2016 National Survey on 

Drug Use and Health: Detailed Tables. (NSDUH 2016, Table 8.6A). Rockville, MD: Substance 

Abuse and Mental Health Services Administration. 

Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services 

Administration (SAMHSA). (2016). The evaluation of the comprehensive community mental 

health services for children with serious emotional disturbances program, report to Congress, 

2015 (SAMHSA Publication No. PEP16-CMHI2015). Retrieved from https://www.samhsa.gov/

sites/default/files/programs_campaigns/nitt-ta/2015-report-to-congress.pdf. 

President’s New Freedom Commission on Mental Health. (2003). Achieving the Promise: 

Transforming Mental Health Care in America. Retrieved from http://govinfo.library.unt.edu/

mentalhealthcommission/reports/FinalReport/downloads/FinalReport.pdf.

Steadman, H. J., Osher, F. C., Robbins, P. C., Case, B., & Samuels, S. (2009). Prevalence of serious 

mental illness among jail inmates. Psychiatric Services, 60(6), 761-765.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). Screening and 

assessment of co-occurring disorders in the justice system. (HHS Publication No. (SMA)-15-

4930). Rockville, MD: Substance Abuse and Mental Health Services Administration.

U.S. Department of Health and Human Services (HHS) Office of the Surgeon General and 

National Action Alliance for Suicide Prevention. (2012). 2012 national strategy for suicide 

prevention: Goals and objectives for action. Washington, DC: U.S. Department of Health & 

Human Services. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK109917.
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Interdepartmental

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Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Chapter 1: The Current Needs of Americans With Serious 

Mental Illnesses and Serious Emotional Disturbances

This report focuses on issues related to adults 

with serious mental illnesses (SMI) and children 

and youth with serious emotional disturbances 

(SED).2

Serious Mental Illnesses

The definition of SMI includes one or more 

diagnoses of mental disorders combined 

with significant impairment in functioning. 

Schizophrenia, bipolar illness, and major 

depressive disorder are the diagnoses most 

commonly associated with SMI, but people 

with one or more other disorders may also fit 

the definition of SMI if those disorders result in 

functional impairment.

About 1 in 25 adults has an SMI in a given year. In 2016, 4.2 percent of U.S. adults age 18 

or older (an estimated 10.4 million adults) had an SMI in the past year (CBHSQ, 2017a). This 

estimate includes new and existing cases of SMI. The percentage of SMI in the past year was 

higher for sexual minority adults (13.1 percent) than for sexual majority adults (3.6 percent) 

(Medley et al., 2016). Across racial and ethnic groups, people of two or more races (7.5 percent) 

and Non-Hispanic Whites (4.8 percent) had higher percentages of SMI in the past year than the 

national average (4.2 percent)(Figure 1.1). In 2016, women accounted for 65.4 percent of adults 

with SMI (CBHSQ, 2017a).

The percentage of SMI in the past year also varies across age groups, with those 50 and older (2.7 

percent) having lower rates than those aged 18 to 25 (5.9 percent) or those aged 26 to 49 (5.3 

percent). The lower prevalence in older adults may be impacted by the increased risk of earlier 

death among people with SMI.

2 For the precise wording of the definition, see https://www.samhsa.gov/sites/default/files/federal-register-notice-58-96-definitions.pdf. Note that impairment resulting from a primary diagnosis of substance use disorder does not qualify a person as having 

a serious mental illness. This report does not address Alzheimer’s disease or related disorders that are listed in the Diagnostic 

and Statistical Manual of Mental Disorders and cause functional impairment. The ISMICC has noted the need for consistent 

definitions of SMI and SED and is considering how best to address these definitional issues moving forward.

Defining SMI2

Serious mental illness (SMI) refers to individuals 18 or 

older, who currently or at any time during the past year 

have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified in the diagnostic manual of the American 

Psychiatric Association and that has resulted in functional impairment, that substantially interferes with or limits 

one or more major life activities. 

Major life activities include basic daily living skills (e.g. 

eating, bathing, dressing); instrumental living skills (e.g., 

maintaining a household, managing money, getting 

around the community, taking prescribed medication); 

and functioning in social, family, and vocational/educational contexts.
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Figure 1.1. Past Year Serious Mental Illness (SMI) Among Adults Age 18 or Older in the 

United States, by Gender, Race/Ethnicity, Age Group: 2016

Source: Center for Behavioral Health Statistics and Quality. (2017). Results from the 2016 National Survey on Drug Use and Health: detailed 

tables. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Adults with SMI often have multiple chronic conditions and general health issues. As 

stated by the Institute of Medicine3 (Daniels, England, Page, and Corrigan, 2005), “Mental and 

substance-use problems and illnesses seldom occur in isolation. They frequently accompany each 

other, as well as a substantial number of general medical illnesses such as heart disease, cancers, 

diabetes, and neurological illnesses. ... Because of this, mental, substance-use, and general health 

problems and illnesses are frequently intertwined, and coordination of all these types of health 

care is essential to improved health outcomes, especially for chronic illnesses.” People with 

co-occurring disorders often experience difficulty seeking and receiving services, which leads 

to poorer health outcomes overall and utilization of high-cost services such as inpatient and 

emergency room care. These individuals need to receive integrated care in settings equipped to 

diagnose and treat these complex and interrelated disorders (SAMHSA, 2002).

Nearly three-quarters of adults with SMI are diagnosed with two or more mental disorders 

(Kessler, Chiu, Demler, & Walters, 2005). About a quarter of adults with SMI (25.4 percent, an 

3 Now known as the National Academy of Medicine
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The Way Forward: Federal Action for a System That 

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Families and Caregivers 

December 13, 2017

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estimated 2.6 million adults) have a substance use disorder (Figure 1.2) (CBHSQ, 2017b), and 

approximately one in six (16.1 percent) misused opioids in the past year (CBHSQ, 2017c). Adults 

with SMI and substance use disorders “show more severe symptoms of mental illness, more 

frequent hospitalizations, more frequent relapses, and a poorer course of illness than patients 

with a single diagnosis, as well as higher rates of violence, suicide, and homelessness” (Bellack, 

Bennett, Gearon, Brown, & Yang, 2006). Nearly half of people with SMI used tobacco in the past 

year (49 percent) (CBHSQ, 2017d). A growing body of research shows that quitting smoking can 

improve mental health and addiction recovery outcomes (SAMHSA, n.d.-a); for example, smoking 

cessation is associated with a decreased risk of anxiety and mood disorders (Cavazos-Rehg et al., 

2014).

Figure 1.2. Past Year Substance Use Disorder (SUD) and Serious Mental Illness (SMI) 

Among Adults Age 18 or Older: 2016

Source: Adapted from Figure 69 of: Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental 

health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA17-5044, 

NSDUH Series H-52). Retrieved from http://www.samhsa.gov/data.

Relatively few adults with SMI receive effective treatments. Treatments that are 

demonstrated to be effective for SMI may include some combination of prescription medications, 

other supports (e.g., inpatient treatment, respite care, assertive community treatment, 

coordinated specialty care, supported employment), and psychotherapy (e.g., cognitive behavioral 

therapy, cognitive remediation therapy). About two-thirds of adults with SMI (64.8 percent, an 

estimated 6.7 million adults) (CBHSQ, 2017e) reported receiving mental health treatment in 2016 

(Figure 1.3). Most treatment is offered in outpatient settings, with only 7.6 percent (an estimated 

789,000 adults) receiving inpatient mental health treatment/counseling in the past year (CBHSQ, 

2017f). Nearly a third (32.6 percent, 2.2 million adults) of those who get treatment receive 

medications only, with no psychosocial or psychotherapeutic services (CBHSQ, 2017g). Among 

adults with co-occurring SMI and substance use disorders, nearly two-thirds (63.2 percent) 

received mental health care, but only 14.3 percent received specialized substance use treatment 

(Figure 1.4).
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Figure 1.3. Receipt of Mental Health Services in the Past Year Among Adults Age 18 or 

Older With Serious Mental Illness (SMI): Percentages, 2016

Source: Adapted from Table 8.33 of: Center for Behavioral Health Statistics and Quality. (2017). 2016 national survey on drug use and health: 

Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Figure 1.4. Receipt of Mental Health Care and Specialty Substance Use Treatment in 

the Past Year Among Adults Age 18 or Older Who Had Past Year Serious 

Mental Illness and Substance Use Disorders: Percentages, 2016

Source: Adapted from Figure 73 of: Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental 

health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA17-5044, 

NSDUH Series H-52). Retrieved from http://www.samhsa.gov/data.
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Effective treatment models exist, but are not widely available. States report annually 

on the implementation of select evidence-based practices (EBPs) in their systems. EBPs are 

practices that are based on rigorous research that has demonstrated effectiveness in achieving the 

outcomes that the practices were designed to achieve. State mental health systems often serve 

those with mental health conditions, including SMI and SED, who are Medicaid eligible and 

whose conditions require levels of care not paid for by private insurance. The percentage of the 

population who have access to these EBPs remains low and varies widely across states, recognizing 

that not all EBPs are appropriate for all people with SMI or SED (Table 1.1). For example, assertive 

community treatment, an intensive team-based care model that is a long-established best 

practice for adults with SMI, is provided to only 2.1 percent of the people served in state systems 

nationwide. Similarly, the individual placement and support model of supported employment, 

which should be provided to all adults with SMI who have a goal of employment, also is provided 

to only 2.1 percent of adults in state systems.

Table 1.1. Populations Receiving Select Evidence-Based Practices in Selected State 

Mental Health Systems in 20164

Evidence-Based Practice Target Population for Service

Percent of State MH 

Population Who Receive Practice in States 

that Report Data

Medication management Adults and youth with SMI/SED 32.0%

Illness self-management Adults with SMI 19.0%

Dual diagnosis treatment Adults with SMI and SUD 10.5%

Assertive community treatment Adults with SMI 2.1%

Supported employment Adults and transition-age youth 

with SMI

2.1%

Supported housing Adults and transition-age youth 

with SMI

3.1%

Therapeutic foster care Children and youth with SED 1.5%

Multi-systemic therapy Children and youth with SED 3.6%

Functional family therapy Children and youth with SED 6.9%

Family psychoeducation Families of people with SMI 1.9%

Most counties in the United States face shortages of mental health professionals. In 

96 percent of the counties in the nation, there is a shortage of psychiatrists who prescribe 

medications for people with SMI (Thomas, Ellis, Konrad, Holzer, & Morrissey, 2009). From 

2003 to 2013, the number of practicing psychiatrists decreased by 10 percent when adjusted for 

population size (Bishop, Seirup, Pincus, & Ross, 2016). Many psychiatrists are shifting to private 

practice, accepting only cash for reimbursement. In part, this may reflect low reimbursement 

4 From SAMHSA Uniform Reporting System Data - https://wwwdasis.samhsa.gov/dasis2/urs.htm. These figures only represent a 

subset of states that provided data. 
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for psychiatric services from state Medicaid programs and Medicaid-contracted managed care 

payers, cuts to federal and state funding for public sector programs, and inadequate rate setting 

for psychiatric services (Bishop, Press, Keyhani, & Pincus, 2014; National Council Medical 

Director Institute, 2017). The greatest shortages are in poorer and more rural counties. The 

need for child psychiatrists is even greater than the shortage of psychiatrists for adults with SMI 

(Thomas & Holzer, 2006). The lack of access to psychiatric services creates several issues, such as 

long wait times for scheduled appointments, often leading to emergency department visits and 

hospitalizations (National Council Medical Director Institute, 2017). 

Expanding the workforce by allowing advanced practice registered nurses to practice to the full 

extent of their training, broadening the scope of practice of psychologists to prescribe some 

medications, and educating more advanced practice registered nurses and psychiatric-mental 

health physician assistants, are examples of strategies to address the shortage. Tele-mental 

health is widely accepted as a mechanism that can address shortages in some geographic areas. 

One county in five also has a shortage of non-prescriber mental health professionals, defined 

as psychologists, advanced practice psychiatric nurses, social workers, licensed professional 

counselors, and marriage and family therapists (Thomas, Ellis, Konrad, Holzer, & Morrissey, 

2009). Also, there are categories of mental health service providers, including licensed 

professional counselors and marriage and family therapists, whose services are not eligible for 

reimbursement by Medicare (CMS, 2015). Peer support can play an important role in a functioning 

mental health system and should be included as a part of a full continuum of services, whenever 

possible (Myrick & del Vecchio, 2016). Peer support services have been demonstrated to promote 

recovery and resiliency through the generation of hope, engagement in treatment services, and 

activation for improved health outcomes (Repper & Carter, 2011). Youth and family peer support 

services have also generated notable outcomes in this area (Center for Health Care Strategies, 

2013). 

Most states report insufficient psychiatric crisis response capacity as well as insufficient 

numbers of inpatient psychiatric hospital beds. It is critical that every state have adequate 

bed capacity to respond to the needs of people experiencing both psychiatric crises and those 

who are in need of longer periods of inpatient care, such as people in forensic care (care that is 

provided because of involvement in the criminal or juvenile justice systems). In many areas, bed 

shortages have led to long delays in gaining access to treatment and an increase in individuals 

waiting for competency restoration services needed to restore competency to participate in legal 

proceedings (NASMHPD, 2017a). A report by the National Association of State Mental Health 

Program Directors Research Institute (NASMHPD, 2017b) found that most states (35 of the 46 

who responded) have shortages of psychiatric hospital beds. The configuration of available beds 

and the number of beds per 100,000 population varies substantially across states, but few states 

report they have adequate numbers of inpatient beds to meet needs. Use of a variety of strategies, 

such as building psychiatric respite bed capacity, may help to address these capacity issues. 
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Adults with SMI are more likely to be jailed or 

involved with the criminal justice system. It is 

estimated that approximately two million people with 

SMI are admitted annually to U.S. jails (Steadman, 

Osher, Robbins, Case, & Samuels, 2009). Among 

these admissions, 72 percent also meet criteria for 

co-occurring substance use disorders (Hyde, 2011). 

In 2016, among U.S. adults age 18 or older with SMI, 

9.5 percent were on probation and 9.7 percent were 

on parole or supervised release (CBHSQ, 2017h). By comparison, 2.9 percent of the general U.S. 

adult population is currently under some form of criminal justice supervision (SAMHSA, 2015). 

Too few jails and prisons offer screening and treatment programs for mental and substance 

use disorders, leading to longer incarceration stays (SAMHSA, 2015). All states require efforts 

to restore legal competence after a person is determined to be incompetent to stand trial, a 

process that typically takes place in state hospitals. However, a lack of available hospital beds for 

competency restoration can lead to waits for pretrial jail detainees that may average weeks, or 

even a year or longer (Fuller, Sinclair, Lamb, Cayce, & Snook, 2017). Only about one in three people 

with mental illness in jails or prisons receives any treatment (Bronson & Berzofsky, 2017). These factors 

contribute, in turn, to higher rates of recidivism. Specialty courts for people with mental or substance 

use disorders are promising, but their availability is extremely limited. 

Many adults with SMI are unemployed. Only 36 percent (CBHSQ, 2017a) of people with SMI 

have full-time employment, while most would prefer to work (McQuilken, Zahniser, Novak, 

Starks, Olmos & Bond, 2003). SMI also is a major driver of disability: 24.55 percent of adult 

disability applications in Federal Fiscal Year 2016 to the Social Security Administration were based 

on mental health, as were 64.56 percent of childhood disability applications (Social Security 

Administration, 2017).

Nearly twice as many adults with SMI have incomes below the poverty level as in the 

general population (22.8 percent, compared to 13.5 percent) (CBHSQ, 2017i; U.S. Census 

Bureau, n.d.). 

SMI is common among people experiencing homelessness. The Department of Housing 

and Urban Development (HUD) and SAMHSA (SAMHSA, n.d.-b) estimate that about one in five 

people (nearly 108,000 people)(HUD, 2016) experiencing homelessness has an SMI, and a similar 

percentage have a chronic substance use disorder. The Office of National Drug Control Policy 

reports that approximately 30 percent of people who are chronically homeless live with an SMI 

(Office of National Drug Control Policy, n.d.).

Most adults with SMI have private insurance or Medicaid. About one-quarter (24.9 percent) 

of adults with SMI were enrolled in Medicaid at some time during 2015, while slightly more than 

“Successful reentry into the community is a 

challenge for returning inmates with SMI. They 

are more likely than returning inmates without 

SMI to experience homelessness and are less 

likely to find employment.”

— Conclusions from a systematic review by the 

Agency for Healthcare Research and Quality 

(AHRQ, 2012)
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half (51.5 percent) had private insurance during the year. For some period of the year, more than 

1 in 10 (12.5 percent) had no insurance (CBHSQ, 2017i). However, individuals with insurance may 

still face challenges in accessing treatment. For example, many individuals with SMI still lack a 

usual source of care or delay medical care because of cost (Sherrill & Gonzales, 2017). An analysis 

of the 2016 Affordable Care Act Marketplaces demonstrated that, of those practicing in a given 

state-level market, plan networks included mental health care providers at a much lower rate (11.3 

percent) in comparison to primary care providers (24.3 percent) (Zhu, Zhang, & Polsky, 2017). 

Adults with SMI are at particularly high risk of 

death by suicide. A suicide occurs in the United 

States about every 13 minutes (Centers for Disease 

Control and Prevention [CDC], 2015); more than 

44,000 suicides occurred in 2015 (CDC, 2017). 

According to the Surgeon General’s National Strategy 

for Suicide Prevention (HHS, 2012), the rate of death 

by suicide for people with mood disorders such as 

depression or bipolar disorder is estimated to be 25 

times higher than among the general population. 

Among adults diagnosed with schizophrenia, 1 in 20 dies by suicide, a rate 20 times higher than 

for the general populations (Hor & Taylor, 2010). 

Mental illnesses lead to high medical costs. Health care costs are increased by two to three 

times for people with mental illness, even if their conditions are not among the most serious 

(Melek, Norris & Paulus, 2014). It is noteworthy that most of these higher costs for people with 

mental disorders result from medical spending for chronic health conditions, not for behavioral 

health medications or services. A high proportion of the most costly patients served by the health 

care system have mental or substance use disorders (Boyd et al., 2010). High medical costs are 

often incurred at hospitals, due to emergency department visits and hospitalizations. Between 

2006 and 2014, the rate of mental health/substance abuse-related emergency department visits 

increased approximately 44 percent (Moore, Stocks, & Owens, 2017). In 2014, people diagnosed 

with schizophrenia or mood disorders made 10.8 million visits to emergency departments (HCUP, 

2014a). Hospitalizations for people with schizophrenia or mood disorders cost $27.7 billion 

nationwide (HCUP, 2014b). 

Adults with mental illness receive a disproportionate share of opioid prescriptions. While 

people with any mental health condition represent only 17.9 percent of the population, a recent 

study concluded: “Adults with mental health conditions receive 51.4 percent (60 million of 115 

million prescriptions) of the total opioid prescriptions distributed in the United States each year” 

(Davis, Lin, Liu, & Sites, 2017).

Most civil commitment statutes fall short of adequately protecting patients or 

communities. In many jurisdictions, civil commitment criteria focus primarily on the immediate 

“My 39-year old son killed himself today. He 

hung himself in a solitary confinement cell in a 

prison. He died alone, afraid, and powerless. 

He needed help. Instead, he got punishment. 

Like all mothers, I had dreams for my children 

– dreams that didn’t include mental illness or 

prison.”

— Anne (submitted through public comments to the 

ISMICC)
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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threat of harm to self or others and do not consider 

patient history or capacity to make informed decisions 

about the need for or benefits of treatment (Goldman, 

2014). This results in many patients being unable to 

access care when decompensated until they have done 

something which may lead to their arrest. Although 

virtually all states have legal provisions for the use 

of assisted outpatient treatment (AOT), this form of 

court-ordered outpatient treatment is realistically 

available in few areas in the nation currently. AOT can 

be valuable to help ensure that people with SMI who 

are at high risk of damaging behavior are engaged at 

some level with treatment services. SAMHSA currently 

is working with the HHS Assistant Secretary for 

Planning and Evaluation and the National Institute of 

Mental Health to evaluate the effect of various aspects 

of AOT implementation in 17 communities throughout 

the United States. Other strategies may be considered 

to address some of these issues, such as advance directives and other forms of consumer-directed 

care planning such as wellness recovery action plans.

Caregivers of people with mental illness face complex situations and a high burden of 

care. A study of unpaid caregivers by the National Alliance for Caregiving estimates that nearly 

8.4 million Americans provide care to an adult with an emotional or mental health issue, mainly 

related to SMI (NAC, 2016). It found that, for nearly one in five mental health caregivers, taking 

care of a loved one is equivalent to a full-time job. Approximately one in three caregivers provides 

care for more than 10 years (NAC, 2016). Many people with SMI are financially dependent on 

family and friends. Caregivers also bear a significant emotional burden, and often report feeling 

isolated and stigmatized because of their loved one’s illness. This stress can lead to physical health 

problems, as nearly 4 in 10 caregivers report difficulty taking care of their own health, and about 

half cite caregiving as a cause of worsening health (NAC, 2016). Caregivers also face logistical 

challenges in coordinating care for their loved one, such as finding appropriate providers, 

managing medications, handling paperwork and finances, and accessing community services 

“If assisted outpatient treatment had been 

available to my paranoid schizophrenic son, 

countless heartaches and dangers could have 

been averted over the course of the 25 years 

he has endured this cruel disease. No, instead 

we have had to wait until our psychotic loved 

ones became a danger to self or others. There 

are red flags that maybe only family members 

can see, but still we have to wait until it is too 

late. My son has been homeless, dangerous, 

and now in prison. I have not heard from him in 

3 years because I “know” he’s been off meds, 

but he has a right to refuse treatment! He is lost! 

And I can get no information because of HIPAA. 

We need assisted outpatient treatment, revised 

HIPAA, and more hospital beds instead of jail 

cells.” 

— Judy (submitted through public comments to the 

ISMICC)
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(NAC, 2016). Despite their involvement in day-to-day disease management, many caregivers 

report they are often excluded from care conversations and cannot speak to the provider about the 

patient’s condition. Parents caring for an adult child face these challenges more frequently, as 77 

percent have been told they cannot speak to a provider and 69 percent feel they have been left out 

of care conversations (NAC, 2016).

Serious Emotional Disturbances

The definition of SED is similar to SMI, but applies5

to children and youth; it requires the presence of a 

diagnosable mental, behavioral or emotional disorder 

and substantial functional impairment. While some 

of the diagnoses that contribute to meeting criteria 

for SED are the same as for SMI, some are different. 

Diagnoses that are more commonly seen in children 

than adults include disruptive behavior disorders, and 

others that are less commonly seen in children than 

adults, include bipolar disorder and schizophrenia. 

As with SMI, individuals with SED can also 

have substance use disorders and intellectual/

developmental disabilities that co-occur with their 

mental disorders. Those whose sole diagnosis 

is a substance use disorder or an intellectual/

developmental disorder are not considered to have 

SED. The type of functional impairment in SED also 

reflects the nature of childhood; role functioning in family, school, and community naturally 

varies depending on the age of the child.

Many children and youth have an SED. It has been challenging to assess functional impairment 

across age groups, as no national survey currently estimates the prevalence of SED. SAMHSA 

estimates prevalence ranging between 6.8 and 11.5 percent, based on published studies that differ 

on the study design and ages of children and youth included.

Reviews of the literature have produced some estimates. According to a 2013 CDC review of 

population-level information, estimates of the number of children with a mental disorder range 

from 13 percent to 20 percent (CDC, 2013). A recent meta-analysis of U.S. epidemiological studies 

concluded that 10 percent of children meet the criteria of significant impairment in one domain of 

role functioning (family, school, peers, community, or school) (Williams, Scott, & Aarons, 2017). 

5 Adapted from Federal Register, Vol. 58, No. 96, pages 29422-29425; for detail on the criteria for emotional disturbance under 

IDEA, see http://idea.ed.gov/explore/view/p/,root,regs,300,A,300.8,.html.

Defining SED5

Serious emotional disturbance (SED) refers to 

children and youth who have had a diagnosable 

mental, behavioral, or emotional disorder in the 

past year, which resulted in functional impairment that substantially interferes with or limits 

the child’s role in family, school, or community 

activities.

