July 22, 2003 

Dear Mr. President: 

On April 29, 2002, you announced the creation of the New Freedom Commission on 

Mental Health, and declared, “Our country must make a commitment. Americans with 

mental illness deserve our understanding and they deserve excellent care.” You charged 

the Commission to study the mental health service delivery system, and to make 

recommendations that would enable adults with serious mental illnesses and children 

with serious emotional disturbance to live, work, learn, and participate fully in their 

communities. We have completed the task. Today, we submit our final report, Achieving 

the Promise: Transforming Mental Health Care in America. 

After a year of study, and after reviewing research and testimony, the Commission finds 

that recovery from mental illness is now a real possibility. The promise of the New 

Freedom Initiative—a life in the community for everyone—can be realized. Yet, 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. Today’s mental health care system is a patchwork relic—the result of 

disjointed reforms and policies. Instead of ready access to quality care, the system 

presents barriers that all too often add to the burden of mental illnesses for individuals, 

their families, and our communities. 

The time has long passed for yet another piecemeal approach to mental health reform. 

Instead, the Commission recommends a fundamental transformation of the Nation’s 

approach to mental health care. This transformation must ensure that mental health 

services and supports actively facilitate recovery, and build resilience to face life’s 

challenges. Too often, today’s system simply manages symptoms and accepts long-term 

disability. Building on the principles of the New Freedom Initiative, the 

recommendations we propose can improve the lives of millions of our fellow citizens 

now living with mental illnesses. The benefits will be felt across America in families, 

communities, schools, and workplaces. 
2 

The members of the Commission are gratified by your invitation to serve, are inspired by 

the innovative programs across America that we learned about, and are impressed by the 

readiness for change that we find in the mental health community. We look forward to 

the work ahead to make recovery from mental illness the expected outcome from a 

transformed system of care. 

Sincerely, 

Michael F. Hogan, Ph.D. 

Chairman, President’s New Freedom Commission on Mental Health 

The Commission members: 

Jane Adams, Ph.D. 

Rodolfo Arrendondo, Jr., Ed.D. 

Patricia Carlile 

Charles G. Curie, M.A., A.C.S.W. 

Daniel B. Fisher, M.D., Ph.D. 

Anil G. Godbole, M.D. 

Henry T. Harbin, M.D. 

Larke N. Huang, Ph.D. 

Thomas R. Insel, M.D. 

Norwood W. Knight-Richardson, M.D., M.B.A. 

The Honorable Ginger Lerner-Wren 

Stephen W. Mayberg, Ph.D. 

Frances M. Murphy, M.D., M.P.H. 

Robert H. Pasternak, Ph.D. 

Robert N. Postlethwait, M.B.A. 

Waltraud E. Prechter, B.A.Ed. 

Dennis G. Smith 

Chris Spear, B.A., M.P.A. 

Nancy C. Speck, Ph.D. 

The Honorable Randolph J. Townsend, M.Ed. 

Deanna F. Yates, Ph.D. 
The President’s New Freedom Commission on Mental

Health

Roster of Commissioners

Michael F. Hogan, Ph.D. 

Chair 

Director, Ohio Department of Mental Health 

30 East Broad Street, 8th Floor 

Columbus, Ohio 43215-3430 

Jane Adams, Ph.D. 

Executive Director 

Keys for Networking, Inc. 

1301 South Topeka Boulevard 

Topeka, Kansas 66612 

 

Rodolfo Arredondo, Jr., Ed.D. 

Professor of Neuropsychiatry 

Department of Neuropsychiatry 

Southwest Institute for Addictive Diseases 

Texas Tech University Health Sciences Center 

3601 Fourth Street 

Lubbock, Texas 79430 

 

Patricia Carlile 

Deputy Assistant Secretary, Special Needs 

Programs 

U.S. Department of Housing and Urban 

Development 

Robert C. Weaver Federal Building 

451 Seventh Street, S.W. 

Washington, DC 20410 

Charles G. Curie, M.A., A.C.S.W. 

Administrator 

Substance Abuse and Mental Health 

Services Administration 

5600 Fishers Lane, Room 12-105 

Rockville, Maryland 20857 

 

Daniel B. Fisher, M.D., Ph.D. 

Co-Director 

National Empowerment Center 

599 Canal Street 

Lawrence, Massachusetts 01840 

Anil G. Godbole, M.D. 

Chairman 

Advocate Illinois Masonic Medical Center 

Advocate Health Care 

836 West Wellington, Suite 7318 

Chicago, Illinois 60657 

 

Henry T. Harbin, M.D. 

Chairman of the Board 

Magellan Health Services 

6950 Columbia Gateway Drive 

Columbia, Maryland 21046 

 

Larke N. Huang, Ph.D. 

Director of Research 

Center for Child Health and Mental Health 

Policy 

Georgetown University 

3307 M Street, N.W., Suite 401 

Washington, DC 20007 

Thomas R. Insel, M.D. 

Director 

National Institutes of Mental Health 

National Institutes of Health 

6001 Executive Boulevard, Room 8235 

Bethesda, Maryland 20892-9669 

 

Norwood W. Knight-Richardson, M.D., M.B.A. 

CEO, Richardson Group 

Associate Professor 

Oregon Health and Sciences University 

11565 N.W. McDaniel Rd. 

Portland Oregon 97229 

The Honorable Ginger Lerner-Wren 

Seventeenth Judicial Circuit 

Broward County, Florida 

Broward County Courthouse 

201 Southeast 6th Street 

Fort Lauderdale, Florida 33301 
Stephen W. Mayberg, Ph.D. 

Director 

California Department of Mental Health 

1600 Ninth Street, Room 151 

Sacramento, California 95814 

 

Frances M. Murphy, M.D., M.P.H. 

Deputy Under Secretary for Health Policy 

Coordination 

Department of Veterans Affairs 

810 Vermont Avenue, N.W., Suite 10H 

Washington, DC 20420 

 

Robert H. Pasternack, Ph.D. 

Assistant Secretary for Special Education 

and Rehabilitative Services 

U.S. Department of Education 

330 C Street, S.W. 

Washington, DC 20202 

Robert N. Postlethwait, M.B.A. 

Consultant 

7274 Hunt Club Lane 

Zionsville, Indiana 46077 

Waltraud E. Prechter, B.A. Ed. 

Chairman 

Heinz C. Prechter Fund for Manic Depression 

One Heritage Place, Suite 400 

Southgate, Michigan 48195 

Dennis G. Smith 

Director 

Center for Medicaid and State Operations 

Center for Medicare and Medicaid Services 

200 Independence Avenue, S.W. 

Room 301H 

Washington, D.C. 20201 

 

Chris Spear, B.A., M.P.A. 

Assistant Secretary of Labor for Policy 

U.S. Department of Labor 

200 Constitution Avenue, N.W. 

Washington, DC 20210 

Nancy C. Speck, Ph.D. 

Telehealth Consultant 

University of Texas Medical Branch, 

Galveston 

3316 Huntington Circle 

Nacogdoches, Texas 75965 

 

The Honorable Randolph J. Townsend, M.Ed. 

Nevada Senate 

695 Sierra Rose Drive 

Reno, Nevada 89511 

Deanna F. Yates, Ph.D. 

Psychologist 

14815 San Pedro Avenue 

San Antonio, Texas 78232 

Executive Staff 

Claire Heffernan, J.D. 

Executive Director 

New Freedom Commission on Mental Health 

5600 Fishers Lane, Room 13C-26 

Rockville, Maryland 20857 

H. Stanley Eichenauer, M.S.W., A.C.S.W. 

Deputy Executive Director 

New Freedom Commission on Mental Health 

5600 Fishers Lane, Room 13C-26 

Rockville, Maryland 20857 
v

Contents

Executive Summary......................................................................... 1 

Summary of Goals and Recommendations ............................................. 17 

Goal 1: Americans Understand that Mental Health Is Essential to Overall 

Health ........................................................................... 19 

Understanding the Goal ............................................................. 19 

Many People with Mental Illnesses Go Untreated....................................................... 19 

Stigma Impedes People from Getting the Care They Need ......................................... 20 

Suicide Presents Serious Challenges............................................................................ 20 

Better Coordination Needed Between Mental Health Care and Primary Health Care. 21 

Mental Health Financing Poses Challenges................................................................. 21 

Services and Funding Are Fragmented Across Several Programs ............................... 22 

Financing Sources Can Be Restrictive......................................................................... 22 

Achieving the Goal ................................................................... 23 

Public Education Activities Can Help Encourage People to Seek Treatment.............. 23 

Swift Action Is Need to Prevent Suicide...................................................................... 24 

Recognize the Connection Between Mental Health and Physical Health .................... 26 

Address Unique Needs of Mental Health Financing.................................................... 26 

Goal 2: Mental Health Care Is Consumer and Family Driven................... 27 

Understanding the Goal ............................................................. 27 

The Complex Mental Health System Overwhelms Many Consumers......................... 27 

Program Efforts Overlap.............................................................................................. 28 

Consumers and Families Do Not Control Their Own Care ......................................... 28 

Consumers Need Employment and Income Supports.................................................. 29 

A Shortage of Affordable Housing Exists.................................................................... 30 

Limited Mental Health Services Are Available in Correctional Facilities................... 32 

Fragmentation Is a Serious Problem at the State Level................................................ 33 

Consumers and Families Need Community-based Care.............................................. 33 

Consumers Face Difficulty in Finding Quality Employment....................................... 34 

The Use of Seclusion and Restraint Creates Risks....................................................... 34 

Achieving the Goal ................................................................... 35 

Develop Individualized Plans of Care for Consumers and Families............................ 35 

Involve Consumers and Families in Planning, Evaluation, and Services .................... 37 

Realign Programs to Meet the Needs of Consumers and Families .............................. 37 

Align Federal Financing for Health Care..................................................................... 38 

 DEMONSTRATION: “Money Follows the Individual” Rebalancing................. 39 

DEMONSTRATION: Community-based Alternatives for Children in Psychiatric 

Residential Treatment Facilities ................................................... 39 

DEMONSTRATION: Respite Care Services for Caregivers .............................. 40 

Make Supported Employment Services Widely Available.......................................... 40 

Make Housing with Supports Widely Available.......................................................... 42 
vi

Address Mental Health Problems in the Criminal Justice and Juvenile Justice Systems 43 

Create Comprehensive State Mental Health Plans to Coordinate Services.................. 44 

Protect and Enhance Consumer and Family Rights ..................................................... 45 

End Unnecessary Institutionalization........................................................................... 45 

Eliminate the Need to Trade Custody for Mental Health Care .................................... 46 

End Employment Discrimination................................................................................. 46 

Reduce the Use of Seclusion and Restraint.................................................................. 46 

Goal 3 Disparities in Mental Health Services Are Eliminated ................. 49 

Understanding the Goal ............................................................. 49 

Minority Populations Are Underserved in the Current Mental Health System............ 49 

Minorities Face Barriers to Receiving Appropriate Mental Health Care..................... 50 

Cultural Issues Also Affect Service Providers............................................................. 50 

Rural America Needs Improved Access to Mental Health Services ............................ 50 

Achieving the Goal ................................................................... 52 

Culturally Competent Services Are Essential to Improve the Mental Health System . 52 

Rural Needs Must Be Met............................................................................................ 54 

Goal 4: Early Mental Health Screening, Assessment, and Referral to Services 

Are Common Practice ........................................................ 57 

Understanding the Goal ............................................................. 57 

Early Assessment and Treatment are Critical Across the Life Span............................ 57 

If Untreated, Childhood Disorders Can Lead to a Downward Spiral........................... 57 

Schools Can Help Address Mental Health Problems................................................... 58 

People With Co-occurring Disorders Are Inadequately Served................................... 58 

Mental Health Problems Are Not Adequately Addressed in Primary Care Settings.... 59 

Achieving the Goal ................................................................... 60 

Early Detection Can Reduce Mental Health Problems ................................................ 60 

Schools Should Have the Ability to Play a Larger Role 

in Mental Health Care for Children ............................................................... 62 

Treatment for Co-occurring Disorders Must Be Integrated ......................................... 64 

Expand Screening and Collaborative Care in Primary Care Settings .......................... 65 

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

Accelerated .................................................................... 67 

Understanding the Goal ............................................................. 67 

The Delay Is Too Long Before Research Reaches Practice......................................... 67 

Too Few Benefit from Available Treatment ................................................................ 68 

Reimbursement Policies Do Not Foster Converting Research to Practice................... 69 

Serious Workforce Problems Exist .............................................................................. 70 

Four Areas Have Not Been Studied Enough................................................................ 70 

Disparities in Mental Health Research .......................................................... 70 

Long-term Use of Medications ...................................................................... 71 

The Impact of Trauma ................................................................................... 71 

Acute Care ..................................................................................................... 71 
vii

Achieving the Goal ................................................................... 71 

Speed Research On Treatment and Recovery .............................................................. 71 

Bridge the Gap Between Science and Service ............................................................. 72 

Change Reimbursement Policies to More Fully Support Evidence-Based Practices... 74 

Address the Workforce Crisis in Mental Health Care.................................................. 75 

Study Disparities for Minorities in Mental Health....................................................... 76 

Study the Effects of Long-term Medication Use.......................................................... 77 

Examine the Effects of Trauma.................................................................................... 77 

Address the Problems of Acute Care ........................................................................... 77 

Goal 6: Technology Is Used to Access Mental Health Care and Information 79 

Understanding the Goal ............................................................. 79 

Mental Health Care Lags in Using Technology........................................................... 79 

Access to Care Is a Concern in Rural and Other Underserved Areas .......................... 80 

Information Technology Can Now Enhance Medical Records Systems...................... 80 

Consumers May Not Have Access to Reliable Health Information............................. 80 

Achieving the Goal ................................................................... 81 

Underserved Populations Can Benefit from Health Technology ................................. 81 

Electronic Medical Records Will Improve Coordination and Quality ......................... 81 

Personal Health Information Systems Can Help Consumers Manage Their Own Care 83 

Conclusion .................................................................................... 86 

References.................................................................................... 87 

Executive Order 13263, President's New Freedom Commission on Mental Health 

Acknowledgments 

Acronyms 

List of Figures 

1.1. Causes of Disability – United States, Canada and Western Europe, 2000 .................. 20 

1.2. Suicide Is the Leading Cause of Violent Deaths Worldwide .................................. 21 

1.3. Distribution of Public and Private Mental Health Expenditures, 1997...................... 22 

1.4. MODEL PROGRAM: Suicide Prevention and Changing Attitudes About Mental Health Care. 25 

2.1. MODEL PROGRAM: Integrated System of Care for Children with Serious 

Emotional Disturbances and Their Families ................................. 36 

2.2. MODEL PROGRAM: Supported Employment for People with Serious Mental Illnesses........ 41 

2.3. MODEL PROGRAM: Integrated Services for Homeless Adults with Serious Mental Illnesses . 45 

3.1. MODEL PROGRAM: A Culturally Competent School-Based Mental Health Program........... 53 
viii

4.1. MODEL PROGRAM: Intervening Early to Prevent Mental Health Problems ..................... 61 

4.2. MODEL PROGRAM: Screening Program for Youth .................................................. 63 

4.3. MODEL PROGRAM: Collaborative Care for Treating Late-life Depression in 

Primary Care Settings........................................................... 66 

5.1. MODEL PROGRAM: Quality Medications Care for Serious Mental Illnesses..................... 69 

5.2. MODEL PROGRAM: Critical Time Intervention with Homeless Families ........................ 73 

6.1. MODEL PROGRAM: Veterans Administration Health Information and Communication 

Technology System .............................................................. 82 

6.2. MODEL PROGRAM: Individualized Mental Health Resource Web Site........................... 84 
Executive Summary

VISION STATEMENT

We envision a future when everyone with a mental 

illness will recover, a future when mental illnesses can 

be prevented or cured, a future when mental illnesses 

are detected early, and a future when everyone with a 

mental illness at any stage of life has access to effective 

treatment and supports — essentials for living, working, 

learning, and participating fully in the community. 

n February 2001, President George W. Bush 

announced his New Freedom Initiative to 

promote increased access to educational and 

employment opportunities for people with 

disabilities. The Initiative also promotes 

increased access to assistive and universally 

designed technologies and full access to 

community life. Not since the Americans with 

Disabilities Act (ADA) — the landmark 

legislation providing protections against 

discrimination — and the Supreme Court’s 

Olmstead v. L.C. decision, which affirmed the 

right to live in community settings, has there been 

cause for such promise and opportunity for full 

community participation for all people with 

disabilities, including those with psychiatric 

disabilities. 

On April 29, 2002, the President identified three 

obstacles preventing Americans with mental 

illnesses from getting the excellent care they 

deserve: 

• Stigma that surrounds mental illnesses, 

• Unfair treatment limitations and financial 

requirements placed on mental health benefits 

in private health insurance, and 

• The fragmented mental health service delivery 

system. 

The President’s New Freedom Commission on 

Mental Health (called the Commission in this 

report) is a key component of the New Freedom 

Initiative. The President launched the Commission 

to address the problems in the current mental 

health service delivery system that allow 

Americans to fall through the system’s cracks. 

In his charge to the Commission, the President 

directed its members to study the problems and 

gaps in the mental health system and make 

concrete recommendations for immediate 

improvements that the Federal government, State 

governments, local agencies, as well as public and 

private health care providers, can implement. 

Executive Order 13263 detailed the instructions to 

the Commission. (See the Appendix.) 

The Commission’s findings confirm that there are 

unmet needs and that many barriers impede care 

for people with mental illnesses. Mental illnesses 

are shockingly common; they affect almost every 

American family. It can happen to a child,a

 a 

 

a In this Final Report, whenever child or children is used, it is 

understood that parents or guardians should be included in 

the process of making choices and decisions for minor 

children. This allows the family to provide support and 

guidance when developing relationships with mental health 

I
2

brother, a grandparent, or a co-worker. It can 

happen to someone from any background — 

African American, Alaska Native, Asian 

American, Hispanic American, Native American, 

Pacific Islander, or White American. It can occur 

at any stage of life, from childhood to old age. No 

community is unaffected by mental illnesses; no 

school or workplace is untouched. 

In any given year, about 5% to 7% of adults have a 

serious mental illness, according to several 

nationally representative studies.1-3 A similar 

percentage of children — about 5% to 9% — have 

a serious emotional disturbance. These figures 

mean that millions of adults and children are 

disabled by mental illnesses every year.1; 4

President Bush said, 

“... Americans must understand and send 

this message: mental disability is not a 

scandal — it is an illness. And like physical 

illness, it is treatable, especially when the 

treatment comes early.” 

Over the years, science has broadened our 

knowledge about mental health and illnesses, 

showing the potential to improve the way in which 

mental health care is provided. The U.S. 

Department of Health and Human Services (HHS) 

released Mental Health: A Report of the Surgeon 

General,

5

 which reviewed scientific advances in 

our understanding of mental health and mental 

illnesses. However, despite substantial investments 

that have enormously increased the scientific 

knowledge base and have led to developing many 

effective treatments, many Americans are not 

benefiting from these investments.6; 7 

Far too often, treatments and services that are 

based on rigorous clinical research languish for 

years rather than being used effectively at the 

earliest opportunity. For instance, according to the 

Institute of Medicine report, Crossing the Quality 

Chasm: A New Health System for the 21st 

Century, the lag between discovering effective 

forms of treatment and incorporating them into 

 

professionals, community resource representatives, teachers, 

and anyone else the individual or family invites. This same 

support and guidance can also include family members for 

individuals older than 18 years of age.

routine patient care is unnecessarily long, lasting 

about 15 to 20 years.8

 

In its report, the Institute of Medicine (IOM) 

described a strategy to improve the quality of 

health care during the coming decade, including 

priority areas for refinement.9

 These documents, 

along with other recent publications and research 

findings, provide insight into the importance of 

mental heath, particularly as it relates to overall 

health. 

In this Final Report ... 

Adults with a serious mental illness are persons 

age 18 and over, 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 within DSM-III-R (Diagnostic and 

Statistical Manual for Mental Disorders)

10, that 

has resulted in functional impairmentb which 

substantially interferes with or limits one or 

more major life activities. 

A serious emotional disturbance is defined as a 

mental, behavioral, or emotional disorder of 

sufficient duration to meet diagnostic criteria 

specified in the DSM-III-R that results in 

functional impairment that substantially 

interferes with or limits one or more major life 

activities in an individual up to 18 years of age. 

Examples of functional impairment that 

adversely affect educational performance 

include an inability to learn that cannot be 

explained by intellectual, sensory, or health 

factors; an inability to build or maintain 

satisfactory interpersonal relationships with 

peers and teachers; inappropriate types of 

behavior or feelings under normal circumstances; 

a general pervasive mood of unhappiness or 

depression; or a tendency to develop physical 

symptoms or fears associated with personal or 

school problems.11

 

b Functional impairment is defined as difficulties that 

substantially interfere with or limit role functioning in one 

or more major life activities, including 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 (Section 1912 (c) of the 

Public Health Services Act, as amended by Public Law 

102-321).
3

Mental Illnesses Presents 

Serious Health Challenges 

Mental illnesses rank first among illnesses that 

cause disability in the United States, Canada, and 

Western Europe.12 This serious public health 

challenge is under-recognized as a public health 

burden. In addition, one of the most distressing 

and preventable consequences of undiagnosed, 

untreated, or under-treated mental illnesses is 

suicide. The World Health Organization (WHO) 

recently reported that suicide worldwide causes 

more deaths every year than homicide or war .13

In addition to the tragedy of lost lives, mental 

illnesses come with a devastatingly high financial 

cost. In the U.S., the annual economic, indirect 

cost of mental illnesses is estimated to be $79 

billion. Most of that amount — approximately $63 

billion — reflects the loss of productivity as a 

result of illnesses. But indirect costs also include 

almost $12 billion in mortality costs (lost 

productivity resulting from premature death) and 

almost $4 billion in productivity losses for 

incarcerated individuals and for the time of those 

who provide family care.14

In 1997, the latest year comparable data are 

available, the United States spent more than $1 

trillion on health care, including almost $71 billion 

on treating mental illnesses. Mental health 

expenditures are predominantly publicly funded at 

57%, compared to 46% of overall health care 

expenditures. Between 1987 and 1997, mental 

health spending did not keep pace with general 

health care because of declines in private health 

spending under managed care and cutbacks in 

hospital expenditures.15

 In 1997, the United States spent more 

than $1 trillion on health care, 

including almost $71 billion on 

treating mental illnesses. 

The Current Mental Health 

System Is Complex 

In its Interim Report to the President, the 

Commission declared, “... the mental health 

delivery system is fragmented and in disarray ...

lead[ing] to unnecessary and costly disability, 

homelessness, school failure and incarceration.” 

The report described the extent of unmet needs 

and barriers to care, including: 

• Fragmentation and gaps in care for children, 

• Fragmentation and gaps in care for adults with 

serious mental illnesses, 

• High unemployment and disability for people 

with serious mental illnesses, 

• Lack of care for older adults with mental 

illnesses, and 

• Lack of national priority for mental health and 

suicide prevention. 

The Interim Report concluded that the system is 

not oriented to the single most important goal of 

the people it serves — the hope of recovery. Stateof-the-art treatments, based on decades of 

research, are not being transferred from research to 

community settings. In many communities, access 

to quality care is poor, resulting in wasted 

resources and lost opportunities for recovery. 

More individuals could recover from even the 

most serious mental illnesses if they had access in 

their communities to treatment and supports that 

are tailored to their needs. 

The Commission recognizes that thousands of 

dedicated, caring, skilled providers staff and 

manage the service delivery system. The 

Commission does not attribute the shortcomings 

and failings of the contemporary system to a lack 

of professionalism or compassion of mental health 

care workers. Rather, problems derive principally 

from the manner in which the Nation’s 

community-based mental health system has 

evolved over the past four to five decades. In 

short, the Nation must replace unnecessary 

institutional care with efficient, effective 
4

community services that people can count on. It 

needs to integrate programs that are fragmented 

across levels of government and among many 

agencies. 

Building on the research literature and comments 

from more than 2,300 consumers,c

 family 

members, providers, administrators, researchers, 

government officials, and others who provided 

valuable insight into the way mental health care is 

delivered, after its yearlong study, the Commission 

concludes that traditional reform measures are not 

enough to meet the expectations of consumers and 

families. 

To improve access to quality care and services, the 

Commission recommends fundamentally 

transforming how mental health care is delivered 

in America. The goals of this fundamental change 

are clear and align with the direction that the 

President established. 

 To improve access to quality care and 

services, the Commission 

recommends fundamentally 

transforming how mental health care 

is delivered in America. 

The Goal of a Transformed 

System: Recovery 

To achieve the promise of community living for 

everyone, new service delivery patterns and 

incentives must ensure that every American has 

easy and continuous access to the most current 

treatments and best support services. Advances in 

research, technology, and our understanding of 

how to treat mental illnesses provide powerful 

means to transform the system. In a transformed 

system, consumers and family members will have 

access to timely and accurate information that 

promotes learning, self-monitoring, and 

accountability. Health care providers will rely on 

 

c In this Final Report, consumer identifies people who use or 

have used mental health services (also known as mental 

health consumers, survivors, patients, or clients).

up-to-date knowledge to provide optimum care for 

the best outcomes. 

When a serious mental illness or a serious 

emotional disturbance is first diagnosed, the health 

care provider — in full partnership with 

consumers and families — will develop an 

individualized plan of care for managing the 

illness. This partnership of personalized care 

means basically choosing who, what, and how

appropriate health care will be provided: 

• Choosing which mental health care 

professionals are on the team, 

• Sharing in decision making, and 

• Having the option to agree or disagree with 

the treatment plan. 

The highest quality of care and information will be 

available to consumers and families, regardless of 

their race, gender, ethnicity, language, age, or 

place of residence. Because recovery will be the 

common, recognized outcome of mental health 

services, the stigma surrounding mental illnesses 

will be reduced, reinforcing the hope of recovery 

for every individual with a mental illness. 

In this Final Report ... 

Stigma refers to a cluster of negative attitudes 

and beliefs that motivate the general public to 

fear, reject, avoid, and discriminate against 

people with mental illnesses. Stigma is 

widespread in the United States and other 

Western nations.16 Stigma leads others to avoid 

living, socializing, or working with, renting to, or 

employing people with mental disorders — 

especially severe disorders, such as 

schizophrenia. It leads to low self-esteem, 

isolation, and hopelessness. It deters the public 

from seeking and wanting to pay for care.5

Responding to stigma, people with mental health 

problems internalize public attitudes and become 

so embarrassed or ashamed that they often 

conceal symptoms and fail to seek treatment. 

As more individuals seek help and share their 

stories with friends and relatives, compassion will 

be the response, not ridicule. 
5

Successfully transforming the mental health 

service delivery system rests on two principles: 

• First, services and treatments must be consumer 

and family centered, geared to give consumers 

real and meaningful choices about treatment 

options and providers — not oriented to the 

requirements of bureaucracies. 

• Second, care must focus on increasing consumers’ 

ability to successfully cope with life’s challenges, 

on facilitating recovery, and on building 

resilience, not just on managing symptoms. 

Built around consumers’ needs, the system must 

be seamless and convenient. 

In this Final Report ... 

Recovery refers to the process in which people are 

able to live, work, learn, and participate fully in 

their communities. For some individuals, recovery is 

the ability to live a fulfilling and productive life 

despite a disability. For others, recovery implies the 

reduction or complete remission of symptoms. 

Science has shown that having hope plays an integral 

role in an individual’s recovery. 