The members of the ISMICC have concerns 

about the term “serious emotional disturbance.” The use of the word “emotional” does 

not capture the reality that mental disorders 

experienced by children and youth often have 

cognitive or behavioral aspects. The word 

“disturbance” also does not seem fitting for 

diagnosable disorders that are just as important 

to address in young people as disorders expe-
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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The National Comorbidity Survey – Adolescent Supplement (NCS-A), was a large-scale national 

survey of youth ages 13 to 18 conducted between 2001 and 2004 (Merikangas, He, Burstein, 

Swanson, Avenevoli, Cui & Swendsen, 2010). Interviews of 10,123 youth used an instrument that 

generated DSM-IV diagnoses. The overall prevalence of disorders with severe impairment and/

or distress was 22.2 percent. Lifetime prevalence of mood disorders (including major depressive 

disorder, dysthymia, and bipolar I and II) with severe impairment was the most common class of 

disorders (11.2 percent). Lifetime prevalence of behavior disorders (including conduct disorder 

and oppositional defiant disorder) with severe impairment was found at a rate of 9.6 percent, and 

the rate of anxiety disorder with severe impairment was 8.3 percent. By any measure, the problem 

is substantial, and addressing it is important for the healthy development of our nation’s youth. 

Children and youth have a range of SED diagnoses. SAMHSA’s Children’s Mental Health 

Initiative (CMHI) provides funds to a limited number of public entities to promote recovery and 

resilience for children and youth who have an SED and their families by providing comprehensive 

services for mental and substance use disorders using the system of care framework. Systems of 

care refers to a coordinated network of community-based services and supports organized to meet 

the challenges of children and youth and their families. Among youth entering the CMHI program 

in 2015, the five most common diagnoses were mood disorders (such as depression, 29.3 percent), 

attention deficit hyperactivity disorder (ADHD, 24.9 percent), oppositional defiant disorder (15.8 

percent), adjustment disorders (15.3 percent), and post-traumatic stress disorder (PTSD) or acute 

stress disorder (12.6 percent) (CMHS/SAMHSA, 2016). Data from the 2016 National Survey of 

Children’s Health (NSCH), shown in Table 1.2, indicate reported diagnoses for younger children, 

ages birth to 11, as well as for older youth. It should be noted that the NSCH methodology involves 

asking a parent about the statements made by a doctor or health provider, an approach that may 

be less precise and result in lower estimates than a diagnostic interview.

On average, 15 percent of young children (ages 2-8) in the United States have a parent-reported 

mental, behavioral, or developmental disorder (MBDD) diagnosis, which includes ADHD, 

depression, anxiety problems, behavioral or conduct problems such as oppositional defiant 

disorder or conduct disorder, Tourette syndrome, autism spectrum disorder, learning disability, 

intellectual disability, developmental delay, or speech or other language problems.1 The 

percentage of children with diagnosed MBDD is similar for small rural and urban areas, at 18.6 

percent and 15 percent, respectively (Robinson et al., 2017).
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Table 1.2. Weighted Data From 2016 National Survey of Children’s Health

Condition

Percentage by Age Category:

Age 0-11 

(N=48,534,964)

Age 12-17

(N=24,815,076)

Doctor/health provider ever said child had anxiety problems 4.4 12.4

Doctor/health provider ever said child had depression 1.1 8.2

Doctor/health provider/educator ever said child had behavioral/conduct problems 7.1 10.1

* Missing data excluded from denominator

Racial and ethnic differences among youth. The NCS-A study found few differences across 

racial and ethnic groups in the major classes of mental disorders (mood, anxiety, or behavior 

disorders), except that the rates of anxiety disorders were higher and rates of substance use 

disorder were lower among Non-Hispanic Black or African-American adolescents, compared to 

Non-Hispanic White adolescents, and there were higher rates of mood disorders among Hispanic 

adolescents compared to Non-Hispanic Whites. 

SAMHSA’s ongoing National Survey of Drug Use and Health estimates the rate of major 

depressive disorder annually among youth. In 2016, 12.8 percent of youth in this age group (an 

estimated 3.1 million youth) experienced a major depressive episode (CBHSQ, 2017j). There were 

differences in the rate of major depressive episodes across ethnic groups, with Non-Hispanic Black 

or African-American youth having lower rates and Non-Hispanic White youth having higher rates 

(Figure 1.5).

Figure 1.5. Past Year Major Depressive Episode Among Adolescents Ages 12 to 17 in 

the United States, by Race/Ethnicity: 2016

Source: Based on Table 9.7B of: Center for Behavioral Health Statistics and Quality. (2017). Results from the 2016 National Survey on Drug 

Use and Health: detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration.
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Youth with SED often have multiple disorders. The NCS-A study found that 6 percent of 

youth had disorders in two or more major classes of mental disorders (i.e., mood, anxiety, or 

behavior disorders). Among youth with a past year major depressive episode, 12.1 percent (an 

estimated 333,000) also had a substance use disorder (CBHSQ, 2017k). An estimated 333,000 

adolescents ages 12 to 17 had both a substance use disorder and a major depressive episode in 

the past year (Figure 1.6). Children and youth with SED also have increased rates of co-occurring 

health conditions such as obesity (Pastor & Reuben, 2011), asthma (Goodwin et al., 2014), and the 

onset of cigarette smoking (Blum, Kelly, & Ireland, 2001).

Figure 1.6. Past Year Substance Use Disorder (SUD) and Major Depressive Episode 

(MDE) Among Youth Ages 12 to 17: 2016

Source: Adapted from Figure 66 of: Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental 

health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA17-5044, 

NSDUH Series H-52). Retrieved from http://www.samhsa.gov/data.

Early intervention is crucial to address development of mental disorders. The vast majority 

of individuals who will develop a mental health disorder in their lifetime do so before age 24 

(Kessler et al., 2005). Strong prevention and early intervention efforts should occur at these 

ages, but occur far too rarely. There are many standards for assessing mental health conditions 

in children and adolescents up to age 18 in pediatric care (U.S. Preventive Services Task Force, 

n.d.). There are also consensus-based guidelines for care of children and adolescents, such as 

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (Hagan, 

Shaw, & Duncan, 2017). These guidelines call for regular screening for a variety of mental health 

conditions, and include recommendations for pediatric screening of those up to age 21. Medicaid’s 

Early and Periodic, Screening, Diagnosis, and Testing (EPSDT) benefit requires mental health 

assessment of all covered children. Other expert groups have developed guidelines for screening 

for a broader array of mental health conditions in children and adolescents (Weitzman et al., 

2015). However, screening is recommended only when systems are in place to ensure accurate 
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diagnosis, treatment, and follow-up, so screening efforts must be accompanied by an expansion 

of access to mental health care. Low uptake of screening procedures likely reflects the shortage 

of mental health care for children and youth, the stigmatizing nature of these conditions, and 

cultural variations in views of mental health needs (Wissow et al., 2013). Mental health screening 

for children and adolescents can be conducted in schools (Essex et al., 2009), but the vast majority 

of schools do not conduct universal screening, as they face many of the same challenges as 

screening in pediatric care settings, and have limited resources to do so.

As youth enter young adulthood, mental health screening and early intervention continues to be 

limited. Screening rates are very low (IOM & NRC, 2014). Screening tools and processes have not 

been developed explicitly for 18- to 26-year-olds (Ozer, Scott, & Brindis, 2013). This is a critical 

age at which screening for development of the most serious mental illnesses (i.e., psychotic 

illness) can substantially reduce the impact of these disorders. Yet screening for early psychosis 

rarely takes place outside mental health clinics affiliated with early psychosis research programs. 

The following recommendation was issued by the National Academy of Science, Engineering, 

and Medicine (IOM & NRC, 2014): “The U.S. Preventive Services Task Force should develop a 

consolidated set of standardized evidence-based recommendations for clinical preventive services 

such as screenings, counseling services, and preventive medications specifically for young adults 

ages 18-26. Behavioral and oral health should be included in these recommendations.” This is an 

important step toward achieving a system of care that ensures screening for youth during this 

critical time.

Children and youth with SED often have 

challenging life circumstances (CMHS/SAMHSA, 

2016). Caregivers of youth entering the CMHI program 

reported that 4 in 10 (39.7 percent) children and youth 

had been exposed to domestic violence at some point 

in life, and one in five (21.7 percent) had been exposed 

to such violence during the prior six months. More 

than one in five of these youth were missing school 

frequently, and nearly half (47.2 percent) had been 

suspended or expelled from school. Nearly threequarters of these youth (73.5 percent) lived with 

someone who had shown signs of depression in the six 

months before entering services, and nearly half (48.4 

percent) had a family member with a mental illness 

other than depression (CMHS/SAMHSA, 2016). These 

types of adverse childhood experiences increase the 

likelihood of developing SED and later SMI (Dube, 

Anda, Felitti, Chapman, Williamson & Giles, 2001; 

Chapman, Whitfield, Felitti, Dube, Edwards & Anda, 

2004). 

“Three years ago, I took in my cousin because 

my uncle and aunt are both SMI and they could 

no longer care for him. His mom was in jail 

and his father was in a long-term community 

placement. At only 8 years old, he was very 

much out of control due to a number of abuses 

and a general lack of a nurturing environment. 

We quickly pulled together the services and 

supports we thought he needed in school, in 

the community, and in our home. He was still 

failing miserably in all of his life domains. This 

year, I sat down with every provider he had ever 

used and we developed strategies, services, 

and supports that cut across all of his programs 

as a team. We developed new approaches that 

were customized to his unique needs and life 

experiences. Here we are today, I am finalizing 

his adoption and he is starting to mesh into our 

family and community. He is a survivor; but the 

system had to work collaboratively to throw him 

the lifelines he needed.”

— SJ 
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Effective treatments are available. There are a wide range of evidence-based treatments for 

many mental disorders that children and youth experience (e.g., anxiety, depression, ADHD, 

autism, eating disorders, obsessive compulsive disorder [OCD], exposure to traumatic events, 

disruptive behavior, substance abuse) (Silverman & Hinshaw, 2008). Psychotherapeutic or 

psychosocial services such as cognitive behavioral therapy and social skills training are evidencebased interventions that may be provided independently or along with medications. Coordinated 

specialty care is an evidence-based approach to working with youth nearing or in early adulthood 

who experience a first episode of psychosis. Psychotropic medications are commonly given for 

disorders such as anxiety, depression, psychosis, ADHD, and OCD, among others, and should be 

used for children and youth in keeping with the latest research and guidelines. Prescribers should 

be careful, as psychotropic medications have been overused in some populations of young people 

in ways that are not supported by research or practice guidelines (American Academy of Child 

and Adolescent Psychiatrists, 2015). In addition, the system of care approach continues to evolve 

to reflect advances in research and service delivery. The core values of community-based, familydriven, youth-guided, and culturally and linguistically competent services are widely accepted. 

The guiding principles calling for a broad array of effective services, individualized care, and 

coordination across child-serving systems are extensively used as the standards of care throughout 

the nation (Stroul & Friedman, 2011).

Most children and youth with SED do not receive 

treatment. Identifiable mental health problems are 

common, but few children receive services for those 

problems. The lack of services received by these young, 

multi-challenged children is a services systems and 

social policy failure (McCue Horwitz et al., 2012). 

About 4 in 10 (40.9 percent) of youth ages 12 to 17 with 

major depressive episodes (1.2 million youth) received 

treatment of any kind in 2016 (Figure 1.7) (CBHSQ, 

2017j). This is similar to the findings from the NCS-A 

study, that 36.2 percent of adolescents with mental 

disorders received treatment across diagnostic groups. 

However, that study also reported that treatment 

rates were higher for adolescents with attention deficit hyperactivity disorder (59.8 percent) and 

behavior disorders, such as oppositional defiant disorder and conduct disorder (45.4 percent), 

but lower for those with anxiety disorders (17.8 percent), while children and youth with mood 

disorders had received treatment 37.7 percent of the time (Merikangas, He, Burstein, Swendsen, 

Avenevoli, Case, & Olfson, 2011). Among youth in 2016 with a past year major depressive episode 

who received treatment for depression, only 18.9 percent saw or talked to a health professional 

and also took prescription medication (CBHSQ, 2017l).

“The last 10 months of our lives have been filled 

with a life-altering and horrific change as my beloved youngest son had a psychotic break and 

was diagnosed with schizophrenia. Like many 

other families, we were naïve. We have been 

screaming for help and information, waiting 

on services, and watching my son slowly fade 

away. Things need to change. It is evident that 

mental illness is still treated with casual effort 

and not as a true and serious medical illness.”

— Charlene (submitted through public comments to the 

ISMICC)
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Figure 1.7. Past Year Treatment for Depression Among Adolescents Ages 12 to 17 With 

Major Depressive Episodes in the United States: 2016

Source: Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United 

States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA17-5044, NSDUH Series H-52). Retrieved 

from http://www.samhsa.gov/data.
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Transition-age youth face particular challenges.

Youth with SED encounter problems as they age from 

adolescence to adulthood, and undergo the transition from 

youth-oriented systems of care to the adult behavioral 

health system. Exact definitions of the transition period 

ages have been described broadly (ages 14 to 30) to more 

narrowly (ages 17 to 25). Regardless of the exact age range, 

this is a developmentally critical stage, i.e., transition from 

childhood into adult responsibilities. It is also the age range 

during which many adult SMI diagnoses first become 

apparent (Kessler et al., 2005; Hafner et al., 1994). Program 

structures, eligibility criteria, expectations related to family 

participation in treatment and sharing of information, and 

expectations for adult functioning can change substantially, 

based solely on the passage of a birthday (Davis, 2003; 

Davis & Koroloff, 2005). For these and other reasons, 

many of these youth drop out of services when they 

reach adulthood. The adult outcomes for most youth who 

enter adulthood with SED or SMI are bleak; many don’t 

finish high school, college enrollment and completion 

is low, unemployment is high, and they are at increased 

risk of homelessness (Davis & Vander Stoep, 1997; Rinaldi et al., 2010; Wagner & Newman, 2012). As 

with the general population, substance use peaks during these ages, as does justice system involvement 

(Sheidow, McCart, Zajac, & Davis, 2012; Davis, Banks, Fisher, Gershenson, & Grudzinskas, 2007). 

Evidence-based practices such as supported employment and supported housing have been adapted 

and shown promising results for transition-age youth. The coordinated specialty care model also 

shows great promise for people who experience a first episode of psychosis in late adolescence or 

early adulthood (Kane et al., 2016). A review of health care and services for young adults by the 

Institute of Medicine and National Research Council6 (2014) describes the variety of evidence-based 

interventions and recommends steps for increasing the use of evidence-based approaches for young 

adults.

6 Now known as the National Academy of Medicine and the National Academies of Science, Engineering, and Medicine.

“My son was treated for serious psychiatric 

disorders as a child. At age 17, in an attempt to 

escape the discrimination of his peers, he refused treatment. It was not long before he quickly became aggressively psychotic. My husband 

and I were encouraged to file a beyond control 

petition in civil court, just 6 months prior to our 

son’s 18th birthday—hoping to save his life and 

us from his reckless and often dangerous behavior. Instead, he was ordered to jail, punished 

for behaviors that were symptoms of his untreated brain disease! None of my son’s medical 

records and history transitioned to the adult system. My son was homeless, desperate for food, 

and still refused treatment. When we petitioned 

him to a hospital, he was not held long enough 

to stabilize. Many times, he threatened homicide 

or suicide. We have felt powerless, as we have 

watched his brain disease deteriorate year after 

year from countless psychotic episodes.”

— Regina (submitted through public comments to the 

ISMICC)
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Many children and youth with SED are living in poverty. More than one in five (20.2 percent) 

youth with major depressive episodes (CBHSQ, 2017m), and almost one in three (29.8 percent) of 

special education students with emotional disturbance 

(Wagner et al., 2003) have family incomes below 

the poverty line. Almost two-thirds (65.1 percent) of 

children and youth with SED who receive services from 

SAMHSA’s CMHI program live below the poverty line 

(CMHS/SAMHSA, 2016). 

Children and youth account for nearly a quarter 

of people experiencing homelessness. The 

Department of Housing and Urban Development 

(HUD) estimates that more than 120,000 people 

experiencing homelessness are age 18 or under 

(HUD, 2016), with most being accompanied by a 

parent. Estimates of those with SED are not currently 

available. SAMHSA notes that lesbian, gay, bisexual, 

and transgender (LGBT) youth are at high risk for 

homelessness and SED (SAMHSA, n.d.-b). A national 

survey found that as many as 40 percent of youth 

experiencing homelessness self-identify as LGBT 

(Durso & Gates, 2012).

Most children and youth with past year major depressive episode do have health 

insurance. More than one-third (34.9 percent) of children or youth were enrolled in Medicaid or 

the Children’s Health Insurance Program at some time during 2016, while 6 in 10 (60.1 percent) 

had private insurance. Only 5.2 percent had no health insurance (CBHSQ, 2017m).

Youth with SED are at high risk for suicide. Among youth entering the CMHI program in 2015, 

almost one-fifth (19.4 percent) had thought about committing suicide, and almost 1 in 10 (9.1 

percent) had attempted suicide prior to receiving services (CMHS/SAMHSA, 2016). In particular, 

youth involved in the juvenile justice and child welfare systems are at higher risk for suicide, and 

often have a history of mental health and/or substance use disorders and traumatic experiences 

(HHS, 2012). One study found that adolescents in foster care were almost four times more likely 

to have attempted suicide in the previous year than those who had never been in foster care 

(Pilowsky & Wu, 2006). In addition, the CDC has found that the prevalence of having seriously 

considered attempting suicide was higher among gay, lesbian, and bisexual students (42.8 

percent) than heterosexual students (14.8 percent) and that the prevalence of having attempted 

suicide was higher among gay, lesbian, and bisexual students (29.4 percent) than heterosexual 

students (6.4 percent) (Kann et al., 2016).

“Our mentally ill are filling up our jails and living 

homeless in our streets. Why would we let a 

20-year-old suffering from a disease with many 

of the same symptoms as dementia wander 

around the streets without care and treatment? 

People suffering from serious mental illness 

have loving families but are often too psychotic to remember that, and they don’t have the 

capacity to realize they need to be in a hospital. If our children were stricken with diabetes 

or cancer, we would not be waiting until they 

reached stage 4 in the disease, or became a 

danger to themselves or others, before being 

able to access treatment. I cannot think of a single disease, other than serious mental illness, 

where this would happen. Mental illness is not a 

crime yet the criminalization of mental illness is 

an epidemic of national proportion.”

— Jeanne (submitted through public comments to the 

ISMICC)
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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While the highest rates of death by suicide are among middle-aged adults, especially 

males, suicide rates have increased among Black or African-American children. While the 

suicide rate among young children has remained relatively stable, a recent study shows that the 

number of Black or African-American children between the ages of 5 and 11 who die by suicide has 

almost doubled since 1993. The research shows that from 1993 to 2012, a total of 657 U.S. children 

in that age group killed themselves; 84 percent were boys and 16 percent were girls. Over the 

nearly 20-year period, the rate among Black or African-American children significantly rose while 

the rate among White children dropped (Bridge et al., 2015). 

Compared with early adolescents who died by suicide, children who died by suicide were more 

commonly male, Black or African-American, died by hanging, strangulation, suffocation, 

and died at home. Among suicide decedents with known mental health problems, childhood 

decedents more often experienced attention deficit disorder with or without hyperactivity and less 

often experienced depression/dysthymia compared with early adolescent decedents (Sheftall et 

al., 2017).
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References

Agency for Healthcare Review and Quality (AHRQ). (2012, September). Evidence-based practice 

center systematic review protocol: Interventions for adults with serious mental illness who are 

involved with the criminal justice system. Retrieved from https://effectivehealthcare.ahrq.gov.

American Academy of Child and Adolescent Psychiatry (2015). Recommendations About the Use 

of Psychotropic Medications for Children and Adolescents Involved in Child-Serving Systems. 

Retrieved from https://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/

systems_of_care/AACAP_Psychotropic_Medication_Recommendations_2015_FINAL.pdf. 

Bellack, A. S., Bennett, M. E., Gearon, J. S., Brown, C. H., & Yang, Y. (2006). A randomized clinical 

trial of a new behavioral treatment for drug abuse in people with severe and persistent mental 

illness. Archives of General Psychiatry, 63(4), 426-432.

Boyd, C., Leff, B., Weiss, C., Wolff, J., Hamblin, A., & Martin, L. (2010). Faces of medicaid: 

Clarifying multimorbidity patterns to improve targeting and delivery of clinical services for 

medicaid populations. Hamilton, New Jersey: Center for Health Care Strategies, Inc. Retrieved 

from https://www.chcs.org/resource/faces-of-medicaid-clarifying-multimorbidity-patternsto-improve-targeting-and-delivery-of-clinical-services-for-medicaid-populations.

Bishop, T.F., Press, M. J. , Keyhani, S. & Pincus, H.A. (2014). Acceptance of Insurance by 

Psychiatrists and the Implications for Access to Mental Health Care. JAMA Psychiatry, 

71(2):176-181.

Bishop, T. F., Seirup, J. K., Pincus, H. A., & Ross, J. S. (2016). Population of US practicing 

psychiatrists declined, 2003-2013, which may help explain poor access to mental health care. 

Health Affairs, 35(7), 1271-1277. 

Blum, R. W., Kelly, A., & Ireland, M. (2001). Health-risk behaviors and protective factors among 

adolescents with mobility impairments and learning and emotional disabilities. Journal of 

Adolescent Health, 28(6), 481-490.

Bridge, J. A., Asti, L., Horowitz, L. M., Greenhouse, J. B., Fontanella, C. A., Sheftall, A. H., . . . 

Campo, J. V. (2015). Suicide trends among elementary school-aged children in the United 

States from 1993 to 2012. JAMA Pediatrics, 169(7), 673-677. 

Bronson, J., & Berzofsky, M. (2017). Indicators of mental health problems reported by prisoners 

and jail inmates, 2011-2012. Washington, DC: Bureau of Justice Statistics.
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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71 20 , 31 

31

Cavazos-Rehg, P. A., Breslau, N., Hatsukami, D., Krauss, M. J., Spitznagel, E. L., Grucza, R. A., 

... Bierut, L. J. (2014). Smoking cessation is associated with lower rates of mood/anxiety and 

alcohol use disorder. Psychological Medicine, 44(12), 2523–2535. 

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017a). 2016 national survey on 

drug use and health: Detailed tables. (NSDUH 2016, Table 8.5A). Rockville, MD: Substance 

Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017b). 2016 national survey 

on drug use and health: Detailed tables. (NSDUH 2016, Tables 8.24A, B). Rockville, MD: 

Substance Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017c). 2016 national survey on 

drug use and health: Detailed tables. (NSDUH 2016, Table 8.9B). Rockville, MD: Substance 

Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017d). 2016 national survey on 

drug use and health: Detailed tables. (NSDUH 2016, Table 8.20B). Rockville, MD: Substance 

Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017e). 2016 national survey 

on drug use and health: Detailed tables. (NSDUH 2016, Tables 8.33A, B). Rockville, MD: 

Substance Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017f). 2016 national survey 

on drug use and health: Detailed tables. (NSDUH 2016, Tables 8.42A, B). Rockville, MD: 

Substance Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017g). 2016 national survey on 

drug use and health: Detailed tables. (NSDUH 2016, Table 8.40B). Rockville, MD: Substance 

Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017h). 2016 national survey on 

drug use and health: Detailed tables. (NSDUH 2016, Tables 8.31B and 8.32B). Rockville, MD: 

Substance Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017i). 2016 national survey on 

drug use and health: Detailed tables. (NSDUH 2016, Table 8.6A). Rockville, MD: Substance 

Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017j). 2016 national survey on 

drug use and health: Detailed tables. (NSDUH 2016, Tables 9.6A, B). Rockville, MD: Substance 

Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017k). 2016 national survey on 

drug use and health: Detailed tables. (NSDUH 2016, Table 9.11A). Rockville, MD: Substance 

Abuse and Mental Health Services Administration.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2017l). 2016 national survey 

on drug use and health: Detailed tables. (NSDUH 2016, Tables 9.14A, B). Rockville, MD: 

Substance Abuse and Mental Health Services Administration.
partmental ed Inter

Mental Illness ious r Se

ee t ating Commit ni d Coor

t ahT em t sy S a for n ctio A eral d Fe : d ar wr oFya WehT

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Center for Behavioral Health Statistics and Quality (CBHSQ). (2017m). 2016 national survey on 

drug use and health: Detailed tables. (NSDUH 2016, Table 9.8A). Rockville, MD: Substance 

Abuse and Mental Health Services Administration.

Center for Health Care Strategies. (2013). Family and youth peer support literature review. 

CHIPRA Quality Improvement Collaborative. Retrieved from http://www.chcs.org/media/

FYPS_Literature_Review_FINAL.pdf.

Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services 

Administration (SAMHSA). (2016). The evaluation of the comprehensive community mental 

health services for children with serious emotional disturbances program, report to Congress, 

2015 (SAMHSA Publication No. PEP16-CMHI2015). Retrieved from https://www.samhsa.gov/

sites/default/files/programs_campaigns/nitt-ta/2015-report-to-congress.pdf.

Centers for Disease Control and Prevention (CDC). (2013, May). Mental health surveillance 

among children—United States, 2005–2011. Morbidity and Mortality Weekly Report, 62(02), 

135.