Resilience means the personal and community 

qualities that enable us to rebound from adversity, 

trauma, tragedy, threats, or other stresses — and to 

go on with life with a sense of mastery, competence, 

and hope. We now understand from research that 

resilience is fostered by a positive childhood and 

includes positive individual traits, such as optimism, 

good problem-solving skills, and treatments. Closelyknit communities and neighborhoods are also 

resilient, providing supports for their members. 

Transforming the system so that it will be both 

consumer and family centered and recoveryoriented in its care and services presents 

invigorating challenges. Incentives must change to 

encourage continuous improvement in agencies 

that provide care. New, relevant research findings 

must be systematically conveyed to front-line 

providers so that they can be applied to practice 

quickly. Innovative strategies must inform 

researchers of the unanswered questions of 

consumers, families, and providers. Research and 

treatment must recognize both the commonalities 

and the differences among Americans and must 

offer approaches that are sensitive to our diversity. 

Treatment and services that are based on proven 

effectiveness and consumer preference — not just 

on tradition or outmoded regulations — must be 

the basis for reimbursements. 

The Nation must invest in the infrastructure to 

support emerging technologies and integrate them 

into the system of care. This new technology will 

enable consumers to collaborate with service 

providers, assume an active role in managing their 

illnesses, and move more quickly toward recovery. 

The Commission identified the following six goals 

as the foundation for transforming mental health 

care in America. The goals are intertwined. No 

single step can achieve the fundamental 

restructuring that is needed to transform the 

mental health care delivery system. 

GOALS

In a Transformed Mental Health System ...

GOAL 1 Americans Understand that Mental Health Is Essential to 

Overall Health.

GOAL 2 Mental Health Care Is Consumer and Family Driven. 

GOAL 3 Disparities in Mental Health Services Are Eliminated. 

GOAL 4 Early Mental Health Screening, Assessment, and Referral to 

Services Are Common Practice. 

GOAL 5 Excellent Mental Health Care Is Delivered and Research Is 

Accelerated. 

GOAL 6 Technology Is Used to Access Mental Health Care and 

Information. 
6

Achieving these goals will transform mental health 

care in America. 

The following section of this report gives an 

overview of each goal of the transformed system, 

as well as the Commission’s recommendations for 

moving the Nation toward achieving it. In the 

remainder of this report, the Commission 

discusses each goal in depth, showcasing model 

programs to illustrate the goal in practice and 

providing specific recommendations needed to 

transform the mental health system in America. 
7

GOAL 1 Americans Understand that Mental Health Is Essential to

Overall Health.

n a transformed mental health system, 

Americans will seek mental health care when 

they need it — with the same confidence that 

they seek treatment for other health problems. 

As a Nation, we will take action to ensure our 

health and well being through learning, selfmonitoring, and accountability. We will continue 

to learn how to achieve and sustain our mental 

health. 

The stigma that surrounds mental illnesses and 

seeking care for mental illnesses will be reduced 

or eliminated as a barrier. National education 

initiatives will shatter the misconceptions about 

mental illnesses, thus helping more Americans 

understand the facts and making them more 

willing to seek help for mental health problems. 

Education campaigns will also target specific 

audiences, including: 

• Rural Americans who may have had little 

exposure to the mental health service system, 

• Racial and ethnic minority groups who may 

hesitate to seek treatment in the current 

system, and 

• People whose primary language is not 

English. 

When people have a personal understanding of the 

facts, they will be less likely to stigmatize mental 

illnesses and more likely to seek help for mental 

health problems. The actions of reducing stigma, 

increasing awareness, and encouraging treatment 

will create a positive cycle that leads to a healthier 

population. As a Nation, we will also understand 

that good mental health can have a positive impact 

on the course of other illnesses, such as cancer, 

heart disease, and diabetes. 

Improving services for individuals with mental 

illnesses will require paying close attention to how 

mental health care and general medical care 

systems work together. While mental health and 

physical health are clearly connected, the 

transformed system will provide collaborative care 

to bridge the gap that now exists. 

Effective mental health treatments will be more 

readily available for most common mental 

disorders and will be better used in primary care 

settings. Primary care providers will have the 

necessary time, training, and resources to 

appropriately treat mental health problems. 

Informed consumers of mental health service will 

learn to recognize and identify their symptoms and 

will seek care without the fear of being 

disrespected or stigmatized. Older adults, children 

and adolescents, individuals from ethnic minority 

groups, and uninsured or low-income patients who 

are treated in public health care settings will 

receive care for mental disorders. 

 Understanding that mental health is 

essential to overall health is 

fundamental for establishing a health 

system that treats mental illnesses 

with the same urgency as it treats 

physical illnesses. 

The transformed mental health system will rely on 

multiple sources of financing with the flexibility to 

pay for effective mental health treatments and 

services. This is a basic principle for a recoveryoriented system of care. 

To aid in transforming the mental health system, 

the Commission makes two recommendations: 

1.1 Advance and implement a national campaign 

to reduce the stigma of seeking care and a 

national strategy for suicide prevention. 

1.2 Address mental health with the same urgency 

as physical health. 

I
8

GOAL 2 Mental Health Care Is Consumer and Family Driven.

n a transformed mental health system, a 

diagnosis of a serious mental illness or a 

serious emotional disturbance will set in 

motion a well-planned, coordinated array of 

services and treatments defined in a single 

plan of care. This detailed roadmap — a 

personalized, highly individualized health 

management program — will help lead the way to 

appropriate treatment and supports that are 

oriented toward recovery and resilience. 

Consumers, along with service providers, will 

actively participate in designing and developing 

the systems of care in which they are involved. 

An individualized plan of care will give 

consumers, families of children with serious 

emotional disturbances, clinicians, and other 

providers a valid opportunity to construct and 

maintain meaningful, productive, and healing 

relationships. Opportunities for updates — based 

on changing needs across the stages of life and the 

requirement to review treatment plans regularly — 

will be an integral part of the approach. The plan 

of care will be at the core of the consumercentered, recovery-oriented mental health system. 

The plan will include treatment, supports, and 

other assistance to enable consumers to better 

integrate into their communities; it will allow 

consumers to realize improved mental health and 

quality of life. 

In partnership with their health care providers, 

consumers and families will play a larger role in 

managing the funding for their services, 

treatments, and supports. Placing financial support 

increasingly under the management of consumers 

and families will enhance their choices. By 

allowing funding to follow consumers, incentives 

will shift toward a system of learning, selfmonitoring, and accountability. This program 

design will give people a vested economic interest 

in using resources wisely to obtain and sustain 

recovery. 

The transformed system will ensure that needed 

resources are available to consumers and families. 

The burden of coordinating care will rest on the 

system, not on the families or consumers who are 

already struggling because of a serious illness. 

Consumers’ needs and preferences will drive the 

types and mix of services provided, considering 

the gender, age, language, development, and 

culture of consumers. 

 The plan of care will be at the core of 

the consumer-centered, recoveryoriented mental health system. 

To ensure that needed resources are available to 

consumers and families in the transformed system, 

States will develop a comprehensive mental health 

plan to outline responsibility for coordinating and 

integrating programs. The State plan will include 

consumers and families and will create a new 

partnership among the Federal, State, and local 

governments. The plan will address the full range 

of treatment and support service programs that 

mental health consumers and families need. 

In exchange for this accountability, States will 

have the flexibility to combine Federal, State, and 

local resources in creative, innovative, and more 

efficient ways, overcoming the bureaucratic 

boundaries between health care, employment 

supports, housing, and the criminal justice 

systems. 

Increased flexibility and stronger accountability 

will expand the choices and the array of services 

and supports available to attain the desired 

outcomes. Creative programs will be developed to 

respond to the needs and preferences of consumers 

and families, as reflected in their individualized 

plans of care. 

I
9

Giving consumers the ability to participate fully in 

their communities will require a few essentials: 

• Access to health care, 

• Gainful employment opportunities, 

• Adequate and affordable housing, and 

• The assurance of not being unjustly 

incarcerated. 

Strong leadership will need to: 

• Align existing programs to deliver services 

effectively, 

• Remove disincentives to employment (such as 

loss of financial benefits or having to choose 

between employment and health care), and 

• Provide for a safe place to live. 

In this transformed system, consumers’ rights will 

be protected and enhanced. Implementing the 

1999 Olmstead v. L.C decision in all States will 

allow services to be delivered in the most 

integrated setting possible — services in 

communities rather than in institutions. And 

services will be readily available so that 

consumers no longer face unemployment, 

homelessness, or incarceration because of 

untreated mental illnesses. 

No longer will parents forgo the mental health 

services that their children desperately need. No 

longer will loving, responsible American parents 

face the dilemma of trading custody for care. 

Families will remain intact. Issues of custody will 

be separated from issues of care. 

In this transformed system, stigma and 

discrimination against people with mental illnesses 

will not have an impact on securing health care, 

productive employment, or safe housing. Our 

society will not tolerate employment 

discrimination against people with serious mental 

illnesses — in either the public or private sector. 

Consumers’ rights will be protected concerning 

the use of seclusion and restraint. Seclusion and 

restraint will be used only as safety interventions 

of last resort, not as treatment interventions. Only 

licensed practitioners who are specially trained 

and qualified to assess and monitor consumers’ 

safety and the significant medical and behavioral 

risks inherent in using seclusion and restraint will 

be able to order these interventions. 

The hope and the opportunity to regain control of 

their lives —often vital to recovery — will 

become real for consumers and families. 

Consumers will play a significant role in shifting 

the current system to a recovery-oriented one by 

participating in planning, evaluation, research, 

training, and service delivery. 

To aid in transforming the mental health system, 

the Commission makes five recommendations: 

2.1 Develop an individualized plan of care for 

every adult with a serious mental illness and 

child with a serious emotional disturbance. 

2.2 Involve consumers and families fully in 

orienting the mental health system toward 

recovery. 

2.3 Align relevant Federal programs to improve 

access and accountability for mental health 

services. 

2.4 Create a Comprehensive State Mental Health 

Plan. 

2.5 Protect and enhance the rights of people with 

mental illnesses. 
10

GOAL 3 Disparities in Mental Health Services Are Eliminated.

n a transformed mental health system, all 

Americans will share equally in the best 

available services and outcomes, regardless of 

race, gender, ethnicity, or geographic 

location. Mental health care will be highly 

personal, respecting and responding to individual 

differences and backgrounds. The workforce will 

include members of ethnic, cultural, and linguistic 

minorities who are trained and employed as 

mental health service providers. People who live 

in rural and remote geographic areas will have 

access to mental health professionals and other 

needed resources. Advances in treatments will be 

available in rural and less populated areas. 

Research and training will continuously aid 

clinicians in understanding how to appropriately 

tailor interventions to the needs of consumers, 

recognizing factors such as age, gender, race, 

culture, ethnicity, and locale. 

Services will be tailored for culturally diverse 

populations and will provide access, enhanced 

quality, and positive outcomes of care. American 

Indians, Alaska Natives, African Americans, 

Asian Americans, Pacific Islanders, and Hispanic 

Americans will not continue to bear a 

disproportionately high burden of disability from 

mental health disorders.1

 These populations will 

have accessible, available mental health services. 

They will receive the same high quality of care 

that all Americans receive. To develop culturally 

competent treatments, services, care, and support, 

mental health research will include these 

underserved populations. In addition, providers 

will include individuals who share and respect the 

beliefs, norms, values, and patterns of 

communication of culturally diverse populations. 

In rural and remote geographic areas, service 

providers will be more readily available to help 

create a consumer-centered system. Using such 

tools as videoconferencing and telehealth, 

advances in treatments will be brought to rural and 

less populated areas of the country. These 

technologies will be used to provide care at the 

same time they break down the sense of isolation 

often experienced by consumers. 

Mental health education and training will be 

provided to general health care providers, 

emergency room staff, and first responders, such 

as law enforcement personnel and emergency 

medical technicians, to overcome the uneven 

geographic distribution of psychiatrists, 

psychologists, and psychiatric social workers. 

 In a transformed mental health 

system, all Americans will share 

equally in the best available services 

and outcomes, regardless of race, 

gender, ethnicity, or geographic 

location. 

To aid in transforming the mental health system, 

the Commission makes two recommendations: 

3.1 Improve access to quality care that is 

culturally competent. 

3.2 Improve access to quality care in rural and 

geographically remote areas. 

I
11

GOAL 4 Early Mental Health Screening, Assessment, and Referral

to Services Are Common Practice.

n a transformed mental health system, the 

early detection of mental health problems in 

children and adults — through routine and 

comprehensive testing and screening — will 

be an expected and typical occurrence. At the 

first sign of difficulties, preventive interventions 

will be started to keep problems from escalating. 

For example, a child whose serious emotional 

disturbance is identified early will receive care, 

preventing the potential onset of a co-occurring 

substance use disorder and breaking a cycle that 

otherwise can lead to school failure and other 

problems. 

Quality screening and early intervention will occur 

in both readily accessible, low-stigma settings, such 

as primary health care facilities and schools, and in 

settings in which a high level of risk exists for 

mental health problems, such as criminal justice, 

juvenile justice, and child welfare systems. Both 

children and adults will be screened for mental 

illnesses during their routine physical exams. 

For consumers of all ages, early detection, 

assessment, and links with treatment and supports 

will help prevent mental health problems from 

worsening. Service providers across settings will 

also routinely screen for co-occurring mental 

illnesses and substance use disorders. Early 

intervention and appropriate treatment will also 

improve outcomes and reduce pain and suffering 

for children and adults who have or who are at risk 

for co-occurring mental and addictive disorders. 

Early detection of mental disorders will result in 

substantially shorter and less disabling courses of 

impairment. 

 For consumers of all ages, early 

detection, assessment, and links with 

treatment and supports will help 

prevent mental health problems from 

worsening. 

To aid in transforming the mental health system, 

the Commission makes four recommendations: 

4.1 Promote the mental health of young 

children. 

4.2 Improve and expand school mental health 

programs. 

4.3 Screen for co-occurring mental and 

substance use disorders and link with 

integrated treatment strategies. 

4.4 Screen for mental disorders in primary 

health care, across the lifespan, and 

connect to treatment and supports. 

I
12

GOAL 5 Excellent Mental Health Care Is Delivered and Research Is

Accelerated.

n a transformed mental health system, 

consistent use of evidence-based, state-of-the 

art medications and psychotherapies will be 

standard practice throughout the mental health 

system. Science will inform the provision of 

services, and the experience of service 

providers will guide future research. Every time any 

American — whether a child or an adult, a member 

of a majority or a minority, from an urban or rural 

area — comes into contact with the mental health 

system, he or she will receive excellent care that is 

consistent with our scientific understanding of what 

works. That care will be delivered according to the 

consumer’s individualized plan. 

Research has yielded important advances in our 

knowledge of the brain and behavior, and helped 

develop effective treatments and service delivery 

strategies for many mental disorders. In a 

transformed system, research will be used to 

develop new evidence-based practices to prevent 

and treat mental illnesses. These discoveries will 

be immediately put into practice. Americans with 

mental illnesses will fully benefit from the 

enormous increases in the scientific knowledge 

base and the development of many effective 

treatments. 

Also benefiting from these developments, the 

workforce will be trained to use the most advanced 

tools for diagnosis and treatments. Translating 

research into practice will include adequate 

training for front-line providers and professionals, 

resulting in a workforce that is equipped to use the 

latest breakthroughs in modern medicine. 

Research discoveries will become routinely 

available at the community level. To realize the 

possibilities of advances in treatment, and 

ultimately in prevention or a cure, the Nation will 

continue to invest in research at all levels. 

Knowledge about evidence-based practices (the 

range of treatments and services of welldocumented effectiveness), as well as emerging best 

practices (treatments and services with a promising 

but less thoroughly documented evidentiary base), 

will be widely circulated and used in a variety of 

mental health specialties and in general health, 

school-based, and other settings. Countless people 

with mental illnesses will benefit from improved 

consumer outcomes including reduced symptoms, 

fewer and less severe side effects, and improved 

functioning. The field of mental health will be 

encouraged to expand its efforts to develop and test 

new treatments and practices, to promote awareness 

of and improve training in evidence-based practices, 

and to better finance those practices. 

 Research discoveries will become 

routinely available at the community 

level. 

The Nation will have a more effective system to 

identify, disseminate, and apply proven treatments 

to mental health care delivery. Research and 

education will play critical roles in the 

transformed mental health system. Advanced 

treatments will be available and adapted to 

individual preferences and needs, including 

language and other ethnic and cultural 

considerations. Investments in technology will 

also enable both consumers and providers to find 

the most up-to-date resources and knowledge to 

provide optimum care for the best outcomes. 

Studies will incorporate the unique needs of 

cultural, ethnic, and linguistic minorities and will 

help ensure full access to effective treatment for 

all Americans. 

I
13

To aid in transforming the mental health system, 

the Commission makes four recommendations: 

5.1 Accelerate research to promote recovery and 

resilience, and ultimately to cure and prevent 

mental illnesses. 

5.2 Advance evidence-based practices using 

dissemination and demonstration projects and 

create a public-private partnership to guide 

their implementation. 

5.3 Improve and expand the workforce providing 

evidence-based mental health services and 

supports. 

5.4 Develop the knowledge base in four 

understudied areas: mental health disparities, 

long-term effects of medications, trauma, and 

acute care. 
14

GOAL 6 Technology Is Used to Access Mental Health Care and

Information.

n a transformed mental health system, 

advanced communication and information 

technology will empower consumers and 

families and will be a tool for providers to 

deliver the best care. Consumers and families 

will be able to regularly communicate with the 

agencies and personnel that deliver treatment and 

support services and that are accountable for 

achieving the goals outlined in the individual plan 

of care. Information about illnesses, effective 

treatments, and the services in their community 

will be readily available to consumers and 

families. 

Access to information will foster continuous, 

caring relationships between consumers and 

providers by providing a medical history, allowing 

for self-management of care, and electronically 

linking multiple service systems. Providers will 

access expert systems that bring to bear the most 

recent breakthroughs and studies of optimal 

outcomes to facilitate the best care options. 

Having agreed to use the same health messaging 

standards, pharmaceutical codes, imaging 

standards, and laboratory test names, the Nation’s 

health system will be much closer to speaking a 

common language and providing superior patient 

care. Informed consumers and providers will result 

in better outcomes and will more efficiently use 

resources. 

Electronic health records can improve quality by 

promoting adoption and adherence to evidencebased practices through inclusion of clinical 

reminders, clinical practice guidelines, tools for 

clinical decision support, computer order entry, 

and patient safety alert systems. For example, 

prescription medications being taken or specific 

drug allergies would be known, which could 

prevent serious injury or death resulting from drug 

interactions, excessive dosages or allergic 

reactions. 

Access to care will be improved in many 

underserved rural and urban communities by using 

health technology, telemedicine care, and 

consultations. Health technology and telehealth 

will offer a powerful means to improve access to 

mental health care in underserved, rural, and 

remote areas. The privacy of personal health 

information — especially in the case of mental 

illnesses — will be strongly protected and 

controlled by consumers and families. With 

appropriate privacy protection, electronic records 

will enable essential medical and mental health 

information to be shared across the public and 

private sectors. 

Reimbursements will become flexible enough to 

allow implementing evidence-based practices and 

coordinating both traditional clinical care and ehealth visits. In both the public and private sectors, 

policies will change to support these innovative 

approaches. 

 The privacy of personal health 

information — especially in the case of 

mental illnesses — will be strongly 

protected and controlled by 

consumers and families. 

I
15

An integrated information technology and 

communications infrastructure will be critical to 

achieving the five preceding goals and 

transforming mental health care in America. To 

address this technological need in the mental 

health care system, this goal envisions two critical 

technological components: 

• A robust telehealth system to improve access 

to care, and 

• An integrated health records system and a 

personal health information system for 

providers and patients. 

To aid in transforming the mental health system, 

the Commission makes two recommendations: 

6.1 Use health technology and telehealth to 

improve access and coordination of mental 

health care, especially for Americans in 

remote areas or in underserved populations. 

6.2 Develop and implement integrated electronic 

health record and personal health information 

systems. 
16

reventing mental illnesses remains a 

promise of the future. Granted, the best 

option is to avoid or delay the onset of 

any illness, but the Executive Order 

directed the Commission to conduct a 

comprehensive study of the delivery of mental 

health services. The Commission recognizes that it 

is better to prevent an illness than to treat it, but 

unmet needs and barriers to services must first be 

identified to reach the millions of Americans with 

existing mental illnesses who are deterred from 

seeking help. The barriers may exist for a variety 

of reasons: 

• Stigma, 

• Fragmented services, 

• Cost, 

• Workforce shortages, 

• Unavailable services, and 

• Not knowing where or how to get care. 

These barriers are all discussed in this report. 

The Commission — aware of all the limitations on 

resources — examined realigning Federal 

financing with a keen awareness of the constraints. 

As such, the policies and improvements 

recommended in this Final Report reflect policy 

and program changes that make the most of 

existing resources by increasing cost effectiveness 

and reducing unnecessary and burdensome 

regulatory barriers, coupled with a strong measure 

of accountability. A transformed mental health 

system will more wisely invest resources to 

provide optimal care while making the best use of 

limited resources. 

The process of transforming mental health care in 

America drives the system toward a delivery 

structure that will give consumers broader 

discretion in how care decisions are made. This 

shift will give consumers more confidence to 

require that care be sensitive to their needs, that 

the best available treatments and supports be 

available, and that demonstrably effective 

technologies be widely replicated in different 

settings. This confidence will then enhance 

cooperative relationships with mental health care 

professionals who share the hope of recovery. 

P
17

GOALS AND RECOMMENDATIONS

In a Transformed Mental Health System ...

GOAL 1 Americans Understand that Mental Health Is Essential to Overall Health. 

RECOMMENDATIONS 1.1 Advance and implement a national campaign to reduce the stigma of seeking 

care and a national strategy for suicide prevention. 

1.2 Address mental health with the same urgency as physical health.

GOAL 2 Mental Health Care Is Consumer and Family Driven.

RECOMMENDATIONS 2.1 Develop an individualized plan of care for every adult with a serious mental 

illness and child with a serious emotional disturbance. 

2.2 Involve consumers and families fully in orienting the mental health system 

toward recovery. 

2.3 Align relevant Federal programs to improve access and accountability for 

mental health services. 

2.4 Create a Comprehensive State Mental Health Plan. 

2.5 Protect and enhance the rights of people with mental illnesses.

GOAL 3 Disparities in Mental Health Services Are Eliminated.

RECOMMENDATIONS 3.1 Improve access to quality care that is culturally competent. 

3.2 Improve access to quality care in rural and geographically remote areas.

GOAL 4 Early Mental Health Screening, Assessment, and Referral to Services Are Common Practice.

RECOMMENDATIONS 4.1 Promote the mental health of young children. 

4.2 Improve and expand school mental health programs. 

4.3 Screen for co-occurring mental and substance use disorders and link with 

integrated treatment strategies. 

4.4 Screen for mental disorders in primary health care, across the life span, and 

connect to treatment and supports.
18

GOAL 5 Excellent Mental Health Care Is Delivered and Research Is Accelerated.

RECOMMENDATIONS 5.1 Accelerate research to promote recovery and resilience, and ultimately to 

cure and prevent mental illnesses. 

5.2 Advance evidence-based practices using dissemination and demonstration 

projects and create a public-private partnership to guide their 

implementation.

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

services and supports. 

5.4 Develop the knowledge base in four understudied areas: mental health 

disparities, long-term effects of medications, trauma, and acute care. 

GOAL 6 Technology Is Used to Access Mental Health Care and Information.

RECOMMENDATIONS 6.1 Use health technology and telehealth to improve access and coordination of 

mental health care, especially for Americans in remote areas or in 

underserved populations. 

6.2 Develop and implement integrated electronic health record and personal 

health information systems.
19

GOAL 1 Americans Understand that Mental

Health Is Essential to Overall Health.

RECOMMENDATIONS

1.1 Advance and implement a national campaign to 

reduce the stigma of seeking care and a national 

strategy for suicide prevention. 

1.2 Address mental health with the same urgency as 

physical health. 

Understanding the Goal 

Many People with Mental 

Illnesses Go Untreated 

Too many Americans are unaware that mental 

illnesses can be treated and recovery is possible. In 

fact, a wide array of effective mental health 

services and treatments is available to allow 

children and adults to be vital contributors to their 

communities. Yet, too many people remain 

unserved, and the consequences can be shattering. 

Some people end up addicted to drugs or alcohol, 

on the streets and homeless, or in jail, prison, or 

juvenile detention facilities. 

The World Health Organization (WHO) identified 

mental illnesses as the leading causes of disability 

worldwide. (See Figure 1.1.) This groundbreaking 

study found that mental illnesses (including 

depression, bipolar disorder, and schizophrenia) 

account for nearly 25% of all disability across 

major industrialized countries.12

As the President indicated in his speech 

announcing the Commission (Albuquerque, New 

Mexico, April 29, 2002), 

“Our country must make a 

commitment: Americans with mental 

illness deserve our understanding, 

and they deserve excellent care. 

They deserve a health system that 

treats their illness with the same 

urgency as a physical illness.” 

Unfortunately, several obstacles to achieving this 

goal remain. For example, stigma frequently 

surrounds mental illnesses, prompting many 

people to hide their symptoms and avoid 

treatment. Sadly, only 1 out of 2 people with a 

serious form of mental illness seeks treatment for 

the disorder.2-4 
20

FIGURE 1.1. Causes of Disability* 

United States, Canada and Western Europe, 2000 

0% 4% 8% 12% 16% 20% 24%

All Other Causes of Disability

Migraine

Diabetes

Cancer (Malignant neoplasms)

Communicable Diseases

Digestive Diseases

Injuries (Disabling)

Sense Organ Diseases

Cardiovascular Diseases

Respiratory Diseases

Musculoskeletal Diseases

Alzheimer’s Disease and Dementias

Alcohol and Drug Use Disorders

Mental Illnesses

* Causes of disability for all ages combined. Measures of disability are based 

on the number of years of “healthy” life lost with less than full health (i.e., 

YLD: years lost due to disability) for each incidence of disease, illness, or 

condition. All data shown add up to 100%. 

Stigma Impedes People from 

Getting the Care They Need 

Stigma is a pervasive barrier to understanding the 

gravity of mental illnesses and the importance of 

mental health. For instance, 61% of Americans 

think that people with schizophrenia are likely to 

be dangerous to others.17 However, in reality, 

these individuals are rarely violent. If they are 

violent, the violence is usually tied to substance 

abuse.18

 Stigma is a pervasive barrier to 

understanding the gravity of mental 

illnesses and the importance of 

mental health. 

Some people may not recognize or correctly 

identify their symptoms of mental illness; when 

they do recognize them, they may be reluctant to 

seek care because of stigma.19; 20 Stigma is 

particularly pronounced among older adults, ethnic 

and racial minorities, and residents of rural areas.1 

Suicide Presents Serious 

Challenges 

Suicide is a serious public health challenge that has 

not received the attention and degree of national 

priority it deserves. Many Americans are unaware of 

suicide’s toll and its global impact. It is the leading 

cause of violent deaths worldwide, outnumbering 

homicide or war-related deaths.13 (See Figure 1.2.) 
21

FIGURE 1.2. 

Suicide Is the Leading Cause of 

Violent Deaths Worldwide 

In the U.S., suicide claims approximately 30,000 

lives each year. Overall, suicide was the 11th

leading cause of death among Americans in 

2000.21 In 1999, more than 152,000 hospital 

admissions and more than 700,000 visits to 

hospital emergency rooms were for self-harming 

behaviors.22 The vast majority of all people who 

die by suicide have a mental illness — often 

undiagnosed or untreated.21

Suicide was also the fourth leading cause of death 

among youth aged 10-14, third among those 

between 15 and 24, second among 25- to 34-year 

olds, and fourth among those 35-44 years in 

1999.23 The rate of suicide is highest among older 

men, compared with all other age groups. But 

alarmingly, the rate of teen suicide (for those from 

ages 15 to 19) has tripled since the 1950s.21 

Better Coordination Is Needed 

Between Mental Health Care 

and Primary Health Care 

Research demonstrates that mental health is key to 

overall physical health.24-26 Therefore, improving 

services for individuals with mental illnesses 

requires paying close attention to how mental 

health care and general medical care interact. 

While mental health and physical health are 

clearly connected, a chasm exists between the 

mental health care and general health care systems 

in financing and practice. Primary care providers 

may lack the necessary time, training, or resources 

to provide appropriate treatment for mental health 

problems. 

Mental health is key to overall 

physical health. 

Mental disorders frequently co-exist with other 

medical disorders. For example, a number of studies 

have shown that adults with common medical 

disorders have high rates of depression and 

anxiety.27-29 Depression is also common in people 

with coronary heart disease and other cardiac 

illnesses. This situation is especially dangerous 

because depression increases the risk of dying from 

heart disease by as much as three-fold.30; 31

Depression impairs self-care and adherence to 

treatments for chronic medical illnesses.32 Similarly, 

people with both diabetes and depression have a 

greater likelihood of experiencing a greater number 

of diabetes complications compared to those without 

depression.33 

Mental Health Financing Poses 

Challenges 

Insurance plans that place greater restrictions on 

treating mental illnesses than on other illnesses 

prevent some individuals from getting the care that 

would dramatically improve their lives. Mental 

health benefits have traditionally been more 

limited than other medical benefits. 

The Commission strongly supports the President’s 

call for Federal legislation to provide full parity 

between insurance coverage for mental health care 

and for physical health care. 

States have relied on the Medicaid program to 

support their mental health systems. As a result, 

Medicaid is now the largest payer of mental health 

services in the country. 
22

Studies show that 20% to 25% of services for nonelderly adult users of mental health are funded 

only by Medicaid. Between 7% and 13% of 

Medicaid enrollees are mental health service users. 

By 1997, Medicaid spent more than $14 billion 

that accounted for 20% of all mental health 

spending and 36% of all public mental health 

spending in the United States.15; 34; 35 (See Figure 

1.3.) Although States have used Medicaid as a 

primary source of funding, missed opportunities 

exist because States are often uncertain about: 

• How to cover evidence-based practices, 

• Which services may be covered under the 

traditional State plan, 

• Which services are allowable under waiver, 

and 

• How to use Medicaid funds seamlessly with 

other private sources. 

FIGURE 1.3. 

Distribution of Public and Private Mental 

Health Expenditures, 1997 

Also, many older adults and disabled individuals 

may rely on Medicare for their health care. 

However, in this program, coverage is an issue — 

with the most obvious example being the lack of a 

prescription drug benefit. As important as 

Medicaid and Medicare have been, they have not 

always grown along with the dramatic 

improvements in health care, such as prescription 

drugs, preventive care, and coordination of care. 

Action is needed now to remedy this problem. 

Services and Funding Are 

Fragmented Across Several 

Programs 

To add to the problem, services and funding are 

fragmented across different programs. 

Increasingly, multiple programs with disparate 

objectives and requirements finance services and 

supports for those with mental illnesses including: 

• State and local general fund appropriations, 

• Medicare, 

• Social Security (Social Security Income/ 

Social Security and Disability Income 

payments), 

• Vocational rehabilitation, 

• Education, 

• Temporary Assistance for Needy Families 

(TANF), 

• Juvenile justice and criminal justice, 

• Child welfare, and 

• Federal block grants. 

While each program provides essential assistance, 

together they create a financing approach that is 

complex, fragmented, and inconsistent in its 

coverage. 

Financing Sources Can Be 

Restrictive 

The current system of mental health care must rely 

on many sources of financing. Too many of those 

funding streams are tightly restricted in how they 

can be used or for whom. Providing access to 

effective treatments and services that are easy to 

navigate and that use flexible funding streams is 

crucial to transforming mental health care in 

America. 
23

 Providing access to effective 

treatments and services that are easy 

to navigate and that use flexible 

funding streams is crucial to 

transforming mental health care in 

America. 

Currently, eligibility requirements for receiving 

services or supports and reimbursement policies 

vary widely, and States must rely on waivers to 

provide treatments and supports that Federal 

standards deem optional. If the mental health care 

system is to be responsive to the unique needs of 

consumers, then it must be flexible enough to 

accommodate each person. Our treatment systems 

should be able to serve consumers who are 

uninsured or who need a service that isn’t covered 

by their insurer. Steps must be taken to improve 

the flexibility and accountability of financing in 

both private insurance and public programs. 

Achieving the Goal 

Public Education Activities Can 

Help Encourage People to Seek 

Treatment 

Research findings support the connection between 

good mental health and overall personal health.24-26

Increasing public understanding that mental health 

is an essential and an integral part of overall health 

can lead to improved services, more balanced 

policy decisions, and a healthier Nation. 

Increasing public understanding about mental 

health and mental illnesses requires action at every 

level of government and in the private sector. The 

first step is to reduce the stigma surrounding 

mental illnesses, using targeted public education 

activities that are designed to provide the public 

with factual information about mental illnesses 

and to suggest strategies for enhancing mental 

health, much like anti-smoking campaigns 

promote physical health. 

Research shows that the most effective way to 

reduce stigma is through personal contact with 

someone with a mental illness.36 The U.S. 

Department of Health and Human Services (HHS) 

has incorporated this research finding into its new 

campaign targeted to men, Real Men. Real 

Depression. Through compelling personal stories 

told through television, video, the Internet, and 

print media, the campaign encourages men to 

recognize depression and its impact on their work, 

home, and community life. For America to move 

forward in addressing the seriousness of mental 

health issues, the public must understand that these 

mental conditions are illnesses that can be reliably 

diagnosed and effectively treated. 

 Research shows that the most 

effective way to reduce stigma is 

through personal contact with 

someone with a mental illness. 

Targeted public education can increase awareness 

about the effectiveness of mental health services 

and can encourage people to seek treatment, thus 

reducing the stigma and discrimination associated 

with mental illnesses. Eliminating stigma will also 

help reduce the isolation of these individuals from 

society. 

Media-oriented and other types of mental health 

awareness campaigns can inform the public about 

RECOMMENDATION

1.1 Advance and implement a national campaign to reduce 

the stigma of seeking care and a national strategy for 

suicide prevention. 
24

where and how to obtain help. Collaboration 

between the public and private sectors and close 

coordination with consumers and other 

stakeholders is encouraged to reduce the 

possibility of sending mixed messages or 

duplicated messages to the public. 

Campaigns should use a multi-faceted approach 

that includes various public education strategies, 

as well as direct, consumer-to-target audience, 

interpersonal contact methods, such as dialog 

meetings and speakers’ bureaus. The campaigns 

should also address and promote the themes of 

recovery and the positive societal contributions 

that people with mental illnesses make, correcting 

the misperceptions associated with these illnesses. 

 By increasing the public’s 

understanding that mental illnesses 

are treatable and recovery is possible, 

stigma and discrimination will be 

reduced for people with mental 

illnesses. 

The Commission recommends that the Substance 

Abuse and Mental Health Services Administration 

(SAMHSA) and National Institutes of Health 

(NIH) take the lead to coordinate and develop 

targeted public education initiatives to increase 

understanding of mental illnesses and to encourage 

help-seeking behaviors. By increasing the public’s 

understanding that mental illnesses are treatable 

and recovery is possible, stigma and 

discrimination will be reduced for people with 

mental illnesses. In addition, this change of 

attitude is important because screening and 

identifying mental illnesses are of little value 

unless the person with the problem is willing to 

accept the care that may be offered. 

Swift Action Is Needed to 

Prevent Suicide 

The urgent need for action on suicide prevention is 

the subject of a number of recent reports and 

congressional resolutions. For example, just last 

year the Institute of Medicine (IOM) underscored 

suicide prevention as a significant public health 

problem with the publication Reducing Suicide: A 

National Imperative.

21 

As another example, through its pioneering 

program on suicide prevention, the U.S. Air Force 

works to reverse deep-seated attitudes in the 

military that seeking help should be avoided and is 

shameful. (See Figure 1.4.) The program helps the 

target audience — in this case Air Force personnel 

— recognize that it takes courage to confront life’s 

stresses and that taking steps to do so is “careerenhancing.” 

In addition, the National Strategy for Suicide 

Prevention (NSSP) was developed and launched 

through the combined work of advocates, 

clinicians, researchers, and survivors around the 

Nation.37 It is the first attempt in the United States 

to prevent suicide through such a coordinated 

approach. The NSSP lays out a suicide prevention 

framework for action and guides development of 

an array of services and programs. It requires 

involving a variety of organizations and 

individuals and emphasizes coordinating resources 

and delivering culturally appropriate services at all 

levels of a public-private partnership. This 

promising blueprint for change is poised to guide 

the Nation toward a brighter future for suicide 

prevention. 

The Commission urges swiftly implementing and 

enhancing the NSSP to serve as a blueprint for 

communities and all levels of government. Within 

the public education component of this initiative, 

the messages should encourage the target 

audiences to seek help for mental health problems 

and to understand that suicide is preventable. 

Public education efforts should also be targeted to 

distinct and often hard-to-reach populations, such 

as ethnic and racial minorities, older men, and 

adolescents. 
25

FIGURE 1.4. MODEL PROGRAM: Suicide Prevention and Changing Attitudes About Mental Health Care 

Program Air Force Initiative to Prevent Suicide 

Goal To reduce the alarming rate of suicide. Between 1990 and 1994, one in every 

four deaths among active duty U.S. Air Force personnel was from suicide. After 

unintentional injuries, suicide was the second leading cause of death in the Air 

Force. 

Features In 1996, the Air Force Chief of Staff initiated a community-wide approach to 

prevent suicide through hard-hitting messages to all active duty personnel. The 

messages recognized the courage of those confronting life’s stresses and 

encouraged them to seek help from mental health clinics  actions that were 

once regarded as career hindering, but were now deemed “career-enhancing.” 

Other features of the program: education and training, improved surveillance, 

critical incident stress management, and integrated delivery systems of care. 

Outcomes From 1994 to 1998, the suicide rate dropped from 16.4 to 9.4 suicides per 

100,000. By 2002, the overall decline from 1994 was about 50%. Researchers also 

found significant declines in violent crime, family violence, and deaths that 

resulted from unintentional injuries.38 Air Force leaders have emphasized 

community-wide involvement in every aspect of the project. 

Biggest challenge Sustaining the enthusiasm by service providers as the program has become more 

established. 

How other 

organizations can 

adopt 

The program can be transferred to any community that has identified leaders 

and organization, especially other military services, large corporations, police 

forces, firefighters, schools, and universities. 

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

Further, the Commission recommends forming a 

national level public-private partnership to 

advance the goals and objectives of the NSSP that 

proposes local projects in every State. This publicprivate partnership would emphasize building 

voluntary coalitions to address suicide prevention 

in communities and would include local leaders, 

business and school personnel, and representatives 

of the faith community. 
26

RECOMMENDATION 1.2 Address mental health with the same urgency as physical 

health. 

Recognize the Connection 

Between Mental Health and 

Physical Health 

Health care and other human service systems 

should treat adults with serious mental illnesses 

and children with serious emotional disturbances 

with the same dignity, urgency, and quality of care 

that is given to people with any other form of 

illness. Doing so can contribute greatly to reducing 

stigma while encouraging people in need to seek 

help. 

Good mental health improves the quality of life for 

people with serious physical illnesses and may 

contribute to longer life in general. When 

considering older adults who have general medical 

illnesses  such as heart disease, stroke, cancer, 

and arthritis  about 25% also have depression.39-

44 Depression is associated with a shortened life 

expectancy.30; 31 

The Commission recommends reviewing existing 

scientific literature and initiating new studies to 

examine the impact of mental health and mental 

illnesses on physical illnesses and health. It is 

anticipated that reviewing the current scientific 

knowledge in this critical area will contribute 

significantly to identifying new research priorities. 

New studies should focus on innovative and 

effective ways to enhance the balance between 

mental and physical health. These studies should 

also support using best practices to improve 

quality of life, provide effective treatment, and 

enhance cost-effectiveness. 

 Good mental health improves the 

quality of life for people with serious 

physical illnesses and may contribute 

to longer life in general. 

Address Unique Needs of Mental 

Health Financing 

As future opportunities emerge to transform health 

care in America, mental health care must be 

considered part of the reform necessary to achieve 

optimal health benefits for the American public. 

The Commission recommends including issues of 

critical importance for mental health service 

delivery as part of the national dialog on health 

care reform. The two largest Federal health care 

programs — Medicare and Medicaid — as well as 

private insurance programs must address the 

delivery of mental health care. Any effort to 

strengthen or improve the Medicare and Medicaid 

programs should offer beneficiaries options to 

effectively use the most up-to-date treatments and 

services. Critical issues to be addressed include: 

• Prescription drug coverage, 

• Accessibility of services, 

• Affordability of services, 

• Clarification of coordination of benefits 

between the Medicare and Medicaid 

programs, 

• Support for evidenced-based services and 

supports, 

• Support for self-direction, 

• Choice of health care services and resources, 

and 

• Outcomes and accountability. 

To be effective and comprehensive, mental health 

care must rely on many sources of financing. 

Flexible, accountable financing that pays for 

treatments and services that work and result in 

recovery is an essential aspect of transforming 

mental health care in America. 
27

GOAL 2 Mental Health Care Is Consumer and

Family Driven.

RECOMMENDATIONS

2.1 Develop an individualized plan of care for every adult 

with a serious mental illness and child with a serious 

emotional disturbance. 

2.2 Involve consumers and families fully in orienting the 

mental health system toward recovery. 

2.3 Align relevant Federal programs to improve access 

and accountability for mental health services. 

2.4 Create a Comprehensive State Mental Health Plan. 

2.5 Protect and enhance the rights of people with mental 

illnesses. 

Understanding the Goal 

The Complex Mental Health 

System Overwhelms Many 

Consumers 

Nearly every consumer of mental health services 

who testified before or submitted public comments 

to the Commission expressed the need to fully 

participate in his or her plan for recovery. In the 

case of children with serious emotional 

disturbances, their parents and guardians strongly 

echoed this sentiment. Consumers and families told 

the Commission that having hope and the 

opportunity to regain control of their lives was vital 

to their recovery. 

Indeed, emerging research has validated that hope 

and self-determination are important factors 

contributing to recovery.45; 46 However, 

understandably, consumers often feel overwhelmed 

and bewildered when they must access and integrate 

mental health care, support services, and disability 

benefits across multiple, disconnected programs that 

span Federal, State, and local agencies, as well as 

the private sector. 

As the President said in his speech announcing the 

creation of the Commission, one of the major 

obstacles to quality mental health care is: 

“... our fragmented mental health 

service delivery system. Mental 

health centers and hospitals, 

homeless shelters, the justice 

system, and our schools all have 

contact with individuals suffering 

from mental disorders.” 

Consumers of mental health services must stand at 

the center of the system of care. Consumers’ needs 

must drive the care and services that are provided. 

Unfortunately, the services currently available to 

consumers are fragmented, driven by financing rules 

and regulations, and restricted by bureaucratic 

boundaries. They defy easy description. 
28

Program Efforts Overlap 

Loosely defined, the mental health care system 

collectively refers to the full array of programs for 

anyone with a mental illness. These programs exist 

at every level of government and throughout the 

private sector. They have varying missions, 

settings, and financing. They deliver or pay for 

treatments, services, or other types of supports, 

such as housing, employment, or disability 

benefits. For instance, one program’s mission 

might be to offer treatment through medication, 

psychotherapy, substance abuse treatment, or 

counseling, while another program’s purpose 

might be to offer rehabilitation support. The 

setting could be a hospital, a community clinic, a 

private office, a school, or a business. 

 Many mainstream social welfare 

programs are not designed to serve 

people with serious mental illnesses, 

even though this group has become 

one of the largest and most severely 

disabled groups of beneficiaries. 

A brief look at traditional funding sources for 

mental health services illustrates the impact of this 

overly complex system. The Community Mental 

Health Services Block Grant, funded by the U.S. 

Department of Health and Human Services (HHS) 

through the Substance Abuse and Mental Health 

Services Administration (SAMHSA), provides 

funding to the 59 States and territories. It is only 

one source of Federal funding that State mental 

health authorities manage. The funding totaled 

approximately $433 million in 2002,47 or less than 

3% of the revenues of these State agencies.48

But larger Federal programs that are not focused 

on mental health care play a much more 

substantial role in financing it. For example, 

through Medicare and Medicaid programs alone, 

HHS spends nearly $24 billion each year on 

beneficiaries’ mental health care.15 Moreover, the 

largest Federal program that supports people with 

mental illnesses is not even a health services 

program — the Social Security Administration’s 

Supplemental Security Income (SSI) and Social 

Security Disability Income (SSDI) programs, with 

payments totaling approximately $21 billion in 

2002.49-51

Other significant programs that are funded 

separately and play a role in State and local 

systems include: 

• Housing, 

• Rehabilitation, 

• Education, 

• Child welfare, 

• Substance abuse, 

• General health, 

• Criminal justice, and 

• Juvenile justice, among others. 

Each program has its own complex, sometimes 

contradictory, set of rules. Many mainstream 

social welfare programs are not designed to serve 

people with serious mental illnesses, even though 

this group has become one of the largest and most 

severely disabled groups of beneficiaries. 

If this current system worked well, it would 

function in a coordinated manner, and it would 

deliver the best possible treatments, services, and 

supports. However, as it stands, the current system 

often falls short. Many people with serious mental 

illnesses and children with serious emotional 

disturbances remain homeless or housed in 

institutions, jails, or juvenile detention centers. 

These individuals are unable to participate in their 

own communities. 

Consumers and Families Do Not 

Control Their Own Care 

In a consumer- and family-driven system, 

consumers choose their own programs and the 

providers that will help them most. Their needs 

and preferences drive the policy and financing 

decisions that affect them. Care is consumercentered, with providers working in full 

partnership with the consumers they serve to 

develop individualized plans of care. 

Individualized plans of care help overcome the 

problems that result from fragmented or 

uncoordinated services and systems. 
29

Currently, adults with serious mental illnesses and 

parents of children with serious emotional 

disturbances typically have limited influence over 

the care they or their children receive. Increasing 

opportunities for consumers to choose their 

providers and allowing consumers and families to 

have greater control over funds spent on their care 

and supports facilitate personal responsibility, 

create an economic interest in obtaining and 

sustaining recovery, and shift the incentives 

towards a system that promotes learning, selfmonitoring, and accountability. Increasing choice 

protects individuals and encourages quality. 

 Individualized plans of care help 

overcome the problems that result 

from fragmented or uncoordinated 

services and systems. 

Evidence shows that offering a full range of 

community-based alternatives is more effective 

than hospitalization and emergency room 

treatment.18 Without choice and the availability of 

acceptable treatment options, people with mental 

illnesses are unlikely to engage in treatment or to 

participate in appropriate and timely interventions. 

Thus, giving consumers access to a range of 

effective, community-based treatment options is 

critical to achieving their full community 

participation. To ensure this access, the array of 

community-based treatment options must be 

expanded. 

In particular, community-based treatment options 

for children and youth with serious emotional 

disorders must be expanded. Creating alternatives 

to inpatient treatment improves engagement in 

community-based treatment and reduces 

unnecessary institutionalization. These young 

people are too often placed in out-of-state 

treatment facilities, hours away from their families 

and communities. Further segregating these 

children from their families and communities can 

impede effective treatment. 

Emerging evidence shows that a major Federal 

program to establish comprehensive, communitybased systems of care for children with serious 

emotional disturbances has successfully reduced 

costly out-of-state placements and generated 

positive clinical and functional outcomes. 

Clinically, youth in systems of care sites showed 

an increase in behavioral and emotional strengths 

and a reduction in mental health problems. For 

these children, residential stability improved, 

school attendance and school performance 

improved, law enforcement contacts were reduced, 

and substance use decreased.52

Consumers Need Employment 

and Income Supports 

The low rate of employment for adults with mental 

illnesses is alarming. People with mental illnesses 

have one of the lowest rates of employment of any 

group with disabilities — only about 1 in 3 is 

employed.53 The loss of productivity and human 

potential is costly to society and tragically 

unnecessary. High unemployment occurs despite 

surveys that show the majority of adults with serious 

mental illnesses want to work — and that many 

could work with help.54; 55 

Many individuals with serious mental illnesses 

qualify for and receive either SSI or SSDI 

benefits. SSI is a means-tested, income-assistance 

program; SSDI is a social insurance program with 

benefits based on past earnings. A sizable 

proportion of adults with mental illnesses who 

receive either form of income support live at, or 

below, the poverty level. For more than a decade, 

the number of SSI and SSDI beneficiaries with 

psychiatric disabilities has increased at rates 

higher than each program’s overall growth rate. 

Individuals with serious mental illnesses represent 

the single largest diagnostic group (35%) on the 

SSI rolls, while representing over a quarter (28%) 

of all SSDI recipients.49; 51 

 People with mental illnesses have one 

of the lowest levels of employment of 

any group with disabilities — only 

about 1 in 3 is employed. 

Though living in poverty, SSI recipients 

paradoxically find that returning to work makes 

them even poorer, primarily because employment 

results in losing Medicaid coverage, which is vital 

in covering the cost of medications and other 
30

treatments. According to a large, eight-State study, 

only 8% of those returning to full time jobs had 

mental health coverage.56

Recent Federal legislation has tried to address the 

loss of Medicaid and other disincentives to 

employment. For instance, the “Medicaid Buy-In” 

legislation allows States to extend Medicaid to 

disabled individuals who exit the SSI/SSDI rolls to 

resume employment, but many States cannot 

afford to implement Medicaid Buy-In. The 

Balanced Budget Act of 1997 allows States to 

extend Medicaid coverage to disabled individuals 

whose earned income is low, but still above the 

Federal Poverty Guidelines. 

Another statutory reform — The Ticket to Work 

and Work Incentives Improvement Act 

(TWWIIA) of 1999 — is problematic because its 

rules do not give vocational rehabilitation 

providers enough incentives to take on clients who 

have serious mental illnesses. Rather, these 

programs are more inclined to serve the least 

disabled — a process called creaming, in reference 

to the legislation’s unintentional incentives for 

vocational rehabilitation providers to serve less 

disabled people rather than more disabled ones 

(the latter most commonly people with serious 

mental illnesses). One large study found that only 

23% of people with schizophrenia received any 

kind of vocational services.6

 Since TWWIIA 

rewards only those providers who help their 

clients earn enough to no longer qualify for SSI, 

the bottom line is that most people with serious 

mental illnesses do not receive any vocational 

rehabilitation services at all. 

Because they cannot work in the current climate, 

many consumers with serious mental illnesses 

continue to rely on Federal assistance payments in 

order to have health care coverage, even when 

they have a strong desire to be employed. 

Regrettably, a financial disincentive to achieve full 

employment exists because consumers lose 

Federal benefits if they become employed. Adding 

to the problem is the fact that most jobs open to 

these individuals have no mental health care 

coverage, so consumers must choose between 

employment and coverage. Consequently, they 

depend on a combination of disability income and 

Medicaid (or Medicare), all the while preferring 

work and independence. 

For youth with serious emotional disturbances, the 

employment outlook is also bleak. A national 

study found that only 18% of these youth were 

employed full time, while another 21% worked 

part-time for one to two years after they left high 

school. This group had work experiences 

characterized by greater instability than all other 

disability groups.57

Other financial disincentives to employment exist 

as well, including potential loss of housing and 

transportation subsidies. 

Over the next ten years, the U.S. economy is 

projected to grow by 22 million jobs, many in 

occupations that require on-the-job training.58

With appropriate forms of support, people with 

mental illnesses could actively contribute to that 

economic growth, as well as to their own 

independence. They could fully participate in their 

communities. Instead, they are trapped into longterm dependence on disability income supports 

that leave them living below the poverty level. 

A Shortage of Affordable 

Housing Exists 

The lack of decent, safe, affordable, and integrated 

housing is one of the most significant barriers to 

full participation in community life for people 

with serious mental illnesses. Today, millions of 

people with serious mental illnesses lack housing 

that meets their needs. 

The shortage of affordable housing and 

accompanying support services causes people with 

serious mental illnesses to cycle among jails, 

institutions, shelters, and the streets; to remain 

unnecessarily in institutions; or to live in seriously 

substandard housing.59 People with serious mental 

illnesses also represent a large percentage of those 

who are repeatedly homeless or who are homeless 

for long periods of time.60

In fact, people with serious mental illnesses are 

over-represented among the homeless, especially 

among the chronically homeless. Of the more than 

two million adults in the U.S. who have at least one 

episode of homelessness in a given year, 46% report 

having had a mental health problem within the 

previous year, either by itself or in combination with 
31

substance abuse.59 Chronically homeless people 

with mental illnesses are likely to: 

• Have acute and chronic physical health 

problems; 

• Use alcohol and drugs; 

• Have escalating, ongoing psychiatric 

symptoms; and 

• Become victimized and incarcerated.61

A recent study shows that people who rely solely on 

SSI benefits — as many people with serious mental 

illnesses do — have incomes equal to only 18% of 

the median income and cannot afford decent 

housing in any of the 2,703 housing market areas 

defined by the U.S. Department of Housing and 

Urban Development (HUD).62 HUD reports to 

Congress show that as many as 1.4 million adults 

with disabilities who receive SSI benefits — 

including many with serious mental illnesses — pay 

more than 50% of their income for housing.63

Affordable housing programs are extremely 

complex, highly competitive, and difficult to 

access. Federal public housing policies can make it 

difficult for people with poor tenant histories, 

substance use disorder problems, and criminal 

records — all problems common to many people 

with serious mental illnesses — to qualify for 

Section 8 vouchers and public housing units. 

Those who do receive Section 8 housing vouchers 

often cannot use them because: 

• The cost of available rental units may exceed 

voucher program guidelines, particularly in 

tight housing markets; 

• Available rental units do not meet Federal 

Housing Quality Standards for the voucher 

program; 

• Private landlords often refuse to accept 

vouchers; and 

• Housing search assistance is often unavailable 

to consumers. 

 The lack of decent, safe, affordable, 

and integrated housing is one of the 

most significant barriers to full 

participation in community life for 

people with serious mental illnesses. 

Tragically, many housing providers discriminate 

against people with mental illnesses. Too many 

communities are unwilling to have supportive 

housing programs in their neighborhoods. Since 

the 1980s, the Federal government has had the 

legal tools to address these problems, yet has 

failed to use them effectively. Between 1989 and 

2000, HUD’s fair housing enforcement activities 

diminished, despite growing demand. The average 

age of complaints at their closure in FY 2000 was 

nearly five times the 100-day period that Congress 

set as a benchmark.64

Just as the U.S. Supreme Court’s Olmstead

decision has increased the demand for integrated 

and affordable housing for people with serious 

mental illnesses, public housing is less available. 