Centers for Disease Control and Prevention (CDC). (2015). Suicide: Facts at a Glance. Retrieved 

from https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf. 

Centers for Disease Control and Prevention (CDC). (2017). National Violent Death Reporting 

System. Retrieved from https://www.cdc.gov/violenceprevention/nvdrs/index.html.

Centers for Medicare & Medicaid Services (CMS). (2015). Mental health services. Baltimore, MD: 

Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/Outreachand-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Mental-HealthServices-Booklet-ICN903195.pdf.

Chapman, D. P., Whitfield, C. L., Felitti, V. J., Dube, S. R., Edwards, V. J., & Anda, R. F. (2004). 

Adverse childhood experiences and the risk of depressive disorders in adulthood. Journal of 

affective disorders, 82(2), 217-225.
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

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33

Daniels, A., England, M. J., Page, A. K., & Corrigan, J. (2005). Crossing the quality chasm: 

Adaptation for mental health and addictive disorders. International Journal of Mental 

Health, 34(1), 5-9.

Davis, M. (2003). Addressing the needs of youth in transition to adulthood. Administration and 

Policy in Mental Health, 30(6), 495-509.

Davis, M., Banks, S. M., Fisher, W. H., Gershenson, B., & Grudzinkas, A. J. (2007). Arrests of 

adolescent clients of a public mental health system during adolescence and young adulthood. 

Psychiatric Services, 58(11), 1454-1460.

Davis, M., & Koroloff, N. (2006). The great divide: how public mental health policy fails young 

adults. Community Based Mental Health Services for Children and Adolescents, Volume 14. 

Oxford, UK: Elsevier Services, 53-74.

Davis, M. A., Lin, L. A., Liu, H., & Sites, B. D. (2017). Prescription opioid use among adults 

with mental health disorders in the United States. Journal of the American Board of Family 

Medicine, 30(4), 407-417. doi: 10.3122/jabfm.2017.04.170112.

Davis, M., & Vander Stoep, A. (1997). The transition to adulthood for youth who have serious 

emotional disturbance: developmental transition and young adult outcomes. Journal of 

Mental Health Administration, 24(4), 400-427.

Dube, S. R., Anda, R. F., Felitti, V. J., Chapman, D. P., Williamson, D. F., & Giles, W. H. (2001). 

Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the 

life span: findings from the Adverse Childhood Experiences Study. Jama, 286(24), 3089-3096.

Durso, L. E., & Gates, G. J. (2012). Serving our youth: Findings from a national survey of service 

providers working with lesbian, gay, bisexual, and transgender youth who are homeless or at 

risk of becoming homeless. Los Angeles, CA: The Williams Institute with True Colors Fund 

and The Palette Fund. Retrieved from https://williamsinstitute.law.ucla.edu/wp-content/

uploads/Durso-Gates-LGBT-Homeless-Youth-Survey-July-2012.pdf.

Essex, M. J., Kraemer, H. C., Slattery, M. J., Burk, L. R., Boyce, W. T., Woodward, H. R., & 

Kupfer, D. J. (2009). Screening for childhood mental health problems: outcomes and early 

identification. Journal of Child Psychology and Psychiatry, 50(5), 562-570.

Fuller, D. A., Sinclair, E., Lamb, H. R., Cayce, J. D., & Snook, J. (2017). Emptying the “new asylums”: 

A beds capacity model to reduce mental illness behind bars. Arlington, VA: Treatment 

Advocacy Center.
partmental ed Inter

Mental Illness ious r Se

ee t ating Commit ni d Coor

t ahT em t sy S a for n ctio A eral d Fe : d ar wr oFya WehT

ir ehT d n a D d SE na SMI With ing vi L le po Pe l or Al f Works 

rs e iv ge ar Cd na seil Fami

71 20 , 31 ber mece D

departmental

us Mental Illness

dinating Committee

y Forward: Federal Action for a System That 

or All People Living With SMI and SED and Their

s and Caregivers 

13, 2017

34

Goldman, H. H. (2014). Commentary: Outpatient commitment reexamined: A third 

way. Psychiatric Services, 65(6), 816-811.

Goodwin, R. D., Hottinger, K., Pena, L., Chacko, A., Feldman, J., Wamboldt, M. Z., & Hoven, 

C. (2014). Asthma and mental health among youth in high-risk service settings. Journal of 

Asthma, 51(6), 639-644. 

Hafner, H., Maurer, K., Loffler, W., Fatkenheuer, B., an der Heiden, W., Riecher-Rossler, A., ... & 

Gattaz, W. F. (1994). The epidemiology of early schizophrenia. Influence of age and gender on 

onset and early course. The British Journal of Psychiatry, 23, 29-38.

Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). (2017). Bright Futures: Guidelines for Health 

Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American 

Academy of Pediatrics.

Healthcare Cost and Utilization Project (HCUP). (2014a). Emergency department national 

statistics. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from https://

hcupnet.ahrq.gov.

Healthcare Cost and Utilization Project (HCUP). (2014b). Hospital inpatient national statistics. 

Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from https://hcupnet.

ahrq.gov.

Hepburn, S. (2017). Crisis services’ role in reducing avoidable hospitalization. Alexandria, VA: 

National Association of State Mental Health Program Directors.

Hor, K., & Taylor, M. (2010). Suicide and schizophrenia: a systematic review of rates and risk 

factors. Journal of psychopharmacology, 24(4_suppl), 81-90.

Hyde, Pamela S. (2011). Behavioral health and justice involved populations. Powerpoint presented 

at the Bureau of Justice Assistance, Justice and Mental Health Collaboration Program, 

Baltimore, MD. Retrieved from https://store.samhsa.gov/shin/content/SMA11-PHYDE021111/

SMA11-PHYDE021111.pdf.

Institute of Medicine (IOM), & National Research Council (NRC). (2014). Investing in the health 

and well-being of young adults. Washington, DC: The National Academies Press.

Kane, J. M., Robinson, D. G., Schooler, N. R., Mueser, K. T., Penn, D. L., Rosenheck, R. A., . . 

. & Heinssen, R. K. (2016). Comprehensive versus usual community care for first episode 

psychosis: two-year outcomes from the NIMH RAISE early treatment program. The American 

Journal of Psychiatry, 173(4), 362-372.

Kann, L., Olsen, E.O., McManus, T., Harris, W., Shaklin, S.L., Flint, K.H., Queen, B., Lowry, R., 

Chyen, D., Whittle, L., Thornton, J., Lim, C., Yamakawa, Y., Brener, N., &Zaza, S. (2016). Sexual 

Identity, Sex of Sexual Contacts, and Health-Related Behaviors Among Students in Grades 

9-12 – United States and Selected Sites, 2015. MMWR Surveillance Summary, 65(No. SS-9):1-

202. 
Interdepartmental

Serious Mental Illness

Coordinating Committee

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rs e iv ge ar Cd na s

71 20 , 31 

35

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime 

prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity 

survey replication. Archives of General Psychiatry, 62(6), 593-602.

Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and 

comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. 

Archives of General Psychiatry, 62(6), 617-627.

McCue Horwitz, S., Hurlburt, M. S., Heneghan, A., Zhang, J., Rolls-Reutz, J., Fisher, E., . . . Stein, 

R. E. (2012). Mental health problems in young children investigated by U.S. child welfare 

agencies. Journal of the American Academy of Child and Adolescent Psychiatry, 51(6), 572-581.

Medley, G., Lipari, R. N., Bose, J., Cribb, D. S., Kroutil, L. A., & McHenry, G. (2016). Sexual 

orientation and estimates of adult substance use and mental health: Results from the 2015 

National Survey on Drug Use and Health. NSDUH Data Review. Retrieved from http://www.

samhsa.gov/data.

Melek, S. P., Norris, D. T., & Paulus, J. (2014). Economic impact of integrated medical-behavioral 

healthcare. Milliman Am Psychiatr Assoc Rep.

Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., . . . & Swendsen, J. 

(2010). Lifetime prevalence of mental disorders in US adolescents: results from the National 

Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American 

Academy of Child & Adolescent Psychiatry, 49(10), 980-989. 

Merikangas, K. R., He, J. P., Burstein, M., Swendsen, J., Avenevoli, S., Case, B., & Olfson, M. (2011). 

Service utilization for lifetime mental disorders in US adolescents: results of the National 

Comorbidity Survey–Adolescent Supplement (NCS-A). Journal of the American Academy of 

Child & Adolescent Psychiatry, 50(1), 32-45.

McQuilken, M., Zahniser, J. H., Novak, J., Starks, R. D., Olmos, A., & Bond, G. R. (2003). The work 

project survey: Consumer perspectives on work. Journal of Vocational Rehabilitation, 18(1), 

59-68.

Moore, B. J., Stocks, C., & Owens, P. L. (2017). Trends in emergency department visits, 2006-2014. 

HCUP Statistical Brief #227. Rockville, MD: Agency for Healthcare Research and Quality.
partmental ed Inter

Mental Illness ious r Se

ee t ating Commit ni d Coor

t ahT em t sy S a for n ctio A eral d Fe : d ar wr oFya WehT

ir ehT d n a D d SE na SMI With ing vi L le po Pe l or Al f Works 

rs e iv ge ar Cd na seil Fami

71 20 , 31 ber mece D

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us Mental Illness

dinating Committee

y Forward: Federal Action for a System That 

or All People Living With SMI and SED and Their

s and Caregivers 

13, 2017

36

Myrick, K., & del Vecchio, P. (2016). Peer support services in the behavioral healthcare workforce: 

State of the field. Psychiatric Rehabilitation Journal, 39(3), 197-203.

National Alliance for Caregiving (NAC). (2016). On pins & needles: caregivers of adults with 

mental illness. Bethesda, MD: National Alliance for Caregiving.

National Association of State Mental Health Program Directors (NASMHPD). (2017a). Forensic 

patients in state psychiatric hospitals: 1999-2016. Alexandria, Virginia: NASMHPD. Retrieved 

from https://www.nasmhpd.org/sites/default/files/TACPaper.10.Forensic-Patients-in-StateHospitals_508C.pdf.

National Association of State Mental Health Program Directors (NASMHPD). (2017b). Trend in 

psychiatric inpatient capacity, United States and each state, 1970 to 2014. Falls Church, VA: 

NRI. Retrieved from https://www.nri-inc.org/our-work/nri-reports/trends-in-psychiatricinpatient-capacity-united-states-and-each-state-1970-to-2014.

National Council Medical Director Institute. (2017). The psychiatric shortage: causes and 

solutions. Washington, DC: National Council for Behavioral Health.

Office of National Drug Control Policy. (n.d.). Integrate treatment for substance use disorders into 

mainstream health care and expand support for recovery. [Archived Obama Administration 

document.] Retrieved from https://obamawhitehouse.archives.gov/ondcp/chapter-integratetreatment-for-substance-use-disorders#preventinghomeless3. 

Ozer, E. M., Scott, J. T., & Brindis, C. D. (2013). Seizing the opportunity: improving young adult 

preventive health care. Adolescent Medicine: State of the Art Reviews, 24(3), 507-525.

Pastor, P. N., & Reuben, C. A. (2011). Emotional/behavioral difficulties and adolescent obesity: 

effect of sex and Hispanic origin/race. Journal of Pediatric Obesity, 6(5-6), 462-466.

Pilowsky, D. J., & Wu, L. (2006). Psychiatric symptoms and substance use disorders in a 

nationally representative sample of American adolescents involved with foster care. Journal of 

Adolescent Health, 38(4), 351-358.

Repper, J., & Carter, T. (2011). A review of the literature on peer support in mental health services. Journal of Mental Health, 20(4), 392-411.

Rinaldi, M., Killackey, E., Smith, J., Shepherd, G., Singh, S. P., & Craig, T. (2010). First episode 

psychosis and employment: a review. International Review of Psychiatry, 22(2), 148-162.
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

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December 13, 2017

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ir ehT d n a D d SE na SMI With ing vi L le po Pe l or Al 

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37

Robinson, L. R., Holbrook, J. R., Bitsko, R. H., Hartwig, S. A., Kaminski, J. W., Ghandour, R. M., . . 

. Boyle, C. A. (2017). Differences in health care, family, and community factors associated with 

mental, behavioral, and developmental disorders among children aged 2-8 years in rural and 

urban areas—United States, 2011-2012. Morbidity and Mortality Weekly Report, 66(8), 1-11.

Sheftall, A.H., Asti, L., Horowitz, L.M., Felts, A., Fontanella, C.A., Campo, J.V., & Bridge, J.A. 

(2016). Suicide in Elementary School-Aged Children and Early Adolescents. Pediatrics, 138(4), 

e20160436; DOI: 10.1542/peds.2016-0436.

Sheidow, A. J., McCart, M., Zajac, K., & Davis, M. (2012). Psychiatric Rehabilitation Journal, 35(3), 

235-243.

Sherrill, E., & Gonzales, G. (2017). Recent changes in health insurance coverage and access to care 

by mental health status, 2012-2015. JAMA Psychiatry, 74(10), 1076-1079.

Silverman, W. K., & Hinshaw, S. P. (2008). The second special issue on evidence-based 

psychosocial treatments for children and adolescents: A ten-year update. Journal of Clinical 

Child Adolescent Psychology, 37(1).

Social Security Administration. (2017). Internal Review of Data for all SSA Initial Applications 

Adjudicated in FY 2016. Washington, DC: Social Security Administration.

Steadman, H. J., Osher, F. C., Robbins, P. C., Case, B., & Samuels, S. (2009). Prevalence of serious 

mental illness among jail inmates. Psychiatric Services, 60(6), 761-765.

Stroul, B. A., & Friedman, R. M. (2011). Issue brief: Strategies for expanding the system of care 

approach. Washington, DC: Technical Assistance Partnership for Child and Family Mental 

Health.

Substance Abuse and Mental Health Services Administration (SAMHSA). (n.d.-a). Tobacco and 

behavioral health: The issue and resources. Rockville, MD: Substance Abuse and Mental 

Health Services Administration. Retrieved from https://www.samhsa.gov/atod/tobacco.

Substance Abuse and Mental Health Services Administration (SAMHSA). (n.d.-b). Homelessness 

and housing. Retrieved from https://www.samhsa.gov/homelessness-housing.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2002). Report 

to Congress on the prevention and treatment of co-occurring substance abuse disorders 

and mental disorders. Rockville, MD: Substance Abuse and Mental Health Services 

Administration.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). Screening and 

assessment of co-occurring disorders in the justice system (HHS Publication No. (SMA)-15-

4930). Rockville, MD: Substance Abuse and Mental Health Services Administration.
partmental ed Inter

Mental Illness ious r Se

ee t ating Commit ni d Coor

t ahT em t sy S a for n ctio A eral d Fe : d ar wr oFya WehT

ir ehT d n a D d SE na SMI With ing vi L le po Pe l or Al f Works 

rs e iv ge ar Cd na seil Fami

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us Mental Illness

dinating Committee

y Forward: Federal Action for a System That 

or All People Living With SMI and SED and Their

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Thomas, C. R., & Holzer, C. E. (2006). The continuing shortage of child and adolescent 

psychiatrists. Journal of the American Academy of Child & Adolescent Psychiatry, 45(9), 1023-

1031.

Thomas, K. C., Ellis, A. R., Konrad, T. R., Holzer, C. E., & Morrissey, J. P. (2009). Countylevel estimates of mental health professional shortage in the United States. Psychiatric 

Services, 60(10), 1323-1328.

U.S. Census Bureau. (n.d.). Poverty. Retrieved from https://www.census.gov/topics/incomepoverty/poverty.html.

U.S. Department of Health & Human Services (HHS). (1999). Mental health: A report of the 

surgeon general. Rockville, MD: US Department of Health and Human Services, Substance 

Abuse and Mental Health Services Administration, Center for Mental Health Services, 

National Institutes of Health, National Institute of Mental Health.

U.S. Department of Health & Human Services (HHS) Office of the Surgeon General and National 

Action Alliance for Suicide Prevention. (2012). 2012 national strategy for suicide prevention: 

Goals and objectives for action. Washington, DC: U.S. Department of Health & Human 

Services. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK109917.

U.S. Department of Housing and Urban Development (HUD). (2016). HUD 2016 continuum 

of care homeless assistance programs homeless populations and subpopulations. Retrieved 

from https://www.hudexchange.info/resource/reportmanagement/published/CoC_PopSub_

NatlTerrDC_2016.pdf.

U.S. Preventive Services Task Force. (n.d.). Published recommendations. Retrieved from https://

www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations. 

Wagner, M., Marder, C., Levine, P., Cameto, R., Cadwallader, T. W., Blackorby, J., . . . & Newman, 

L. (2003). The individual and household characteristics of youth with disabilities. A 

report from the National Longitudinal Transition Study-2 (NLTS2). Washington, DC: U.S. 

Department of Education. Retrieved from https://nlts2.sri.com/reports/2003_08/nlts2_

report_2003_08_complete.pdf.

Wagner, M., & Newman, L. (2012). Longitudinal transition outcomes of youth with emotional 

disturbance. Psychiatric Rehabilitation Journal, 35(3), 199-208.
Interdepartmental

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39

Weitzman, C., Wegner, L., Section on Developmental and Behavioral Pediatrics, Committee on 

Psychosocial Aspects of Child and Family Health, Council on Early Childhood, & Society for 

Developmental and Behavioral Pediatrics. (2015). Promoting optimal development: screening 

for behavioral and emotional problems. Pediatrics, 135(2), 384-395.

Williams, N. J., Scott, L., & Aarons, G. A. (2017). Prevalence of serious emotional disturbance 

among U.S. children: A meta-analysis. Psychiatric Services. Advance online publication. 

Retrieved from https://doi.org/10.1176/appi.ps.201700145.

Wissow, L. S., Brown, J., Fothergill, K. E., Gadomski, A., Hacker, K., Salmon, P., & Zelkowitz, 

R. (2013). Universal mental health screening in pediatric primary care: a systematic review. 

Journal of the American Academy of Child and Adolescent Psychiatry, 52(11), 1134-1147.

Wright, D., Livermore, G., Hoffman, D., Grau, E., & Bardos, M. (2012). 2010 National Beneficiary 

Survey: Methodology and Descriptive Statistics. Washington, DC: Mathematica Policy 

Research.

Zhu, J. M., Zhang, Y., & Polsky, D. (2017). Networks in ACA marketplaces are narrower for mental 

health care than for primary care. Health Affairs, 36(9), 1624-1631.
partmental ed Inter

Mental Illness ious r Se

ee t ating Commit ni d Coor

t ahT em t sy S a for n ctio A eral d Fe : d ar wr oFya WehT

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December 13, 2017

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Chapter 2: Improving Practice Related to Serious Mental 

Illness and Serious Emotional Disturbances

This chapter highlights some key advances in research 

on serious mental illnesses (SMI) and serious 

emotional disturbances (SED). It also includes 

strategies to improve services for people with SMI and 

SED that were highlighted in the first ISMICC meeting. 

This is an exciting time, and many innovations are 

available to help federal departments, states, and 

providers meet the needs of people with SMI and SED 

and their families.

The first ISMICC meeting occurred on August 31, 2017, 

at the Department of Health and Human Services 

headquarters at the Hubert H. Humphrey Building in 

Washington D.C. Federal and non-federal experts were 

invited to present information on relevant advances 

for addressing the needs of people with SMI and SED. 

This chapter reflects the content of the presentations, 

discussion during the meeting, and later input from 

ISMICC members.

The advances included in this chapter come directly 

from the presentations of the federal leaders and 

national experts. All of the advances are relevant 

to SMI and SED populations. Each advance has a 

substantial evidence base and has been tested in realworld settings. The order in which the information is 

summarized within the chapter corresponds to the 

order of the ISMICC meeting presentations. Within 

the chapter, attention is given to the areas outlined in 

the Congressional legislation regarding the ISMICC:

• Prevention

• Diagnosis

• Intervention

• Treatment and recovery

Federal Leaders Who Presented on Federal 

Advances in Addressing the Needs of 

People With SMI and SED

Joshua Gordon, Director, National Institute of 

Mental Health (NIMH) 

Paolo del Vecchio, Director, Center for Mental 

Health Services (CMHS), Substance Abuse 

and Mental Health Services Administration 

(SAMHSA) 

John McCarthy, Director, Serious Mental Illness 

Treatment Resource and Evaluation Center 

(SMITREC), Department of Veterans Affairs 

(VA) 

Ruby Qazilbash, Associate Deputy Director, 

Bureau of Justice Assistance (BJA), Department 

of Justice 

National Experts Who Presented on NonFederal Advances in Addressing the Needs 

of People With SMI and SED

Lynda Gargan, Executive Director, National 

Federation of Families for Children’s Mental 

Health

Lisa Dixon, Professor of Psychiatry, Columbia 

University Medical Center; Director, Division 

of Behavioral Health Services and Policy 

Research

Sergio Aguilar-Gaxiola, Professor of Clinical 

Internal Medicine, University of California, 

Davis; Director, Center for Reducing Health 

Disparities; Director, Community Engagement 

Program, Clinical and Translational Science 

Center

Joseph Parks, Medical Director, National 

Council for Behavioral Health
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• Access to services and supports 

The presentations do not cover the full breadth of current advances. The chapter ends with 

additional advances that ISMICC members identified as areas that warrant further exploration by 

the ISMICC. 

As with the other chapters in this report, we expect 

to build on the foundation outlined in this chapter. 

Moving forward, the ISMICC will update and consider 

the range of evidence-based practices and advances 

that should be available to people with SMI and SED.

Federal Presentations

National Institute of Mental Health: 

Support of Advances to Address Challenges of SMI and SED 

Joshua A. Gordon, Director, National Institute of Mental Health (NIMH)

Dr. Gordon noted that NIMH 

priorities include: (1) identify 

risk and enhance our ability 

to predict the development of 

SMI, (2) identify biomarkers 

that help predict risk 

and follow the course of 

disease, (3) chart the illness 

throughout development, 

and (4) develop personalized 

interventions. NIMH seeks 

to understand SMI across the 

entire cycle of development.

The growth of genetic knowledge provides indicators for predicting risk. However, genetic risk is 

only one part. There is a need to understand the environmental factors and developmental factors 

that play a role in the development of SMI.

The advances highlighted in this chapter come 

from experts invited by the ISMICC to present 

at the ISMICC inaugural meeting, August 31, 

2017. 

Additional advances and innovations are listed 

at the end of this chapter.
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Dr. Gordon remarked that biomarkers may someday make it possible to chart the course of the 

illness. NIMH avoids studying simple individual diagnoses, but instead pools data on people with 

SMI across diagnostic domains. Researchers are looking at “deep phenotyping,” which includes 

measurement of a combinations of factors such as behavior, brain activity, and symptoms. Using 

this approach, researchers seek to group people with psychosis according to common anatomic 

and/or biologic origins. This may better predict their disease course and response to treatment.

Longitudinal studies that use multiple modalities—including neuroimaging and 

neuropsychological measures—allow the development of predictive tools and methods for 

charting illness progression. The Recovery After an Initial Schizophrenia Episode (RAISE) 

project was a research initiative of the NIMH. RAISE studied coordinated specialty care (CSC), 

an integrated approach to care for patients who experience their first episode of psychosis, 

including psychotherapy, family education and support, supported employment, education, 

and medication. Patients who received CSC had better outcomes. SAMHSA and NIMH are 

collaborating closely to implement CSC in community settings via the Mental Health Block Grant 

10 percent set-aside for early serious mental illness, including psychotic disorders. Several related 

NIMH research efforts aim to reduce treatment delays in first-episode psychosis by identifying 

people at high risk, improving the care of those high-risk people in community mental health 

centers, and developing novel approaches to treating youth and adults. The evidence shows that 

diagnoses are not sufficient predictors of response to treatment; an individualized approach is 

needed. Understanding the relationship between patterns of brain activity and treatment will 

help develop novel treatments aimed at patterns of dysfunctional brain activity.
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NIMH is also focused on predicting 

which people are at high risk 

of suicide, and approaches for 

treatment. In collaboration with 

the Department of Justice and other 

partners, NIMH is studying people 

who are particularly at high risk 

for suicide following release from 

jail or prison. The research aims to 

improve understanding of mortality 

outcomes. The use of data sets 

can ultimately make it possible to 

identify those at highest risk, so that 

appropriate services can be accessed efficiently.

Substance Abuse and Mental Health Services Administration: 

Support of Advances to Address Challenges of SMI and SED

Paolo del Vecchio, Director, Center for Mental Health Services (CMHS), Substance Abuse 

and Mental Health Services Administration (SAMHSA)

Mr. del Vecchio focused on the central issue of access to evidence-based treatments. Data from 

2016 show that most people who receive public mental health services for SMI or SED do not 

receive evidence-based 

practices such as medication 

management, assertive 

community treatment, 

supported employment, and 

family psychoeducation.