Since 1992, approximately 75,000 units of HUD 

public housing have been converted to “elderly 

only” housing and more units are being converted 

every year, leaving fewer units for people with 

disabilities.65 

Too few mental health systems dedicate resources to 

ensuring that people with mental illnesses have 

adequate housing with supports. These systems 

often lack staff who are knowledgeable about public 

housing programs and issues. Partnerships and 

collaborations between public housing authorities 

and mental health systems are far too rare. Highly 

categorical Federal funding streams (silos) for 

mental health, housing, substance abuse, and other 

health and social welfare programs greatly 

contribute to the fragmentation and failure to 

comprehensively address the multiple service needs 

of many people with serious mental illnesses. 
32

Limited Mental Health Services 

Are Available in Correctional 

Facilities 

In the U.S., approximately 1.3 million people are 

in State and Federal prisons, and 4.6 million are 

under correctional supervision in the 

community.66; 67 Remarkably, approximately 13 

million people are jailed every year, with about 

631,000 inmates serving in jail at one time. The 

rate of serious mental illnesses for this population 

is about three to four times that of the general U.S. 

population.68 This means that about 7% of all 

incarcerated people have a current serious mental 

illness; the proportion with a less serious form of 

mental illness is substantially higher.68

People with serious mental illnesses who come 

into contact with the criminal justice system are 

often: 

• Poor, 

• Uninsured, 

• Disproportionately members of minority 

groups, 

• Homeless, and 

• Living with co-occurring substance abuse and 

mental disorders. 

They are likely to continually recycle through the 

mental health, substance abuse, and criminal 

justice systems.69 

 As a shrinking public health care 

system limits access to services, many 

poor and racial or ethnic minority 

youth with serious emotional 

disorders fall through the cracks into 

the juvenile justice system. 

When they are put in jail, people with mental 

illnesses frequently do not receive appropriate 

mental health services. Many lose their eligibility 

for income supports and health insurance benefits 

that they need to re-enter and re-integrate into the 

community after they are discharged. 

Women are a dramatically growing presence in all 

parts of the criminal justice system. Current 

statistics reveal that women comprise 11% of the 

total jail population,70 6% of prison inmates,71

22% of adult probationers, and 12% of parolees.72

Many women entering jails have been victims of 

violence and present multiple problems in addition 

to mental and substance abuse disorders, including 

child-rearing and parenting difficulties, health 

problems, histories of violence, sexual abuse, and 

trauma.73 Gender-specific services and genderresponsive programs are in increasing demand but 

are rarely present in correctional facilities 

designed for men. Early needs assessment, 

screening for mental and substance abuse 

disorders, and identification of other needs relating 

to self or family are critical to effectively plan 

treatment for incarcerated women. 

More than 106,000 teens are in custody in juvenile 

justice facilities.74 As a shrinking public health 

care system limits access to services, many poor 

and racial or ethnic minority youth with serious 

emotional disorders fall through the cracks into the 

juvenile justice system. (See Goal 4 for a broader 

discussion of mental health screening.) 

Recent research shows a high prevalence of 

mental disorders in children within the juvenile 

justice system. A large-scale, four-year, Chicago–

based study found that 66% of boys and nearly 

75% of girls in juvenile detention have at least one 

psychiatric disorder. About 50% of these youth 

abused or were addicted to drugs and more than 

40% had either oppositional defiant or conduct 

disorders. 

The study also found high rates of depression and 

dysthymia: 17% of boys; 26% of detained girls.75

As youth progressed further into the formal 

juvenile justice system, rates of mental disorder 

also increased: 46% of youth on probation met 

criteria for a serious emotional disorder compared 

to 67% of youth in a correctional setting.76

Appropriate treatment and diversion should be 

provided in juvenile justice settings followed by 

routine and periodic screening. 
33

Fragmentation Is a Serious 

Problem at the State Level 

State mental health authorities have enormous 

responsibility to deliver mental health care and 

support services, yet they have limited influence 

over many of the programs consumers and 

families need. Most resources for people with 

serious mental illnesses (e.g., Medicaid) are not 

typically within the direct control or accountability 

of the administrator of the State mental health 

system. For example, depending on the State and 

how the budget is prepared, Medicaid may be 

administered by a separate agency with limited 

mental health expertise. Separate entities also 

administer criminal justice, housing, and education 

programs, contributing to fragmented services. 

 A Comprehensive State Mental Health 

Plan would create a new partnership 

among the Federal, State, and local 

governments and must include 

consumers and families. 

The development of a Comprehensive State 

Mental Health Plan would create a new 

partnership among the Federal, State, and local 

governments and must include consumers and 

families. To be effective, the plan must reach 

beyond the traditional State mental health agency 

and the block grant to address the full range of 

treatment and support service programs that 

mental health consumers and their families should 

have. The planning process should support a 

respectful, collaborative dialogue among 

stakeholders, resulting in an extensive, 

coordinated State system of services and supports. 

As States accept increased responsibility for 

coordinating mental health care, they should have 

greater flexibility in spending Federal resources to 

meet these needs. Using a performance partnership 

model, the Federal government and the State will 

negotiate an agreement on outcomes. This shift 

will then give States the flexibility to determine 

how they will achieve the desired outcomes 

outlined in their plans. 

Aligning relevant Federal programs to support 

Comprehensive State Mental Health Plans can 

have the powerful impact of fostering consumers’ 

independence and their ability to live, work, learn, 

and participate fully in their communities. (See 

Recommendations 2.3 and 2.4.) 

Consumers and Families Need 

Community-based Care 

In the 1999 Olmstead v. L.C. decision, the U.S. 

Supreme Court held that the unnecessary 

institutionalization of people with disabilities is 

discrimination under the Americans with 

Disabilities Act.77 The Court found that: 

“...confinement in an institution 

severely diminishes the everyday life 

activities of individuals, including 

family relations, social contacts, 

work options, economic 

independence, educational 

advancement, and cultural 

enrichment.” 

President Bush urged promptly implementing the 

Olmstead decision in his 2001 Executive Order 

13217, mobilizing Federal resources in support of 

Olmstead. However, many adults and children 

remain in institutions instead of in more 

appropriate community-based settings. 

On a separate topic, the General Accounting 

Office (GAO) recently issued a report that 

illustrates the tragic and unacceptable 

circumstances that result in thousands of parents 

being forced to place their children into the child 

welfare or juvenile justice systems each year so 

that they may obtain the mental health services 

they need. Loving and responsible parents who 

have exhausted their savings and health insurance 

face the wrenching decision of surrendering their 

parental rights and tearing apart their families to 

secure mental health treatment for their troubled 

children. The GAO report estimates that, in 2001, 

parents were forced to place more than 12,700 

children in the child welfare or juvenile justice 

systems as the last resort for those children to 

receive needed mental health care treatment. 

Moreover, these numbers are actually an 

undercount because 32 states, including the five 
34

largest, were unable to provide data on the number 

of children affected.78

According to the report, several factors contribute 

to the consequence of “trading custody for 

services,” including: 

• Limitations of both public and private health 

insurance, 

• Inadequate supply of mental health services, 

• Limited availability of services through mental 

health agencies and schools, and 

• Difficulties meeting eligibility rules for 

services. 

When parents cede their rights in order to place 

their children in foster care or in a program for 

delinquent youth, they may also be inadvertently 

placing their children at risk for abuse or neglect.79

These placements also increase the financial 

burden on State child welfare and juvenile justice 

authorities. A more family-friendly policy must be 

found to remedy this situation. 

Consumers Face Difficulty in 

Finding Quality Employment 

Only about one-third of people with mental 

illnesses are employed, and many of them are 

under-employed.53 For example, about 70% of 

people with serious mental illnesses with college 

degrees earned less than $10 per hour.80 Overall, 

people with psychiatric disabilities earned a 

median wage of only about $6 per hour versus $9 

per hour for the general population.53 

Problems begin long before consumers enter the 

work force. Many individuals with serious mental 

illnesses lack the necessary high school and postsecondary education or training vital to building 

careers. A major study found that youth with 

emotional disturbances have the highest 

percentage of high school non-completion and 

failing grades compared with other disabled 

groups.81 

 Only about one-third of people with 

mental illnesses are employed, and 

many of them are under-employed. 

Special education legislation  the Individuals 

with Disabilities Education (IDEA) Act  was 

designed to prepare school-aged youth to make the 

transition to the workplace, but its promise 

remains largely unfulfilled. Similarly, the 

Americans with Disabilities Act (ADA) has not 

fulfilled its potential to prevent discrimination in 

the workplace. Workplace discrimination, either 

overt or covert, continues to occur. According to 

surveys conducted over the past five decades, 

employers have expressed more negative attitudes 

about hiring workers with psychiatric disabilities 

than any other group.82; 83 Economists have found 

unexplained wage gaps that are evidence of 

discrimination against those with psychiatric 

disabilities.84 

The Use of Seclusion and 

Restraint Creates Risks 

An emerging consensus asserts that the use of 

seclusion and restraint in mental health treatment 

settings creates significant risks for adults and 

children with psychiatric disabilities. These risks 

include serious injury or death, re-traumatizing 

people who have a history of trauma, loss of 

dignity, and other psychological harm. 

Consequently, it is inappropriate to use seclusion 

and restraint for the purposes of discipline, 

coercion, or staff convenience. 

Seclusion and restraint are safety interventions of 

last resort; they are not treatment interventions. In 

light of the potentially serious consequences, 

seclusion and restraint should be used only when 

an imminent risk of danger to the individual or 

others exists and no other safe, effective 

intervention is possible. It is also inappropriate to 

use these methods instead of providing adequate 

levels of staff or active treatment. 
35

Achieving the Goal 

Develop Individualized Plans of 

Care for Consumers and Families 

The Commission recommends that each adult with 

a serious mental illness and each child with a 

serious emotional disturbance have an 

individualized plan of care. These plans of care 

give consumers, families of children with serious 

emotional disturbances, clinicians, and other 

providers a genuine opportunity to construct and 

maintain meaningful, productive, and healing 

partnerships. The goals of these partnerships 

include: 

• Improving service coordination, 

• Making informed choices that will lead to 

improved individual outcomes, and 

• Ultimately achieving and sustaining recovery. 

The plans should form the basis for care that is 

both consumer centered and coordinated across 

different programs and agencies. A consumer’s 

plan of care should describe the services and 

supports they need to achieve recovery. The 

funding for the plan would then follow the 

consumer, based on their individualized care plan. 

For those consumers who need multiple services 

and supports, the burden of coordination and 

access to care should not rest solely on them or on 

their families, but rather it should be shared with 

service providers. 

 Providers should develop these 

customized plans in full partnership 

with consumers. 

Consumer needs and preferences should drive the 

type and mix of services provided, and should take 

into account the developmental, gender, linguistic, 

or cultural aspects of providing and receiving 

services. Providers should develop these 

customized plans in full partnership with 

consumers, while understanding changes in 

individual needs across the lifespan and the 

obligation to review treatment plans regularly. For 

consumers and families, the system should be easy 

to understand and navigate. The Commission 

recommends that SAMHSA convene a consensus 

panel to examine and explore developing models 

to guide individual plans of care. 

Where a range of services are available, increased 

opportunities for choice will create a more viable 

marketplace for mental health care and provide a 

greater level of satisfaction by giving consumers 

and families control over important funding 

decisions that affect their lives. A recent Medicaid 

Cash and Counseling Demonstration waiver 

program that focuses on people with physical 

disabilities, developmental disabilities/mental 

retardation, and older adults confirms what many 

have long suspected. The evaluation, jointly 

funded by HHS and the Robert Wood Johnson 

Foundation, found that, when compared to 

traditional agency-directed personal care services, 

consumer-directed services resulted in: 

• Higher client satisfaction, 

• Increased numbers of needs being met, and 

• Equivalent levels of health and safety in a 

large population of people with disabilities.85 

In this demonstration, these selected Medicaid 

waiver program beneficiaries choose their own 

support services (e.g., personal care attendants and 

adaptive equipment) from an approved list. The 

Commission sees the value in undertaking a 

similar demonstration waiver program to evaluate 

the potential benefits for people with mental 

illnesses. 

An exemplary program that expressly targets 

children with serious emotional disturbances and 

their families, Wraparound Milwaukee strives to 

RECOMMENDATION

2.1 Develop an individualized plan of care for every adult 

with a serious mental illness and child with a serious 

emotional disturbance. 
36

integrate services and funding for the most seriously 

affected children and adolescents. (See Figure 2.1.) 

Most program participants are racial or ethnic 

minority youth in the child welfare and juvenile 

justice systems. Wraparound Milwaukee 

demonstrates that the seemingly impossible can be 

made possible: children’s care can be seamlessly 

integrated. The services provided to children not 

only produce better clinical results, reduce 

delinquency, and result in fewer hospitalizations, 

but are cost-effective.86 

Each consumer or child’s family should receive 

the technical assistance necessary to develop the 

individual plan of care, including: 

• Necessary information about services and 

supports, 

• Opportunities to network with other consumers 

and families, and 

• Participation in a full partnership with providers 

on decisions about treatment and services. 

Youth with serious emotional disturbances should 

participate in meetings to ensure that their voices 

are heard in educational decisions that affect their 

school-based intervention and placement, 

particularly in the student’s Individualized 

Education Program (IEP). To succeed, the plan 

must also be supported by the proposed 

Comprehensive State Mental Health Plan. (See 

Recommendation 2.4.) 

FIGURE 2.1. MODEL PROGRAM: Integrated System of Care for Children with Serious Emotional 

Disturbances and Their Families 

Program Wraparound Milwaukee 

Goal To offer cost-effective, comprehensive, and individualized care to children with 

serious emotional disturbances and their families. The children and adolescents 

that the program serves are under court order in the child welfare or juvenile 

justice system; 64% are African American. 

Features Provides coordinated system of care through a single public agency (Wraparound 

Milwaukee) that coordinates a crisis team, provider network, family advocacy, and 

access to 80 different services. The program’s $30 million budget is funded by 

pooling child welfare and juvenile justice funds (previously spent on institutional 

care) and by a set monthly fee for each Medicaid-eligible child. (The fee is derived 

from historical Medicaid costs for psychiatric hospitalization or related services.) 

Outcomes Reduced juvenile delinquency, higher school attendance, better clinical 

outcomes, lower use of hospitalization, and reduced costs of care. Program costs 

$4,350 instead of $7,000 per month per child for residential treatment or juvenile 

detention.86

Biggest challenge To expand the program to children with somewhat less severe needs who are at 

risk for worse problems if they are unrecognized and untreated. 

How other 

organizations can 

adopt 

Encourage integrated care and more individualized services by ensuring that 

funding streams can support a single family-centered treatment plan for children 

whose care is financed from multiple sources. 

Sites Milwaukee and Madison, Wisconsin; Indianapolis, Indiana; and the State of New 

Jersey 
37

Involve Consumers and Families 

in Planning, Evaluation, and 

Services 

Through consumer and family member public 

testimony, comments, and letters, the Commission 

is convinced of the need to increase opportunities 

for consumers and family members to share their 

knowledge, skills, and experiences of recovery. 

Recovery-oriented services and supports are often 

successfully provided by consumers through 

consumer-run organizations and by consumers who 

work as providers in a variety of settings, such as 

peer-support and psychosocial rehabilitation 

programs. 

Consumers who work as providers help expand the 

range and availability of services and supports that 

professionals offer. Studies show that consumer-run 

services and consumer-providers can broaden access 

to peer support, engage more individuals in 

traditional mental health services, and serve as a 

resource in the recovery of people with a psychiatric 

diagnosis.18 Because of their experiences, consumerproviders bring different attitudes, motivations, 

insights, and behavioral qualities to the treatment 

encounter.87; 88 

In the past decade, mental health consumers have 

become involved in planning and evaluating the 

quality of mental health care and in conducting 

sophisticated research to affect system reform. 

Consumers have created and operated satisfaction 

assessment teams, used concept-mapping 

technologies, and carried out research on self-help, 

recovery, and empowerment.89; 90

Local, State, and Federal authorities must encourage 

consumers and families to participate in planning 

and evaluating treatment and support services. The 

direct participation of consumers and families in 

developing a range of community-based, recoveryoriented treatment and support services is a priority. 

Consumers and families with children with serious 

emotional disturbances have a key role in expanding 

the mental health care delivery workforce and 

creating a system that focuses on recovery. 

Consequently, consumers should be involved in a 

variety of appropriate service and support settings. 

In particular, consumer-operated services for which 

an evidence base is emerging should be promoted. 

Realign Programs to Meet the 

Needs of Consumers and 

Families 

The Federal government is the largest single payer 

for mental health and supportive services, 

including health care, employment, housing, and 

education. To be effective, Federal funding and 

regulatory systems must make the necessary range 

of services, treatments, and supports accessible. 

The Commission has come to the emphatic 

conclusion that transforming mental health care in 

America requires at least two fundamental 

undertakings: 

• Relevant Federal programs that determine 

eligibility, policy, and financing in the core 

areas of health care, housing, employment, 

education, and child welfare must examine 

their potential to better align their programs to 

meet the needs of adults and children with 

mental illnesses. Because of the exceedingly 

RECOMMENDATION 2.2 Involve consumers and families fully in orienting the 

mental health system toward recovery. 

RECOMMENDATION 2.3 Align relevant Federal programs to improve access and 

accountability for mental health services. 
38

high rates of mental illnesses among 

incarcerated populations, this examination 

must also include Federal policy, program, 

and financing roles in the criminal and 

juvenile justice systems. 

• The President’s vision is to ensure that all 

Americans with disabilities have opportunities 

to live, work, learn, and participate fully in the 

community. Federal agencies can greatly help 

to realize this vision by better aligning their 

programs that address the systems mentioned 

above. The Commission believes that 

realigning Federal programs will help provide 

States with incentives to develop and use 

Comprehensive State Mental Health Plans. 

(See Recommendation 2.4.) 

Federal expenditures and policies have a 

tremendous impact on consumers and families. 

Particularly at the Federal level, leadership must 

increase opportunities for consumers and families, 

and develop innovative solutions. 

The Federal government must also provide 

leadership in demonstrating accountability for 

funding approaches and in removing regulatory 

and policy barriers. The funding and regulatory 

systems should advance the goal of making the 

mental health system consumer- and family-driven 

and should encourage choice and selfdetermination. 

In a transformed system, the key goals of a revised 

Federal agenda for mental health would include: 

• Clarifying and coordinating regulations and 

funding guidelines that are relevant to people 

with mental illnesses for housing, vocational 

rehabilitation, criminal and juvenile justice, 

social security, and education to improve 

access and accountability for effective 

services; and 

• Providing guidance to States to create a 

Comprehensive State Mental Health Plan that 

would address the same fragmentation and 

coordination issues at the State level. (See 

Recommendation 2.4.) 

As States increase their levels of interagency 

coordination, the Federal agencies would provide 

greater flexibility in how funds could be used. 

The Commission recommends that HHS take the 

lead responsibility to develop a cross-Department 

mental health agenda with the goal of better 

aligning Federal policy on mental health treatment 

and support services across agencies and reducing 

fragmentation in services. The HHS Secretary 

should require that key agencies and programs that 

serve people with serious mental illnesses 

coordinate their responsibilities, including: 

• Substance Abuse and Mental Health Services 

Administration (SAMHSA), 

• National Institutes of Health (NIH), 

• Centers for Medicare and Medicaid Services 

(CMS), 

• Administration for Children and Families 

(ACF), 

• Social Security Administration (SSA), 

• U.S. Department of Veterans Affairs (VA), 

• U.S. Department of Education (ED), 

• The juvenile and adult criminal justice 

systems, 

• Child welfare, 

• Vocational rehabilitation, and 

• Housing. 

Align Federal Financing for 

Health Care 

The two largest Federal health care programs — 

Medicare and Medicaid — strongly influence the 

nature and characteristics of the health care 

reimbursement system. How States use Medicaid to 

finance mental health care varies greatly. All too 

often, the interplay of existing policies, waivers, and 

exemptions can cause the collaboration between the 

State mental health authorities and State Medicaid 

programs directors to be inconsistent. 
39

Beneficiaries must be able to exercise choice, selfdirection, and control over their health care services. 

To provide this choice, critical issues must be 

addressed so that Federal funding programs and 

State resources are coordinated. In transforming the 

health care financing system, the various 

characteristics and unique local needs must be 

addressed. 

Both CMS and SSA recognize the challenges to 

modernizing the current delivery system for 

people with disabilities, as well as the fiscal 

constraints under which States operate. New ways 

of doing business, innovation, and a willingness to 

explore viable options will lead the way to 

improving the system. 

The Balanced Budget Act of 1997 allows States to 

extend Medicaid coverage to individuals with 

disabilities whose earned income is low, but still 

above the Federal Poverty Guidelines by up to 

250%. This action directly benefits individuals 

with disabilities who could not ordinarily qualify 

for Medicaid. By setting the net income eligibility 

at this level, States can provide Medicaid coverage 

to more individuals with disabilities who might 

not be able to be employed. 

The Commission recognizes that Medicaid 

demonstration projects are an essential tool to 

inform policy makers and Federal payers about the 

effectiveness and fiscal impact of health care 

innovations. Therefore, the Commission 

recommends introducing legislation to implement 

those New Freedom Initiative Demonstration 

proposals included in the President’s Fiscal Year 

2004 Budget. 

Specifically, these demonstrations include: 

• “Money Follows the Individual” Rebalancing, 

• Community-based alternatives for children 

who are currently residing in psychiatric 

residential treatment facilities, and 

• Respite care services for caregivers of adults 

with disabilities or long-term illnesses, and 

respite care for caregivers of children with 

substantial disabilities. 

DEMONSTRATION: “Money Follows the 

Individual” Rebalancing 

This demonstration creates a system of flexible 

financing for long-term services and supports that 

enables available funds to move with the 

individual to the most appropriate and preferred 

setting as the individual’s needs and preferences 

change. To the participant, the movement of funds 

is seamless. 

This project would help States develop and adopt a 

coherent strategy to make their long-term care 

systems more responsive to the needs and desires 

of its citizens, more cost-effective, less dependent 

on institutional settings, and more responsive to 

the ADA. This demonstration would also support 

State initiatives to increase self-direction and 

comply with the Olmstead decision. 

 

Rebalancing means adjusting a State’s Medicaid 

programs and services to achieve a more equitable 

balance between the proportion of total Medicaid 

long-term support expenditures used for 

institutional services (i.e., nursing facilities and 

intermediate care facilities – mental retardation) 

and the proportion of funds used for communitybased support under its State Plan and waiver 

services. A balanced, long-term support system 

offers individuals a reasonable array of options, 

including meaningful community and institutional 

choices. 

DEMONSTRATION: Community-based 

Alternatives for Children in Psychiatric 

Residential Treatment Facilities 

Over the last decade, psychiatric residential 

treatment facilities have become the primary 

provider for children with serious emotional 

disturbances who require an institutional level of 

care. The Medicaid program provides Federal 

matching funds for inpatient psychiatric services 

for children under age 21 in hospitals or in 

psychiatric residential treatment facilities. A 

primary tool for States to develop communitybased alternatives to institutional settings, such as 

hospitals, is the Home and Community-based 

Services waiver authority under Section 1915(c) of 

the Social Security Act. 
40

However, since psychiatric residential treatment 

facilities are not explicitly listed as an institution 

in the Act, this tool is not available to States. 

Extending home- and community-based services 

(HCBS) as an alternative to residential treatment 

facilities could allow children to receive treatment 

in their own homes, surrounded by their families, 

at a cost per child that would be less than the cost 

of institutional care. However, no analysis of the 

effectiveness or efficiency of such an approach 

exists. While limiting Federal financial exposure 

by capping total participation, a demonstration 

would allow CMS to develop reliable cost and 

utilization data to evaluate the impact of Medicaid 

waiver services on the effectiveness of community 

placements for children with serious emotional 

disturbances. The data would also serve as a useful 

predictor of what would be expected if permanent 

authority is granted for the HCBS waiver as an 

alternative to psychiatric residential treatment 

centers. 

DEMONSTRATION: Respite Care Services for 

Caregivers 

When the demands of caregiving overwhelm 

caregivers, people with disabilities may be forced 

to leave their homes for a less desirable, more 

restrictive environment. Fortunately, respite 

services that provide temporary relief for 

caregivers can enable individuals with disabilities 

to remain in their homes and communities. 

Although respite care can take many forms, its 

essential purpose is to provide community-based, 

planned or emergency short-term relief to family 

caregivers, alleviating the pressures of ongoing 

care. It is frequently provided in the family home. 

Without respite care, family caregivers who are 

forced to stay at home to provide care experience 

significant stress, loss of employment, financial 

burdens, and marital difficulties. Many caregivers 

report that it is unsafe to leave their family 

members at home alone; they are unable to leave 

their family members with another relative; and 

they face barriers in accessing generic day care or 

companion services. A demonstration would 

expand the ability of States to develop respite care 

service alternatives outside the scope of an HCBS 

waiver and test the financial impact of this service. 

The Commission also recommends that CMS 

work with relevant HHS components and other 

Federal agencies to explore and propose 

demonstrations for future fiscal years to address 

the following areas: 

• The Institutions for Mental Diseases (IMDs) 

exclusion be addressed within Medicaid reform 

efforts, including issues such as Home and 

Community-based Services Demonstration as 

an alternative to IMDs or a redefinition of IMDs 

and the services funded, and 

• Self-directed services and supports for people 

with mental illnesses.

Make Supported Employment 

Services Widely Available 

Every adult served in the mental health system and 

every young person with serious emotional 

disturbances making the transition from school to 

work must have access to supported employment 

services if they are to participate fully in society. 

 Most vocational rehabilitation services 

are ineffective for the small 

proportion of people with mental 

illnesses who manage to get them.

Disturbingly, most vocational rehabilitation 

services are ineffective for the small proportion of 

people with mental illnesses who manage to get 

them. Traditional vocational services that most 

vocational rehabilitation programs offer are far 

less effective for people with serious mental 

illnesses than a widely researched approach known 

as supported employment. Supported employment 

programs assign an employment specialist to the 

treatment team. That specialist helps consumers by 

conducting assessments and rapid job searches, 

and by providing ongoing, on-the-job support. 

Studies of supported employment show that 60% 

to 80% of people with serious mentally illnesses 

obtain at least one competitive job (compared to 

19% who remained in traditional vocational 

programs) — a clear success rate.54 The cost of 

supported employment is similar to that of 

traditional vocational services. (See Figure 2.2.) 
41

FIGURE 2.2. MODEL PROGRAM: Supported Employment for People with Serious Mental Illnesses 

Goal To secure employment quickly and efficiently for people with mental illnesses. 

Alarmingly, only about one-third of people with mental illnesses are employed,53

yet most wish to work. 

Features An employment specialist on a mental health treatment team. The employment 

specialist collaborates with clinicians to make sure that employment is part of 

the treatment plan. Then the specialist conducts assessments and rapid job 

searches and provides ongoing support while the consumer is on the job. 

Outcomes In general, about 60% to 80% of those served by the supported employment 

model obtain at least one competitive job, according to findings from three 

randomized controlled trials in New Hampshire; Washington, DC; and 

Baltimore.55 Those trials find the supported employment model far superior to 

traditional programs that include prevocational training. The cost of the 

supported employment model is no greater than that for traditional programs, 

suggesting that supported employment is cost-effective. 

Biggest challenge To move away from traditional partial hospital programs, which are ineffective 

at achieving employment outcomes but are still reimbursable under Medicaid. 

How other 

organizations can 

adopt 

Restructure State and Federal programs to pay for evidence-based practices, 

such as Individual Placement and Support (IPS)55 that help consumers achieve 

employment goals rather than pay for ineffective, traditional day treatment 

programs that do not support employment. 

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

countries 

Even though supported employment is effective, 

few people with mental illnesses receive these 

services. One reason is that individuals with 

psychiatric disabilities often receive services that 

may be called “supported employment,” but are 

supported employment in name only. These 

vocational services lack the key ingredients that 

make supportive employment effective. 

Additionally, State-Federal vocational 

rehabilitation services are funded for limited time 

periods and do not pay for ongoing job support 

(other than a “post-employment services” status 

that is rarely used). Similarly, Medicaid does not 

reimburse for most vocational rehabilitation 

services. Thus, the lack of available financing 

mechanisms and the inadequately implemented 

supported employment models are barriers that 

prevent people with mental illnesses from 

benefiting from supported employment. 

 Studies of supported employment 

show that 60% to 80% of people with 

serious mentally illnesses obtain at 

least one competitive job — a clear 

success rate. 

The Commission recommends strengthening and 

expanding supported employment services, such 

as Individualized Placement and Support,55 to all 

people with psychiatric disabilities. The system 

must make opportunities for supported 

employment available for anyone who wants to 

participate. To make supported employment 

services more widely available, the Commission 

urges CMS to provide technical assistance to 

States on how to effectively use the Medicaid 
42

Rehabilitation Services Option to fund those 

components of supported employment that are 

consistent with Medicaid policy. The Commission 

encourages the Social Security Administration to 

evaluate the possibility of removing disincentives 

to employment in both the SSI and SSDI 

programs. 

The Commission encourages States to use 

Medicaid Buy-In legislation to extend Medicaid 

coverage to disabled individuals who are working. 

The widespread use of supported employment, 

coupled with the reduced disincentive to 

employment, could result in productive work and 

independence for consumers while accruing 

enormous cost-savings in Federal disability 

payments. Additionally, CMS and SSA should 

determine the feasibility of using savings accrued 

by SSA as beneficiaries go back to work to offset 

increased State and Federal Medicaid costs. 

CMS and SSA should launch a national campaign to 

encourage States to use this powerful incentive to 

employment. The campaign should be designed to: 

• Reduce barriers to implementation; 

• Improve SSA and CMS communication; and 

• Promote education and outreach to consumers, 

youth, families, vocational rehabilitation 

counselors, and community rehabilitation 

programs. 

The Commission recommends developing a 

Federal-State interagency initiative involving all 

Federal agencies that are charged with addressing 

mental health, employment, and disability issues. 

Through this initiative, agencies can: 

• Collaborate to inventory and assess existing 

Federal programs, 

• Better coordinate the administration of these 

programs, and 

• Promote interagency demonstration projects 

that are designed to eliminate employment 

barriers and increase employment 

opportunities for youth and adults with mental 

illnesses. 

Make Housing with Supports 

Widely Available 

The Commission believes it is essential to address 

the serious housing affordability problems of people 

with severe mental illnesses who have extremely 

low incomes. Progress toward this objective will 

significantly advance the goal of ending chronic 

homelessness and will have a great impact on the 

crisis of inadequate housing and homelessness for 

people with severe mental illnesses. 

Research shows that consumers are much more 

responsive to accepting treatment after they have 

housing in place.91 People with mental illnesses 

consistently report that they prefer an approach 

that focuses on providing housing for consumers 

or families first. However, affordable housing 

alone is insufficient. Flexible, mobile, 

individualized support services are also necessary 

to support and sustain consumers in their housing. 

Many consumers have troubled tenant histories 

and higher rates of incarceration — both of which 

can lead to long-term ineligibility for Federal 

housing programs, such as Section 8 vouchers and 

public housing. In addition, access to ongoing 

support services is limited 

 Research shows that consumers are 

much more responsive to accepting 

treatment after they have housing in 

place. 

Research and demonstration programs have 

documented the effectiveness of the supportive 

housing model for people with serious mental 

illnesses.92; 93 Research has also found that 

permanent supportive housing can be cost 

effective when compared to the cost of 

homelessness.94 For example, a University of 

Pennsylvania study found that homeless people 

with mental illnesses who were placed in 

permanent supportive housing cost the public 

$16,282 less per person per year compared to their 

previous costs for mental health, corrections, 

Medicaid, and public institutions and shelters.92
43

The Commission recommends making affordable 

housing more accessible to people with serious 

mental illnesses and ending chronic homelessness 

among this population. To begin, in partnership 

with the Interagency Council on Homelessness 

(comprising 20 Federal agencies), the Department 

of Housing and Urban Development (HUD) 

should develop and implement a comprehensive 

plan designed to facilitate access to 150,000 units 

of permanent supportive housing for consumers 

and families who are chronically homeless. During 

the next ten years, this initiative should develop 

specific cost-effective approaches, strategies, 

technical assistance activities, and actions to be 

implemented at the Federal, State, and local levels. 

Expanding and ensuring a continuum of housing 

services would represent positive elements to 

include in such a plan. The Commission 

recommends that individuals who have a history 

of serious mental illnesses be given fair access to 

these 150,000 units of supportive housing. 

The Commission recommends that States and 

communities commit to the goal of ending chronic 

homelessness and develop the means to achieve it. 

The Commission recognizes that national 

leadership must make a concerted effort to address 

the problem of homelessness and lack of 

affordable housing among people with serious 

mental illnesses. The Commission urges HUD to 

collaborate with HHS, VA, and other relevant 

agencies to provide leadership to States and local 

communities to improve housing opportunities for 

this population. HUD should aggressively pursue 

administrative, regulatory, and statutory changes 

to existing mainstream housing programs; e.g., 

Section 811 Supportive Housing. Input from 

stakeholders to identify existing barriers to 

accessing housing should be an integral part of 

HUD’s considerations. 

Address Mental Health 

Problems in the Criminal Justice 

and Juvenile Justice Systems 

Providing adequate services in correctional 

facilities for people with serious mental illnesses 

who do need to be there is both prudent and 

required by law. The Eighth Amendment of the 

U.S. Constitution protects the right to treatment 

for acute medical problems, including psychiatric 

problems, for inmates and detainees in America’s 

prisons and jails. Professional organizations have 

published guidelines for mental health care in 

correctional settings and some States have 

implemented them.69; 95-97

All too often, people are misdiagnosed or not 

diagnosed with the root problem of mental illnesses. 

It is important to keep adults and youth with serious 

mental illnesses who are not criminals out of the 

criminal justice system. Too often, the criminal 

justice system unnecessarily becomes a primary 

source for mental health care. The potential for 

recovery for the offender with a mental illness is too 

frequently derailed by inadequate care and the 

superimposed stigma of a criminal record. Cost 

studies suggest that taxpayers can save money by 

placing people into mental health and substance 

abuse treatment programs instead of in jails and 

prisons.98; 99 With the appropriate diversion and reentry programs, these consumers could be 

successfully living in and contributing to their 

communities. Many non-violent offenders with 

mental illnesses could be diverted to more 

appropriate and typically less expensive supervised 

community care. Proven models exist for diversion 

programs operating in many areas around the 

country. 

 Too often, the criminal justice system 

unnecessarily becomes a primary 

source for mental health care. 

Unfortunately, one of the groups most isolated from 

society are those consumers who attempt to return to 

the community after being incarcerated. Linking 

people with serious mental illnesses to communitybased services — and in the case of youth, also to 

educational services — when they are diverted or 

released from jails or prisons through re-entry 

transition programs is an important strategy to reintegrate consumers into their communities. 

The Commission recommends widely adopting 

adult criminal justice and juvenile justice diversion 

and re-entry strategies to avoid the unnecessary 

criminalization and extended incarceration of nonviolent adult and juvenile offenders with mental 
44

illnesses. HHS and the Department of Justice, in 

consultation with the Department of Education, 

should provide Federal leadership to help States 

and local communities develop, implement, and 

monitor a range of adult and youth diversion and 

re-entry strategies. 

RECOMMENDATION 2.4 Create a Comprehensive State Mental Health Plan. 

Create Comprehensive State 

Mental Health Plans to 

Coordinate Services 

The Commission envisions that developing and 

using Comprehensive State Mental Health Plans 

will greatly facilitate new partnerships among the 

Federal, State, and local governments to better use 

existing resources for people with mental illnesses. 

Incorporating the principles in this report, at the 

very least, the plan should: 

• Increase the flexibility of resource use at the 

State and local levels, encouraging innovative 

uses of Federal funding and flexibility in 

setting eligibility requirements; 

• Have State and local levels of government be 

more accountable for results, not solely to 

Federal funding agencies, but to consumers 

and families as well; and 

• Expand the options and the array of services 

and supports. 

To accomplish this change, the Federal 

government must reassess pertinent financing and 

eligibility policies and align reporting 

requirements to avoid duplication, promote 

consistency, and seek accountability from the 

States. 

The underlying premise of the Commission’s 

support for Comprehensive State Mental Health 

Plans is consistent with the principles of 

Federalism — providing incentives to States by 

granting increased flexibility in exchange for 

greater accountability and improved outcomes. 

For example, California’s AB-34 program, 

designed to meet the needs of adults with mental 

illnesses who are homeless, demonstrates that 

services provided through programs that allow 

flexibility in financing care do, indeed, produce 

positive outcomes that benefit individuals, 

families, and society while most efficiently using 

resources. (See Figure 2.3.) 

The intended outcome of Comprehensive State 

Mental Health Plans is to encourage States and 

localities to develop a comprehensive strategy to 

respond to the needs and preferences of consumers 

or families. 

The Commission recommends that each State, 

Territory, and the District of Columbia develop a 

Comprehensive State Mental Health Plan. The 

plans will have a powerful impact on overcoming 

the problems of fragmentation in the system and 

will provide important opportunities for States to 

leverage resources across multiple agencies that 

administer both State and Federal dollars. The 

Office of the Governor should coordinate each 

plan. The planning process should support a 

dialogue among all stakeholders and reach beyond 

the traditional State mental health agency to 

address the full range of treatment and support 

service programs that consumers and families 

need. The final result should be an extensive and 

coordinated State system of services and supports 

that work to foster consumer independence and 

their ability to live, work, learn, and participate 

fully in their communities. 
45

FIGURE 2.3. MODEL PROGRAM: Integrated Services for Homeless Adults with Serious Mental 

Illnesses 

Program AB-34 Projects — Named after California Legislation of 2000 

Goal To “do whatever it takes” to meet the needs of homeless persons with serious 

mental illnesses, whether on the street, under a bridge, or in jail. 

Features Outreach (often by formerly homeless people), comprehensive services, 24/7 

availability, partnerships with community providers, and real-time evaluation. 

Flexible funding, not driven by eligibility requirements. 

Outcomes 66% decrease in number of days of psychiatric hospitalization, 82% decrease in 

days of incarceration, and 80% fewer days of homelessness.100

Biggest challenge To change the culture, attitudes, and values around treating difficult 

populations with different strategies. Traditional services and providers tend to 

want to continue “business as usual” and follow funding streams rather than 

integrate services or share responsibility. 

How other 

organizations can 

adopt 

Change infrastructure to integrate services. This concept is a different way of 

doing business and requires links to a broader array of services, not just mental 

health. 

Web sites www.ab34.org (The web site is currently being developed and will be expanded 

soon.) 

www.dmh.ca.gov (click on Community Mental Health Services, Homeless 

Mentally Ill Programs, and then Integrated Services for the Homeless Mentally 

Ill. 

Sites 38 California counties 

RECOMMENDATION 2.5 Protect and enhance the rights of people with mental 

illnesses. 

Protect and Enhance Consumer 

and Family Rights 

The Commission strongly endorses protecting and 

enhancing the rights of people with serious mental 

illnesses and children with serious emotional 

disturbances, particularly in the following four 

areas: 

• Fully integrating consumers into their 

communities under the Olmstead decision, 

• Eliminating conditions under which parents 

must forfeit parental rights so that their 

children with serious emotional disturbances 

can receive adequate mental health treatment, 

• Eliminating discrimination — especially in 

employment — based on past assignment of a 

psychiatric diagnosis or mental health 

treatment, and 

• Reducing the use of seclusion and restraint in 

mental health treatment settings. 

End Unnecessary 

Institutionalization 

The Commission calls for swiftly eliminating 

unnecessary and inappropriate institutionalization 

that severely limits integrating adults with serious 

mental illnesses and children with serious 

emotional disturbances into their communities. 
46

Federal, State, and local entities must continue to 

implement Olmstead and ensure full community 

integration for all individuals with psychiatric 

disabilities. The Commission urges the HHS 

Office for Civil Rights (OCR) to follow through 

on the current Olmstead voluntary compliance 

initiatives, including widely disseminating 

information about Olmstead compliance and 

promoting community care, technical assistance 

for States, and clarifying Medicaid policies that 

affect individuals with serious mental illnesses. 

Eliminate the Need to Trade 

Custody for Mental Health Care 

The Commission is resolved that Federal, State, 

and local governments must work together with 

family and provider organizations to eliminate the 

practice of trading custody for care and to find a 

more family-friendly solution. One way to correct 

this appalling circumstance and allow children to 

stay with their families is to provide familycentered services. 

The Commission endorses the General Accounting 

Office’s recommendation: 

“The Departments of Health and Human 

Services (HHS) and Justice (DOJ) should 

consider the feasibility of tracking 

children placed by their parents in the 

child welfare and juvenile justice systems 

to obtain mental health services. HHS, 

DOJ, and the Department of Education 

(Education) should develop an 

interagency working group to identify the 

causes of the misunderstandings at the 

State and local levels and create an 

action plan to address those causes. 

These agencies should also continue to 

encourage States to evaluate the 

programs that the States fund or initiate 

and determine the most effective means 

of disseminating the results of these and 

other available studies.”101 

If States reallocated the funds that currently pay 

for inappropriate services toward more appropriate 

mental health treatment and supports, more 

children could remain with their families. Not only 

would this shift of funds and services better help 

the children toward their own recovery, but it 

would also use resources more wisely. 

End Employment Discrimination 

The Commission acknowledges the need to 

eliminate employment discrimination in any form; 

it is too often based on current or past psychiatric 

diagnosis or mental health treatment. In particular, 

the Commission recommends strong national 

leadership to end employment discrimination 

against people with psychiatric disabilities in the 

public and private sectors. 

All levels of Federal, State, and local government 

should review their employment policies to 

eradicate discriminatory practices on the basis of 

mental health treatment or diagnosis. A great 

opportunity exists for all levels of government and 

the private sector to serve as models by hiring 

individuals with disabilities. 

Reduce the Use of Seclusion and 

Restraint 

The Commission notes that professionals agree 

that the best way to reduce restraint deaths and 

injuries is to minimize restraint use as much as 

possible. High restraint rates are seen as evidence 

of treatment failure. 

The Commission endorses reducing the use of 

seclusion and restraint and, when such 

interventions are used, appropriately trained 

personnel should administer them as safely and 

humanely as possible. It is also important to apply 

preventive measures (e.g., de-escalation 

techniques) that will minimize the need to use 

seclusion and restraint. 

Many facilities and State agencies have had 

substantial success in reducing the use of restraint, 

while also reducing staff and patient injuries. 

However, much work remains for both institutional 

and community settings before this cultural change 

can fully occur. Leadership to continue these 

important changes will move us closer to a 

transformed mental health system that is defined by 

respect, compassion, and collaborative partnerships 

with the people it serves. 
47

The Commission recommends that States have 

mechanisms to: 

• Report deaths and serious injuries resulting 

from the use of seclusion and restraint, 

• Ensure that they investigate these incidents, 

and 

• Track patterns of seclusion and restraint use. 

To encourage frank and complete assessments and 

to ensure the individual’s confidentiality, these 

internal reviews should be protected from 

disclosure. 

The Commission recognizes that to decrease the 

use of seclusion and restraint, policies and facility 

guidelines must be developed collaboratively with 

input from consumers, families, treatment 

professionals, facility staff, and advocacy groups. 

Supporting technical assistance, staff training, and 

consumer/peer-delivered training and involvement 

should be implemented to effectively improve and 

implement policies and guidelines based on 

research about seclusion and restraint. To improve 

the quality of care and ensure positive outcomes, 

model programs and best practices must be 

identified and information must be shared. 
48
49

GOAL 3 Disparities in Mental Health Services

Are Eliminated.

RECOMMENDATIONS

3.1 Improve access to quality care that is culturally 

competent. 

3.2 Improve access to quality care in rural and 

geographically remote areas. 

Understanding the Goal 

Minority Populations Are 

Underserved in the Current 

Mental Health System 

Racial and ethnic minority Americans comprise a 

substantial and vibrant segment of the U.S. 

population, enriching our society with many 

unique strengths, cultural traditions, and important 

contributions. As a segment of the overall 

population, these groups are growing rapidly; 

current projections show that by 2025, they will 

account for more than 40% of all Americans.102 

Unfortunately, the mental health system has not 

kept pace with the diverse needs of racial and 

ethnic minorities, often underserving or 

inappropriately serving them. Specifically, the 

system has neglected to incorporate respect or 

understanding of the histories, traditions, beliefs, 

languages, and value systems of culturally diverse 

groups. Misunderstanding and misinterpreting 

behaviors have led to tragic consequences, 

including inappropriately placing minorities in the 

criminal and juvenile justice systems. 

While bold efforts to improve services for 

culturally diverse populations currently are 

underway, significant barriers still remain in 

access, quality, and outcomes of care for 

minorities. As a result, American Indians, Alaska 

Natives, African Americans, Asian Americans, 

Pacific Islanders, and Hispanic Americans bear a 

disproportionately high burden of disability from 

mental disorders. This higher burden does not 

arise from a greater prevalence or severity of 

illnesses in these populations. Rather it stems from 

receiving less care and poorer quality of care.16

 The mental health system has not 

kept pace with the diverse needs of 

racial and ethnic minorities, often 

underserving or inappropriately 

serving them. 

Receiving appropriate mental health care depends 

on accurate diagnosis. Racial and ethnic 

minorities’ higher rates of misdiagnosis may 

contribute to their greater burden of disability. For 

instance, African Americans are more likely to be 

overdiagnosed for schizophrenia and underdiagnosed for depression.16 To compound this 

problem, physicians are less likely to prescribe 

newer generation antidepressant or antipsychotic 

medications to African American consumers who 

need them.103

The report, Mental Health: Culture, Race and 

Ethnicity, A Supplement to Mental Health: A 

Report of the Surgeon General, highlighted 
50

striking disparities in mental health services for 

racial and ethnic minority populations. For 

example, these populations: 

• Are less likely to have access to available 

mental health services, 

• Are less likely to receive needed mental health 

care, 

• Often receive poorer quality care, and 

• Are significantly under-represented in mental 

health research.16 

Minorities Face Barriers to 

Receiving Appropriate Mental 

Health Care 

Although many barriers deter minority populations 

from accessing and receiving proper treatment, 

some barriers are shared by all populations. For 

instance, all populations with mental disorders are 

affected by fragmented services, unavailable 

services, and high costs, as well as societal stigma. 

However, additional barriers prevent racial and 

ethnic minorities from seeking services, including: 

• Mistrust and fear of treatment; 

• Different cultural ideas about illnesses and 

health; 

• Differences in help-seeking behaviors, 

language, and communication patterns; 

• Racism; 

• Varying rates of being uninsured; and 

• Discrimination by individuals and 

institutions.16

 Racial and ethnic minorities are 

seriously under-represented in the 

core mental health professions. 

Cultural Issues Also Affect Service 

Providers 

Cultural issues affect not only those who seek help 

but also those who provide services. Each group of 

providers embodies a culture of shared beliefs, 

norms, values, and patterns of communication. 

They may perceive mental health, social support, 

diagnosis, assessment, and intervention for 

disorders in ways that are both different from one 

another and different from the culture of the 

person seeking help. 

While professionals of all racial and ethnic 

backgrounds can and do deliver culturally 

competent care, much of the existing workforce is 

inadequately trained in this area. Racial and ethnic 

minorities are seriously under-represented in the 

core mental health professions, many providers are 

inadequately prepared to serve culturally diverse 

populations, and investigators are not trained in 

research on minority populations.104; 105 

Without concerted efforts to remedy this problem, 

the shortage of providers and researchers will 

intensify the disproportionate burden of mental 

disorders on racial and ethnic minorities. With the 

rapid growth in minority populations, disparities 

will deepen if they are not systemically and 

urgently addressed. 

Rural America Needs Improved 

Access to Mental Health 

Services 

The vast majority of all Americans living in 

underserved, rural, and remote areas also 

experience disparities in mental health services. 

Rural America makes up 90% of our Nation’s 

landmass and is home to approximately 25% of 

the U.S. population.102 Despite these proportions, 

rural issues are often misunderstood, minimized, 

and not considered in forming national mental 

health policy. Too often, policies and practices 

developed for metropolitan areas are erroneously 

assumed to apply to rural areas. 
51

 Access to mental health care, 

attitudes toward mental illnesses, and 

cultural issues that influence whether 

people seek and receive care differ 

profoundly between rural and urban 

areas. 

While the prevalence and incidence of serious 

mental illnesses among adults and serious 

emotional disturbances for children are similar in 

rural and urban areas,106 the experience of 

individuals in those areas differs in important 

ways. In rural and other geographically remote 

areas, many people with mental illnesses have 

inadequate access to care, limited availability of 

skilled care providers, lower family incomes, and 

greater social stigma for seeking mental health 

treatment than their urban counterparts.5; 107 As a 

result, rural residents with mental health needs: 

• Enter care later in the course of their disease 

than their urban peers, 

• Enter care with more serious, persistent, and 

disabling symptoms, and 

• Require more expensive and intensive 

treatment response.108 

For rural racial and ethnic minorities, these 

problems are compounded by their minority status 

and the dearth of culturally competent or bilingual 

providers in these medically underserved areas. 

Compounding the problems of availability and 

access is the fact that rural Americans have lower 

family incomes and are less likely to have private 

health insurance benefits for mental health care 

than their urban counterparts.109 Lack of coverage 

often occurs because small groups and individual 

purchasers dominate the rural health insurance 

marketplace, so insurance policies are more likely 

to have large deductibles and limited or no mental 

health coverage.109 

Rural residents also have longer periods without 

insurance coverage than their urban peers and are 

less likely to seek services when they cannot pay 

for them.110 For many rural Americans, the cost of 

mental health services — particularly prescription 

drugs — may be too high. 

Rural areas also suffer from chronic shortages of 

mental health professionals. Virtually all of the 

rural counties in this country have a shortage of 

practicing psychiatrists, psychologists, and social 

workers.111 Of the 1,669 Federally designated 

mental health professional shortage areas, more 

than 85% are rural.112 These professional shortage 

problems are even worse for children and older 

adults.111 

In addition, many primary care providers who 

work in rural areas are unprepared to diagnose or 

treat mental illnesses. Where general health 

providers in rural areas often use physician 

extenders, mental health extenders are not yet 

widely used. Where they are available, their 

services are frequently not reimbursed by 

insurance. 

Another problem is that suicide rates are 

significantly higher among older men and Native 

American youth who live in rural areas. The rate 

of suicide appears to increase as the population 

becomes more rural.21; 108; 113 While several factors 

may contribute to this phenomenon, researchers 

have yet to conduct in-depth analyses and studies 

across different geographic settings. 

However, one certainty is that access to mental 

health care, attitudes toward mental illnesses, and 

cultural issues that influence whether people seek 

and receive care differ profoundly between rural 

and urban areas. 
52

Achieving the Goal 

RECOMMENDATION 3.1 Improve access to quality care that is culturally 

competent 

Culturally Competent Services 

Are Essential to Improve the 

Mental Health System 

Culturally competent services are “the delivery of 

services that are responsive to the cultural 

concerns of racial and ethnic minority groups, 

including their language, histories, traditions, 

beliefs, and values.”16 Cultural competence in 

mental health is a general approach to delivering 

services that recognizes, incorporates, practices, 

and values cultural diversity. Its basic objectives 

are to ensure quality services for culturally diverse 

populations, including culturally appropriate 

prevention, outreach, service location, 

engagement, assessment, and intervention.16 

Despite widespread use of the concept of cultural 

competence, research on putting the concept into 

practice and measuring its effectiveness is lacking. 

While critical indicators and standards for 

culturally competent care have been available for 

several years, the field has yet to systematically 

apply, measure, and link these standards to 

treatment outcomes. In addition, implementing 

these standards in the public sector has been slow. 

Culturally competent services —

the delivery of services that are 

responsive to the cultural concerns 

of racial and ethnic minority groups, 

including their language, histories, 

traditions, beliefs, and values. 

Nevertheless, many in the mental health field 

consider cultural competence to be essential to 

ensure quality of care, responsiveness of services, 

and renewed hope for recovery among ethnic and 

racial minorities. Empirical research is needed to 

assess the effectiveness of culturally competent 

practices. (See Goal 5.) 

Meanwhile, mental health systems can respond to 

the needs of ethnic and racial minority populations 

by implementing existing standards, thus building 

trust, increasing cultural awareness, and responding 

to cultural and linguistic differences. In fact, 

programs that reflect the demographics, diversity, 

and values of a community—as shown by the Dallas 

school-based mental health model—are more likely 

to engage and keep racial and ethnic minorities in 

mental health services. (See Figure 3.1.) 

The Commission recommends that States address 

and monitor racial and ethnic disparities in access, 

availability, quality, and outcomes of mental 

health services as part of their Comprehensive 

State Mental Health Plans. (See Goal 2.) This 

State-level strategic effort should include: 

• Setting standards for culturally competent care; 

• Collecting data to identify points of disparity; 

• Evaluating services for effectiveness and 

consumer satisfaction; 

• Developing collaborative relationships with 

culturally driven, community-based providers; 

and 

• Establishing benchmarks and performance 

measures. 

In addition, State plans should promote increased 

opportunities to include individuals from diverse 

cultural backgrounds in the mental health 

workforce. These opportunities should reflect the 

changing demographics and needs of communities 

for culturally and linguistically competent providers. 
53

FIGURE 3.1. MODEL PROGRAM: A Culturally Competent School-Based Mental Health Program

Program Dallas School-based Youth and Family Centers 

Goal To establish the first comprehensive, culturally competent, school-based 

program in mental health care in the 12th largest school system in the Nation. 

The program overcomes stigma and inadequate access to care for underserved 

minority populations. 

Features Annually serves the physical and mental health care needs of 3,000 low-income 

children and their families. The mental health component features partnerships 

with parents and families, treatment (typically 6 sessions), and follow-up with 

teachers. The well-qualified staff, who reflect the racial and ethnic composition 

of the population they serve (more than 70% Latino and African American), train 

school nurses, counselors, and principals to identify problems and create 

solutions tailored to meet each child’s needs. 

Outcomes Improvements in attendance, discipline referrals, and teacher evaluation of 

child performance. 114 Preliminary findings reveal improvement in children’s 

standardized test scores in relation to national and local norms. 

Biggest challenge To sustain financial and organizational support of collaborative partners despite 

resistance to change or jurisdictional barriers. Program’s $3.5 million funding 

comes from the school district and an additional $1.5 million from Parkland 

Hospital. 

How other 

organizations 

can adopt 

Recognize the importance of mental health for the school success of all 

children, regardless of race or ethnicity. Rethink how school systems can more 

efficiently partner with and use State and Federal funds to deliver culturally 

competent school-based mental health services. 