Research shows that the 

most effective way to 

provide services is through 

comprehensive, coordinated, 

and collaborative care. 

Meeting the complex needs 

of people with SMI and SED 

requires a multidisciplinary approach that often includes medication, therapy, and community 

recovery supports.
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Serious Mental Illness

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The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Only 2 percent of public mental 

health clients have access to 

effective therapeutic approaches 

such as cognitive behavioral 

therapy. Similarly, few are receiving 

evidence-based approaches such 

as dialectical behavior therapy and 

cognitive remediation therapy. 

People with SMI need access 

to effective psychiatric care, 

including diagnostic examination, 

medication, and psychotherapeutic 

interventions. 

Of the 70 percent of people with SMI who are unemployed and want to work, only 2 percent 

receive evidence-based supported employment. Similarly, few have access to supportive housing, 

despite the link between housing and reduced symptoms, decreased criminal justice and juvenile 

justice systems involvement, and increased employment. Jail diversion programs have also 

demonstrated effectiveness. Major advances have been made in recent decades to promote peer 

and family support, with 40 states including this as a billable Medicaid optional service. As a 

part of recovery support services, and given the elevated rates of mortality, attention to self-care 

and general health by people with SMI and SED is also important. Studies show the benefits of 

exercise, healthy diet, and other self-management activities.

Coordinated care approaches are critical. Through a partnership across the Centers for Medicare 

& Medicaid Services (CMS), SAMHSA, and the Assistant Secretary for Planning and Evaluation 

(ASPE), over 70 Certified Community Behavioral Health Clinics in eight states have enhanced 

Medicaid federal match to provide comprehensive, coordinated care as a result of the Section 223 

Demonstration Program to Improve Community Mental Health Services. Equally promising is the 

collaboration involving SAMHSA, ASPE, and NIMH to look at the impact of assisted outpatient 

treatment on engagement in effective care in 17 representative communities throughout the 

United States.

An estimated 50 percent of clients stop engaging in treatment in the first six months. People 

must be engaged in their care, and providers should be trained to deliver individualized and 

personalized approaches that address individual goals and strengths as well as culture, age, sexual 

orientation, and geography.
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For an estimated 50 percent of people, the onset of mental illness happens before age 15; onset 

happens before age 25 for 75 percent of people. It is critical that problems be identified early in 

educational and health settings, and that children and youth have access to a range of services.

There is a critical need to standardize and increase data collection. Further work is needed to 

address privacy rights and offer protections against the abuse and neglect that continue for this 

vulnerable population.

Department of Veterans Affairs: 

Support of Advances to Address Challenges of SMI and SED

John McCarthy, Director, Serious Mental Illness Treatment Resource and Evaluation 

Center, Department of Veterans Affairs (VA)

Dr. McCarthy noted that the VA has substantially increased its capacity to meet the needs of 

veterans with mental health conditions. Veterans Health Administration (VHA) users with 

schizophrenia and bipolar disorder constitute a small proportion of the patient population, yet 

they generate disproportionate expenditures and service utilization.

In response, the VA established the National Psychosis Registry in 1999, which generates data 

about patients with schizophrenia, bipolar disorder, or other psychoses. The VA’s SMI Re-Engage 

Initiative identifies people with schizophrenia or bipolar disorder who experience a gap in VHA 

services lasting a year or more, and provides outreach in an effort to bring them back into VHA 

care.

The number of people receiving care for bipolar disorder increased steadily between 1999 and 

2016. The data also reflects a decrease in the prevalence of patients diagnosed with schizophrenia. 

Changes from 2015 to 2016 may be related to the transition from ICD-9 to ICD-10 diagnosis 

coding.

From 1999 through 2016, the percentage of VHA patients receiving inpatient psychiatric care has 

decreased, whereas receipt of non-psychiatric inpatient care has been relatively stable. For people 

with SMI, the decrease may be associated with changes in treatment practices and the success 

of outpatient programs such as the Mental Health Intensive Case Management Program, VHA’s 

version of assertive community treatment. Data related to outpatient utilization for people with 

SMI shows more encounters in non-mental health clinic settings than in mental health settings. 
Interdepartmental

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The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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The VA has conducted 

comprehensive suicide 

monitoring and analysis. 

Among those who received 

VHA care since 1999, suicide 

rates through 2006 were 

elevated, with the highest 

rates among those with 

bipolar disorder, but the rates 

have declined somewhat 

since then. Among VHA 

patients from 2001 through 

2014, suicide rates have stayed 

high among people with 

bipolar disorder, despite VA efforts such as the Mental Health Enhancement Initiative and the 

development of suicide prevention coordinators on the crisis line. However, suicide rates have 

decreased somewhat for VHA users with schizophrenia, and overall among people with mental or 

substance use disorders. Suicide risks are particularly high after inpatient discharges, especially 

among people with depressive disorder, followed by bipolar disorder and schizophrenia.

Suicide prevention for people with SMI is an important priority. REACH VET (Recovery 

Engagement And Coordination for Health—Veterans Enhanced Treatment) uses a suicide 

predictive model based on information in the VA’s electronic health record system to identify 

and engage veterans at high risk for suicide, particularly among those with SMI. Strategic 

partnerships—such as the one between the Veterans Administration, CMS, SAMHSA, and the 

Administration for Community Living—are critical given the substantial numbers of veterans 

who die of suicide and who are not recent users of VHA care or otherwise connected with the VA.

Department of Justice: 

Support of Advances to Address Challenges of SMI and SED

Ruby Qazilbash, Associate Deputy Director, Bureau of Justice Assistance (BJA), 

Department of Justice

With close to 11 million people being processed through jails each year, compared with 

approximately 625,000 being admitted into the nation’s prisons, jails house the majority of the 

inmate population with SMI. BJA policy focuses on helping local jails use validated screening 

instruments consistently in order to understand and reduce SMI prevalence rates within a 
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jurisdiction’s jail, and to connect people who are cycling in and out of jails to services within the 

community.

Law enforcement agencies and officers have become first responders for people in mental health 

crises, as well as for their family members. The volume of calls to law enforcement involving 

people with SMI appears to be increasing, with one Florida report indicating that 1 in 10 calls is 

mental health-related. Similarly, law enforcement agencies in Deschutes County, Oregon, have 

reported sharp increases in recent years in mental health-related service calls. Generally, service 

calls involving mental health issues take much longer to resolve than other calls. These individual 

communities reflect the state of systems across the nation. 

Bureau of Justice Statistics surveys show that approximately one-third of inmates with a 

mental health indicator are receiving treatment, and local studies supported by BJA show that 

people with mental illnesses stay longer in jail. Research shows that providing connections to 

community-based services, particularly case management services, increases length of time in the 

community following release. Yet only a fraction of people—at the point of court, jail diversion, 

or reentry from the jail or prison back into the community—are getting connected to that care. 

For example, in the Franklin County, Ohio, jail population, out of 10,523 bookings into the jail, 

969 people were flagged with an SMI, and of those, only 609 received follow-up treatment in the 

community. According to the national estimates previously mentioned, as many as 1,700 people 

with SMI in that county were not connected to community treatment but likely needed it. Of 

those not connected to services, estimates suggest that more than half are at moderate to high risk 

for reoffending.
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Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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In 2012, BJA and the Council of State Governments Justice Center released a shared framework 

for reducing recidivism and promoting recovery for adults with behavioral health needs who are 

under correctional supervision. The framework reflects a consensus with SAMHSA, the National 

Institute of Corrections, and major associations representing state directors of corrections, 

probations and parole, substance use services, and mental health services. The outcome was that 

there is a need for risk and needs assessments for people under correctional control who have 

behavioral health needs. People with low criminogenic risk need to be connected to community 

services and medical care. People with moderate to high criminogenic risk need intensive 

supervision with a combination of supports. The shared framework is part of the Justice and 

Mental Health Collaboration Program funded by the Bureau of Justice Assistance, which is 

adding 55 new grantees in 2017 to help communities apply the framework and allocate resources 

appropriately.
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The Stepping Up Initiative focuses on reducing the prevalence of people with SMI in jails. 

Stepping Up works to increase community efforts to support law enforcement and create effective 

systems and processes that connect people with SMI to services in the community. To date, at 

least 384 county boards (representing 115 million people) have passed resolutions committing to 

the Stepping Up Initiative. The initiative’s “Six Questions” ask counties to answer key questions 

and track four measures: (1) the percent of people within the jail population who have an SMI 

(which necessitates screening and assessment), (2) the average length of stay in jail for people 

with SMI as compared to the general jail population, (3) the rate of connection to care upon 

release, and (4) the recidivism rate for this population, compared to a general release cohort.

The Police and Mental Health Collaboration Toolkit launched by BJA provides information 

about how to build a police and mental health collaboration, provide training, track data and 

outcome measures, and evaluate progress. The toolkit features six learning sites, their policies, 

and memoranda of understanding. The sites accept site visits and are on call to help other 

jurisdictions. A 2017 Congressional appropriation for a National Training and Technical Assistance 

Center to Improve Law Enforcement Responses to People with Mental Illness and Intellectual and 

Developmental Disabilities will operationalize more supports to law enforcement agencies.
Interdepartmental

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Coordinating Committee

The Way Forward: Federal Action for a System That 

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Families and Caregivers 

December 13, 2017

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Non-Federal Stakeholder Presentations

Challenges and Opportunities in Improving Children’s Mental Health Care

Lynda Gargan, Executive Director, National Federation of Families for Children’s Mental

Health

Prevalence data show that approximately 20 percent of children under age 18 (approximately 7.5 

million) will have a significant mental health issue sometime in life. 

Dr. Gargan emphasized that stigma associated with mental illness is real. She compared the 

rally around families whose children developed catastrophic medical illnesses with the silence 

and prejudice surrounding mental illness. To help our children, there is a need to reject stigma, 

identify children’s behavioral 

health as a public health 

crisis, and support a system 

that will help our teachers 

teach. Children are not little 

adults, so data cannot be 

extrapolated from what works 

for adults, and then applied 

to children. She noted the 

example of medications 

that are dispensed without 

longitudinal data or Food 

and Drug Administration 

indications for children. 

Prescriptions should not be the first line of response. Culturally responsive supports are needed.

Peer support services constitute a valuable tool in supporting families. For families, a peer is a 

person who possesses the lived experience of having parented a child who experiences mental/

behavioral health challenges. Because families trust families, peers offer guidance and support 

that cannot be matched by professionals. Peers act as cultural translators, navigators, and 

advocates for families.
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Key Advances in the Clinical Care of People With SMI and SED

Lisa Dixon, Professor of Psychiatry, Columbia University Medical Center; Director, 

Division of Behavioral Health Services and Policy Research

Dr. Dixon emphasized the need for partnerships of the federal, state, local, and private sectors 

to achieve progress. This effort requires ongoing attention to engagement and a continuum of 

integrated care that includes evidence-based pharmacologic treatment, recovery support and a 

person-centered approach.

She reported on a recent example of an advance in the treatment of people with first-episode 

psychosis. Research shows improved outcomes in people with a shorter duration psychosis 

compared to those with a longer period of not being in treatment. Emerging evidence supports 

coordinated specialty care (CSC), a 

package of interventions delivered 

by a team of providers and focused 

on transition-age youth with early 

psychosis. Based on the positive 

outcomes associated with CSC, 

Congress has asked states to 

set aside funds to provide CSC 

services through the SAMHSAadministered Mental Health Block 

Grant program. In many states, 

state and local government provide 

additional support to further the 

development of this evidencebased intervention.

The Mental Health Block Grant and the contributions of states and localities have promoted 

advances from research to practice. For example, providers in New York State have enrolled over 

800 young adults across 20 sites. This has led to dramatic reductions in hospitalization. 
Interdepartmental

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Coordinating Committee

The Way Forward: Federal Action for a System That 

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Families and Caregivers 

December 13, 2017

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Upon entry into the New York program, only about 40 percent of youth worked or were in school. 

This rate increased to 72 percent at the last or most recent follow-up. Studies show that most 

youth and adults want to work or go to school, and see that as an essential part of recovery. A 

no-exclusion, integrated approach to evidence-based supported employment, with the goal of 

competitive employment, has consistently been demonstrated as more effective than traditional 

vocational rehabilitation and other rehabilitative approaches.

Early psychosis treatment is critical, as is peer support. Peer support has an emerging evidence 

base demonstrating reduced use of acute services, decreased substance abuse, and increased 

engagement.

Approximately 5-20 percent of people with SMI die by suicide. The highest risk follows discharge 

from an emergency department or inpatient hospitalization. Effective strategies that reduce risk 

during the post-discharge period include:

• Systematized safety planning prior to discharge,

• Follow-up outreach (phone, text, home visits), and

• Suicide-specific psychotherapies (e.g., cognitive therapy for suicide prevention, dialectical 

behavior therapy).

Knowledge about detecting and treating suicidality (i.e., selective prevention) is not routinely 

employed in health care systems.
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Data show that people with SMI die roughly 10 years earlier than their age-matched counterparts 

who do not have SMI. Strategic care integration, attention to health behaviors, and high-quality 

services is needed to address this issue.

Disparities and Closing the Treatment Gap

Sergio Aguilar-Gaxiola, Professor of Clinical Internal Medicine, University of California, 

Davis; Director, Center for Reducing Health Disparities; Director, Community 

Engagement Program, Clinical and Translational Science Center

Dr. Aguilar-Gaxiola focused on the difficulty of people accessing care—the treatment gap—

especially for traditionally underserved populations. National data on the treatment gap reveals 

that 50 to 90 percent of those in need of mental health treatment are not receiving services.

There is a need to work with community-based organizations to capture the effectiveness 

of practices and programs used for diverse populations. An initiative in California called the 

Mental Health Services Act generated over $2 billion for services last year, especially for those 

experiencing disparities. Other examples include the statewide stigma reduction campaign called 

Each Mind Matters that includes materials tailored to specific ethnic groups, and the California 

Reducing Disparities Project focused on reducing stigma and discrimination.
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The Way Forward: Federal Action for a System That 

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December 13, 2017

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Engaging people with SMI and SED and their families in the treatment process is key. 

Engagement is an iterative process in which clinicians and investigators reach out to the client 

and his/her family and continually evaluate their efforts. Incorporating the family in a culturally 

appropriate fashion within routine 

clinical settings improves access 

to treatment, client participation 

in care, integration of care, and 

ultimately, clinical outcomes for 

populations with SMI and SED. 

Public health interventions should 

include audiovisual tools and 

social marketing campaigns to 

reduce stigma, promote evidencebased treatment approaches, and 

disseminate community-defined 

evidence. Public health messaging 

should be inclusive and respectful 

of diversity.

The Challenges and Opportunities for Improving the System 

That Supports the Care of People With SMI and SED

Joseph Parks, Medical Director, National Council for Behavioral Health

Dr. Parks indicated that many 

effective services are available for 

people with SMI. Peer support and 

population health management 

services are especially important.
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The bad news is that most 

people with SMI have 

approximately three or four 

behavioral health disorders 

and three or four physical 

health disorders. They often 

have deficits in memory, 

concentration, executive 

functioning, and ability to 

organize information. Yet they 

are expected to figure out what 

they need and when they 

need it.

Dr. Parks noted that there are many effective treatments for addressing the needs of people 

with SMI. Yet there are not enough psychiatrists to treat people. Additionally, there is a lack of 

resources to address the needs of people with SMI and SED in crisis. Generally, the availability and 

quality of treatment and services vary by state and community. A substantial number of people 

with SMI are uninsured.

The psychiatry shortage is 

particularly severe. Reports 

indicate a shortage of available 

psychiatric treatment, with 

hospitals closing beds or not 

providing care due to financial 

loss. 

Community providers also report 

that they are unable to obtain 

reimbursement for new practices 

that are not reflected in Current 

Procedural Terminology (CPT) 

coding and available billing 

streams. The payments for behavioral health services need to be actuarially sound—meaning that 

the amount of the payment is sufficient to cover the actual cost of what is done, plus a reasonable 

profit. Comparing payment rates in behavioral health to the rates in general medical care to 

identify possible parity concerns is also critical, as well as assessing the adequacy of provider 

panels by secret shopper to see if someone actually answers the phone and if appointments are 

available. 
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Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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The new Certified Community Behavioral Health 

Clinic (CCBHC) demonstration program may provide 

strategies for addressing these issues. The CCBHC 

program covers the full range of evidence-based 

services, but it remains a demonstration program 

operating in only eight states and limited to just two 

years. 

Dr. Parks discussed the importance of level of care 

assessment instruments that include scores for social 

determinants. These instruments may help address 

the bed crisis by reflecting appropriate lengths of stay. 

For example, after Missouri required the use of LOCUS (Level of Care Utilization System) and 

CALOCUS (Child and Adolescent Level of Care Utilization System), which assess housing and 

other social determinants, insurers enhanced coverage for evidence-based services.

Finally, Dr. Parks outlined technical ways to address psychiatric service shortages, such as revising 

the Conrad 30 Waiver Program, which allows medical doctors to apply for a waiver for the 2-year 

residence requirement upon completion of the J-1 exchange visitor program, so waivers provided 

to psychiatrists do not count toward the ceiling of 30 slots; revising the Group on Educational 

Affairs (Association of American Medical Colleges) graduate medical education calculation for 

supporting psychiatry residents to be the same as for obstetrician- gynecologists or primary care 

physicians; revising redistribution requirements for unused Medicare direct graduate medical 

education training slots so the psychiatry slots cannot be reduced; and removing regulatory 

barriers to telepsychiatry. Dr. Parks noted that success will largely be a question of willingness to 

exert executive powers in areas such as payments rates and performance measurement.

Areas to Be Explored by the ISMICC

The federal and expert presentations described above provide an important overview of key areas 

of opportunity and innovation for application on the federal level and in the broader behavioral 

health field. Table 2.1 summarizes other areas that the ISMICC will consider in the future.

What Is a Certified Community 

Behavioral Health Clinic?

Section 223 of the Protecting Access to Medicare Act (PAMA) creates and evaluates a 2-year 

demonstration program for states to certify 

community behavioral health clinics. Certified 

clinics must meet specific criteria emphasizing 

high-quality care and integration across community services to address the holistic needs of people 

with SMI and SED, and others. Learn more about 
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Table 2.1. Areas for the ISMICC to Explore During Future Meetings 

Focus Area Advances, Including Evidence-Based and Promising Practices

Diagnosis • Deep phenotyping/biomarkers to provide indicators for predicting genetic risk, along with 

understanding of environmental/developmental factors

• Neuroimaging/neuropsychological measures to allow for the development of predictive tools for 

charting illness progression 

• Implementation of American Psychiatric Association practice guidelines 

• Jail-based Mental Health Screening

Intervention: 

Adults

• Assertive community treatment

• Cognitive behavioral therapy (CBT); trauma-focused CBT

• Dialectical behavioral therapy 

• Cognitive remediation therapy

• Social rhythm therapy 

• Brief interpersonal therapy 

• Problem-solving therapy

• Dialogic therapy

• Coordinated specialty care for adults with first-episode psychosis

• National Association of State Mental Health Program Directors, core strategies for reduction of 

restraint and seclusion

Intervention: 

Children and 

Youth

• High-fidelity wraparound 

• CBT; trauma-focused CBT

• Interpersonal therapy for adolescents with depression

• Coordinated specialty care for youth with first-episode psychosis

• Exposure and response prevention for obsessive-compulsive disorder

• Trauma-informed and trauma-specific services, including Promising Path to Success (New Jersey 

Division of Children’s System of Care) 

• Multisystemic therapy

• Behavioral classroom management; 

• Behavioral parent training 

• Intensive behavioral peer intervention for attention deficit hyperactivity disorder

• Family-based treatments

Intervention: 

Criminal Justice

• Jail diversion

• Mental health courts

• Drug courts

• Civil commitment laws, including compulsory treatment

• Crisis intervention team training

• Forensic assertive community treatment

• Cognitive behavioral therapy, cognitive skills training (Reasoning and Rehabilitation Program)

• Re-entry programs with navigational assistance and links to community health

• Trauma-informed officers

• Sequential intercept model

• Strategies and approaches included in the Stepping Up Initiative

Treatment and 

Recovery

• Findings from CATIE (NIMH-funded Clinical Antipsychotic Trials of Intervention Effectiveness); 

STAR*D (NIMH-funded Sequenced Treatment Alternatives to Relieve Depression); PORT 

(Schizophrenia Patient Outcomes Research Team)

• Veterans Administration Uniform Mental Health Standards 

• Medication treatment and management

• Medication optimization

• Medication development

• Exploration of levels of care and their place in the treatment of SMI
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Table 2.1. Areas for the ISMICC to Explore During Future Meetings (continued)

Focus Area Advances, Including Evidence-Based and Promising Practices

Treatment and 

Recovery 

(continued)

• Exploration of need for inpatient beds in different settings

• Telemedicine

• Use of mobile applications and social media

• American Diabetes Association and American Psychiatric Association consensus report on 

antipsychotic drugs and obesity and diabetes

• Georgia model of crisis call center engagement and support

• Family psychoeducation; family consultation; caregiver respite

• Shared decision-making; supported decision-making; therapeutic alliance; advance directives

• Assisted outpatient treatment

• Wellness coaching to address co-occurring disorders

• Peer-led engagement; peer groups; programs such as Hearing Voices Network

• Complementary approaches (e.g., mindfulness, diet, exercise)

• Supportive housing

• Supported employment

• Supported education

• Housing first

Access to 

Services and 

Supports

• System of care approach for children’s behavioral health

• Comprehensive coordinated care; integration approaches 

• Standards included in the Certified Community Behavioral Health Clinic demonstration

• Specialized services and cultural competence training to address disparities among underserved 

groups such as people of color, and lesbian, gay, bisexual and transgender individuals

• Health navigator programs such as the Peer Bridger Program and other family- and youth-led 

programs

• Findings from Meadows Mental Health Policy Institute continuum of crisis services, and related adult 

and child crisis stabilization services

• Arizona model for connecting law enforcement to facility-based crisis stabilization

• Use of secret shopper surveys to assess network adequacy

• Level of care instruments such as LOCUS and CALOCUS

Additionally, advances in our understanding of genetic, environmental, and developmental 

factors across the lifespan hold great promise for earlier diagnosis of SMI and SED. Research 

on early intervention and treatment demonstrates the potential to improve the course of the 

illnesses.

There have not been many significant recent advances in the biologic treatment of people with 

SMI. Decades of experience with second-generation antipsychotic medications have yielded 

medications with much better tolerability, but little improvement in effectiveness. Even though 

this class of medications often avoids the more debilitating side effects of older antipsychotic 

medications (such as sedation, movement disorders, and cardiac conduction abnormalities), 

the newer medications have more silent side effects such as blood glucose elevation, blood lipid 

elevation, and obesity. One of the second-generation antipsychotic agents, clozapine, continues 

to stand out as potentially effective in individuals who have not responded to other medications. 

However, this medication is underutilized in the United States. SAMHSA has engaged in several 

recent projects to develop interventions to highlight underutilization of clozapine.
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Recent advances in drug development have included a focus on delivery mechanisms, so that 

more agents are available in long-acting injection forms that can be administered monthly, or 

even once every three months (for at least one product). Lithium and clozapine can reduce the 

intensity of suicidal ideation in people with SMI, and other medicines such as antidepressants, 

mood stabilizers, and anxiety medications are often used to augment the effects of antipsychotics. 

We remain hopeful that advances in understanding the biologic underpinnings of psychosis 

and other elements of SMI symptomology will result in new opportunities to develop better 

pharmacotherapeutic interventions.

Many people have concurrent issues that are not adequately addressed, including physical 

health issues, intellectual or developmental disabilities, substance use, trauma, homelessness, 

justice involvement, and other challenges. Many of the evidence-based practices include a team 

approach that recognizes the importance of interdisciplinary and cross-sector support, as well as 

client and family involvement. The ISMICC will continue to explore and capture the broad range 

of effective treatments and services to meet the needs of people with SMI and SED across the 

lifespan. The ISMICC will also work to understand and define the resources needed to effectively 

serve Americans living with SMI and SED and their families and caregivers. 
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Serious Mental Illness

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The Way Forward: Federal Action for a System That 

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December 13, 2017

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Chapter 3: Setting the Stage for Evaluation of Federal 

Programs Related to SMI and SED

The central charge of the ISMICC is to improve the lives of Americans with serious mental 

illnesses (SMI) and serious emotional disturbances (SED) and their families. This is to be 

achieved in part by enhancing coordination across federal departments to improve service 

access and delivery of care. Working with leaders of the eight departments that serve on the 

ISMICC, committee members will inform efforts to evaluate the effect that federal policies and 

programs related to SMI and SED have on public health outcomes. The ISMICC will develop 

specific recommendations for actions that federal departments can take to better coordinate the 

administration of mental health services for adults with SMI and children and youth with SED.