Sites Dallas and Fort Worth, Texas 

Finally, emerging evidence shows that 

collaborative efforts to bridge community health 

and mental health services are effective in the 

outreach, identification, engagement, and 

treatment for racial and ethnic minorities with 

mental illnesses.16 Accordingly, national 

leadership is needed to improve the training of 

general medical practitioners and specialty mental 

health practitioners in caring for consumers at the 

intersection of these two parts of our overall health 

care system. 

Therefore, the Commission recommends making 

strong efforts to recruit, retain, and enhance an 

ethnically, culturally, and linguistically competent 

mental health workforce throughout the country. 

The Commission encourages government 

agencies, colleges, universities, professional 

associations, and minority advocacy groups to 

work together to address the workforce crisis in 

mental health services for racial and ethnic 

minority populations, especially for youth and 

their families. These efforts could include: 

• Recruiting and retaining racial and ethnic 

minority and bilingual professionals; 

• Developing and including curricula that 

address the impact of culture, race, and 

ethnicity on mental health and mental 

illnesses, on help-seeking behaviors, and on 

service use; 

• Training and research programs targeting 

services to multicultural populations; 

• Funding these training programs; and 

• Engaging minority consumers and families in 

workforce development, training, and 

advocacy. 
54

The Commission recommends forming publicprivate partnerships for pre-service and in-service 

training. All Federally funded health and mental 

health training programs should explicitly include 

cultural competence in their curricula and training 

experiences. (See Goal 5 for a broader 

recommendation on the mental health workforce.) 

 The Commission recommends making 

strong efforts to recruit, retain, and 

enhance an ethnically, culturally, and 

linguistically competent mental health 

workforce throughout the country. 

Given the significant role of faith-based 

organizations and leaders in the lives of many 

people, including ethnic and racial minorities, the 

Commission recommends enlisting their support 

and partnership in mental health care. This effort 

would involve working with the faith communities 

and leaders to help: 

• Increase understanding of mental and physical 

health in their communities, 

• Reduce stigma associated with mental 

disorders and problems, 

• Encourage individuals and families to seek 

help, 

• Collaborate with mental health providers, and 

• When necessary, link people with appropriate 

services. 

These faith-based leaders also may be critical in 

helping the mental health system and providers 

better understand the community. 

RECOMMENDATION 3.2 Improve access to quality care in rural and geographically 

remote areas. 

Rural Needs Must Be Met 

To address the specific needs of the rural and 

geographically remote communities, the 

Commission encourages the U.S. Department of 

Health and Human Services (HHS) to convene a 

cross-agency workgroup to examine rural 

workforce issues to: 

• Study current Federal workforce enhancement 

programs, 

• Encourage a collaborative focus on rural 

mental health needs, and 

• Oversee development of a rural mental health 

workforce strategy that includes using and 

supporting mid-level and alternative providers 

of mental health services. 

The Commission recommends that the Substance 

Abuse and Mental Health Services Administration 

(SAMHSA) and the Health Resources and 

Services Administration (HRSA) collaborate to 

support the training, deployment, and continuing 

education of rural mental health professionals. 

Such efforts should focus on strengthening the 

capacity and competency of the workforce to 

sustain an evidence-based service delivery system. 

(Also see Goals 5 and 6.) 

In addition, the Commission recommends 

developing a Rural Mental Health Plan with 

specific, measurable targets and benchmarks. An 

important goal for this plan would be to fully 

integrate mental health into the existing 

infrastructure for rural public health. SAMHSA 

and HRSA should fully participate in developing 

this plan and should carefully consider the 

recommendations of the HHS Rural Task Force 

and the Initiative on Rural America. This national 

plan should closely align with States’ 

Comprehensive Mental Health Plans. (See 

Recommendation 2.4.) 

The Commission recommends that rural 

Americans receive increased access to mental 

health emergency response, early identification 

and screening, diagnosis, treatment and recovery 

services. 

The Commission recognizes that affordable 

mental health care is a critical issue for rural 
55

communities and residents. Federal and State 

agencies should explore policy options that enable 

rural individuals and small businesses to enter 

pools to purchase insurance so that they gain 

access to more affordable, high quality, health 

insurance. In addition, Federal agencies should 

ensure that new funding announcements do not 

place unrealistic non-Federal matching fund 

requirements on rural entities. 

The emergence of telehealth offers access to care. 

Telehealth is using electronic information and 

telecommunications technologies to provide longdistance clinical health care, patient and 

professional health-related education, public 

health, and health administration. (See Goal 6.)

The Commission recommends that SAMHSA, 

HRSA, and the National Institutes of Health fund 

demonstration grants in rural areas to provide and 

evaluate the effectiveness of mental health 

services delivered by distant providers through 

new technologies. Enhanced coordination between 

funded telehealth systems and public mental health 

systems must be promoted. 

The Commission supports this technology as one 

of the most promising means of improving access 

to specialty mental health care in underserved 

rural areas. 
56
57

GOAL 4 

Early Mental Health Screening,

Assessment, and Referral to Services

Are Common Practice.

RECOMMENDATIONS

4.1 Promote the mental health of young children. 

4.2 Improve and expand school mental health programs. 

4.3 Screen for co-occurring mental and substance use 

disorders and link with integrated treatment 

strategies. 

4.4 Screen for mental disorders in primary health care, 

across the life span, and connect to treatment and 

supports. 

Understanding the Goal 

Early Assessment and 

Treatment Are Critical Across 

the Life Span 

For consumers of all ages, early detection, 

assessment, and linkage with treatment and 

supports can prevent mental health problems from 

compounding and poor life outcomes from 

accumulating. Early intervention can have a 

significant impact on the lives of children and 

adults who experience mental health problems. 

Emerging research indicates that intervening early 

can interrupt the negative course of some mental 

illnesses and may, in some cases, lessen long-term 

disability. New understanding of the brain 

indicates that early identification and intervention 

can sharply improve outcomes and that longer 

periods of abnormal thoughts and behavior have 

cumulative effects and can limit capacity for 

recovery.115 

If Untreated, Childhood 

Disorders Can Lead to a 

Downward Spiral 

Early childhood is a critical period for the onset of 

emotional and behavioral impairments.115 In 1997, 

the latest data available, nearly 120,000 

preschoolers under the age of six — or 1 out of 200 

— received mental health services.116 Each year, 

young children are expelled from preschools and 

childcare facilities for severely disruptive behaviors 

and emotional disorders. 

Since children develop rapidly, delivering mental 

health services and supports early and swiftly is 

necessary to avoid permanent consequences and to 

ensure that children are ready for school. 

Emerging neuroscience highlights the ability of 

environmental factors to shape brain development 

and related behavior. Consequently, early 

detection, assessment, and links with treatment 

and supports can prevent mental health problems 

from worsening. 
58

Without intervention, child and adolescent 

disorders frequently continue into adulthood. For 

example, research shows that when children with 

co-existing depression and conduct disorders 

become adults, they tend to use more health care 

services and have higher health care costs than 

other adults.117 If the system does not 

appropriately screen and treat them early, these 

childhood disorders may persist and lead to a 

downward spiral of school failure, poor 

employment opportunities, and poverty in 

adulthood. No other illnesses damage so many 

children so seriously.118 

One of the many factors that can affect the 

emotional health of young children is the mental 

health status of their parents. For example, 

depression among young mothers has been shown 

to influence the mental health of their young 

children.119; 120 These findings are significant 

because mental disorders that occur before the age 

of six can interfere with critical emotional, 

cognitive, and physical development, and can 

predict a lifetime of problems in school, at home, 

and in the community.121 

 Early detection, assessment, and links 

with treatment and supports can 

prevent mental health problems from 

worsening. 

Schools Can Help Address 

Mental Health Problems 

Currently, no agency or system is clearly 

responsible or accountable for young people with 

serious emotional disturbances. They are 

invariably involved with more than one 

specialized service system, including mental 

health, special education, child welfare, juvenile 

justice, substance abuse, and health. 

The mission of public schools is to educate all 

students. However, children with serious 

emotional disturbances have the highest rates of 

school failure. Fifty percent of these students drop 

out of high school, compared to 30% of all 

students with disabilities.81 Schools are where 

children spend most of each day. While schools 

are primarily concerned with education, mental 

health is essential to learning as well as to social 

and emotional development. Because of this 

important interplay between emotional health and 

school success, schools must be partners in the 

mental health care of our children. 

Schools are in a key position to identify mental 

health problems early and to provide a link to 

appropriate services. Every day more than 52 

million students attend over 114,000 schools in the 

U.S. When combined with the six million adults 

working at those schools, almost one-fifth of the 

population passes through the Nation’s schools on 

any given weekday.122 Clearly, strong school 

mental health programs can attend to the health 

and behavioral concerns of students, reduce 

unnecessary pain and suffering, and help ensure 

academic achievement. 

People with Co-occurring 

Disorders Are Inadequately 

Served 

Early intervention and appropriate treatment can 

also reduce pain and suffering for children and 

adults who have or who are at risk for cooccurring mental and addictive disorders.115; 123

Seven to ten million people in the United States 

have at least one mental disorder in addition to an 

alcohol or drug abuse disorder.124; 125 Too often, 

these individuals are treated for only one of the 

two disorders — if they are treated at all. 

In his speech announcing the Commission, the 

President used an example that affirms this point. 

The President spoke of: 

“... a 14-year-old boy who started 

experimenting with drugs to ease his 

severe depression. This former honor 

student became a drug addict. He 

dropped out of school, was incarcerated 

six times in 16 years. Only two years 

ago, when he was 30 years old, did the 

doctors finally diagnose his condition as 

bipolar disorder, and he began a 

successful program ...” 
59

Co-occurring substance use and mental disorders 

can occur at any age. Research suggests that as 

many as half of the adults who have a diagnosable 

mental disorder will also have a substance use 

disorder at some point during their lifetime.106; 126 

A substantial number of children and adolescents 

also have co-occurring mental illnesses and 

substance use disorders.124 If one co-occurring 

disorder remains untreated, both usually get worse. 

Additional complications often arise, including the 

risk for other medical problems, unemployment, 

homelessness, incarceration, suicide, and 

separation from families and friends.124 

Older adults are at risk of developing both 

depression and alcohol dependence for perhaps the 

first time in their lives. This phase of the life cycle 

has new risk factors for both of these disorders. 

The number of older adults with mental illnesses is 

expected to double to 15 million in the next 30 

years.127 Mental illnesses have a significant impact 

on the health and functioning of older people and 

are associated with increased health care use and 

higher costs.128-130 The current mental health 

service system is inadequate and unprepared to 

address the needs associated with the anticipated 

growth in the number of older people requiring 

treatment for late-life mental disorders.127 

Individuals with co-occurring disorders challenge 

both clinicians and the treatment delivery system. 

They most frequently use the costliest services 

(emergency rooms, inpatient facilities, and 

outreach intensive services), and often have poor 

clinical outcomes.124 The combination of problems 

increases the severity of their psychiatric 

symptoms and the likelihood for suicide attempts, 

violent behaviors, legal problems, medical 

problems, and periods of homelessness.124 

Studies show that few providers or systems that 

treat mental illnesses or substance use disorders 

adequately address the problem of co-occurring 

disorders. Only 19% of people who have cooccurring serious mental illnesses and substance 

dependence disorders are treated for both 

disorders; 29% are not treated for either problem. 

For people with less serious mental illnesses and 

substance dependence problems, the pattern of 

under-treatment is even worse. Most (71%) 

receive no treatment; only 4% receive treatment 

for both disorders.124 The same pattern of undertreatment holds for youth with co-occurring 

disorders.131 

Widespread barriers impede effective treatment 

for people with co-occurring disorders at all levels, 

including Federal, State, and local governments, 

and individual treatment agencies. 

Mental Health Problems Are 

Not Adequately Addressed in 

Primary Care Settings 

People with mental health disorders are routinely 

seen in primary care settings. The Epidemiologic 

Catchment Area Study, conducted in the early 

1980s, found that while people with common 

mental illnesses had some contact with primary 

care services, few received specialty mental health 

care. About half of the care for common mental 

disorders is delivered in general medical settings.7; 

132; 133 Primary care providers actually prescribe 

the majority of psychotropic drugs for both 

children and adults. While primary care providers 

appear positioned to play a fundamental role in 

addressing mental illnesses, there are persistent 

problems in the areas of identification, treatment, 

and referral. 

Despite their prevalence, mental disorders often go 

undiagnosed, untreated, or under-treated in 

primary care. Primary care providers’ rates of 

recognition of mental health problems are still 

low, although the number identified is increasing. 

When mental illnesses are identified, they are not 

always adequately treated in the primary care 

setting, and referrals from primary care to 

specialty mental health treatment are often never 

completed. 

 Despite their prevalence, mental 

disorders often go undiagnosed, 

untreated, or under-treated in 

primary care. 
60

While effective treatments exist for most common 

mental disorders, studies have shown that many 

consumers seen in primary care settings do not 

receive them.7; 134 Even in the 1990s, most adults 

with depression, anxiety, and other common 

mental disorders did not receive appropriate care 

in primary care settings.7; 134 Older adults, children 

and adolescents, individuals from ethnic minority 

groups, and uninsured or low-income patients seen 

in the public sector are particularly unlikely to 

receive care for mental disorders.5; 16 

Of individuals who die by suicide, approximately 

90% had a mental disorder,21 and 40% of these 

individuals had visited their primary care doctor 

within the month before their suicide.135; 136 During 

visits in the primary care setting, the question of 

suicide was seldom raised. 

A significant percentage of patients in primary 

care shows signs of depression,137 yet up to half go 

undetected and untreated.138 This is especially 

problematic for women,139 people with a family 

history of depression,140 the unemployed,141 and 

those with chronic disease,141 all of whom are at 

increased risk for depression. 

 A significant percentage of patients in 

primary care shows signs of 

depression, yet up to half go 

undetected and untreated. 

Of all the children they see, primary care physicians 

identify about 19%with behavioral and emotional 

problems.142 While these providers frequently refer 

children for mental health treatment, significant 

barriers exist to referral, including lack of available 

specialists, insurance restrictions, appointment 

delays, and stigma. In one study, 59% of youth who 

were referred to specialty mental health care never 

made it to the specialist.142 

Finally, it is noteworthy that there is a parallel 

problem in specialty mental health care. Specialty 

mental health providers often have difficulty 

providing adequate medical care to consumers with 

co-existing mental and physical illnesses.124 Given 

that individuals with serious mental illnesses, such 

as schizophrenia, have high levels of nonpsychiatric medical illnesses and excess medical 

mortality, this is also a troubling situation.143 

Achieving the Goal 

RECOMMENDATION 4.1 Promote the mental health of young children. 

Early Detection Can Reduce 

Mental Health Problems 

Early detection and treatment of mental disorders 

can result in a substantially shorter and less 

disabling course of illness.144; 145 As the mental 

health field becomes increasingly able to identify 

the early antecedents of mental illnesses at any 

age, interventions must be implemented, provided 

in multiple settings, and connected to treatment 

and supports. 

Early interventions, such as the Nurse-Family 

Partnership (See Figure 4.1.), and educational 

efforts can help a greater number of parents, the 

public, and providers learn about the importance 

of the first years of a child’s life and how to 

establish a foundation for healthy social and 

emotional development. 

Quality screening and early intervention should 

occur in readily accessible, low-stigma settings, 

such as primary health care facilities and schools, 

and in settings where a high level of risk for 

mental health problems exists, such as juvenile 

justice and child welfare. 
61

FIGURE 4.1. MODEL PROGRAM: Intervening Early to Prevent Mental Health Problems 

Program Nurse-Family Partnership 

Goal To improve pregnancy outcomes by helping mothers adopt healthy behavior, 

improve child health and development, reduce child abuse and neglect, and 

improve families’ economic self-sufficiency. 

Features A nurse visits the homes of high-risk women when pregnancy begins and 

continues for the first year of the child’s life. The nurse adheres to visit-by-visit 

protocols to help women adopt healthy behaviors and to responsibly care for 

their children. In many states, Nurse-Family Partnership programs are funded as 

special projects or through State appropriations. 

Outcomes For mothers: 80% reduction in abuse of their children, 25% reduction in maternal 

substance abuse, and 83% increase in employment. For children (15 years later):

54% to 69% reduction in arrests and convictions, less risky behavior, and fewer 

school suspensions and destructive behaviors. This is the only prevention trial in 

the field with a randomized, controlled design and 15 years of follow-up. The 

program began in rural New York 20 years ago and its benefits have been 

replicated in Denver and in minority populations in Memphis.146-148

Biggest challenge To preserve the program’s core features as it grows nationwide. The key feature 

is a trained nurse, rather than a paraprofessional, who visits homes. A 

randomized, controlled trial found paraprofessionals to be ineffective.149

How other 

organizations can 

adopt 

Modify requirements of Federal programs, where indicated, to facilitate 

adopting this successful, cost-effective model. 

Sites 270 communities in 23 states. 

For additional 

information 

http://www.nccfc.org/nurseFamilyPartnership.cfm 

The Commission suggests a national focus on the 

mental health needs of young children and their 

families that includes screening, assessment, early 

intervention, treatment, training, and financing 

services. The national focus will: 

• Build on coordination mechanisms already in 

place, such as Part C of the Individuals with 

Disabilities Education Act (IDEA); and 

• Expand the coordination of services for 

children ages 3 through 21 for those who 

qualify for services under Part B of IDEA, 

thus building capacity for improved and 

increased services in communities. 

A coordinated, national approach to these issues 

will help eliminate social and emotional barriers to 

learning and will promote success in school and in 

other community settings for young children. This 

effort may involve collaborations among parents, 

mental health providers, and early childhood and 

child care programs. Other important dimensions 

of the approach will include: 

• Training a workforce skilled in treating young 

children and their families; 

• Training primary health providers to screen 

for and recognize early signs of emotional and 

behavioral problems and to offer connections 

to appropriate interventions; 

• Eliminating barriers to coverage, such as a 

required psychiatric diagnosis when an 

alternative diagnosis that minimizes labeling 

and stigma is more appropriate; and 

• Including “social and emotional check-ups” in 

primary health care. 
62

The IDEA specifically provides for a statewide, 

comprehensive, interagency system for early 

prevention services for children with disabilities 

from birth to 3 years old who have a 

developmental delay and physical, cognitive, 

communication, social or emotional, or adaptive 

development problem, or have a diagnosed 

physical or mental condition that has a high 

probability of resulting in a developmental delay. 

More effort is needed to heighten public 

awareness of the developmental requirements for 

children’s social and emotional well-being — just 

as public awareness of the early developmental 

and educational needs for reading skills has been 

increased through public and private initiatives. 

When children with disabilities reach age 3, they 

may be eligible for services under Part B of IDEA 

if they have one of the specified impairments and 

if, because of the impairment, they need special 

education and related services. However, services 

and other resources for children who have 

emotional and mental health issues are sometimes 

less readily available with respect to workforce, 

interventions, and financing, than other services, 

such as speech and language therapy or physical 

therapy. 

Addressing the mental health of young children 

may also involve providing information, supports, 

and treatment for parents. For the young child, 

treating the parents’ mental health problems also 

benefits the child.150 

RECOMMENDATION 4.2 Improve and expand school mental health programs. 

Schools Should Have the Ability 

to Play a Larger Role in Mental 

Health Care for Children 

Growing evidence shows that school mental health 

programs improve educational outcomes by 

decreasing absences, decreasing discipline 

referrals, and improving test scores.114 The key to 

improving academic achievement is to identify 

mental health problems early and, when needed, 

provide appropriate services or links to services. 

The extent, severity, and far-reaching 

consequences make it imperative that our Nation 

adopt a comprehensive, systematic approach to 

improving the mental health status of children. 

Clearly, school mental health programs must 

provide any screening or treatment services with 

full attention to the confidentiality and privacy of 

children and families. The Columbia University 

TeenScreen® program provides a model for early 

intervention. (See Figure 4.2.) 

The Commission recommends that Federal, State, 

and local child-serving agencies fully recognize 

and address the mental health needs of youth in 

the education system. They can work 

collaboratively with families to develop, evaluate, 

and disseminate effective approaches for 

providing mental health services and supports to 

youth in schools along a critical continuum of 

care. This continuum includes education and 

training, prevention, early identification, early 

intervention, and treatment. 
63

FIGURE 4.2. MODEL PROGRAM: Screening Program for Youth 

Program Columbia University TeenScreen® Program 

Goal To ensure that all youth are offered a mental health check-up before graduating 

from high school. TeenScreen® identifies and refers for treatment those who are 

at risk for suicide or suffer from an untreated mental illness. 

Features All youngsters in a school, with parental consent, are given a computer-based 

questionnaire that screens them for mental illnesses and suicide risk. At no 

charge, the Columbia University TeenScreen® Program provides consultation, 

screening materials, software, training, and technical assistance to qualifying 

schools and communities. In return, TeenScreen® partners are expected to 

screen at least 200 youth per year and ensure that a licensed mental health 

professional is on-site to give immediate counseling and referral services for 

youth at greatest risk. The Columbia TeenScreen® Program is a not-for-profit 

organization funded solely by foundations. When the program identifies youth 

needing treatment, their care is paid for depending on the family’s health 

coverage. 

Outcomes The computer-based questionnaire used by TeenScreen® is a valid and reliable 

screening instrument.151 The vast majority of youth identified through the 

program as having already made a suicide attempt, or at risk for depression or 

suicidal thinking, are not in treatment.152 A follow-up study found that screening 

in high school identified more than 60% of students who, four to six years later, 

continued to have long-term, recurrent problems with depression and suicidal 

attempts.153 

Biggest challenge To bridge the gap between schools and local providers of mental health services. 

Another challenge is to ensure, in times of fiscal austerity, that schools devote a 

health professional to screening and referral. 

How other 

organizations can 

adopt 

The Columbia University TeenScreen® Program is pilot-testing a shorter 

questionnaire, which will be less costly and time-consuming for the school to 

administer. It is also trying to adapt the program to primary care settings. 

Website www.teenscreen.org 

Sites where 

implemented 

69 sites (mostly middle schools and high schools) in 27 States 

The No Child Left Behind Act of 2001154 is designed 

to help all children, including those with serious 

emotional disturbances reach their optimal potential 

and achievement. To fulfill the promise of this Act, 

schools must work to remove the emotional, 

behavioral, and academic barriers that interfere with 

student success in school. Consequently, it is critical 

to strengthen mental health programs in schools. 

This effort may involve: 

• Working with parents, local providers, and 

local agencies to support screening, 

assessment, and early intervention; 

• Ensuring that mental health services are part 

of school health centers; 

• Ensuring that these services are Federally 

funded as health, mental health, and education 

programs; 
64

• Building on a recommendation from the 

President’s Commission on Excellence in 

Special Education155 to implement empirically 

supported prevention and early intervention 

approaches at the school district, local school, 

classroom, and individual student levels; and 

• Creating a State-level structure for schoolbased mental health services to provide 

consistent State-level leadership and 

collaboration between education, general 

health, and mental health systems. 

Since the IDEA requires that a variety of 

professionals collaborate in the school and in the 

community, the Commission urges that 

coordinating services be regarded as a “related 

service” in the child’s Individual Education Plan 

(IEP). In developing the IEP, there should be a 

stronger family focus and youth involvement and 

support. The training and research funds 

designated in this Act should be considered for use 

to train teachers, related services professionals, 

and parents to recognize signs of emotional and 

behavioral problems in children, make appropriate 

referrals for assessment and services and 

classroom accommodations, and implement and 

evaluate evidence-based school mental health 

interventions. 

On a related topic, the Commission recognizes the 

particular challenges for youth in transition from 

adolescence to adulthood. IDEA has transition 

requirements beginning at age 14, but to date, 

these requirements have not resulted in acceptable 

post-school outcomes. 

Studies show that approximately 42% of students 

with serious emotional disturbances graduate from 

high school as opposed to 57% of students with 

other disabilities.81 Schools and local mental 

health agencies could improve their collaboration 

and use of evidence-based practices to develop 

transition-to-work services so that children with 

serious emotional disorders can move successfully 

from school to employment or to post-secondary 

education. 

RECOMMENDATION 4.3 Screen for co-occurring mental and substance use 

disorders and link with integrated treatment strategies. 

Treatment for Co-occurring 

Disorders Must Be Integrated 

Integrated treatment is a means of coordinating 

both substance abuse and mental health 

interventions to treat the whole person more 

effectively. From studies and first-hand 

experiences, many researchers and clinicians in 

these fields believe that both disorders must be 

addressed as primary illnesses and treated as such. 

Integrated treatment can improve client 

engagement, reduce substance abuse, improve 

mental health status, and reduce relapses for all 

age groups.124 

Integrated services should appear seamless to the 

individual who seeks and receives care. Mental 

health and substance abuse treatment can be 

integrated by one clinician, two or more clinicians 

working together, one program, or a network of 

services. 

 A key challenge to developing 

integrated treatment programs is 

overcoming the traditional separation 

between mental health and substance 

abuse treatment. 

Integrated treatment often involves other systems 

as well, because individuals with co-occurring 

disorders typically have a wide range of health and 

social service needs. For example, children in the 

juvenile justice system are at high risk for cooccurring mental and substance abuse disorders.156

Similarly, in the child welfare system, research 

strongly demonstrates that children in foster care 

at a high-risk for maladaptive outcomes, including 

socio-emotional, behavioral, and psychiatric 

problems warranting mental health treatment and 

supports.157-159 
65

A key challenge to developing integrated 

treatment programs is overcoming the traditional 

separation between mental health and substance 

abuse treatment. At least 36 States are attempting 

some change to their systems by addressing this 

problem through creative leadership with a 

sustained vision and by engaging strong local 

stakeholder support — including consumers and 

families — in program design and advocacy.124

However, much remains to be accomplished. 

Studies of these efforts have shown that State and 

local regulatory issues and impediments to 

multiple State and local funding streams continue 

as major barriers to changing the systems. The 

Commission commends the Substance Abuse and 

Mental Health Services Administration 

(SAMHSA) for its Report to Congress on the 

Prevention and Treatment of Co-occurring 

Substance Abuse Disorders and Mental Disorders

and supports the five-year blueprint for action 

contained in the report.124

The Commission supports implementing 

systematic screening procedures to identify mental 

health and substance use problems and treatment 

needs in all settings in which children, youth, 

adults, or older adults are at high risk for mental 

illnesses or in settings in which a high occurrence 

of co-occurring mental and substance use 

disorders exists. In addition to specialty mental 

health and substance abuse treatment settings, 

screening for co-occurring disorders should be 

implemented when an individual enters the 

juvenile or criminal justice systems, child welfare 

system, homeless shelters, hospitals, senior 

housing, long-term care facilities, nursing homes, 

and other settings where populations are at high 

risk. Screening should also occur periodically after 

an individual enters any of these facilities. 

When mental health problems are identified, 

children, youth, adults, and older adults should be 

linked with appropriate services, supports, or 

diversion programs. Additionally, given the high 

incidence of substance use disorders among 

parents of children in the child welfare system, 

where indicated, these parents should be screened 

for co-occurring disorders and linked with 

appropriate treatment and supports. 

The Commission supports coordinated and, where 

appropriate, integrated mental health and substance 

abuse screening, assessment, early intervention, and 

treatment for co-occurring disorders in all Federally 

funded adult and child health and human services, 

criminal and juvenile justice programs, and 

veteran’s services. Health and mental health training 

programs that receive HHS funding should include 

co-occurring disorders in curriculum design and 

training experiences. 

The Center for Medicare and Medicaid Services 

(CMS) should be encouraged to develop and 

implement policy guidance to promote access and 

use of covered services by Medicaid and Medicare 

beneficiaries with co-occurring mental and 

substance use disorders. 