Those efforts begin now. Over the next five years, the ISMICC will work in collaboration with 

federal interdepartmental leadership to build shared accountability for a system that provides 

the full range of treatments and supports needed by individuals and families living with SMI and 

SED. 

This will be a challenging undertaking. ISMICC members recognize that it will require 

partnerships with all levels of government and a diverse array of other stakeholders. Mental health 

care and treatment is not solely a federal responsibility, but rather one shared across federal, 

state, tribal, and local governments; private insurers; diverse provider organizations; advocates; 

caregivers; families; and people with SMI and SED. Figure 3.1 illustrates this point by showing the 

complexity of funding for treatment of mental health and substance use disorders in the United 

States. 

In the course of their deliberations, ISMICC members have emphasized that this review of federal 

initiatives must rise above the level of simply looking at individual programs. The ISMICC vision 

calls for federal interdepartmental leadership in collaboration with others to build responsive 

and effective systems of care that meet the needs of people with SMI and SED and their families. 

Members have stressed the importance of focusing not only on prevention and treatment, 

but also on key social determinants of health such as housing, employment, education, and 

transportation.
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Figure 3.1. Government and Private Funding Sources for Mental Health (MH) and 

Substance Use Disorder (SUD) Treatment

37.2 %

Private Funding

for MH/SUD by Source 

62.8 % 

Government Funding

for MH/SUD by Source

24.3 % Private Insurance

10.1 % Out of Pocket

2.8 % Other Private

28.5 % Medicaid

15.9 % Other State & Local

12.6 % Medicare

5.8 % Other Federal

Source: Mark, T. L., Levit, K. R., Yee, T., & Chow, C. M. (2014). Spending on mental and substance use disorders projected to grow more 

slowly than all health spending through 2020. Health Affairs, 33(8), 1407-1415.

Each of the eight departments represented on the ISMICC supports programs that address the 

needs of people with SMI and SED. Programs differ according to each department’s mission, 

its population of focus, its authorizing legislation and level of funding, and the performance 

metrics through which it is held accountable to Congress and its constituents. For example, 

the Department of Veterans Affairs serves veterans and the Department of Defense (DoD) 

serves active duty military and their families, while the Department of Health and Human 

Services (HHS) has public health agencies such as the Substance Abuse and Mental Health 

Services Administration (SAMHSA) and the Centers for Medicare & Medicaid Services that have 

components related to the health of the nation at large. 

Five other agencies represented on the ISMICC—Housing and Urban Development (HUD), 

Education, Labor, Justice, and Social Security—have missions that are highly relevant to the target 

population, but are more broadly focused and tied to their mission and authorizing legislation. 

The same is true for other components of the HHS that are not specifically represented on the 

ISMICC, such as the Administration for Children and Families, the Health Resources and Services 

Administration, and the Indian Health Service. These departments all have programs that 

contribute in important ways to supporting the delivery of effective prevention, treatment, and 

recovery support services for people with SMI and SED.
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December 13, 2017

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The review of federal initiatives must include the large federal health insurance and disability 

programs such as Medicare, Medicaid, the Children’s Health Insurance Program, and Social 

Security disability programs that serve a broad and diverse population, including many people 

with SMI and SED. These insurance and disability programs are of critical importance and serve 

as a major source of funding for treatment and recovery support services for people with SMI and 

SED. School-based services in affiliation with the Department of Education play a central role 

in the lives of children and youth with SED. HUD-funded housing is also critically important. 

ISMICC members have stressed that it is essential to include these programs in any meaningful 

analysis of population health outcomes for people with SMI and SED.

The formation of the ISMICC marks the first time in many years that an interdepartmental group 

has come together to coordinate their efforts related to the broad spectrum of issues that impact 

people with SMI and SED. It is the first time that such a group has been chaired by an Assistant 

Secretary for Mental Health and Substance Use. This newly created position brings a new level 

of authority, experience, and expertise to the coordination of efforts at HHS to address the needs 

of people with SMI and SED. The Assistant Secretary must work across HHS and the federal 

government so people with SMI and SED receive the highest possible standard of care—care that 

is deeply informed by our knowledge of science and medicine.

These eight departments have made a commitment to align their policies, assess their 

programming, and improve care for people with SMI and SED. Their collaboration will be 

informed and strengthened by the participation of non-federal ISMICC members, including 

national experts on health care research, mental health providers, advocates, and people with 

mental health conditions and their families. 

Direct and Indirect Levers of Federal Influence

As the ISMICC undertakes the challenging work of evaluating and recommending ways to 

strengthen federal policies and programs, a key goal will be to ensure that changes made at the 

federal level actually lead to better lives for people with SMI and SED throughout the nation. 

As Figure 3.1 illustrates, there are many contributors to our complex national system for mental 

health care. All federal sources combined account for almost half of all spending on mental 

and substance use disorders (46.9 percent; Mark, Levit, Yee & Chow, 2014). It is important to 

note that the data in Figure 3.1 includes little if any of the spending that occurs for housing, 

disability payments, vocational training, educational services, etc., much of which also reflects a 

combination of federal, state, tribal, local, and private resources.

The ISMICC process will examine the various approaches that can be used to improve population 

health for people with SMI and SED, using the broad range of direct and indirect levers of federal 

influence. The goal of this process is to improve collaboration of federal agencies that provide 

services, such as:
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•	 Government-operated systems run by the Veterans Health Administration 

(VHA) and DoD health care facilities. VHA and DoD have done promising work 

in areas such as integration of health and behavioral health care, suicide prevention, 

and ongoing outreach to people with SMI and SED. This work improves the care of 

active duty service members and veterans and—importantly—serves as a model to be 

emulated in other systems.

•	 Medicare, TRICARE, and the Indian Health Service. These are examples of 

programs where the federal government directly reimburses health care providers for 

services provided to eligible enrollees or works with intermediaries to provide health 

coverage. These programs are highly influential, not only for the impact on enrollees 

and their ability to access care, but also because they often serve as a model for private 

insurers. Making their policies and programs more effective at addressing the needs 

of people with SMI and SED could have widespread benefits, particularly through the 

Medicare program because of its great reach.

•	 Medicaid and the Children’s Health Insurance Program (CHIP). Medicaid, 

a federal/state partnership for reimbursement of services, is the largest payer for 

behavioral health services, and frequently offers the most comprehensive array of 

services relevant to people with SMI and SED. Because Medicaid is jointly operated 

by the federal and state governments, the configuration of reimbursable services and 

methods of payment for services can vary substantially from one state to the next. 

The mix of mandated and optional services provides extensive opportunities for the 

creative exercise of the principles of federalism, and allows each state (and counties 

in some states) to tailor its service system. An example of this is the Medicaid Health 

Home program, which often serves people with SMI and SED, an optional benefit 

under Medicaid. States differ widely in the extent to which this flexibility has been 

used to create a responsive and effective system of services for people with SMI and 

SED. CHIP, like Medicaid, is a federal/state partnership. CHIP provides low-cost health 

coverage, including behavioral health services, to uninsured children in families that 

earn too much to qualify for Medicaid. In some states, CHIP also covers pregnant 

women. Medicaid and CHIP policy can greatly influence the range and types of 

services available in communities throughout the nation, but cannot always overcome 

disparities in local economies and circumstances. 

•	 Social Security disability programs. These programs have long played a major role 

in the lives of adults with SMI and children and youth with SED. One facet of the role 

of the Social Security Disability Insurance (SSDI) and Supplemental Security Income 

(SSI) programs is that they provide an entitlement to Medicare or Medicaid eligibility. 

Another is the direct income support and other services they provide to recipients with 

SMI and SED. Demonstration programs currently underway are assessing whether 

enhanced access to supported employment and evidence-based treatment can 
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The Way Forward: Federal Action for a System That 

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enable people with SMI to avoid enrolling in the programs and move to competitive 

employment instead.

The federal government also provides a diverse mix of other services and functions that influence 

the lives of people with SMI and SED and their families. A partial list of examples would include: 

•	 Basic and applied research that helps us better understand the course of a 

disorder and the means to prevent, cure, or lessen its impact. This includes the 

work of the National Institute of Mental Health that aims to unravel the causes and 

course of SMI and to assess the effectiveness of models such as coordinated specialty 

care for first-episode psychosis.

•	 Surveys and other surveillance programs that provide information on the 

incidence, prevalence, and distribution of disorders. SAMHSA, the Agency for 

Healthcare Research and Quality, and the Centers for Disease Control and Prevention 

conduct ongoing major national surveys to help us understand patterns and 

prevalence of a broad range of health and behavioral health disorders, patterns of care, 

as well as some of the contributing social factors.

•	 Demonstrations and evaluations of prevention, treatment, and support models 

that can improve the lives of people with SMI and SED. SAMHSA, the Office of 

the Assistant Secretary for Planning and Evaluation, and the Centers for Medicare & 

Medicaid Services have collaborated on relevant demonstration programs, such as 

the Certified Community Behavioral Health Clinic (CCBHC) program that provides 

alternative payment models and more integrated, comprehensive care for people with 

SMI and SED. The Center for Medicare and Medicaid Innovation has implemented 

and is assessing an extensive roster of alternative delivery and payment programs, 

including many that impact health and behavioral health care for people with SMI and 

SED.

•	 Time-limited grant programs to fund development of promising models at 

the state, tribal, and local levels. This widely used tool encourages widespread 

implementation of promising models through time-limited federal funding. Examples 

include suicide prevention initiatives, efforts to develop trauma-informed systems, 

expansion of mental and substance use disorder treatment in federally qualified 

health centers, and many others. A general concern with this strategy is whether gains 

achieved are retained over the longer term after the grant funding ends.

•	 Longer-term formula-funded programs. These include block grants and other 

funding streams that support critical infrastructure and system capacity. They may 

be used to ensure a focus on specific issues, such as the focus on intervening early 

for serious mental illness included in the Community Mental Health Services Block 

Grant.
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•	 Technical assistance and support. Many technical assistance centers address a wide 

variety of topics relevant to people with SMI and SED, and provide education, tools, 

and supports to aid implementation of effective models at state, tribal, and local levels. 

For example, SAMHSA and the Departments of Justice, Education, and Labor fund 

several such programs. 

•	 Quality measurement and reporting. These are required for receipt of a wide 

variety of federal grants, as well as reimbursement funding streams from Medicare, 

Medicaid, and other insurers. These requirements have the potential to shape service 

delivery in ways that can improve responsiveness and effectiveness. However, many 

providers complain about the costs and burden associated with these requirements, 

while advocates tend to push for additional, more specific measures and reports. 

The evaluation of this diverse array of federal policies and programs will be an enormous 

undertaking. The ISMICC will support coordination across the participating departments and 

agencies to advance evaluation of the federal system of services and supports for people with 

SMI and SED. Examining these policies and programs, and the ways in which they can serve as 

beneficial influences on practices at the community level, will be a major focus of the committee 

in the years ahead.

The ISMICC Role in Evaluating Federal Programs and 

Enhancing Coordination to Improve Outcomes 

The ISMICC is newly formed and this evaluation will require an extended process. Since the first 

ISMICC meeting, we have begun to collect information about federal programs serving people 

with SMI and SED in order to inform the development of this evaluation. 

The ISMICC proposes to examine the information obtained from the request to federal members, 

and from a Government Accountability Office (GAO) report that was released in 2014 and based 

on data from 2013, Mental Health: HHS Leadership Needed to Coordinate Federal Efforts Related 

to Serious Mental Illness, as a first step in developing a high-level perspective on the array of 

federally supported services. 

A deeper examination of this broad array of federal programs should attempt to answer common 

evaluation questions such as the following:

1. How effective are federal policies and programs in addressing the needs of 

people with SMI and SED? Consider and examine the full spectrum of services 

and supports necessary to make possible an acceptable quality of life for people 

with SMI and SED and their families. Are there important gaps—areas that are not 

being addressed at all, or not being adequately addressed? What areas could benefit 

from new, innovative approaches to meet the needs across the full range of health, 
Interdepartmental

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The Way Forward: Federal Action for a System That 

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Families and Caregivers 

December 13, 2017

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behavioral health, education, employment, income supports, housing, or other areas? 

2. How effectively are federal departments collaborating and coordinating 

policies and programs to enhance the quality of life for people with SMI and 

SED? In addition to the ISMICC, what structures are in place to develop and sustain 

coordination on an ongoing basis? What accountability measures exist or are needed 

to ensure that efforts to improve policy and programmatic coordination are achieving 

desired public health outcomes?

3. Do current policies and programs have sufficient reach to serve all of the 

people with SMI and SED who could benefit? A concern is that programs may 

be designed, accidentally or intentionally, to restrict the number of people who 

can participate and consequently exclude vulnerable populations or those with 

limited access such as people in rural areas. This may occur inadvertently through 

the construction of program eligibility criteria that fail to acknowledge all relevant 

circumstances. It also may occur simply as the result of inadequate funding—a 

universally important consideration that may be difficult to address. What can be done 

to expand the reach of policies and programs to all of those who are in need?

4. Are there important gaps in knowledge or information that make it difficult 

to assess the extent to which we are achieving goals related to public health 

outcomes for people with SMI and SED? Given the context of our complex system 

in which federal, state, tribal, local, and private players hold important roles, there are 

many important concerns about which information is not yet readily available to assess 

key issues or progress in resolving problems. What can be done to improve access to 

public health indicators in such areas? For example, the need to involve the criminal 

justice system is widely viewed as a sign of failure of community treatment systems, 

yet we have no way to obtain comprehensive information on such incidents. In other 

cases, programs that serve people with SMI and SED do not collect information that 

allows identification of that segment of program participants. 

5. How effectively do policies and programs meet the needs of the people they 

serve or impact? As currently constructed and operated, do they advance the goal of 

improving care and quality of life for people with SMI and SED? Do they incorporate 

adaptations to cultural, linguistic, and local circumstances? Do they address health 

disparities and vulnerable populations in the areas served? Has the effectiveness of the 
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program been evaluated, or are there plans to evaluate it? Has the program undergone 

improvements in response to evaluation recommendations? Does current program 

design align with the nature of SMI and SED? For example, do disability programs 

create incentives to work and provide the necessary support for people with episodic or 

cyclical illnesses? 

6. Does the policy or program reflect the state of the science and our knowledge 

about what has been shown to improve outcomes for people with SMI and SED?

A good deal is known about practices and models of care that have a track record of 

success in meeting the needs of people with SMI and SED. Are policies and programs 

being implemented in a manner consistent with those models, with appropriate 

adaptation to cultural, linguistic, and local circumstances?

7. Does the policy or program apply the principles of population health 

management in its operations? Is there an approach to monitoring the proportion 

of those who could benefit from services who are receiving them? Does it take active 

steps to increase the reach of the program and participation in the program? Are 

registries used as a tool to maintain contact with participants, monitor their progress, 

and ensure that they receive needed services? Are there active, meaningful quality 

assurance initiatives so that operations and outcomes can be improved over time?

8. For direct treatment programs, does the program apply the principles of 

measurement-based care? Is the program using validated rating scales appropriate 

to the population served to track progress over time, and to adapt the intervention in a 

person-centered manner if the person is not progressing?

9. Are there areas where clearer guidance for regions or states implementing 

jointly funded programs could improve access and outcomes? For example, could 

there be better guidance related to termination of Medicaid or disability benefits upon 

institutionalization or incarceration, and reinstatement of benefits upon release?
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10. Are there areas in which data collection could be harmonized across 

departments to improve our knowledge of changes in key outcome measures?

Many program measures are set through regulation or law and may be difficult to 

change, but others could be changed administratively to allow better comparisons 

across departments and programs. This could facilitate the collection of data 

relevant to tracking progress on public health outcomes relevant to the SMI and SED 

populations.

11. Could existing large-scale federal data collection efforts be better used to 

provide information about population health outcomes relevant to the SMI 

and SED populations? Could reasonable and affordable changes to these data 

collection efforts be feasible and beneficial? Several federal databases are relevant 

to people with SMI and SED and could provide information about gaps to address, 

such as Medicaid and Medicare claims data, electronic health record data from the 

VHA, and data from surveys such as the National Survey on Drug Use and Health 

and the Medical Expenditure Panel Survey. Is it feasible to use these data to monitor 

the effectiveness of efforts to improve the care and quality of life for SMI and SED 

populations over time?

It will be critical to identify gaps that occur either through the absence of essential policies or 

programs, or through programs that fail to reach all of those in need. The 21st Century Cures 

Act created new programs and initiatives to address the needs of people with SMI and SED. If 

Congress provides funding to implement or continue these programs, the ISMICC can examine 

them to assess what is working and where additional improvements are called for.

This work will require a level of commitment from the departments that participate in the 

ISMICC process, and will benefit from the expertise and guidance of the full membership. A key 

concern will be how to ensure that improvements developed at the federal level are implemented 

comprehensively throughout the states, tribes, and localities across the nation. Given the complex 

and multilayered federal, state, and local funding streams that support services needed by the 

SMI and SED populations, careful attention to principles of implementation science will be very 

important.
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What Is Known to Date About Federal Programs 

Table 3.1 is a listing of programs in each of the eight departments that serve on the ISMICC, 

compiled by committee staff. This list includes programs that focus on SMI and SED, as well as 

programs that serve a broader population but provide services that are important to people with 

SMI and SED. An initial call has gone to all the departments for basic information about these 

programs, and that data collection process is ongoing.

Another source of basic descriptive information for many of these programs is available from the 

2014 GAO report cited above. 

In the months ahead, the ISMICC will, with staff support, continue existing data collection efforts 

and begin the process of a broader evaluation of federal policies and programs, and their impact 

nationally.

Table 3.1. Federal Programs Related to SMI and SED Programs 

That Can Support People With SMI and SED

Department of Defense

• Army Behavioral Health Residential Treatment Facilities

• Direct Care (DC) System Mental Health Services

• In-Transition

• Overcoming Adversity and Stress Injury Support (OASIS)

• Naval Hospital Jacksonville, Substance Abuse Rehabilitation Program (SARP)

• TRICARE

Department of Education

• Early Intervention Program for Infants and Toddlers with Disabilities (Part C of Individuals with Disabilities Education 

Act (IDEA)

• Elementary and Secondary School Counseling Program

• IDEA Parent Information

• IDEA Technical Assistance and Dissemination

• Project SERV (School Emergency Response to Violence)

• School Climate Transformation Grants

• Services for School Aged Children: (Part B of IDEA)

• Special Education – Personnel Development to Improve Services and Results for Children with Disabilities

• State Supported Employment Program

• State Vocational Rehabilitation Services Program

• Student Support and Academic Enrichment Formula Grant

• Vocational Rehabilitation Services
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Table 3.1. Federal Programs Related to SMI and SED Programs 

That Can Support People With SMI and SED (continued)

Department of Health and Human Services

Administration for Children and Families

• National Center on Domestic Violence, Trauma, and Mental Health

• Temporary Assistance for Needy Families

• Title IV-E Foster Care

Administration for Community Living

• Advanced Research Training Program in Employment and Vocational Rehabilitation of Persons with Psychiatric 

Disabilities

• Aging and Disability Resource Centers

• Creating a Multidimensional Model of Engagement for Young Adult with Psychiatric Disabilities in Adult System TeamBased Community Outreach and Support Services

• Customized Employment for Individuals with Serious Psychiatric Disabilities

• Development Center to Enhance Evidence-Based Supportive Employment with a Technology-Based Management 

System

• Empowering Parents: National Research Center for Parents with Disabilities and their Families

• Enhancing the Community Living and Participation of Individuals with Psychiatric Disabilities

• Evaluating the Impact of Employment Services in Supportive Housing

• Identifying Enabling Environments Affecting Adults with Psychiatric Disabilities

• Increasing Community Participation Among Adults with Psychiatric Disabilities Through Intentional Peer Support

• Increasing Community Participation in Adults with Schizophrenia

• Integrated Program to Improve Competitive Employment in Dually Diagnosed Clients

• Integrated Scaling Approach: A Model for Large Scale Implementation of Effective Interventions for Employment.

• Manual and Training Program to Promote Career Development Among Transition Age Youth and Young Adults with 

Psychiatric Conditions

• Recovery 4 US – Development of a Photovoice-Based Social Media Program to Enhance the Community 

Participation and Recovery of Individuals with Psychiatric Disabilities

• Rehabilitation Research and Training Center on Improving Employment Outcomes for Individuals with Psychiatric 

Disabilities

• Rehabilitation Research and Training Center on Self-Directed Recovery and Integrated Health Care

• Research and Training Center for Pathways to Positive Futures: Building Self-Determination and Community Living 

and Participation

• Temple University Rehabilitation Research and Training Center on Community Living and Participation of Individuals 

with Psychiatric Disabilities

• TEST – Translating Evidence to Support Transitions: Improving Outcomes of Youth in Transition with Psychiatric 

Disabilities by Use and Adoption of Best Practice Transition Planning

• The Learning and Working During the Transition to Adulthood Rehabilitation Research and Training Center

• Weight Management and Wellness for People with Psychiatric Disabilities

• Workers with Psychiatric Disabilities and Self-Employment Through Microenterprise

• WorkingWell: Developing a Mobile Employment Support Tool for Individuals with Psychiatric Disabilities
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Table 3.1. Federal Programs Related to SMI and SED Programs 

That Can Support People With SMI and SED (continued)

Department of Health and Human Services (continued)

Agency for Healthcare Research and Quality

• Academy for Integrating Behavioral Health and Primary Care

Assistant Secretary for Preparedness and Response

• Ensuring that the needs of people with SMI are integrated into broader public health preparedness, response, and 

recovery practices

Centers for Disease Control and Prevention

• LET’S CONNECT 

• Senior Connection Research Study 

• National Violent Death Reporting System

• Preventive Health and Health Services Block Grant

• Centers for Medicare & Medicaid Services

• Medicare

• Care Management and Coordination Services

• Medicaid

• Selected Programs Focused on SMI

– Certified Community Behavioral Health Clinics

– Guidance on Opportunities for Innovation

– Health Homes

– Medicaid Innovation Accelerator Program – SMI Data Analytic Tool

– Medicaid and CHIP Quality Measurement and Improvement Program

– Study of Medicaid Managed Care Coverage of Treatment in Institutions for Mental Diseases

– Home- and Community-Based Services

• Children’s Health Insurance Program (CHIP)

• Center for Medicare and Medicaid Innovation Demonstration Projects

Food and Drug Administration

• Critical Path Initiative: Optimizing schizophrenia trial design elements and establishment of exposure-response 

relationship based on efficacy findings of immediate-release and long acting injectable antipsychotic formulations 

sharing the same active moiety

Health Resources and Services Administration

• Health Center Program

• Specialized Health Care Service Grants

– Healthy Start Program

– Home Visiting Program

Ryan White HIV/AIDS Program

• Title V Maternal and Child Health Block Grant

• Training/Workforce Programs

– Nurse Education, Practice, Quality and Retention: Behavioral Health Integration Program

– Behavioral Health Workforce Education and Training Program
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Table 3.1. Federal Programs Related to SMI and SED Programs 

That Can Support People With SMI and SED (continued)

Department of Health and Human Services (continued)

– Teaching Health Center Graduate Medical Education Program

– National Health Service Corps

Indian Health Service

• Behavioral Health Integration Initiative (BH2I)

• Mental Health Direct Care Services

• Zero Suicide Initiative

National Institute of Mental Health

• Addressing Suicide Research Gaps: Aggregating and Mining Existing Data Sets for Secondary Analyses (R01)

• Addressing Suicide Research Gaps: Understanding Mortality Outcomes (R01)

• ALACRITY – Advanced Laboratories for Accelerating the Reach and Impact of Treatments for Youth and Adults with 

Mental Illness (Research Centers (P50) 

• Applied Research Towards Zero Suicide Healthcare Systems (R01)

• Bipolar-Schizophrenia Network for Intermediate Phenotypes

• Detecting and Preventing Suicide Behavior, Ideation and Self-Harm in Youth in Contact with the Juvenile Justice 

System (R01)

• Effectiveness Trials for Post-Acute Interventions and Services to Optimize Longer-term Outcomes (R01 and R34)

• Exploratory Clinical trials of Novel Interventions for Mental Disorders (R61/R33)

• Improving Health Outcomes and Reducing Premature Mortality in Serious Mental Illness 

• North American Prodrome Longitudinal Study

• Pilot Studies to Detect and Prevent Suicide Behavior, Ideation, and Self-Harm in Youth in Contact with the Juvenile 

Justice System (R34)

• Products to Support Applied Research Towards Zero Suicide Healthcare Systems (R43/R44)

• Psychiatric Genomics Consortium

• RAISE Recovery after an Initial Schizophrenia Episode

• Reducing the Duration of Untreated Psychosis in the United States (R01 and R34)

• Temporal Dynamics of Neurophysiological Patterns as Potential Targets for Treating Cognitive Deficits in Brain 

Disorders (R01) 

• Using the NIMH Research Domain Criteria (RDoC) Approach to Understand Psychosis (R21/R01)

Office of Civil Rights

• 21st Century Cures Act: HIPAA Compassionate Communications

• Disability nondiscrimination under Section 504 of the Rehabilitation Act, Title II of the Americans with Disabilities Act 

and Section 1557 of the Affordable Care Act.

Substance Abuse and Mental Health Services Administration

• Assisted Outpatient Treatment 

• Children’s Mental Health Initiative

• Circles of Care 

• Cooperative Agreements to Implement the National Strategy for Suicide Prevention

• Community Mental Health Services Block Grant
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Table 3.1. Federal Programs Related to SMI and SED Programs 

That Can Support People With SMI and SED (continued)

Department of Health and Human Services (continued)

• Cooperative Agreements to Benefit Homeless Individuals

• Garrett Lee Smith Campus Suicide Prevention Program

• Garrett Lee Smith State and Tribal Youth Suicide Prevention Program

• Healthy Transitions

• Homeless and Housing Resource Network

• Jail Diversion

• Minority AIDS Initiative

• National Child Traumatic Stress Initiative

• National Consumer and Consumer Supporter Technical Assistance Centers

• National Suicide Prevention Lifeline

• National Suicide Prevention Lifeline Crisis Center Follow-Up Grants

• National Technical Assistance Center for Trauma-Informed Practice and Alternatives to Restraint and Seclusion

• Native Connections

• Primary and Behavioral Health Care Integration/ Promoting Integration of Primary and Behavioral Health Care

• Programs to Achieve Wellness

• Projects for Assistance in Transition from Homelessness

• Protection and Advocacy for Individuals with Mental Illness

• Recovery to Practice Task 4 Workgroup: Clinical Decision Making with People who have SMI

• SAMHSA’s Behavioral Health and Justice Transformation Center

• SAMHSA Social Inclusion and Public Education Program (VOICE)

• Service Members, Veterans, and their Families – Technical Assistance Center

• Statewide Consumer Networks

• Statewide Family Networks

• Suicide Prevention Resource Center

• The National Consumer and Consumer Supporter Technical Assistance Centers (CCSTAC)

• Transforming Lives Through Supported Employment Grant Program

• Zero Suicide Grants

Department of Housing and Urban Development

Office of Community Planning and Development

• Continuum of Care

• Emergency Solutions Grant

• Housing Opportunities for Persons with AIDS

Office of Housing

• Section 811 Supportive Housing for Persons with Disabilities

Office of Public and Indian Housing

• HUD – VA Supportive Housing
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Table 3.1. Federal Programs Related to SMI and SED Programs 

That Can Support People With SMI and SED (continued)

Department of Justice

Bureau of Justice Assistance

• Justice and Mental Health Collaboration

• Second Chance Act Reentry

• Stepping Up Initiative

Bureau of Prisons

• Dual Diagnosis Residential Drug Abuse Program

• Mental Health Step Down Unit

• Resolve

• Skills Program

• Steps Toward Awareness, Growth, and Emotional Strength

• Office of Juvenile Justice and Delinquency Prevention

• Juvenile Drug Treatment Court Program

• Formula Grants

• Juvenile Accountability Block Grant

• Second Chance Act Reentry

Department of Labor

Office of Disability Employment Policy

• Campaign for Disability Employment

• Job Accommodation Network

• State Leadership Mentoring Programs

• Workforce Recruitment Program

Employment and Training Administration

• American Job Center Network

• Employer Technical Assistance Center 

• Reentry Employment Opportunities

• State Leadership Mentoring Program

• Workforce Innovation and Opportunity Act Programs

• YouthBuild

Veterans’ Employment and Training Service

• Homeless Veterans Reintegration Program

• Jobs for Veterans State Grants Program

Department of Veterans Affairs

Veterans Health Administration

• General Outpatient Mental Health Services

• Inpatient Mental Health
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Table 3.1. Federal Programs Related to SMI and SED Programs 

That Can Support People With SMI and SED (continued)

Department of Veterans Affairs (continued)

• Intensive Community Mental Health Recovery Services

• Mental Health Enhancement Initiative

• Mental Health Residential Rehabilitation Treatment

•

• National Psychosis Registry

• Primary Care – Mental Health Integration

• Psychosocial Rehabilitation and Recovery Center

• REACH VET – Recovery Engagement And Coordination for Health --Veterans Enhanced Treatment

• Re-Engaging Veterans with Serious Mental Illness

• Specialized Homeless Services

• Substance Use Disorder Treatment

• Therapeutic and Supported Employment Services

Social Security Administration

• Homeless with Schizophrenia Presumptive Disability*

• Military Casualties/Wounded Warriors

• PROMISE – Promoting Readiness of Minors in SSI

• Protection and Advocacy

• SOAR – SSI/SSDI Outreach Access and Recovery

• Social Security Disability Insurance

• Supplemental Security Income

• Supported Employment Demonstration

• Work Incentives Planning and Assistance

Future Work of the ISMICC to Evaluate Federal Programs 

Fulfilling the responsibilities outlined in the ISMICC charter will require an extensive effort by 

each of the federal departments, in collaboration with the membership of the ISMICC. This is 

the work of the next several years. The committee looks forward to the opportunity to document 

concrete improvements in the proportion of people with SMI and SED who receive the evidencebased services they need to live in recovery and experience an improved quality of life. The 

ISMICC will strive to do everything possible to improve the direction and coordination of federal 

programs in support of this goal and the committee’s vision.
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Chapter 4: Recommendations From Non-Federal ISMICC 

Members

This chapter was developed solely by the non-federal members of the ISMICC. We, the nonfederal members, have created a list of recommendations that reflects our hope that federal 

departments will better align and coordinate their efforts to support people with serious 

mental illnesses (SMI) and serious emotional disturbances (SED). Our goal is to advance 

the development of a comprehensive continuum of treatments and supports that have been 

demonstrated to improve outcomes for people of all ages with SMI and SED. We envision the 

establishment of standards of care for mental health treatment and supports across the full 

continuum, in communities nationwide. We intend to prom0te evidence-based practices and 

strong community-based systems of care, and to end travesties such as unnecessary incarceration 

and “boarding” of people with acute psychiatric conditions in emergency departments for 

hours or days. We hope that coordinated federal efforts will enable our partners in states and 

communities to strengthen their efforts in support of these goals. 

On the following pages we present these 

recommendations. The recommendations call 

for specific actions that we see as important and 

achievable. The recommendations are grouped into 

five areas of focus. For each recommendation, we 

indicate whether we believe it could be achieved in 1 

year or less (short term), 2-3 years (medium term), or 

4-6 years (longer term). 

All of the recommendations call for actions to be 

taken by federal departments represented on the 

ISMICC. Realization of the broader vision will also 

require changes at the state, tribal, and local levels, 

with assistance from federal policies and programs, 

and through support and legislative action from 

Congress. 

While drafting this report, we received hundreds of recommendations from diverse sources, 

many of which had merit and are worthy of attention in due time. The carefully selected set of 

recommendations included in this first report, however, were chosen to provide critical points of 

deliberation within the ISMICC. They will help shape the activities of the ISMICC in the years to 

come, and we anticipate that they will be refined and amended as the ISMICC moves forward.

Source of Recommendations

These recommendations reflect the views of the 

non-federal ISMICC members. Federal members 

were consulted regarding factual concerns and 

federal processes, but the final list of recommendations are the product of the non-federal 

members. These recommendations do not represent federal policy, and the federal departments 

represented on the ISMICC have not reviewed 

the recommendations to determine what role they 

could play in the future activities of the departments. The recommendations should not be 

interpreted as recommendations from the federal 

government.
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The final ISMICC Report to Congress will include data on what has been accomplished. The final 

report also will include further recommendations to guide federal coordination in future years. 

Full Recommendations 

Focus 1: Strengthen Federal Coordination to Improve Care

1.1. Improve ongoing interdepartmental coordination under the guidance of the 

Assistant Secretary for Mental Health and Substance Use. Develop procedures and 

guidelines for ongoing coordination between federal departments to focus on SMI and 

SED populations. Activities, planning, and policies must focus on improving outcomes for 

people with SMI and SED, and will include the following. [Short-term recommendation]

a. Obtain commitment by all ISMICC federal departments to participate in 

interdepartmental meetings. Department representatives should be empowered to 

actively participate.

b. Conduct regularly occurring interdepartmental meetings of federal ISMICC members. 

Invite sub-agencies such as the Bureau of Prisons and the Office of Special Education 

and Rehabilitative Services as needed.

c. Conduct quarterly ISMICC meetings of federal and non-federal ISMICC members. 

Federal members will update the group on progress within focus areas. These meetings 

are working sessions, and include the two public sessions as required under the ISMICC 

charter. 

d. Content-specific subgroups with federal and non-federal ISMICC members will 

address specific recommendations from this report. Outside experts may be invited to 

participate in workgroup meetings.

e. Draft an annual report due by July 1 following each calendar year of the ISMICC that 

describes how federal agencies have progressed in addressing the recommendations in 

this report. 

f. Budget adequate resources for the level of federal staffing support and committee effort 

needed to operationalize the ISMICC processes over full term of the committee.
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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1.2.Develop and implement an interdepartmental strategic plan to improve the lives of 

people with SMI and SED and their families. Building on the foundation of this report, 

ISMICC federal departments will develop a joint federal strategic plan for improving services 

and outcomes for people with SMI and SED. The plan should be consistent with the “strategic 

planning” language in the 21st Century Cures Act, extend to all the federal ISMICC partners, 

and be complete by September 30, 2018, in conjunction with the strategic plan required under 

the 21st Century Cures Act. The plan must include measurable activities and outcomes for each 

participating department, as well as for all departments operating collectively. Though the 

development and implementation of the strategic plan, the Assistant Secretary for Mental and 

Substance Use shall review and propose modifications to federal programs that serve people 

with SMI and SED. [Short-term recommendation]

1.3. Create a comprehensive inventory of federal activities that affect the provision of 

services for people with SMI and SED. The list of federal programs will include federal 

leadership efforts, regulations, policies, contracts, grants and other programs that focus 

on people with SMI and SED or play a significant role in the service system for people with 

SMI and SED. [Short-term recommendation]

1.4. Harmonize and improve policies to support federal coordination. The federal 

departments participating in the ISMICC will address specific issues that impede 

coordination and effectiveness. Activities include but are not limited to the following. 

[Short-term recommendation]

a. Establish uniform definitions of SMI and SED and a shared lexicon across federal 

departments to promote understanding, coordination, and integration of services 

and supports for people with SMI and SED. Include definitions that support inclusion 

of individuals who have SMI or SED with co-occurring substance use disorders, 

developmental disabilities, and traumatic brain injury. 

b. Identify federal policies or other barriers across federal departments that preclude or 

impede access to services, treatments, or continuity of care. Assess whether federal 

program designs align with what is known from implementation research about 

effective ways to promote lasting practice change and improve systems. 

c. Identify age-based barriers to services in the federal policies of the ISMICC federal 

departments that impede access to needed treatments and services that support the 

transition to adulthood for 16- to 25-year-olds with or at risk of SED or SMI. 

d. Align eligibility and benefits systems across federal departments to facilitate system 

navigation and continuity of care for people with SMI and SED.
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1.5. Evaluate the federal approach to serving people with SMI and SED. Evaluate systems, 

services, and supports for people with SMI and SED, and assess effectiveness. Routinely 

measure, evaluate, and improve the federal government’s efforts. Identify areas where 

the federal government is failing to meet the needs of people with SMI and SED. Support 

evaluation and accountability for individual federal programs. See how federal programs fit 

within the larger support system. Identify and reduce non-coordinated duplication across 

departments. [Short-term recommendation]

1.6. Use data to improve quality of care and outcomes. Review and improve federal and 

national data sets relevant to the lives of people with SMI and SED to incorporate tracking 

of SMI/SED information and outcomes. Include all relevant federal data such as those 

focused on health, education, criminal justice, labor, military personnel, and veterans. 

Use the findings from data sets to reduce across-department variation and to establish 

national benchmarks for making progress on core recovery measures which address key 

issues for the ISMICC, including reduction in health disparities, and improvements in 

access, employment, education, decriminalization of mental illness, and community 

integration. Establish a national dashboard including this set of core recovery measures 

by which federal agencies, states, tribes, and counties can measure progress transparently. 

The measures included in this dashboard should be included in all federal health care 

quality measurement programs, and dashboard results should be regularly published 

for all federal health programs for children and youth experiencing SED and for adults 

experiencing SMI. [Medium-term recommendation]

1.7. Ensure that quality measurement efforts include mental health. Use existing 

bodies, such as the National Quality Forum and/or the HHS Measurement Policy Council, 

to harmonize and coordinate development and adoption of behavioral health quality 

measures across HHS divisions and other departments. Examine existing quality measures, 

such as those that track rehospitalization and emergency department use, to ensure that 

behavioral health data is not excluded, and encourage the inclusion of peers and family 

members in measure development. Through this work, improve the use of measures for 

populations, such as younger children, for whom mental health quality measures do not 

widely exist. [Medium-term recommendation]

1.8. Improve national linkage of data to improve services. Promote national adoption 

by public and private health care systems of routine linking of SMI and SED populations 

to mortality data, including tracking cause/manner of death, and analysis of survival 

rates after suicide attempts, emergency department presentation, and inpatient hospital 

discharge. Standardize similar data gathering across all state and local systems for SMI and 

SED populations within the justice system. [Longer-term recommendation]
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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Focus 2: Access and Engagement: Make It Easier to Get Good Care

2.1. Define and implement a national standard for crisis care. Through federal 

departmental coordination, establish standards consistent with those defined in the 

SAMHSA publication, Crisis Services: Cost Effectiveness and Funding Strategies.

7

 Develop 

standards that are person-centered, youth-guided, family-driven, and responsive to 

the circumstances and developmental needs of children, youth, and adults. Include a 

minimum standard for stabilization under the Emergency Medical Treatment and Labor 

Act (EMTALA). Once established, ensure that federal programs support the standards, and 

enable and incentivize states and communities to support and sustain adequate crisis care 

systems. [Longer-term recommendation]

2.2. Develop a continuum of care that includes adequate psychiatric bed capacity 

and community-based alternatives to hospitalization. Through partnerships at the 

federal, state, and local levels, build the capacity of the mental health system to provide 

a continuum of services that includes inpatient psychiatric care, when needed, with 

community-based resources also available. Ensure that people with SMI and SED receive 

care in the least-restrictive safe setting available that meets their mental health service 

needs. [Longer-term recommendation]

2.3. Educate providers, service agencies, people with SMI and SED and their families, 

and caregivers about the Health Insurance Portability and Accountability Act 

of 1996 (HIPAA) and other privacy laws, including 42 CFR Part 2, in the context 

of psychiatric care. There is a need for clarification and guidance regarding the value 

and need for communication with family members and caregivers. For example, there 

are permitted disclosures of protected health information in the context of psychiatric 

crises. There is justification for engaging families and caregivers in responding to the 

needs of their loved ones. Technical assistance and training is needed on how to involve 

family members and loved ones when a person with SMI or SED is in crisis and unable 

to make their own decisions. This work should include strategies for involving families 

while empowering people with SMI to direct their own care, such as psychiatric advance 

directives. [Short-term recommendation]

2.4. Reassess civil commitment standards and processes. Through federal coordination, 

reexamine current standards and develop model standards that both protect individual 

rights and enable greater flexibility for families, caregivers, and mental health providers to 

provide care, when necessary. Consider standards for inpatient civil commitment, assisted 

outpatient treatment, short-term “holds,” and longer-term civil commitment. Help states 

adopt standards. [Medium-term recommendation]

7 Substance Abuse and Mental Health Services Administration. Crisis Services: Effectiveness, Cost-Effectiveness, and Funding 

Strategies. HHS Publication No. (SMA)-14-4848. Rockville, MD: Substance Abuse and Mental Health Services Administration, 

2014.
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2.5. Establish standardized assessments for level of care and monitoring of consumer 

progress. Through partnership with states and localities, support the use of standardized 

assessment tools such as the Level of Care Utilization System (LOCUS) and the Child and 

Adolescent Level of Care Utilization System (CALOCUS) to create a common methodology 

across the nation to assess the need for level of care for people with SMI and SED receiving 

services. The use of validated instruments will allow for consistent metrics for adequacy 

of system capacity, as well as systematic monitoring of patient progress and response to 

treatment. [Medium-term recommendation]

2.6. Prioritize early identification and intervention for children, youth, and young 

adults. Develop standards that help educational institutions identify signs of mental 

illnesses, especially early psychosis. Enhance the Individuals with Disabilities Education 

Act (IDEA) so that children and youth with SED are identified regardless of the impact 

to learning. Develop policies that provide for educational staff and school-based 

clinics to have appropriate systems (such as standardized assessments) and expertise 

(such as participation by mental health professionals and family support specialists in 

individualized education program [IEP] meetings for students with SMI and SED). Provide 

transition planning for all students ages 16-25 with SED/SMI or first-episode psychosis, 

to ensure that they have access to treatment, services, and supports as they move into 

adulthood. Coordinate transition planning with state vocational rehabilitation agencies, in 

accordance with the Workforce Innovation and Opportunity Act and IDEA. [Longer-term 

recommendation]

2.7. Use telehealth and other technologies to increase access to care. Establish standards 

for the use of telehealth to provide mental health and other support services for people 

with SMI and SED and increase access to care, specifically for rural populations. Change 

regulations that inhibit provision of mental health services by telemedicine (e.g., crossstate licensure issues, requiring presence in a “clinic” setting, and requiring face-to-face 

meetings for payment). Apply telehealth to models of care such as the collaborative 

care model and Project ECHO (Extension for Community Healthcare Outcomes) to 

build workforce capacity and make better use of scarce professional resources. Support 

research, testing, and dissemination of new technology-based behavioral health services 

and supports so that people with SMI and SED and their families have access to accurate 

information regarding the use of these technologies. [Medium-term recommendation]

2.8. Maximize the capacity of the behavioral health workforce. Through federal 

interdepartmental planning, find ways to increase the capacity of the behavioral health 

workforce to meet the needs of people with SMI and SED and their families. [Longer-term 

recommendation]

a. Include coverage of peer and family support specialists in federal health benefit 

programs. 
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Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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b. Incentivize providers to obtain education and continuing education on evidence-based 

treatments and team-based care models. 

c. Provide tuition reimbursement to encourage mental health professionals in roles where 

there are severe shortages, such as child psychiatry and in addressing underserved 

populations.

d. Remove exclusions that disallow payment to certain qualified mental health 

professionals, such as marriage and family therapists and licensed professional 

counselors, within Medicare and other federal health benefit programs. 

e. Remove reimbursement and administrative burdens associated with psychiatric care 

within Medicare, Medicaid, and other federal health benefit programs. 

f. Explore how to fully implement integrated team models that are the most effective in 

addressing the needs of people with SMI and SED. 

g. Enable health care providers to practice to the full extent of their education and 

training. For example, remove barriers that prevent advanced practice registered nurses 

from prescribing medication.

h. Develop a workforce that is representative of the populations served (including racial 

and ethnic minorities, people in rural areas, and populations facing health disparities 

such as lesbian, gay, bisexual, or transgender individuals) and able to provide services 

in a culturally competent manner.

i. Develop standards for network adequacy in health plans, and identify and implement 

processes to monitor access to services and adherence to established standards.

2.9. Support family members and caregivers. Develop and disseminate programs for nonprofessional caregivers of children with SED and adults with SMI. Programming should be 

similar to those that exist for caregivers of people with intellectual disabilities, people with 

developmental disabilities, and older adults. Include caregiver respite, family consultation, 

system navigation, caregiver training, and family psychoeducation. Provide technical 

assistance and financial support for education programs by and for families and other 

caregivers. [Medium-term recommendation]
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2.10. Expect SMI and SED screening to occur in all primary care settings. Expand 

access and facilitate early initiation of treatment for people with SMI and SED through 

identification and engagement in primary care settings. Develop routine expectations that 

behavioral health consultation occurs in primary care, using collaborative care models, and 

then proactively monitor behavioral health provider network adequacy for all payers in all 

communities. This will ensure that those listed as providing services are actually available 

to accept new referrals. [Longer-term recommendation]

Focus 3: Treatment and Recovery: Close the Gap Between What Works and What Is Offered

3.1. Provide a comprehensive continuum of care for people with SMI and SED. Develop 

standards that include a full spectrum of integrated, complementary services known 

to be effective and to improve outcomes. Standards should be appropriate to phases 

of development and aging. Give attention to service disconnections that can occur as 

children and youth transition into adult systems. These standards must include at least the 

following. [Medium-term recommendation]

a. Guidance on effective use of psychopharmacological medications, including taking 

immediate action to promote the appropriate use of clozapine and long-acting 

injectable antipsychotic medications;

b. Supportive services, such as supportive housing, employment, and education;

c. Team-based models of care delivery that are interdisciplinary and incorporate peer and 

family support specialists as a matter of routine practice;

d. Recovery-oriented models of team-based care to be used in conjunction with 

outpatient civil commitment and assisted outpatient treatment;

e. Bidirectional integrated mental health and primary care services; 

f. Integrated services for people with co-occurring SMI/SED and substance use disorders; 

g. Psychiatric crisis response using least-restrictive appropriate settings in communities 

and psychiatric hospitals, and eliminating “psychiatric boarding” in hospital emergency 

departments;

h. Trauma-informed systems of care; 

i. Systems of care that provide family-driven, youth-guided, and culturally and 

linguistically responsive services; and
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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j. Comprehensive and integrated systems of care for people who need varying levels of 

intensive services and supports on an ongoing basis, including community-delivered 

services.

3.2. Make screening and early intervention among children, youth, transitionage youth, and young adults a national expectation. Develop and implement 

interdepartmental guidelines for detecting and treating early signs of SED in children and 

youth, and of SMI in transition-age youth and young adults, in a wide range of settings, 

including primary care, day care, school- and college-based health clinics, public health 

clinics, juvenile justice facilities, jails, and emergency departments. In this work, pay 

special attention to vulnerable populations facing health disparities. [Medium-term 

recommendation]

3.3. Make coordinated specialty care for first-episode psychosis available nationwide. 

Incentivize universal access to coordinated specialty care services in all federal health 

benefit programs, including Medicaid, Medicare, Department of Defense, the Veterans 

Administration, and TRICARE. Continue the SAMHSA block grant set-aside requirements, 

and provide guidance to facilitate payment by all public and private insurance programs. 

[Medium-term recommendation]

3.4. Make trauma-informed, whole-person health care the expectation in all our 

systems of care for people with SMI and SED. Adverse childhood experiences and 

trauma play a tremendously important role in the development of SMI and SED, and 

trauma-informed treatment is increasingly recognized as essential to enable recovery. 

People with SMI and SED commonly experience problems with health, substance use 

disorders, and the need for supportive housing, employment, and education. To address 

the mortality gap, we must provide access to integrated health and behavioral health care 

that identifies and addresses all health and social determinants in every treatment setting. 

[Longer-term recommendation]

3.5. Implement effective systems of care for children, youth, and transition-age youth 

throughout the nation. This must include the following. [Longer-term recommendation]

a. Support national implementation of the SAMHSA System of Care model. 

b. Provide strong supports for students with or at risk of SED/SMI through special 

education and Section 504 of the Rehabilitation Act services and supports, including 

the requirement of a school-based mental health professional and family support 

specialist at all IEP and 504 planning meetings that include a student with SED/SMI 

or its early forms, and identification or development of payment mechanisms through 

Medicaid or other health care coverage for health care services in IEP and 504 plans.
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c. Through collaboration between SAMHSA, Centers for Medicare & Medicaid Services, 

the Health Resources and Services Administration, and the Department of Education, 

establish school-based clinics with Medicaid-billable behavioral health assessment and 

treatment capacity integrated with physical health services in all public schools.

d. Improve postsecondary transition outcomes of all students with or at risk of SED/SMI. 

Expand policies and guidelines that require transition planning for all students ages 

16-22 with SED/SMI or first-episode psychosis, including those not covered within 

special education programs, to ensure that they have a student-centered plan that 

identifies treatment, services, and supports to achieve their best mental health and 

successful assumption of adult roles, including state vocational rehabilitation and other 

employment options.