RECOMMENDATION

4.4 Screen for mental disorders in primary health care, 

across the life span, and connect to treatment and 

supports. 

Expand Screening and 

Collaborative Care in Primary 

Care Settings 

The Commission suggests that collaborative care 

models should be widely implemented in primary 

health care settings and reimbursed by public and 

private insurers. Numerous studies have 

documented the effectiveness of collaborative care 

models.160-162 Expanded screening and 

collaborative care models, such as the 

Collaborative Care Model for treating late-life 

depression in primary care settings (See Figure 

4.3.), could save lives. 

The Commission notes that the Federal 

government could better coordinate the funding 

and the clinical care provided by publicly funded 
66

FIGURE 4-3. MODEL PROGRAM: Collaborative Care for Treating Late-Life Depression in Primary 

Care Settings 

Program IMPACT—Improving Mood: Providing Access to Collaborative Treatment for Late 

Life Depression 

Goal To recognize, treat, and prevent future relapses in older patients with major 

depression in primary care. About 5% -10% of older patients have major 

depression, yet most are not properly recognized and treated. Untreated 

depression causes distress, disability, and, most tragically, suicide. 

Features Uses a team approach to deliver depression care to elderly adults in primary 

care setting. Older adults are given a choice of medication from a primary care 

physician or psychotherapy with a mental health provider. If they do not 

improve, their level of care is increased by adding supervision by a mental 

health specialist. 

Outcomes The intervention, compared to usual care, leads to higher satisfaction with 

depression treatment, reduced prevalence and severity of symptoms, or 

complete remission.163

Biggest challenge To ensure that the intervention is readily adapted from the research setting into 

the practice setting. 

How other 

organizations can 

adopt 

Be receptive to organizational changes in primary care and devise new methods 

of reimbursement. 

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

community health clinics to consumers with 

multiple conditions, including physical, mental, 

and co-occurring substance use disorders. This 

effort would include improved coordination of 

care between Health Resources and Services 

Administration-funded community health clinics 

and SAMHSA- or State-supported community 

mental health centers. 

 Expanded screening and collaborative 

care models could save lives. 

The Commission recommends that Medicare, 

Medicaid, the Department of Veterans Affairs, and 

other Federal and State-sponsored health insurance 

programs and private insurers identify and 

consider payment for core components of 

evidence-based collaborative care, including: 

• Case management, 

• Disease management, 

• Supervision of case managers, and 

• Consultations to primary care providers by 

qualified mental health specialists that do not 

involve face-to-face contact with clients. 
67

GOAL 5 Excellent Mental Health Care Is

Delivered and Research Is Accelerated.

RECOMMENDATIONS

5.1 Accelerate research to promote recovery and 

resilience, and ultimately to cure and prevent mental 

illnesses. 

5.2 Advance evidence-based practices using 

dissemination and demonstration projects and create 

a public-private partnership to guide their 

implementation. 

5.3 Improve and expand the workforce providing 

evidence-based mental health services and supports. 

5.4 Develop the knowledge base in four understudied 

areas: mental health disparities, long-term effects of 

medications, trauma, and acute care. 

Understanding the Goal 

The Delay Is Too Long Before 

Research Reaches Practice 

Over the years, research has yielded important 

advances in our knowledge of the brain, behavior, 

and effective treatments and service delivery 

strategies for many mental disorders. An array of 

evidence-based medications and psychosocial 

interventions — typically used together — now 

allows successful treatment of most mental 

disorders. Despite these advances in science, many 

Americans are not benefiting from these 

investments.6; 7 

Far too often, treatments and services based on 

rigorous clinical research languish for years rather 

than being used effectively at the earliest 

opportunity. According to the Institute of 

Medicine report, Crossing the Quality Chasm: A 

New Health System for the 21st Century,

9

 the lag 

between discovering effective forms of treatment 

and incorporating them into routine patient care is 

unnecessarily long, lasting about 15 to 20 years.164 

Even when these discoveries become routinely 

available at the community level, too often the 

clinical practice is highly uneven and inconsistent 

with the original treatment model that was shown 

to be effective.165 Extended time to conduct 

efficacy and other value-determining tests ensures 

that safeguards are in place for these proven and 

emerging remedies. However, follow-up be 

allowed to research on already proven 

interventions should not be allowed to hinder 

efforts to put that knowledge, service, treatment, 

and supportive service into clinical practice. 
68

Too Few Benefit from Available 

Treatment 

Effective, state-of-the-art treatments vital for 

quality care and recovery are now available for 

most serious mental illnesses and serious 

emotional disorders.18 Yet these new effective 

practices are not being used to benefit countless 

people with mental illnesses. The mental health 

field has developed evidence-based practices

(EBPs) — a range of treatments and services 

whose effectiveness is well documented. A partial 

list of EBPs includes: 

• Specific medications for specific conditions, 

• Cognitive and interpersonal therapies for 

depression, 

• Preventive interventions for children at risk 

for serious emotional disturbances, 

• Treatment foster care, 

• Multi-systemic therapy, 

• Parent-child interaction therapy, 

• Medication algorithms, 

• Family psycho-education, 

• Assertive community treatment, and 

• Collaborative treatment in primary care. 

Evidence-based practice (EBP) is defined by the 

Institute of Medicine as — the integration of bestresearched evidence and clinical expertise with 

patient values.9

 

Emerging best practices — treatments and 

services that are promising but less thoroughly 

documented than evidence-based practices. 

Along with EBPs, the mental health field has also 

developed promising but less thoroughly 

documented emerging best practices, such as: 

• Consumer operated services, 

• Jail diversion and community re-entry 

programs, 

• School mental health services, 

• Trauma-specific interventions, 

• Wraparound services, 

• Multi-family group therapies, and 

• Systems of care for children with serious 

emotional disturbances and their families. 

Despite this range of effective, state-of-the-art 

treatments and best practices, many interventions 

and supports do not reach the people who need 

them because of: 

• Complex reimbursement policies (if payment 

for the treatments is even allowable), 

• The growing crisis in workforce training, 

• The shortage of qualified professionals, and 

• The need for more research on putting new 

and proven methods into practice more 

rapidly. 

The Texas Medication Algorithm Project 

illustrates an evidence-based practice that results 

in better consumer outcomes, including reduced 

symptoms, fewer and less severe side effects, and 

improved functioning.166-168 (See Figure 5.1.) 

However, too few consumers benefit from this 

practice because it is not widely used. 
69

FIGURE 5-1. MODEL PROGRAM: Quality Medications Care for Serious Mental Illnesses 

Program Texas Medication Algorithm Project (TMAP) 

Goal To ensure quality care for people with serious mental illnesses by developing, 

applying, and evaluating medication algorithms. An algorithm is a step-by-step 

procedure in the form of a flow chart to help clinicians deliver quality care 

through the best choice of medications and brief assessment of their effectiveness. 

The target population is people with serious mental illnesses served by public 

programs. 

Features Development of algorithms as well as development of consumer education 

materials and other tools for treating serious mental illnesses. Public sectoruniversity collaboration with support of stakeholders, education and technical 

assistance, and administrative supports to serve the most medically complex 

patients. Early phases of the project developed the algorithms and tested the 

benefits of their use; the program’s latest phases focus on implementing TMAP in 

mental health treatment settings throughout the State. 

Outcomes The algorithm package implemented by Texas was more effective than treatmentas-usual for depression, bipolar disorder and schizophrenia. It reduced symptoms, 

side effects and improved functioning.166-168 The package’s benefit for reducing 

incarceration is being studied. In addition, medication algorithms have been 

developed for treating children with depression or attention deficit hyperactivity 

disorder (AD/HD). TMAP algorithms have also been adapted to treat adult 

consumers who have co-occurring mental and substance use disorders. 

Biggest Challenge To ensure that the entire algorithm package  patient education, frequent 

medical visits, medication availability, and consultation  is properly 

implemented in other States and localities. 

How other 

organizations can 

adopt 

Conduct an active planning process, including meetings with stakeholders, to 

examine what organizational changes are needed to make the algorithm work 

best. 

Sites Texas; Nevada; Ohio; Pennsylvania; South Carolina; New Mexico; Atlanta and 

Athens, GA; Louisville, Kentucky; Washington, D.C.; San Diego County, CA; and 

private sector in Denver, Colorado. 

Reimbursement Policies Do Not 

Foster Converting Research to 

Practice 

The complexities and limitations in paying for 

many well-established, evidence-based practices 

for children and adults cause the quality of mental 

health services to vary greatly. In particular, 

Medicaid, Medicare, and private payers must keep 

current with advances in evidence-based practices, 

continuously examining practice to inform 

reimbursement policies. 

As promising new findings are conveyed from the 

research community into the hands of front-line 

providers, policies and financing criteria at the 

Federal, State, and local levels must provide 

incentives to support adopting and using these new 

findings. In the current system, some disincentives 

exist in cases where private insurance, Medicaid, 

or Medicare may reimburse for a particular EBP, 

but the complexity of the coverage rules makes 

implementing it difficult. Fee-for-service 

reimbursement systems for Medicaid, Medicare, 

and other payers do not allow providers to bill for 

essential components of many EBP programs, 

such as flexible case management, non-face-toface services, or home visits. 
70

Many private insurers do not cover these effective 

supports, services, treatments or practices. While it 

is possible for Medicaid to cover many of these 

practices, the only way to access reimbursement 

for them presently is to navigate the system 

expertly enough to obtain approval to provide 

these services under an option or a waiver. 

Serious Workforce Problems 

Exist 

The Commission heard consistent testimony from 

consumers, families, advocates, and public and 

private providers about the “workforce crisis” in 

mental health care. Today not only is there a 

shortage of providers, but those providers who are 

available are not trained in evidence-based and 

other innovative practices. This lack of education, 

training, or supervision leads to a workforce that is 

ill-equipped to use the latest breakthroughs in 

modern medicine. 

 Despite the recognized importance of 

culturally relevant services, training 

curricula generally lack an adequate 

focus on developing cultural 

competence. 

Although the supply of well-trained mental health 

professionals is inadequate in most areas of the 

country, rural areas are especially hard hit.112 In 

addition, particular shortages exist for mental 

health providers who serve children, adolescents, 

and older Americans.105; 169; 170 

Another challenge in the mental health system is 

the condition of some education programs. While 

some graduate programs have led the field in 

developing and disseminating evidence-based 

practices, many others have not kept pace with 

dramatic technological developments in delivering 

care. Continuing education programs routinely 

employ teaching methods that have been 

demonstrated, through research, to have little 

effect on provider behavior or impact on consumer 

outcomes.171 Also, substantive training in the 

evidence-based treatment of mental illnesses tends 

not to be offered to critical segments of the 

workforce that have an enormous role in direct 

care including bachelor-level staff, 

paraprofessionals, primary care providers, 

consumers, and families.171 

Despite the recognized importance of culturally 

relevant services, training curricula generally lack 

an adequate focus on developing cultural 

competence. Racial, ethnic, and linguistic 

minorities remain significantly under-represented 

in the current workforce.1; 104; 105 (See Goal 3 for a 

related discussion.)

As concepts of recovery and resiliency become 

key principles in mental health care, education and 

training programs must incorporate these concepts 

in their curricula, training materials, and 

experiences. 

Four Areas Have Not Been 

Studied Enough 

The knowledge base in the mental health system is 

lacking sufficient information in at least four 

areas: 

• Minority disparities in mental health research, 

• The long-term effects of medications, 

• The impact of trauma, and 

• Acute care. 

Disparities in Mental Health Research 

While many types of disparities exist in mental 

health care, American Indians, Alaskan Natives, 

African Americans, Asian Americans, Pacific 

Islanders, and Hispanic Americans bear a 

disproportionately high burden of disability from 

mental health disorders, not because of greater 

prevalence or severity of illnesses in these 

populations, but because they receive less care and 

poorer quality of care.1

 Similarly, these groups are 

significantly under-represented in mental health 

research and mental health service delivery.1 (See 

Goal 3 for a related discussion.) 

Long-term Use of Medications 

Breakthroughs in developing the next generation 

of medications provide hope for treatment and 

recovery from mental illnesses. The discovery of 

effective treatments using medications currently 

on the market is also encouraging. However, since 
71

these medications are treatments and not cures, 

some individuals with chronic illnesses, including 

children, are expected to use these medications 

over an extended period of time. Knowledge of the 

clinical and economic effects of these medications 

is limited because systematically evaluating the 

maintenance use of medications is not required for 

FDA approval. Consequently, long-term effects 

have not been well studied for many psychotropic 

medications. 

 Long-term effects have not been 

studied well enough for many 

psychotropic medications. 

The Impact of Trauma 

Stressful life events or the manifestation of mental 

illnesses can upset the balance most adults seek in 

life, resulting in distress and dysfunction. Severe 

or life-threatening traumatic events experienced in 

childhood or adulthood sometimes lead to 

emotional and behavioral reactions that jeopardize 

mental health. The likelihood of developing posttraumatic stress disorder (PTSD) is related to pretrauma vulnerability, magnitude of the event, 

preparedness for the event, and the quality of care 

after the event.172 

Urban and Native American youth are more likely 

to be exposed to violence,173 while women are 

twice as likely to develop PTSD after they are 

exposed to life-threatening trauma.174 The mental 

health field lacks sufficient information about 

dealing with trauma and its effects on different 

populations. Also, few treatments specifically for 

adult survivors of childhood abuse have been 

studied in randomized controlled trials.175

Acute Care 

Shortages exist in the availability of psychiatric 

beds and other levels of acute care in many 

regions of the country.176-178 Too often the shortterm psychiatric inpatient care and emergency 

services in hospitals are used as the first contact 

for uninsured and under-insured populations. 

Other crisis and urgent care service settings — 24-

hour care in residential treatment facilities for 

children, mobile crisis teams, and respite hostels 

— are also forms of acute care facilities. This 

important segment of the health care delivery 

system lacks essential national data, shows 

evidence of treatment gaps in many regions, and 

lacks consistent clinical standards. 

Achieving the Goal 

RECOMMENDATION 5.1 Accelerate research to promote recovery and resilience, 

and ultimately to cure and prevent mental illnesses. 

Speed Research on Treatment 

and Recovery 

The Commission’s study has taken place in a 

context of enormous progress and accomplishment 

in the scientific study of effective treatments and 

services in mental health care. Research is having 

a significant impact on the effectiveness of the 

mental health care delivery system and, given the 

significant co-occurrence of mental disorders with 

general medical illnesses, on the overall quality of 

health care available in the U.S. Progress in 

understanding the causes of disorders of the mind 

and the brain will accelerate discovering new 

treatments and approaches to recovery while 

raising the possibility that mental illnesses will 

ultimately be cured or prevented. 

A commitment is necessary to speed the findings 

of research to treatment and services providers as 

well as to the public as a whole. An on-going 

dialogue among researchers, providers, 

consumers, and families is vital to address 

research priorities, study designs, interpretation of 

results, and the dissemination of findings. The 

Commission recommends making a national 

commitment to continue discovering and applying 

improved treatments and services in mental health 

care, as well as creating a research program with a 
72

long-term goal of developing cures for major 

mental illnesses. 

In addition, the National Institutes of Health 

(NIH), and the Substance Abuse and Mental 

Health Services Administration (SAMHSA) 

should partner with the National Institute on 

Disability and Rehabilitation Research to promote 

research on factors contributing to rehabilitation 

and recovery from mental illnesses. 

RECOMMENDATION

5.2 Advance evidence-based practices using dissemination 

and demonstration projects and create a public-private 

partnership to guide their implementation. 

Bridge the Gap Between Science 

and Service 

To further advance treatment and prevention in 

mental health care, the Nation must continue to 

invest in research at all levels. These research 

activities must include a serious “science-toservices” endeavor, resulting in delivering the very 

best evidence-based practices to consumers in a 

timely way. 

The Nation must have a more effective system to 

identify, disseminate, and apply proven treatments 

or evidenced-based practices (EBPs) to mental 

health care. Systematic approaches to bring 

scientific discovery to service providers, 

consumers, and families must be emphasized 

more. Medicaid demonstration initiatives are an 

essential tool to inform policy makers and Federal 

payers about the effectiveness and fiscal impact of 

health care innovations. As these new practices are 

identified, dissemination projects evaluating best 

methods for widespread implementation are 

needed. 

Technical assistance on the importance of moving 

evidence-based practices into the field must 

accompany any reforms. This support will help 

alleviate the lag time between discovery and 

delivery, thus, bringing about a healthier, more 

robust population. 

The Commission recommends that the Department 

of Health and Human Services provide leadership 

to evaluate implementing evidence-based 

interventions through dissemination projects. The 

Federal government should initiate and sustain a 

public-private partnership, with involvement and 

support from private foundations, advocacy 

groups, and professional organizations. The goal 

of this partnership would be to: 

• Advance knowledge, 

• Disseminate findings, 

• Facilitate workforce development, 

• Recognize those treatments and services that 

should be considered evidence-based, and 

• Ensure they are implemented with adequate 

financial support. 

The partnership should comprise all stakeholders 

including providers, consumers, and families. It 

should guide and oversee many activities that are 

currently scattered throughout the public and 

private sectors, thus eliminating inefficient 

duplication and encouraging collaboration on 

potentially beneficial issues. This leadership is 

needed to bridge the gap between science and 

service. 

The Commission encourages continuing and 

expanding the collaboration between NIH and 

SAMHSA to conduct rigorous peer-reviewed 

research. They should use both quantitative and 

qualitative research methods to increase our 

knowledge about the most effective means of 

disseminating and promoting evidenced-based 

practices. These HHS agencies have already begun 

a formal “science to services” process to further 

develop and expand evidenced-based practices in 

the field. They have jointly funded a grant 

program for State mental health agencies to begin 

developing the infrastructure to conduct research 

alongside dissemination efforts. The process 

should be part of a comprehensive strategy 

moving from science to service and from the field 

back to science. 
73

To promote efficient and cost-effective practices 

for improved consumer outcomes, the field needs 

more rigorous studies of EBP dissemination 

efforts. One such effort is ongoing. National 

Institute of Mental Health and SAMHSA are 

collaborating to support a study on implementing 

the Family Critical Time Intervention Model with 

homeless families and their children. (See Figure 

5.2.) 

The Commission concludes that national 

leadership must overcome the fragmentation and 

blurring of responsibility for translating the 

science of mental health into clinical practice. 

Toward this end, mental health field must expand 

its efforts to develop and test new treatments and 

practices, to promote awareness of and improve 

training in evidence-based practices, and to better 

finance those practices.

FIGURE 5-2. MODEL PROGRAM: Critical Time Intervention with Homeless Families 

Program Family Critical Time Intervention model (FCTI). The program is jointly funded by 

NIMH and the Center for Mental Health Services/Center for Substance Abuse 

Treatment Homeless Families Program. 

Goal To apply effective, time-limited, and intensive intervention strategies to provide 

mental health and substance abuse treatment, trauma recovery, housing, support

and family preservation services to homeless mothers with mental illnesses and 

substance use disorders who are caring for their dependent children. 

Features The Critical Time Intervention model (CTI) was developed in New York City as a 

program to increase housing stability for persons with severe mental illnesses and

long-term histories of homelessness. Its principle components are rapid 

placement in transitional housing, fidelity to a Critical Time Intervention CTI 

model for families (i.e., provision of an intensive, 9-month case management 

intervention, with mental health and substance use treatments), a focused team 

approach to service delivery, with the aim of reducing homelessness, and 

brokering and monitoring the appropriate support arrangements to ensure 

continuity of care. 

Outcomes Data indicate that mothers in this group tend to be poorly educated, have 

meager work histories, and face multiple medical, mental health, and substance 

use problems. Their children’s lives have lacked stability in terms of housing, 

education, and periods of separation from their mothers. African-American and 

Latina women were over-represented in study sites in proportions greater than 

the national average for homeless populations. (An NIMH-funded study of this 

project is ongoing; additional outcomes will be available at its conclusion.) 

Biggest challenge The CTI model for families challenges the assumption that homeless mothers 

with children who are have mental health or substance use disorders require 

confinement and extended stays in congregate shelter living before they can 

independently manage their own households. This can be addressed by acquiring 

buy-in from collaborators and involved agencies, acquiring needed housing 

resources, evaluating the project with respect to model fidelity, and attaining 

ongoing involvement of practice innovators to establish thoughtful compromises 

within local contexts. 

How other

organizations can

adopt

The program is transferable to any community that can align resources needed 

for housing and conduct relevant training for providers in a CTI model for 

families. (A manual to guide program replication will be available at the 

conclusion of the current study.) 

Sites Westchester County, NY 

For additional

information

See http://www.rfmh.org/csipmh/ 
74

Change Reimbursement Policies 

to More Fully Support EBPs 

Successfully transforming the mental health 

system, hinges, in part, on better balancing fiscal 

resources to support using proven, evidence-based 

practices. The Commission encourages public- and 

private-sector payers to reframe their 

reimbursement policies to better support and 

widely implement EBPs. 

The Commission urges the Centers for Medicare 

and Medicaid Services (CMS) to provide technical 

assistance to States on how to effectively finance 

EBPs. This technical assistance should address 

financing strategies for: 

• EBPs in mental health care for adults who are 

supported with Medicaid funding, including 

those practices identified through the 

SAMHSA/Dartmouth project, such as: 

{ Family psycho-education, 

{ Integrated care of co-occurring mental and 

substance use disorders, 

{ Personal illness management, 

{ Supported employment, 

{ Assertive community treatment, and 

{ Medication management.165

• EBPs, such as the Collaborative Care Model, 

for adults with mental illnesses who are seen 

in primary health care settings. (See the 

description in Goal 4.) 

• EBPs in mental health care for children who 

are supported with Medicaid funding, such as 

the clinical aspects of parent-child interaction 

therapy, multi-systemic therapy, functional 

family therapy, and treatment foster care. 

In addition, the Commission urges CMS to 

continue to clarify and simplify the waiver process 

and other administrative processes to facilitate 

States’ using waivers to develop evidence-based 

practices. 

Successfully transforming the mental 

health system, hinges, in part, on 

better balancing fiscal resources to 

support using proven, evidence-based 

practices. 

The Commission notes the particular difficulty of 

engaging consumers in any type of treatment or 

support services — including EBPs — after they 

are released from public institutions, such as 

hospitals, residential treatment centers, jails, or 

prisons. For many of these individuals, losing 

disability benefits when they leave these facilities 

represents a major barrier to engagement. During 

extended stays in these institutions, consumers 

may lose their enrollment, lose their eligibility, or 

have their eligibility suspended from various 

disability income programs and from Medicaid or 

Medicare. When this occurs because rules and 

regulations have not been properly applied, it 

reflects confusion or misunderstanding of the rules 

and regulations. The Commission encourages 

CMS to collaborate with the Social Security 

Administration (SSA), the Veterans 

Administration (VA), and other relevant Federal 

agencies to clarify existing policy on reinstating 

disability benefit eligibility — and to explore 

changing existing policy, as needed. This is 

critical to facilitate following-up and engaging 

individuals in treatment and services after they are 

discharged from public institutions. 

The Commission urges SAMHSA to work with 

CMS to facilitate collaboration between State 

Mental Health Authorities and Single State 

Medicaid Agencies. 
75

RECOMMENDATION 5.3 Improve and expand the workforce providing evidencebased mental health services and supports. 

Address the Workforce Crisis in 

Mental Health Care 

The mental health field must move forward as 

quickly and efficiently as possible to achieve a 

more competent and expanded workforce 

necessary to ensure the full opportunity for 

recovery, resiliency, and wellness for all 

Americans with mental illnesses. 

Workforce issues are a complex blend of training, 

professional, organizational, and regulatory issues. 

Because of this intricacy, the field needs a 

comprehensive strategic plan to improve 

workforce recruitment, retention, diversity, and 

skills training. In fact, without such a plan, it will 

be difficult to achieve many of the Commission’s 

other recommendations. 

To develop this plan, HHS should initiate and 

coordinate a public-private partnership. The 

process should broadly include the many nonFederal stakeholders, as modeled by several 

national groups that are already addressing 

workforce issues, for example, the Annapolis 

Coalition on Behavioral Health Workforce 

Education and the Coalition for Human Resource 

Development within Systems of Care. 

The planning process must address the full 

lifespan of people with mental illnesses, balancing 

attention to the specialized needs of children and 

families, young adolescents, those transitioning to 

adulthood, adults, and older adults. The plan 

should draw on the experience gained through 

previous initiatives to strengthen the workforce, 

such as the National Institute of Mental Health 

Staff College, and on efforts to develop model 

curricula and interdisciplinary training programs. 

Also, the plan must facilitate its adoption by 

accrediting and licensing professional 

organizations. 

The plan itself must include strategies to address 

the severe shortage of practitioners in the mental 

health workforce. In addition to addressing the 

workforce crisis within the formal mental health 

system, the plan must attend to training caregivers 

in other systems that provide mental health 

services, including the primary health care system, 

the corrections system, and schools. 

 The mental health field needs a 

comprehensive strategic plan to 

improve workforce recruitment, 

retention, diversity, and skills 

training. 

Every mental health education and training 

program in the Nation should voluntarily assess 

the extent to which it: 

• Teaches evidence-based approaches to 

practice; 

• Uses teaching methods that have been 

demonstrated to be effective; 

• Offers a curriculum that incorporates the 

competencies that are essential to practice in 

contemporary health systems; 

• Builds skills in treating people with cooccurring mental and addictive disorders; 

• Educates consumers, families, and providers 

about mental illnesses and about the concepts 

of recovery and resiliency; 

• Engages consumers and families as educators 

of other health care providers; 

• Emphasizes developing cultural competence 

in clinical practice; 

• Ensures that the diversity of the community is 

reflected among trainees and in the training 

experience; and 

• Prepares students and trainees to work in 

interdisciplinary environments. 

HHS must partner with State agencies that are 

responsible for the mental health care of children 
76

and adults to develop model, portable curricula to 

train direct care staff in the Nation’s public-sector 

systems. In the case of service systems for 

children and families, these curricula must 

recognize and accommodate a variety of settings 

and providers, such as social service agencies, 

schools, and primary care settings. 

Some curricula must target individuals who do not 

have graduate training. Others should be focused 

on students in graduate training programs or inservice professionals, such as psychologists, 

psychiatrists, social workers and psychiatric 

nurses. All training curricula should clearly reflect 

the perspectives of consumers and families. 

In addition, graduate and continuing education 

programs must train more mental health 

professionals in effective evidence-based and 

emerging best practices. The field must move what 

we know into what we do. This transformation 

may require special attention from administrators 

and policy-makers, as well as from accrediting, 

licensing, and professional organizations, that 

have enormous influence on shaping health and 

mental health workforce education. 

The Commission recommends that HHS refine its 

approach to technology transfer in mental health to 

ensure that: 

• Knowledge is translated more rapidly into the 

content of training curricula, 

• These curricula employ teaching methods of 

demonstrated effectiveness, and 

• Knowledge about effective education, 

recruitment, and retention strategies inform all 

public and private efforts to translate science 

to services. 

 Graduate and continuing education 

programs must train more mental 

health professionals in effective 

evidence-based and emerging best 

practices. 

RECOMMENDATION

5.4 Develop the knowledge base in four understudied areas: 

mental health disparities, long-term effects of 

medications, trauma, and acute care. 

To transform the mental health system, the 

Commission has identified and highlighted the 

critical policy areas of: 

• Eliminating mental health disparities, 

• Assessing the long-term effects of 

medications, 

• Reducing the impact of trauma, and 

• Improving acute care. 