3.6. Make housing more readily available for people with SMI and SED. Housing is an 

essential prerequisite for effective treatment and a life in recovery. Develop consistent 

federal policies to support and require adequate housing as a standard part of recoveryoriented treatment for people with SMI and SED, with special emphasis on providing 

housing, including supported housing, to those exiting jails and prisons, youth who 

have been estranged from their families, those who experience homelessness, and those 

aging out of foster care. Have the Department of Housing and Urban Development 

issue guidance for state and local housing authorities on establishing tenant selection 

preferences for non-elderly people with SMI, consistent with federal fair housing 

requirements. Target resources such as Housing Choice Vouchers for individuals with SMI 

experiencing chronic homelessness or transitioning from settings such as correctional 

facilities, nursing homes, or board and care homes. [Medium-term recommendation]

3.7. Advance the national adoption of effective suicide prevention strategies. All federal 

departments, including VA and DoD, should adopt Zero Suicide as a model for suicide 

reduction, and agree to develop and implement strategic plans with achievable and 

transparent targets for progress. Consider ways to widely disseminate and universally apply 

these strategies in the public health system. [Medium-term recommendation]

3.8. Develop a priority research agenda for SED/SMI prevention, diagnosis, treatment, 

and recovery services. [Medium-term recommendation]

a. Increase funding for research at the National Institute of Mental Health, commensurate 

with prevalence rates of SED/SMI, the direct and indirect costs of these conditions, and 

the burden of disease they impose. 

b. Establish a public-private partnership for discovering biomarkers and breakthrough 

disease-modifying interventions for the treatment of people with SMI and SED.
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Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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3.9. Make integrated services readily available to people with co-occurring mental 

illnesses and substance use disorders, including medication-assisted treatment 

(MAT) for opioid use disorders. Despite the high rate of co-occurring mental illness 

and substance use disorders and the disproportionate share of opioid prescriptions that 

go to people with mental illnesses, people with SMI and SED often do not have access 

to necessary MAT and other substance use disorder treatment services. Co-occurring 

treatment for mental illnesses and substance use disorders must be available in all 

treatment settings. In guidance accompanying federal funds to address the opioid crisis, 

clarify that those services and resources are to be made fully available on an ongoing basis 

to people with SMI and SED, with attention to housing, as well as mental and primary 

health needs. [Medium-term recommendation]

3.10. Develop national and state capacity to disseminate and support implementation 

of the national standards for a comprehensive continuum of effective care for 

people with SMI and SED. The challenges of implementation are well known, but rarely 

adequately addressed. As a consequence, we find a huge gap between what is known 

to be effective and what is available in communities throughout the nation. Several 

states (including New York, Ohio, and Vermont) have used block grant funds to develop 

technical assistance centers to support widespread implementation of effective practices. 

Implement these models more widely with national support, to bring implementation of 

evidence-based and effective practices to scale. [Medium-term recommendation]

Focus 4: Increase Opportunities for Diversion and Improve Care for People With SMI and SED 

Involved in the Criminal and Juvenile Justice Systems

4.1. Support interventions to correspond to all stages of justice involvement. Consider 

all points included in the sequential intercept model. Pay particular attention to 

the “zero intercept”—the avoidance of initial arrest. Provide funding opportunities for 

communities to map their systems, develop programs and services, and promote diversion 

of people with SMI and SED along the continuum of the sequential intercept model.8

[Medium-term recommendation]

8 Substance Abuse and Mental Health Services Administration. (2016). Turning Point: Criminal Justice to Behavioral Health. 

SAMHSA News, July 18, 2016. Retrieved from https://newsletter.samhsa.gov/2016/07/18/criminal-diversion-programs-resources.
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4.2. Develop an integrated crisis response system to divert people with SMI and SED 

from the justice system. Community-based mental health services must be in place 

to address the crisis needs of people with SMI and SED. A crisis response system should 

include services such as 24/7 access to crisis line services staffed by clinicians; warm lines 

staffed by certified peer specialists, including family and youth support specialists; nonlaw enforcement crisis response teams of clinicians and other behavioral health providers 

able to respond independently to nonviolent crisis situations, and to co-respond with 

law enforcement when needed; and dedicated crisis triage centers. A person with SMI or 

SED who is in crisis should be able to get adequate mental health care in the community 

without contact with law enforcement. However, until that goal is achieved, there must 

be plans for information sharing between crisis service providers and law enforcement 

personnel. Sustaining an adequate crisis response system must be addressed through 

an interdepartmental group, including SAMHSA, the Centers for Medicare & Medicaid 

Services, the Veterans Health Administration, and other federal departments. [Longerterm recommendation]

4.3. Prepare and train all first responders on how to work with people with SMI and 

SED. Ideally, crises among people with SMI and SED should be resolved without involving 

law enforcement. When the crisis system fails, or the level of dangerousness warrants, 

law enforcement and other first responders should be prepared to respond safely and 

effectively to people with SMI and SED. All law enforcement staff should be aware of the 

symptoms and needs of people with SMI and SED and have training to de-escalate mental 

health crisis situations. A select cadre of law enforcement officers in a patrol capacity 

within every community must receive specialized training in working with community 

behavioral health resources, and in-depth training on mental health and substance 

abuse issues. Officers who receive this specialized training will then be a resource for the 

community and fellow patrol officers, and be able to engage people within local justice 

diversion programs. [Longer-term recommendation]

4.4. Establish and incentivize best practices for competency restoration that use 

community-based evaluation and services. Develop federal guidelines and work with 

states to ensure that people with SMI wait no more than 5 days, on average, for initiation of 

competency services. Support the use of mathematically based planning tools to develop 

evidence-based strategies for reducing forensic bed waitlists. For people with SMI and SED 

charged with nonviolent crimes, use jail diversion options whenever possible instead of 

holding people in jails to await competency evaluations. Give consideration to pre-arrest, 

post-arrest, and post-competency phases. [Longer-term recommendation]

4.5. Develop and sustain therapeutic justice dockets in federal civilian, state, and 

local courts for any person with SMI or SED who becomes involved in the justice 

system. This includes support of therapeutic court models at local and federal levels, 

therapeutic justice dockets, and probationary units with specialized capacity to work with 
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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people with mental illness. Examples include mental health courts, accountability courts, 

veterans courts, and juvenile courts. Through coordination between federal departments 

and state and local agencies, community-based services for people with SMI and SED 

should support diversion programs. Federal financing should incentivize states to adopt 

and expand wraparound services such as case management; forensic assertive community 

treatment; cognitive skills training; and peer, family, and youth mentoring programs so 

courts and probation systems can connect people with SMI and SED to effective services.

[Longer-term recommendation]

4.6. Require universal screening for mental illnesses, substance use disorders, and 

other behavioral health needs of every person booked into jail. Use evidencebased screening tools to screen for SMI, SED, co-occurring substance use disorders, 

cognitive disabilities, and suicide risk when the person is booked, and later if indicated. 

When people screen “positive” for mental illnesses or substance use disorders, conduct 

a comprehensive assessment of mental and substance use disorder treatment needs, in 

accordance with procedures developed in the Stepping Up Initiative.9 Establish procedures 

for serving people identified through the screening process, including immediate crisis 

response for those with a high risk of suicide, diversion services to behavioral health 

services for lower severity offenses, and adequate jail-based behavioral health services for 

those who remain incarcerated. [Longer-term recommendation]

4.7. Strictly limit or eliminate the use of solitary confinement, seclusion, restraint, 

or other forms of restrictive housing for people with SMI and SED. Develop and 

implement a plan to reduce and eventually eliminate the use of solitary confinement and 

other forms of segregation, seclusion, restraint, and isolation of people with SMI within 

Federal Bureau of Prison facilities. This plan must include implementation of mental and 

substance use disorder treatment services to alleviate symptoms and, when appropriate, 

to help prepare people to reenter communities. Build on this policy to support similar 

measures for people with SMI and SED in state and local jurisdictions, while ensuring 

that effective mental health services are available within juvenile and adult correctional 

facilities. [Longer-term recommendation]

9 Stepping Up Initiative. (n.d.). Stepping Up: A National Initiative to Reduce the Number of People with Mental Illnesses in Jails. 

Website home page. Retrieved from https://stepuptogether.org.
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4.8. Reduce barriers that impede immediate access to treatment and recovery services 

upon release from correctional facilities. Criminal charges that are related to 

symptoms of SMI and SED should not impede a person’s ability to get housing, education, 

employment, and community living. Work at the federal level and help states to adopt 

policies that enable immediate access to benefits (such as Medicaid, Supplemental 

Security Income, and Social Security Disability Income) upon release from correctional 

facilities, including services such as supported employment. Encourage states to suspend, 

rather than terminate, Medicaid coverage and access to disability benefits for people who 

are incarcerated less than 18 months. Help states discontinue the practice of changing 

the Medicaid status of a person who has been arrested, confined but not convicted, or on 

probation or parole. Likewise, support forgiveness of criminal charges, including felonies, 

and actions related to symptoms of SMI and SED. [Longer-term recommendation]

4.9. Build on efforts under the Mentally Ill Offender Treatment and Crime Reduction 

Act, the 21st Century Cures Act, and other federal programs to reduce incarceration 

of people with mental illness and co-occurring substance use disorders. As 

part of a federal interdepartmental strategy, review the language of the Mentally Ill 

Offender Treatment and Crime Reduction Act and the 21st Century Cures Act to identify 

opportunities to maximize resources and provide services. Review federal programs such 

as the Byrne Justice Assistance Grant program and other relevant federal programs for 

juveniles and adults to identify opportunities to coordinate at the state and local level to 

maximize resources and provide services. [Short-term recommendation]

Focus 5: Develop Finance Strategies to Increase Availability and Affordability of Care

5.1. Implement population health payment models in federal health benefit programs. 

Such models provide support for integrated population health care that addresses the 

range of complexity and co-occurring conditions experienced by people with SMI and 

SED. People with SMI and SED often experience co-occurring substance use disorders, 

intellectual and developmental disabilities, and chronic physical health conditions. To 

measure effectiveness and quality of care, federal departments should employ outcome and 

quality measures at the individual and population levels. [Longer-term recommendation]

5.2. Adequately fund the full range of services needed by people with SMI and SED. 

Federal health benefit programs (including Medicaid, Medicare, VA, and TRICARE) should 

cover outreach services, bidirectional integration of physical and behavioral health care, 

care coordination, consultation, supported housing and employment services, family and 

peer support services, and other services needed by people with SMI and SED. Payment 

models should make it easy to reimburse providers for services. Fund such services 

directly or through models such as health homes, accountable care organizations, and 

managed care organizations. Federal departments should partner with private health 

plans, and with state and local governments, to promote similar approaches. [Longer-term 

recommendation]
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

Works for All People Living With SMI and SED and Their

Families and Caregivers 

December 13, 2017

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5.3. Fully enforce parity to ensure that people with SMI and SED receive the mental 

health and substance abuse services they are entitled to, and that benefits are 

offered on terms comparable to those for physical illnesses. Fully implement 

the October 2016 recommendations from the White House Parity Task Force and the 

recommendations made by the President’s Commission on Combating Drug Addiction 

and the Opioid Crisis for improving the implementation and enforcement of the Mental 

Health Parity and Addiction Equity Act (MHPAEA).10 These recommendations include 

enacting legislation to provide the Department of Labor the authority to impose civil 

monetary penalties for findings of noncompliance, authority to enforce MHPAEA 

directly against health plan insurance issuers, and additional funding to increase parity 

enforcement efforts. Review and implement the recommendations from the Coalition for 

Whole Health on parity implementation and enforcement, as documented in an August 

10, 2017, letter to the Office of the Assistant Secretary for Planning and Evaluation.11 Ensure 

that the services needed by people with SMI and SED are covered by health insurance 

and available at the same level as for other health conditions, with attention to parity in 

payment rate setting processes. [Medium-term recommendation]

5.4. Eliminate financing practices and policies that discriminate against behavioral 

health care. Identify and eliminate programs, practices, and policies that make it hard to 

deliver good mental health care. This includes ending the exclusion for reimbursement 

of services to adults under age 65 in Institutions for Mental Diseases (IMD exclusion) 

and ending the 190-day lifetime limit on Medicare psychiatric inpatient hospitalization. 

In addition, provide incentives for behavioral health providers to adopt electronic health 

records similar to incentives that other health care providers have received. [Medium-term 

recommendation]

5.5. Pay for psychiatric and other behavioral health services at rates equivalent to 

other health care services. In many states, reimbursement by public programs for 

mental health services is lower (as a percentage of cost) than reimbursement for other 

health services. This forces providers to offer critical services (including psychiatric care 

and hospitalization) at a loss. As a result, many mental health service providers do not 

participate in public programs, leading to widespread mental health workforce shortages. 

Medicare, Medicaid, and other benefit programs should provide adequate reimbursement 

for the full range of services needed by people with SMI and SED, at rates equivalent to 

rates for other types of health care services. [Longer-term recommendation]

10 Executive Office of the President of the United States. (2016). The Mental Health & Substance Use Disorder Parity Task Force: 

Final Report, October 2016. Retrieved from https://www.hhs.gov/sites/default/files/mental-health-substance-use-disorder-parity-task-force-final-report.pdf.

11 Coalition for Whole Health. (2017). Letter to Office of the Assistant Secretary for Planning and Evaluation, August 10, 2017. 

Retrieved from https://www.aahd.us/wp-content/uploads/2017/09/CWHparitylisteningsessioncomments.pdf.
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5.6. Provide reimbursement for outreach and engagement services related to mental 

health care. The public health care system must cover outreach and engagement services 

that are an essential part of so many effective mental health treatment models. More than 

one-third of adults with SMI and most children and youth with SED received no treatment 

in the past year. Outreach and engagement services allow mental health providers to 

meet with people with SMI and SED and their families in the community and in their 

homes. These activities help ensure that people with SMI and SED get the care they 

need. Outreach and engagement should be supported through financing models that are 

designed to support population health. [Longer-term recommendation]

5.7. Fund adequate home- and community-based services for children and youth with 

SED and adults with SMI. Through federal departmental coordination, help states 

meet the needs of people with SMI and SED. Medicaid waivers and options can be used 

to expand the availability of evidence-based services. Streamline the waiver approval and 

state plan amendment processes so states can easily make changes to better serve people 

with SMI and SED. To support states in this work, highlight best practices across states and 

make technical assistance and materials available, such as model managed care contract 

language. [Medium-term recommendation]

5.8. Expand the Certified Community Behavioral Health Clinic (CCBHC) program 

nationwide. The CCBHC program provides a framework to support effective services 

in a population health framework and offers a sustainable payment model. Evaluate the 

effectiveness of the CCBHC model and, if needed, modify the model to improve the 

reach and quality of services and outcomes. Help interested states to move toward similar 

models of care delivery, even states not funded by the CCBHC program. [Medium-term 

recommendation]
Interdepartmental

Serious Mental Illness

Coordinating Committee

The Way Forward: Federal Action for a System That 

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Appendix A

U.S. Department of Health & Human Services

Interdepartmental Serious Mental Illness Coordinating Committee

Members
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Federal Members

Elinore F. McCance-Katz, M.D., Ph.D.

Assistant Secretary for Mental Health and Substance Use

Eric D. Hargan, Esq.

Acting Secretary of the Department of Health and Human Services

Benjamin Carson, Sr., M.D. 

Secretary of the Department of Housing and Urban Development

Terry Adirim, M.D., M.P.H., F.A.A.P.

Deputy Assistant Secretary of Defense for Health Services Policy and Oversight, Office of the 

Assistant Secretary of Defense for Health Affairs, Department of Defense

Kimberly Brandt, J.D.

Principal Deputy Administrator for Operations, Centers for Medicare & Medicaid Services

Stephen Cox, J.D.

Deputy Associate Attorney General, Department of Justice

Captain Robert DeMartino, M.D.

Lead Medical Officer, Office of Health Services Policy and Oversight, Department of Defense

Thomas McCaffery, M.P.P.

Deputy Assistant Secretary of Defense for Health Affairs, Department of Defense

John McCarthy, Ph.D., M.P.H.

Director, Serious Mental Illness Treatment Resource and Evaluation Center, Department of 

Veterans Affairs 

Ruby Qazilbash, M.P.A.

Associate Deputy Director, Bureau of Justice Assistance, Department of Justice

Kimberly M. Richey, J.D.

Deputy Assistant Secretary and Acting Assistant Secretary for Special Education and 

Rehabilitative Services, Department of Education

Jennifer Sheehy, M.B.A.

Deputy Assistant Secretary, Office of Disability Employment Policy, Department of Labor

Melissa Spencer

Deputy Associate Commissioner, Office of Disability Policy, Social Security Administration
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Non-Federal Members

Linda Beeber, Ph.D., P.M.H.C.N.S.-B.C., F.A.A.N.

Linda Beeber, Ph.D., P.M.H.C.N.S.-B.C., F.A.A.N., is a doctorally prepared 

advanced practice psychiatric mental health nurse with over 40 years of experience 

in practice and over 20 years of research experience in mental health. Funded 

through federal grants and private foundations, Dr. Beeber and her colleagues 

have conducted community-based research focused on reducing maternal 

depressive symptoms and enhancing parenting in populations of high-risk 

mothers of infants and toddlers. Her work has shown that reduction of barriers and provision of 

culturally and contextually tailored, evidence-based interventions can effectively reduce maternal 

depressive symptoms and improve parenting. Dr. Beeber has experience as an educator, academic 

administrator, and psychiatric nursing leader. Through her work with the American Psychiatric 

Nurses Association (APNA) as the Chair of the Research Council, and more recently as PresidentElect, and as the past Co-Chair of the Psychiatric Mental Health and Substance Abuse Expert 

Panel of the American Academy of Nursing, she advocates to reduce the risk factors that threaten 

mental health, and to improve the lives of people living with symptoms of mental illness through 

models of recovery, culturally congruent symptom management, social support mobilization, and 

healthy lifestyle patterning. Dr. Beeber has disseminated her work through peer-reviewed papers, 

national and international presentations, and service on national policymaking panels. 

Ron L. Bruno

Ron L. Bruno is a Utah law enforcement officer with over 22 years of experience. Mr. 

Bruno has dedicated much of his career working with adult and child populations 

dealing with serious mental illness and emotional disturbances. Mr. Bruno is a 

founding board director of CIT International and currently is the corporation’s second 

vice president; a founding board director of CIT Utah, Inc. and the corporation’s 

Executive Director; and the Director of CTS Services, LLC, an organization that 

provides de-escalation training for law enforcement officers and other disciplines throughout 

the country. Mr. Bruno has worked with national organizations such as the National Alliance 

on Mental Illness in developing its CIT for Youth Implementation Manual; the International 

Association of Chiefs of Police in developing and conducting Law Enforcement Leadership 

Institutes on Juvenile Justice; and the Council of State Governments with its Learning Sites 

Program and its report on Statewide Law Enforcement/Mental Health Efforts. Within Utah, 

Mr. Bruno was instrumental in developing the fully integrated Salt Lake County crisis response 

system, and he continues to work with councils and committees for enhanced criminal justice 

and behavioral health services integration. 
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Clayton Chau, M.D.

Clayton Chau, M.D., is the Regional Executive Medical Director for the Mental 

Health Network, St. Joseph Hoag Health/Providence St. Joseph Health System in 

Orange County, California. He obtained his M.D. from the University of Minnesota 

and Ph.D. in clinical psychology from Chelsea University. Dr. Chau completed his 

psychiatry residency at the University of California, Los Angeles, San Fernando 

Valley, followed by a fellowship with the National Institute of Mental Health in 

psychoneuroimmunology focusing on substance use and HIV. Previously, he served as Senior 

Medical Director for Health Services at L.A. Care Health Plan, where he was Co-Principal 

Investigator for a multi-year Center for Medicare & Medicaid Services’ health care innovation 

grant in transforming clinical practice. Dr. Chau also is a lecturer for the UCLA School of 

Public Health and an associate clinical professor of psychiatry at UC Irvine School of Medicine. 

Previously, he worked for the Orange County Health Care Agency Behavioral Health Services 

and was the Director of the Center of Excellence in Education, Training, Research and Advocacy 

for Reducing Health Disparities. Dr. Chau was named the 2012 Visionary Leader by the National 

Council for Behavioral Health and received the Warren Williams, M.D., Award from the American 

Psychiatric Association. He also has conducted international trainings in the areas of health 

care integration, health care system reform, cultural competency, veterans’ health, trauma, 

homelessness, and mental health policy. 

David Covington, L.P.C., M.B.A.

David Covington, L.P.C., M.B.A., is Chief Executive Officer and President of 

RI International (formerly Recovery Innovations). He is a partner in Behavioral 

Health Link, co-founder of CrisisTech 360, and leads the international initiatives 

“Zero Suicide,” “Crisis Now,” and “Peer 2.0.” A licensed professional counselor, 

Mr. Covington received an M.B.A. from Kennesaw State and an M.S. from the 

University of Memphis. He previously served as Vice President at Magellan 

Health, CEO of Behavioral Health Link, and Director of Public Sector Quality Management at 

APS Healthcare. A recognized health care innovations global speaker and blogger, Mr. Covington 

is a two-time national winner of the Council of State Governments Innovations Award. He also 

competed as a finalist in Harvard’s Innovations in American Government in 2009 for the Georgia 

Crisis and Access Line, and the program was subsequently featured in Business Week magazine. 

Mr. Covington is President-Elect of the American Association of Suicidology and has served on 

the National Action Alliance for Suicide Prevention Executive Committee since 2010. He is also 

the Chair of the National Suicide Prevention Lifeline SAMHSA Steering Committee. He has 

served on numerous committees and task forces on clinical care and crisis services, including the 

National Council for Behavioral Health Boards of Directors.
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Maryann Davis, Ph.D.

Maryann Davis, Ph.D., is Research Associate Professor of Psychiatry 

(Psychology) and Director of the Systems and Psychosocial Advances Research 

Center and the Transitions Research and Training Center (RTC) at the 

Department of Psychiatry and the University of Massachusetts Medical School. 

A clinically trained research psychologist, she has spent her career studying 

transition-age youth and young adults with serious mental health conditions. 

Dr. Davis is a grant recipient of the National Institute of Mental Health; the National Institute 

on Disability, Independent Living, and Rehabilitation Research; the National Institute on Drug 

Abuse; and SAMHSA. She has collaborated with the Massachusetts Department of Mental Health 

in addressing the needs of transition-age youth for over 20 years. As Director of the Transitions 

RTC, she has extensive experience in sharing research-based knowledge with key stakeholders, 

including people with lived experience of serious mental health conditions and their families, 

administrators, policymakers, and service providers. Dr. Davis has provided expert testimony 

on transition-age youth with serious mental health conditions before Congress, and served on 

multiple committees of the National Academy of Sciences, Engineering, and Medicine.

Pete Earley

Pete Earley is a New York Times bestselling author and former reporter for The 

Washington Post. A 1973 graduate of Phillips University in Oklahoma, he previously 

worked for the Emporia Gazette in Kansas and the Tulsa Tribune in Oklahoma. 

From 1980 until 1986, Mr. Earley worked as a reporter at The Washington Post before 

writing books full-time. He is the author of six novels and 11 non-fiction books, 

including Crazy: A Father’s Search Through America’s Mental Health Madness,

which was a finalist for the 2007 Pulitzer Prize. Mr. Earley is a member of the National Alliance on 

Mental Illness, serves on the board of the Corporation for Supportive Housing, and was appointed 

to a Virginia Supreme Court task force that recommended changes to that state’s involuntary 

commitment laws and is currently serving on a committee investigating ways to improve Virginia 

jails. An advocate for mental health, Mr. Earley has testified five times before Congress, lectured 

in five foreign countries, spoken in every state except Hawaii, and toured a combined total of 

more than a hundred jails, prisons, treatment programs, and housing facilities.

Paul Emrich, Ph.D.

Paul Emrich, Ph.D., is Undersecretary of Family and Mental Health Services for the 

Chickasaw Nation, with responsibility for leading the integration of human services, 

addiction recovery, mental health, and medical care. Dr. Emrich received his 

training at Oklahoma State University and Oklahoma Baptist University, where he 

completed a postgraduate certificate in Medical Family Therapy, a Ph.D. in Human 

Development and Family Science, an M.S. in Marriage and Family Therapy, and a 
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B.A. in Family Psychology. Dr. Emrich is dually licensed as a licensed marital and family therapist 

(LMFT) and licensed professional counselor. He is also approved by the Oklahoma State Board of 

Behavioral Health Licensure to provide clinical supervision for license candidates. Dr. Emrich is 

a clinical fellow with the American Association for Marriage and Family Therapy and a member 

of the American Society for Addiction Medicine. He has served on Oklahoma’s licensing board 

for LMFT and on the Tribal Technical Advisory Group on Behavioral Health for the Centers for 

Medicare & Medicaid Services. Having worked as a clinician, supervisor, administrator, researcher, 

advocate, and educator, Dr. Emrich has over 20 years of experience in the mental health field 

helping children, adults, and families experiencing serious emotional illnesses.

Mary Giliberti, J.D.

Mary Giliberti, J.D., is the Chief Executive Officer of the National Alliance on Mental 

Illness (NAMI). A native of North Bellmore, NY, she earned her B.A. at Harvard 

College and her J.D. at Yale Law School. During her tenure of over 20 years in the 

mental health field, Ms. Giliberti has served as disability counsel for the Senate 

Committee on Health, Education, Labor, and Pensions and as a senior attorney at the 

Bazelon Center for Mental Health Law. Before becoming CEO of NAMI, she worked 

as a section chief in the Office for Civil Rights at the Department of Health and Human Services. 

Prior to that, Ms. Giliberti served as the Director of Public Policy and Advocacy for federal and 

state issues at NAMI.

Elena M. Kravitz

Elena M. Kravitz is a community mental health provider and advocate. A resident 

of Old Bridge, NJ, she is a Certified Psychiatric Rehabilitation Practitioner and an 

active volunteer and provider who brings a lived experience of recovery. Ms. Kravitz 

manages a peer support wellness center for the Collaborative Support Programs of 

New Jersey, a nationally recognized peer-led mental health organization. She also 

served as coordinator and lead presenter of the Hearts and Minds for the National 

Alliance on Mental Illness (NAMI) New Jersey and assists NAMI as a trainer in the In Our Own 

Voice and NAMI Connection programs. A board member of Disability Rights–New Jersey and 

her county’s Freeholder-appointed Mental Health Board, Ms. Kravitz supports legal protections 

for people pursuing recoveries. She is one of New Jersey’s leading trainers on psychiatric advance 

directives, taking a leadership role in her own county on initiatives to bring law enforcement 

and mental health together, promoting the police crisis intervention team. As a former staff 

member of a peer-staffed crisis respite house and as a peer worker in a psychiatric emergency 

service, Ms. Kravitz works to assist people pursuing recoveries move beyond a medication- and 

hospitalization-based model of mental health care, helping to spread awareness of shared 

decision-making, trauma-informed care, wellness recovery action planning, and the recovery 

library.
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Kenneth Minkoff, M.D.

Kenneth Minkoff, M.D., is a Senior System Consultant for ZiaPartners, Inc., 

a part-time Assistant Professor of Psychiatry for Harvard Medical School, and 

Director of Systems Integration for the Meadows MH Policy Institute in Dallas, 

TX. A recognized expert on integrated services and systems for individuals with 

co-occurring serious mental illnesses and substance use disorders, he is a BoardCertified Addiction Psychiatrist. In the 1990s, he chaired a SAMHSA Managed 

Care Initiative Panel on Co-occurring Disorders and developed a national model for integrated 

system design for individuals with co-occurring mental health and substance use disorders. For 

the past 17 years, Dr. Minkoff has worked with his consulting partner Christie A. Cline, M.D., 

M.B.A., to improve behavioral health systems all over the world. Dr. Minkoff also is active in 

policy and practice on a national and state level, serving as an emeritus board member of the 

American Association of Community Psychiatrists and currently as Chair of the Products and 

Services Plank. An active participant in designing SAMHSA’s Recovery to Practice Curriculum for 

psychiatrists, he is co-chair of the Committee on Psychiatry and the Community for the Group for 

the Advancement of Psychiatry, and is an incoming board member for the College for Behavioral 

Health Leadership.

Elyn R. Saks, J.D., Ph.D.

Elyn R. Saks, J.D., Ph.D., is Orrin B. Evans Professor of Law, Psychology, 

and Psychiatry and the Behavioral Sciences at the University of Southern 

California Gould School of Law. Dr. Saks is also Director of the Saks 

Institute for Mental Health Law, Policy, and Ethics. She is an adjunct 

professor of psychiatry at the University of California, San Diego, School 

of Medicine, and faculty at the New Center for Psychoanalysis. Dr. Saks 

received her J.D. from Yale Law School, and a Ph.D. in Psychoanalytic Science from the New 

Center for Psychoanalysis. She writes extensively on law and mental health, having published five 

books and more than fifty articles and book chapters. Her memoir, The Center Cannot Hold: My 

Journey Through Madness, describes her struggles with schizophrenia and her managing to craft a 

good life for herself in the face of a dire prognosis. Dr. Saks has won numerous honors, including 

a 2009 John D. and Catherine T. MacArthur Fellowship and an honorary Doctor of Laws from 

Pepperdine University.
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John Snook, J.D.

John Snook, J.D., is Executive Director of the Treatment Advocacy Center (TAC), 

an influential mental health advocacy organization. He received his J.D. from the 

George Mason School of Law in Virginia and his B.A. from Washington & Jefferson 

College in Pennsylvania. Mr. Snook brings to TAC nearly 20 years of policy and 

advocacy experience at both the federal and state levels. Prior to joining TAC, he 

worked on housing policy at the Mortgage Bankers Association and at Habitat 

for Humanity International, where he grew its state and local advocacy network into a driving 

nationwide force for affordable housing policy. Mr. Snook’s passion has always been mental health 

reform. His focus on the issue began early, as he saw a loved one struggle with untreated serious 

mental illness. Mr. Snook championed mental illness reform, working first with the West Virginia 

Supreme Court on mental health issues and then at TAC. His return to TAC as Executive Director 

represents a homecoming in his work on these important issues.

Judge Rhathelia Stroud, J.D.

Judge Rhathelia Stroud, J.D., is a DeKalb County, Georgia Magistrate 

and as Chief Judge for the City of Decatur, GA, Municipal Court. A 

native of Atlanta, GA, she graduated from the University of Georgia and 

Georgia State University College of Law. As a magistrate, Judge Stroud 

presides over the DeKalb County Misdemeanor Mental Health Court and 

over Temporary Protective Order calendars as a superior court judge by 

designation. She has presided over the mental health court for 7 years. 

Judge Stroud has served as faculty for the Institute of Continuing Judicial Education eLearning 

20-Hour Jail Diversion Online Course and for Emory University’s School of Law Kessler-Eidson 

Trial Techniques Program. Before serving on the bench, Judge Stroud was a practicing attorney 

and partner with Mitchell Graham & Stroud, P.C., in Decatur, GA, and worked as Deputy General 

Counsel and Executive Director for the Department of Community Health and its Division 

of Health Planning, respectively. Her civic and professional affiliations include the State Bar 

of Georgia, DeKalb Lawyers Association’s Community and Education Foundation, Georgia 

Association of Black Women Attorneys, Delta Sigma Theta Sorority, Inc., and the Providence 

Baptist Church Trustee Ministry. 
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Conni Wells

Conni Wells is a mental health consultant and advocate with over 30 years 

of lived experience. The parent and grandparent of children and young adults 

with health and mental health challenges, she served as a consultant and 

then Project Director of a National Technical Assistance Center, expanding 

the capacity of family- and consumer-run organizations serving children and 

youth with mental, emotional, and behavioral disorders. She was as a member 

of the Systems of Care Site Visit Team for three states, for which she also provided consulting 

on developing organizational capacity for family-run organizations. For 12 years, Ms. Wells 

directed the Florida Statewide Family Network, assisting the state in developing its system of 

care approach for vulnerable populations with mental health challenges. She also developed 

Florida’s statewide family provider program for its Title V/CYSHCN Program, and served as a 

Senior Consultant at the Georgetown University National Center on Cultural Competence and as 

a Transformation Facilitator for the Georgetown University National Technical Assistance Center 

for Systems of Care. The former Chair for the National Certification for Parent Family Peers 

Commission, Ms. Wells currently works as a consultant on projects focusing on multiple systems 

of care values and has multiple publications, including Straight Talk: Families Speak to Families 

about Child and Youth Mental Health.
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Appendix B

U.S. Department of Health and Human Services 

Interdepartmental Serious Mental Illness Coordinating Committee

Glossary of Terms Used in Report

The terms within this glossary appear within the report. Many of the definitions have been taken 

verbatim or adapted from federal websites and reports.
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Access to care: Having the timely use of personal health services to achieve the best health 

outcomes. Attaining good access to care requires three discrete steps: gaining entry into the 

health care system, getting access to sites of care where patients can receive needed services, and 

finding providers who meet the needs of individual patients and with whom patients can develop 

a relationship based on mutual communication and trust (AHRQ, 2011).

Acute care: Short-term care provided in intensive care units, brief hospital stays, and emergency 

rooms for those who are severely intoxicated or dangerously ill (CSAT, 2005).

Behavioral health: A state of mental/emotional being and/or choices and actions that affect 

wellness. Substance use and misuse are one set of behavioral health problems. Others include 

(but are not limited to) serious psychological distress, suicide, and mental illness (SAMHSA, 

n.d.).

Bipolar disorder: A mental condition in which a person has wide or extreme swings in mood. 

Periods of feeling sad and depressed may alternate with periods of being very happy and active, or 

being cross or irritable (MedlinePlus, n.d.-a). 

Block grant: A noncompetitive, formula grant mandated by Congress. Eligible entities must 

submit an annual application to demonstrate statutory and regulatory compliance in order to 

receive the formula-based funding. SAMHSA is responsible for two block grant programs: the 

Substance Abuse Prevention and Treatment Block Grant (SABG) and the Community Mental 

Health Services Block Grant (MHBG) (SAMHSA, 2017b). 

Coordinated care: Integrating the efforts of medical, behavioral health, and social service 

providers while addressing a person’s health and wellness (CIHS, n.d.).

Cognitive behavioral therapy: A therapeutic approach that seeks to modify negative or selfdefeating thoughts and behavior. CBT is aimed at both thought and behavior change—that is, 

coping by thinking differently and coping by acting differently (CSAT, 2005). 

Comorbidity: The existence of two or more illnesses in the same person. These illnesses can be 

physical or mental (NIMH, n.d.). 

Continuing care: Care that supports a client’s progress, monitors his or her condition, and 

can respond to a return to substance use or a return of symptoms of mental disorder. It is both 

a process of post-treatment monitoring and a form of treatment itself. Sometimes referred to 

as “aftercare” (CSAT, 2005). 

Co-occurring mental health and substance use disorder (a.k.a., co-occurring disorders): 

Co-existence of a substance use disorder and a mental health disorder at the same time (for 

example, alcohol dependence and depression). The combination of disorders can include any two 

or more of those identified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth 

Edition (DSM-5). This condition is sometimes referred to as comorbidity (SAMHSA, n.d.).
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Coordinated care: Integrating the efforts of medical, behavioral health, and social service 

providers while addressing a person’s health and wellness (CIHS, n.d.). 

Coordinated specialty care: A type of treatment for first-episode psychosis that uses a team 

of specialists who work with the client to create a personal treatment plan. The specialists 

offer psychotherapy, medication management, CSC case management, family education/support, 

and supported employment/education, depending on the person’s needs and preferences. The 

client and the team work together to make treatment decisions, involving family members as 

much as possible (NIMH, n.d.). 

Crisis services (also known as crisis care or crisis continuum): A continuum of services 

that are provided to people experiencing a psychiatric emergency. The primary goal of these 

services is to stabilize and improve psychological symptoms of distress and to engage people in 

an appropriate treatment service to address the problem that led to the crisis. Core crisis services 

include 24-hour crisis stabilization/observation beds, short-term crisis residential services and 

crisis stabilization, mobile crisis services, 24/7 crisis hotlines, warm lines, psychiatric advance 

directive statements, and peer crisis services (SAMHSA, 2014).

Cultural appropriateness: In the context of public health, sensitivity to the differences among 

ethnic, racial, and/or linguistic groups and awareness of how people’s cultural background, 

beliefs, traditions, socioeconomic status, history, and other factors affect their needs and how 

they respond to services. Generally used to describe interventions or practices (SAMHSA, n.d.). 

Culturally competent treatment: Cultural competence is the ability to interact effectively with 

people of different cultures. In practice, both individuals and organizations can be culturally 

competent. Culture is a term that goes beyond just race or ethnicity. It can also refer to such 

characteristics as age, gender, sexual orientation, disability, religion, income level, education, 

geographical location, or profession. Cultural competence means being respectful and responsive 

to the health beliefs and practices—and cultural and linguistic needs—of diverse population 

groups. Developing cultural competence is an evolving, dynamic process that takes time and 

occurs along a continuum (SAMHSA, 2016a).

Engagement: A client’s commitment to and maintenance of treatment in all of its forms. A 

successful engagement program helps clients view the treatment facility as an important resource 

(CSAT, 2005). 

Evidence-based practice: A practice that is based on rigorous research that has demonstrated 

effectiveness in achieving the outcomes that it is designed to achieve (SAMHSA, n.d.). 

Fidelity: Occurs when implementers of a research-based program or intervention (e.g., teachers, 

clinicians, counselors) closely follow or adhere to the protocols and techniques that are defined as 

part of the intervention (SAMHSA, n.d.). 
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First-episode psychosis: The first time a person experiences an episode of psychosis (see 

definition for psychosis) (NIMH, n.d.). 

Homelessness: Not being able to find a stable and safe place to stay. People experiencing 

homelessness may find themselves in one of the following groups:

• Unsheltered: Living on the streets, camping outdoors, or living in cars or abandoned 

buildings

• Sheltered: Staying in emergency shelters or transitional housing

• Doubled up: Staying with friends or family temporarily (SAMHSA, 2017c)

Implementation: A planned, coordinated group of activities, processes, and procedures 

designed to achieve a specific purpose. An intervention should have specified goals, objectives, 

and structured components (e.g., a defined curriculum, an explicit number of treatment or service 

hours, and an optimal length of treatment) to ensure the intervention is implemented with 

fidelity to its model (SAMHSA, n.d.). 

Inpatient care: Health care that a person receives when admitted as an inpatient to a health care 

facility, such as a hospital or skilled nursing facility (CMS, n.d.). 

Integrated treatment: Any mechanism by which treatment interventions for co-occurring 

disorders are combined within the context of a primary treatment relationship or service setting. 

It recognizes the need for a unified treatment approach to meet the substance abuse, mental 

health, and related needs of a client, and is the preferred model of treatment (CSAT, 2005). 

Intervention: A strategy or approach intended to prevent an undesirable outcome (preventive 

intervention), promote a desirable outcome (promotion intervention), or alter the course of an 

existing condition (treatment intervention) (SAMHSA, n.d.). 

Justice diversion program: A program that addresses the behavioral health needs of people 

involved in, or at risk of involvement in, the criminal justice system by providing an array of 

community-based diversion services designed to keep people with behavioral health issues out of 

the criminal justice system while also addressing issues of public safety (SAMHSA, 2015). 

Justice system: Term meant to be inclusive of both the criminal justice and juvenile justice 

systems.

Juvenile justice system: Youth under age 18 who are accused of committing a delinquent or 

criminal act are typically processed through a juvenile justice system. While similar to the adult 

criminal justice system in many ways—processes include arrest, detainment, petitions, hearings, 

adjudications, dispositions, placement, probation, and reentry—the juvenile justice process 

operates according to the premise that youth are fundamentally different from adults, both in 
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terms of level of responsibility and potential for rehabilitation. The primary goals of the juvenile 

justice system, in addition to maintaining public safety, are skill development, habilitation, 

rehabilitation, addressing treatment needs, and successful reintegration of youth into the 

community (youth.gov, n.d.). 

Major depression: A mood disorder. It occurs when feelings of sadness, loss, anger, or frustration 

get in the way of a person’s life over a long period of time. It also changes how a person’s body 

works (MedlinePlus, n.d.-b). 

Outpatient: A structured service setting or program that provides ambulatory (not overnight) 

care delivered in a specialty mental health facility/hospital/center/clinic, specifically for the 

treatment of mental health clients. Care is generally provided for visits of 3 hours or less in 

duration and 1 or 2 days per week (SAMHSA, 2017a).

Outreach strategies (mental health): Approaches that actively seek out people in a community 

who may have substance use disorders and engage them in substance abuse treatment (CSAT, 

2005). 

Peer: In the context of peer support, a peer is a person who has lived experience with a 

psychiatric, traumatic, and/or addiction challenge, and may benefit from peer support (CIHS, 

n.d.). 

Peer support: The process of giving and receiving nonclinical assistance to achieve long-term 

recovery from severe psychiatric, traumatic, or addiction challenges. This support is provided by 

peer supporters—people who have “lived experience” and have been trained to assist others in 

initiating and maintaining long-term recovery and enhancing the quality of life for people and 

their families. Peer support services are inherently designed, developed, delivered, evaluated, and 

supervised by peers in long-term recovery (CIHS, n.d.). 

Person-centered care (also known as patient-centered care): Means consumers have control 

over their services, including the amount, duration, and scope of services, as well as choice of 

providers. Person-centered care also is respectful and responsive to the cultural, linguistic, and 

other social and environmental needs of the individual (SAMHSA, 2016b). 

Poverty: The Census Bureau uses a set of income thresholds that vary by family size and 

composition to determine who is in poverty. If a family’s total income is less than the family’s 

threshold, then that family and every person in it is considered in poverty (United States Census 

Bureau, 2017).

Practice standards: Rules or guidelines used as the basis for informed decision-making 

about acceptable work performance and practices. They are established by an authoritative 

entity through a collaborative process with input from a wide range of people who perform the 

work. Standards are based on values, ethics, principles, and competencies. Having a core set 
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of standards is one important way to legitimize a field of practice. Practice standards generally 

have three basic components: 1) practice guidelines, 2) identification and description of core 

competencies, and 3) ethical guidelines or code of ethics (CIHS, n.d.). 

Prevention strategies: Approaches that seek to prevent the onset of physical and behavioral 

health disorders. The Institute of Medicine has defined three types of preventions strategies:

• Universal prevention strategies address the entire population (such as national, local 

community, school, or neighborhood), with messages and programs to prevent or delay the 

development of behavioral health disorders.

• Indicated prevention strategies focus on preventing the onset or development of 

problems in people who may be showing early signs but are not yet meeting diagnostic 

levels of a particular disorder.

• Selective prevention strategies focus on specific groups viewed as being at higher risk 

for mental health disorders or substance use disorders because of highly correlated risk 

factors (for example, the children of parents with substance use problems) (SAMHSA, 

n.d.).

Primary care: The care provided by physicians specifically trained for and skilled in 

comprehensive first contact and continuing care for people with any undiagnosed sign, symptom, 

or health concern (the “undifferentiated” patient) not limited by problem origin (biological, 

behavioral, or social), organ system, or diagnosis (CIHS, n.d.). 

Psychosis: A mental disorder that is characterized by distinct distortions of a person’s mental 

capacity, ability to recognize reality, and relationships to others to such a degree that it interferes 

with that person’s ability to function in everyday life (CSAT, 2005). 

Recovery: A process of change through which people improve their health and wellness, live a 

self-directed life, and strive to reach their full potential. Through the Recovery Support Strategic 

Initiative, SAMHSA has delineated four major dimensions that support a life in recovery: health, 

home, purpose, and community (SAMHSA, n.d.).

Restrictive housing: Any type of detention that involves (1) removal from the general inmate 

population, whether voluntary or involuntary; (2) placement in a locked room or cell, whether 

alone or with another inmate; and (3) inability to leave the room or cell for the vast majority of 

the day, typically 22 hours or more. Even this definition, however, leaves substantial room for 

variation (DOJ, 2017). 

Schizophrenia: A brain disorder that impacts the way a person thinks (often described as a 

“thought disorder”), and is characterized by a range of cognitive, behavioral, and emotional 

experiences that can include: delusions, hallucinations, disorganized thinking, and grossly 

disorganized or abnormal motor behavior. Although these symptoms are chronic and severe, 
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significantly impairing occupational and social functioning, recovery is possible (SAMHSA, n.d.). 

Service utilization: A measure of whether the program is reaching the appropriate target 

population (SAMHSA, n.d.). 

Serious emotional disturbance (SED): Refers to children and youth who have had a 

diagnosable mental, behavioral, or emotional disorder in the past year, which resulted in 

functional impairment that substantially interferes with or limits the child’s role in family, school, 

or community activities (SAMHSA, 2017d).12

Serious mental illness (SMI): Refers to people age 18 or older, who currently or at any time 

during the past year have had a diagnosable mental, behavioral, or emotional disorder of 

sufficient duration to meet diagnostic criteria specified in the diagnostic manual of the American 

Psychiatric Association that has resulted in functional impairment, which substantially interferes 

with or limits one or more major life activities. Serious mental illnesses include major depression, 

schizophrenia, and bipolar disorder, and other mental disorders that cause serious impairment 

(SAMHSA, 2017d).

Solitary confinement: See “restrictive housing” (DOJ, 2017).

Stigma: A negative association attached to an activity or condition. A cause of shame or 

embarrassment (CSAT, 2005). 

Sustainability: The long-term survival and continued effectiveness of an intervention (SAMHSA, 

n.d.). 

Symptomatology: The combined symptoms or signs of a disorder or disease (SAMHSA, n.d.). 

Transition-age youth: People between ages 16 to 25. People in this age group are at high risk for 

substance use and mental health disorders, but they are also among those least likely to seek help 

(Development Services Group, Inc., 2016).

Treatment guidelines: Descriptions of best practices for assessment or management of a health 

condition (CIHS, n.d.). 

12 This is different from the IDEA definition of emotional disturbance; for detail on the criteria for emotional disturbance under 

IDEA, see http://idea.ed.gov/explore/view/p/,root,regs,300,A,300.8,.html.
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References

Agency for Healthcare Research and Quality (AHRQ). (2011). National healthcare disparities 

report. Rockville, MD: U.S. Department of Health and Human Services.

Center for Integrated Health Solutions (CIHS). (n.d.). Glossary. SAMHSA-HRSA Center for 

Integrated Health Solutions. Retrieved from https://www.integration.samhsa.gov/glossary.

Centers for Medicare & Medicaid Services (CMS). (n.d.). Glossary. HealthCare.gov. Retrieved from 

https://www.healthcare.gov/glossary.

Center for Substance Abuse Treatment (CSAT). (2005). Substance abuse treatment for persons 

with co-occurring disorders. Treatment Improvement Protocol (TIP) Series, No. 42. Rockville, 

MD: Substance Abuse and Mental Health Services Administration.

Development Services Group, Inc. (2016). NREPP Learning Center literature review: Transition-age 

youth. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved 

from http://nrepp.samhsa.gov/Docs/Literatures/NREPP%20Learning%20Center%20

Literature%20%20Review_Transition-age%20Youth.pdf.

MedlinePlus. (n.d.-a). Bipolar disorder. Medical encyclopedia. U.S. National Library of Medicine. 

Retrieved from https://medlineplus.gov/ency/article/000926.htm.

MedlinePlus. (n.d.-b). Major depression. Medical encyclopedia. U.S. National Library of Medicine. 

Retrieved from https://medlineplus.gov/ency/article/000945.htm.

National Institute of Mental Health (NIMH). (n.d.) Glossary. Recovery After an Initial 

Schizophrenia Episode (RAISE): A research project of the NIMH. Retrieved from https://www.

nimh.nih.gov/health/topics/schizophrenia/raise/glossary.shtml.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). Crisis services: 

Effectiveness, cost-effectiveness, and funding strategies. HHS Publication No. (SMA)-14-4848. 

Rockville, MD: Substance Abuse and Mental Health Services Administration.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). Law 

enforcement and behavioral health partnerships for early diversion. Retrieved from https://

www.samhsa.gov/gains-center/grants-grantees/early-diversion.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2016a). Cultural 

competence. Retrieved from https://www.samhsa.gov/capt/applying-strategic-prevention/

cultural-competence.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2016b). Person- and 

family-centered care and peer support. Retrieved from https://www.samhsa.gov/section-223/

care-coordination/person-family-centered.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2017a). Definitions for 

terms used in the N-MHSS questionnaire. National Mental Health Services Survey (N-MHSS). 

Retrieved from https://info.nmhss.org/Definitions/index.asp.
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Substance Abuse and Mental Health Services Administration (SAMHSA). (2017b). Glossary of 

terms and acronyms for SAMHSA grants. Retrieved from https://www.samhsa.gov/grants/

grants-glossary.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2017c). Homelessness 

and housing. Retrieved from https://www.samhsa.gov/homelessness-housing.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2017d). Mental and 

substance use disorders. Retrieved from https://www.samhsa.gov/disorders.

Substance Abuse and Mental Health Services Administration (SAMHSA). (n.d.). Glossary of 

National Registry of Evidence-based Programs and Practices. Rockville, MD: Substance Abuse 

and Mental Health Services Administration. Retrieved from https://nrepp-learning.samhsa.

gov/glossary.

United States Census Bureau. (2017). How the Census Bureau measures poverty. Retrieved from 

https://www.census.gov/topics/income-poverty/poverty/guidance/poverty-measures.html.

United States Department of Justice (DOJ). (2017). Report and recommendations concerning the 

use of restrictive housing. Retrieved from https://www.justice.gov/archives/dag/report-andrecommendations-concerning-use-restrictive-housing#definitions.

Youth.gov. (n.d.). Juvenile justice. Retrieved from https://youth.gov/youth-topics/juvenile-justice.
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