Research in these understudied areas is essential to 

ultimately improve the quality of mental health 

treatments and services. 

Study Disparities for Minorities 

in Mental Health 

While many types of disparities exist in mental 

health care, American Indians, Alaskan Natives, 

African Americans, Asian Americans, Pacific 

Islanders, and Hispanic Americans bear a 

disproportionately high burden because they 

receive less care and poorer quality of care.1

Similarly, these groups are significantly underrepresented in mental health research and mental 

health service delivery.1

 (See Goal 3 for a related 

discussion.) 
77

To address this discrepancy, the Commission 

recommends conducting studies to inform policy 

decisions and develop a comprehensive research 

program for minority mental health. In particular, 

the Commission urges HHS to further study: 

• Racial and ethnic minority populations in the 

areas of psychiatric epidemiology, 

• Evidence-based treatment, 

• Psychopharmacology, 

• Ethnic- and culture-specific therapeutic 

interventions, 

• Diagnosis and assessment, 

• Prevention of mental illnesses, and 

• Promotion of mental health. 

To close the gap that exists in the quality and 

access of care, the Commission also encourages 

researchers and grant-makers to focus on the 

impact of cultural competence on mental health 

treatment outcomes. Services research should 

focus on eliminating disparities in access to 

quality care among racial and ethnic groups. 

Study the Effects of Long-term 

Medication Use 

Since many psychotropic medications are 

treatments and not cures, some individuals with 

chronic illnesses, including children, must use 

them on a long-term basis. Current knowledge of 

their long-term clinical and economic effects is 

limited and must be expanded. With that goal in 

mind, the Commission recommends that NIH, 

undertake a sustained program of research on the 

long-term positive and negative effects of 

psychotropic medications for maintenance 

treatment of mental disorders — including 

children with serious emotional disturbances. 

NIH and the U.S. Food and Drug Administration 

(FDA) should also provide information to educate 

consumers on the efficacy, effectiveness, and 

limitations of psychotropic medications. This 

research and information should apply to all age 

groups and special populations, particularly 

emphasizing the impact of long-term psychotropic 

medication use for children. 

Examine the Effects of Trauma 

The Commission recommends that HHS, through 

NIH, undertake a sustained program of research on 

the impact of trauma on the mental health of 

specific populations, such as women, children, and 

the victims of violent crime, including victims of 

terrorism. In addition, the Commission 

recommends that NIH and SAMHSA partner to 

enhance the evidence base and to evaluate service 

models for treating post traumatic stress disorder 

and other trauma-related disorders in public 

mental health settings. 

Address the Problems of Acute 

Care 

While the Commission’s focus remains on full 

community integration for people with mental 

illnesses across the lifespan, available and 

effective acute inpatient and other short-term, 24-

hour services are essential components of a 

balanced system of mental health care — 

especially for those in crisis who need the safety 

and intensive treatment in such settings. 

The Commission recommends that HHS take the 

lead in: 

• Synthesizing the acute care knowledge base, 

• Reviewing the many outstanding model 

programs for acute care that already exist, 

• Developing new knowledge as necessary, 

• Assessing existing capacities and shortages, 

and 

• Proposing workable solutions to enhance 

delivering acute care and crisis intervention 

service. 
78
79

GOAL 6 Technology Is Used to Access Mental

Health Care and Information.

RECOMMENDATIONS

6.1 Use health technology and telehealth to improve 

access and coordination of mental health care, 

especially for Americans in remote areas or in 

underserved populations. 

6.2 Develop and implement integrated electronic health 

record and personal health information systems. 

Understanding the Goal 

Mental Health Care Lags in 

Using Technology 

Perhaps the most important medical advance of 

the 21st century will be the application of 

information technology to health care — allowing 

all segments of the health system to interact 

seamlessly and facilitate safe, high-quality care for 

consumers. An integrated information technology 

and communications infrastructure is critical to 

achieving the five preceding goals and 

transforming mental health care in America. 

Although the concept of using technology to 

improve health care has existed for many decades, 

the time has come to establish a national health 

information infrastructure that will encourage the 

public and private sectors to invest in information 

technology while adequately safeguarding 

consumers. To be ultimately useful, systems must 

be carefully designed to produce care that is safe, 

effective, patient-centered, timely, efficient, and 

equitable.9

 

We already know that new technology that aids in 

administering medications can reduce medical 

errors and prevent death or unnecessary injuries. 

However, the technology and communications 

infrastructure in public and private mental health 

care lags far behind other sectors.9

 The time has come to establish a 

national health information 

infrastructure that will encourage the 

public and private sectors to invest in 

information technology while 

adequately safeguarding consumers. 

To address this technological need in the mental 

health care system, this goal envisions two critical 

technological components: 

• A robust telehealth system to improve access 

to care, and 

• An integrated health records system and a 

personal health information system for 

providers and patients. 
80

Access to Care Is a Concern in 

Rural and Other Underserved 

Areas 

Emerging technologies provide the means to 

overcome geographical distances that often hinder 

access to care. Health technology and telehealth 

now offer powerful tools to improve access to 

mental health care in rural, remote, and other 

underserved areas. 

 Emerging technologies provide the 

means to overcome geographical 

distances that often hinder access to 

care. 

Telehealth — using electronic information and 

telecommunications technologies to provide longdistance clinical care and consultation, patient and 

professional health-related education, public 

health and health administration — is a greatly 

underused resource for mental health services. 

Tele-home care and consultations can increase 

access to mental health care for all patients, but 

especially for individuals with multiple chronic 

health conditions, those with severe illness and 

disability, underserved populations, children, and 

the frail elderly. 

Information Technology Can 

Now Enhance Medical Records 

Systems 

Information technology is now available to 

support integrating electronic health record 

systems. Integrated systems can promote high 

quality, coordinated services by helping 

psychiatrists and other physicians, psychologists, 

social workers, nurses, and other health and 

human service providers communicate vital health 

information clearly, confidentially, and when it is 

needed. 

The Institute of Medicine, the National Committee 

on Vital and Health Statistics, and the National 

Quality Forum have all proposed widely 

implementing a paperless, interoperable 

communications and information technology 

infrastructure as a way to improve and integrate 

the Nation’s health care system. Mental health can 

lead this change. 

Already, the Federal government is working to 

establish guidelines and standards to more 

effectively transmit, communicate, and protect 

health information. For example, by agreeing to 

use the same health messaging standards, 

pharmaceutical codes, imaging standards, and 

laboratory test names, the country is one giant step 

closer to speaking a common language and 

providing better patient care — thus leading the 

way to a more integrated health care system. 

Consumers May Not Have 

Access to Reliable Health 

Information 

Science has produced large volumes of 

information about breakthroughs in health 

promotion, disease prevention, diagnosing and 

treating illnesses, and recovery. However, a 

reliable source for this information is not easily or 

universally available to all Americans. 

Although the Commission found that most 

consumers and families want up-to-date 

information about the mental disorders, symptoms, 

treatments, and supportive services for the mental 

disorders with which they are dealing, such 

information is seldom available when people need 

it most. The Commission supports developing a 

personal health information system to that enables 

every American to obtain, maintain, and share 

personal health information. 
81

Achieving the Goal 

RECOMMENDATION

6.1 Use health technology and telehealth to improve access 

and coordination of mental health care, especially for 

Americans in remote areas or in underserved populations. 

Underserved Populations Can 

Benefit from Health Technology 

Telehealth and e-health technologies hold great 

promise for improving access to mental health 

care in many rural, remote, and other underserved 

areas. By using computers and video cameras, 

sending e-mail reminders, transmitting results by 

telephone, and assisting provider follow-up, 

underserved, rural, and remote communities could 

significantly improve care for individuals of all 

ages who have multiple chronic health conditions, 

including severe illness or disability. 

However, a number of barriers must be removed 

to make these new technologies practical. The 

Commission recommends that States address the 

barriers created by restrictive licensure and scopeof-practice restrictions that impede developing 

technology-based services. 

Public and private payers of health care costs do 

not yet appropriately cover or reimburse for ehealth and telehealth services. Reimbursement 

must become flexible enough to allow evidencebased practices to be implemented, coordinating 

both traditional clinical care and e-health visits 

and ensuring that services delivered through new 

technology are sustained. Doing so will require 

changing policies and supports in all sectors of the 

health care industry. 

The Commission encourages public and private 

payers to reimburse for e-health and telemedicine 

services. The Commission recommends that the 

U.S. Department of Health and Human Services 

(HHS) lead a review of how to best deliver and 

finance these services in consultation with private 

payers, insurers, State agencies, and other Federal 

programs. 

RECOMMENDATION 6.2 Develop and implement integrated electronic health 

record and personal health information systems. 

Electronic Medical Records Will 

Improve Coordination and 

Quality 

With the explosion of scientific advances, new 

treatments, breakthroughs in promoting health, 

and medical information, all providers must have 

high-speed electronic access to the latest evidencebased practice guidelines, best practice models, 

ongoing clinical trials, scientific research, and 

other health information. 

Studies show that electronic health records 

improve quality, accountability, and costeffectiveness of health care services.179-181

Enhancing communication between informed 

consumers and health care professionals improves 

their discussions about treatment options and more 

knowledgeable decisions. Health care providers, 

including those in the mental health field, urgently 

need universal access to real-time, computer-based 

health records. Successful models of personcentered, integrated, comprehensive electronic 

health records already exist, such as the 

Department of Veterans Affairs’ (VA) health 

record system. (See Figure 6-1.) 
82

FIGURE 6-1. MODEL PROGRAM: Veterans Administration Health Information and Communication 

Technology System 

Program U.S. Department of Veterans Affairs (VA), Veterans Health Administration (VHA): 

Use of Health Information and Communication Technology. 

Goal Improve the quality, access, equity and efficiency of care by using a fully 

integrated electronic health record system, personal health information 

systems, and telemedicine. 

Features VHA is the largest integrated health care system in the U.S. with approximately 

1,300 sites providing a full continuum of health care services. VA provided 

mental health services to more than 750,000 veterans in 2002. All VHA medical 

facilities (clinics, hospitals, and nursing homes) use a fully integrated electronic 

medical record that is capable of supporting a paperless health record system. 

The VA system incorporates clinical problem lists, clinic notes, hospital 

summaries, laboratory, images and reports from diagnostic tests and radiological 

procedures, pharmacy, computerized order entry, a bar-code medication 

administration system, clinical practice guidelines, reminders and alerts, and a 

specialized package of mental health tools. In addition, VA uses innovative 

information technology and communication systems to give beneficiaries 

information on benefits and services, allow web-based enrollment, support a 

national electronic provider credentialing system, provide veterans and their 

families access to health information and support health care provider 

education. 

Telemedicine is used to increase access to primary and specialty care for rural 

and underserved populations. VA provided approximately 350,000 telemedicine 

visits and consultations last year. Telemedicine mental health consultations and 

follow-up visits provide access to these services at locations where they would 

otherwise be unavailable. 

Outcomes In 2002, the Institute of Medicine reported, “VA’s integrated health care 

information system, including its framework of performance measures, is 

considered to be one of the best in the nation.”182 Utilizing an electronic health 

record with a clinical reminder system, VA screens 89% of primary care patients 

for depression and 81% for substance abuse. In VA, 80% of patients hospitalized 

for mental illnesses receive follow-up outpatient appointments within 30 days; 

the next best reported performance by NCQA is 73% and the Medicaid average is 

only 55%. 

Biggest challenge The public’s lack of confidence in the privacy and security of the electronic 

health record and the lack of national standards for data and communications 

represent the biggest challenges to implementing such a system. 

How other 

organizations can 

adopt 

High-performance, reliable electronic health record and information systems are 

currently available for use by any provider, clinic, hospital, or health system. 

Incentives for adopting electronic health records would speed wider use. 

Sites All VHA clinics, hospitals, and nursing home facilities nationwide 
83

An integrated, interoperable, electronic health 

information system — linked by an individual, 

privacy-protected key card — could enable a 

virtual health care team and a coordinated system 

of care to extend across place, providers, plans, 

and time. Exchanging health information through 

secure means — including appropriate 

authorizations from consumers — can connect 

information from health-related entities with 

consumers’ personal health information. This 

connection will make important data available at 

the right times and places to support optimal care 

and recovery for consumers. 

Electronic mental health records may enhance 

quality by promoting adoption and adherence to 

evidence-based practices by including: 

• Clinical reminders; 

• Clinical practice guidelines for prevention, 

treatment, and monitoring; 

• Tools for decision support; 

• Direct computer entry of health care 

instructions and prescription dosages; and 

• Patient safety alert systems. 

Another promising practice — using 

individualized, computer-generated reminders — 

will also become possible with electronic medical 

records. 

Other innovations in mental health care are even 

more viable with the technology for electronic 

medical records. For example, using hospital barcodes to administer medication reduces 

medication errors and, thus, improves patient 

safety.183 Electronic medical records also provide a 

platform for consumers to receive computerized, 

clinical instructions and automated alerts for drug 

interactions, contraindications, and allergies. 

The Commission recommends that HHS and VA 

lead a voluntary public–private initiative to design 

and adopt a secure, privacy-protected, electronic 

health record and a system of health information 

exchange for providers to share information with 

the approval of consumers. Privacy and security of 

this system must remain primary concerns. The 

Commission proposes this national health 

information infrastructure not as a centralized 

government database, but rather as a means to 

connect and exchange health information in the 

framework of a secure, decentralized network.

• The design initiative should involve Federal, 

State, and local governments; professional 

organizations; health care consumers; 

advocates; providers; payers; purchasers; and 

other relevant groups. 

• The Individualized Plan of Care should be 

included in the electronic health record and be 

developed along with the proposed 

Comprehensive State Mental Health Plan. (See 

Goal 2 for a discussion.) 

• The system should include state-of-the-art 

treatment guidelines and clinical reminders 

that promote using standardized evidencebased and promising practices in managing 

serious mental illnesses for adults and serious 

emotional disturbances for children. System 

administrators should incorporate these 

innovations into the electronic medical records 

systems providers use in clinics, offices, 

hospitals, and acute care and long-term care 

settings. 

Personal Health Information 

Systems Can Help Consumers 

Manage Their Own Care 

The Commission found that the general public can 

now access a great deal of valuable health 

information through the Internet. Most consumers 

and families want up-to-date information about the 

symptoms and mental disorders with which they 

are dealing, as well as information on effective 

treatments and supportive services. But today, 

reliable information is not always available when 

and how people need it most, and it is not readily 

or universally accessible to all Americans. 

Consumers should have the choice and capability 

to obtain, store, and share their personal health 

information. 
84

Systems are already available to support access to 

Internet assessment services and health 

information sources in order to build a 

personalized health information library. 

Consumers can use these systems as research 

tools to: 

• Evaluate the quality of care provided, 

• Participate in on-line support groups, 

• Evaluate best practices, 

• Learn about the most recent treatment 

breakthroughs, and 

• Determine how to best use resources they 

manage. 

 Consumers should have the choice 

and capability to obtain, store, and 

share their personal health 

information. 

The Network of Care for Mental Health, an 

individualized mental health resource Web site, 

provides a model for how consumers can use Internet 

technology to find pertinent mental health 

information; identify available services, supports, 

and community resources; and keep personal records 

on secure computer servers. (See Figure 6-2.) 

FIGURE 6-2. MODEL PROGRAM: Individualized Mental Health Resource Web Site 

Program Network of Care for Mental Health 

Goal To help ensure “No Wrong Door” exists for those who need mental health 

services. 

Features The user-friendly Web site enables consumers and families to find pertinent 

mental health information; identify available services, supports, and community 

resources; and keep personal records on secure servers. Consumers and families 

can search the site’s comprehensive Service Directory — by age group, diagnosis, 

program or agency name, key word, or by using the 20-category menu—for 

mental health treatment and supportive services provided by the county and 

other organizations. The site also offers up-to-date information about diagnoses, 

insurance, and advocacy, as well as daily news from around the world 

concerning mental health. 

Biggest challenge Gathering and organizing an enormous amount of information while making it 

easily accessible to Network of Care for Mental Health Web site users represents 

the major challenge. 

How other 

organizations can 

adopt 

The Network of Care Web site can be easily and cost-effectively replicated in 

any location because the entire infrastructure — and many of the data 

components; e.g., the library and national links — are identical from one region 

to another. Only certain county-specific data (e.g., available mental health 

treatment and support services) must be developed for each new site. 

Sites The San Diego Network of Care for Mental Health Web site was launched April 

30, 2003; another is now being developed for Los Angeles County, California. 

Web site http://www.networkofcare.org 
85

Consumers and families must be assured that their 

privacy and the confidentiality of their health 

information are well protected. If health care 

systems do not make substantial, front-end, 

ongoing investments to protect privacy, electronic 

health information systems are doomed to fail. 

Existing Federal regulations that balance privacy 

protections and the need for shared information 

within the health system, such as the Health 

Insurance Portability and Accountability Act 

(HIPAA), must be constantly re-examined to 

ensure that they adequately address both provider 

and consumer needs. 

 If health care systems do not make 

substantial, front-end, ongoing 

investments to protect privacy, 

electronic health information systems 

are doomed to fail. 

The Commission recommends that HHS and VA 

lead a public-private effort to create and promote 

use of software for Internet access to privacyprotected, personal health information that 

consumers maintain and control. Consumers and 

families must be involved in designing, evaluating, 

and implementing the system that would enable 

them to personalize their records. The software 

and training should enable consumers to 

personalize their health information record 

through links to key portions of their health 

records, local consumer support groups, self-care 

trackers, advance directives, and directories of 

local service providers located in or near their own 

ZIP Codes. This personal health information 

system should include the following elements: 

• Electronic copies of key portions of individual 

health information, including records from 

health care providers, laboratories, and 

pharmacies; personal health trackers; and 

advance directives, care reminders, and selfentered health information; 

• Access to Internet assessment services and 

health information sources so that they can 

build a personalized health information 

library; 

• Interface with a wide range of services and 

programs, including prescription, appointment 

scheduling and reminders, medication refills, 

participation in consumer and support groups, 

and alerts to new research findings and 

projects; 

• Availability to the general public, consumers, 

and families; and 

• Universal design to ensure access for people 

with sensory perceptual and physical 

disabilities and availability in a broad range of 

multilingual formats. 
86

Conclusion

This Final Report conveys the Commission’s bold 

vision for transforming the existing, often 

intimidating maze of mental health services into a 

coordinated, consumer-centered, recovery-oriented 

mental health system. Although barriers stand in 

the way, with national resolve and leadership, they 

will be overcome. 

The Commission recognizes that historically 

Americans have assumed responsibility locally 

and regionally for working together to meet 

challenges and to support their neighbors and 

communities. A major step toward achieving the 

vision will require genuine collaborative efforts 

from all parties who deliver or use mental health 

services and supports. All must recognize the 

interwoven nature of the diverse programs that 

make up the mental health system and, in turn, 

must see where program flexibility and 

cooperation can be strengthened in the interest of 

consumers and families. 

To transform the mental health care system, the 

Commission proposes a combination of goals and 

recommendations that together represent a strong 

plan for action. No single goal or recommendation 

alone can achieve the needed changes. No level or 

branch of government, no element of the private 

sector can accomplish needed change on its own. 

To transform mental health care as proposed, 

collaboration between the private and public 

sectors and among levels of government is crucial. 

Mental illness is the only category of illness for 

which State and local governments operate distinct 

treatment systems, making comprehensive care 

unavailable in the larger health care system. 

Ultimately, this situation must change, but to do so 

requires health care reform beyond the 

Commission’s scope. 

 As has long been the case in America, 

local innovations under the mantle of 

national leadership can lead the way 

for successful transformation 

throughout the country. 

Health care in America is at a pivotal point where 

reform must occur and mental health must share in 

that reform. The Nation has a vested interest and a 

tremendous stake in doing what is right to correct 

a system with problems that resulted from layering 

multiple, well-intentioned programs. 

The integrated strategy outlined in this Final 

Report can achieve the transformation that will 

allow adults with serious mental illness and 

children with serious emotional disturbances to 

live, work, learn, and participate fully in their 

communities. Indeed, as has long been the case in 

America, local innovations under the mantle of 

national leadership can lead the way for successful 

transformation throughout the country. 

As a Commission, we are grateful to the many 

strong and courageous individuals who gave their 

time, and in some cases traveled great distances to 

share their stories. It is for these individuals — as 

well as for the ones who continue to go unserved 

— that we must take swift, courageous action to 

transform the current maze of services, treatments, 

and supports into an efficient and cohesive mental 

health care delivery system. We owe them, their 

families, and future generations nothing less. 
87

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22337 

Federal Register PRESIDENTIAL DOCUMENTS

Vol. 67, No. 86 

Friday, May 3, 2002 

Title 3 -- Executive Order 13263 of April 29, 2002 

The President President's New Freedom Commission on Mental Health 

By the authority vested in me as President by the Constitution and the laws of the 

United States of America, and to improve America's mental health service 

delivery system for individuals with serious mental illness and children with 

serious emotional disturbances, it is hereby ordered as follows: 

Section 1. Establishment. There is hereby established the President's New 

Freedom Commission on Mental Health (Commission). 

Sec. 2. Membership. (a) The Commission's membership shall be composed of: 

(i) Not more than fifteen members appointed by the President, including 

providers, payers, administrators, and consumers of mental health services and 

family members of consumers; and 

(ii) Not more than seven ex officio members, four of whom shall be designated 

by the Secretary of Health and Human Services, and the remaining three of whom 

shall be designated--one each--by the Secretaries of the Departments of Labor, 

Education, and Veterans Affairs. 

(b) The President shall designate a Chair from among the fifteen members of the 

Commission appointed by the President. 

Sec. 3. Mission. The mission of the Commission shall be to conduct a 

comprehensive study of the United States mental health service delivery system, 

including public and private sector providers, and to advise the President on 

methods of improving the system. The Commission's goal shall be to recommend 

improvements to enable adults with serious mental illness and children with 

serious emotional disturbances to live, work, learn, and participate fully in their 

communities. In carrying out its mission, the Commission shall, at a minimum: 

(a) Review the current quality and effectiveness of public and private providers 

and Federal, State, and local government involvement in the delivery of services 

to individuals with serious mental illnesses and children with serious emotional 

disturbances, and identify unmet needs and barriers to services. 

(b) Identify innovative mental health treatments, services, and technologies that 

are demonstrably effective and can be widely replicated in different settings. 
(c) Formulate policy options that could be implemented by public and private 

providers, and Federal, State, and local governments to integrate the use of 

effective treatments and services, improve coordination among service providers, 

and improve community integration for adults with serious mental illnesses and 

children with serious emotional disturbances. 

Sec. 4. Principles. In conducting its mission, the Commission shall adhere to the 

following principles: 

(a) The Commission shall focus on the desired outcomes of mental health care, 

which are to attain each individual's maximum level of employment, self-care, 

interpersonal relationships, and community participation; 

(b) The Commission shall focus on community-level models of care that 

efficiently coordinate the multiple health and human service providers and public 

and private payers involved in mental health treatment and delivery of services; 

(c) The Commission shall focus on those policies that maximize the utility of 

existing resources by increasing cost effectiveness and reducing unnecessary and 

burdensome regulatory barriers; 

(d) The Commission shall consider how mental health research findings can be 

used most effectively to influence the delivery of services; and 

(e) The Commission shall follow the principles of Federalism, and ensure that its 

recommendations promote innovation, flexibility, and accountability at all levels 

of government and respect the constitutional role of the States and Indian tribes. 

Sec. 5. Administration. (a) The Department of Health and Human Services, to the 

extent permitted by law, shall provide funding and administrative support for the 

Commission. 

(b) To the extent funds are available and as authorized by law for 

persons serving intermittently in Government service (5 U.S.C. 5701-5707), 

members of the Commission appointed from among private citizens of the United 

States may be allowed travel expenses while engaged in the work of the 

Commission, including per diem in lieu of subsistence. All members of the 

Commission who are officers or employees of the United States shall serve 

without compensation in addition to that received for their services as officers or 

employees of the United States. 

(c) The Commission shall have a staff headed by an Executive Director, who shall 

be selected by the President. To the extent permitted by law, office space, 

analytical support, and additional staff support for the Commission shall be 

provided by executive branch departments and agencies. 
(d) Insofar as the Federal Advisory Committee Act, as amended, may apply to the 

Commission, any functions of the President under that Act, except for those in 

section 6 of that Act, shall be performed by the Department of Health and Human 

Services, in accordance with the guidelines that have been issued by the 

Administrator of General Services. 

Sec. 6. Reports. The Commission shall submit reports to the President as follows: 

(a) Interim Report. Within 6 months from the date of this order, an interim report 

shall describe the extent of unmet needs and barriers to care within the mental 

health system and provide examples of community-based care models with 

success in coordination of services and providing desired outcomes. 

(b) Final Report. The final report will set forth the Commission's 

recommendations, in accordance with its mission as stated in section 3 of this 

order. The submission date shall be determined by the Chair in consultation with 

the President. 

Sec. 7. Termination. The Commission shall terminate 1 year from the date of this 

order, unless extended by the President prior to that date. 

George W. Bush 

The White House, 

April 29, 2002. 
Acknowledgments

The Commission deeply appreciates the more than 2,300 persons who shared comments, personal stories, and 

recommendations through its web site, at public hearings, and in letters and e-mails. Their insightful and 

heartfelt comments have strengthened and helped shape the work of the President’s New Freedom 

Commission on Mental Health. 

Many people assisted the President’s New Freedom Commission on Mental Health with its work. The 

Commission acknowledges the following individuals for their important contributions: 

Executive staff 

Claire Heffernan, J.D., Executive Director 

H. Stanley Eichenauer, M.S.W., A.C.S.W., Deputy 

Executive Director 

Patty DiToto, Administrative Assistant 

Dawn Foti Levinson, M.S.W., Policy Advisor 

James Finley, M.A., Policy Analyst 

Kevin Hennessey, Ph.D., Senior Policy Advisor 

Ann Jacob Smith, M.S., NCC, LPC, Policy Advisor 

Elaine Viccora, L.C.S.W., Senior Policy Advisor 

Substance Abuse and Mental Health Services Administration 

(SAMHSA) 

Gail Hutchings, M.P.A, Acting Director, Center for 

Mental Health Services, and Senior Advisor to the 

Administrator, SAMHSA 

Mark Weber, M.B.A., Associate Administrator for 

Communications, SAMHSA 

Jeffrey Buck, Ph.D., Associate Director for 

Organization and Financing, Center for Mental 

Health Services 

Kana Enomoto, M.A., Special Assistant to the 

Director, Center for Mental Health Services 

Sybil Goldman, M.S.W., Senior Advisor on 

Children, Office of the Administrator 

Michael Malden, Public Health Advisor, Center for 

Mental Health Services 

Ronald Manderscheid, M.D., Chief, Survey and 

Analysis Branch, Center for Mental Health Services 

Barbara McGrath, Administrative Officer, Office of 

Program Services, Division of Administrative Services 

Rich Morey, Webmaster, Division of Information 

Resources Management 

Renee Perthuis, Department of Health and Human 

Services, Washington, DC 

Susette Rego, Web Team Leader, Division of 

Information Resources Management 

Eleanor Vincent, M.P.A., Manager, Andrea Adams 

and Andre McCabe, Mental Health Information 

Center, SAMHSA 
Expert consultants advising the Commission’s subcommittees 

Steve Adelsheim, M.D., Children and Families, New 

Mexico Department of Health, Albuquerque, NM 

Lynn Aronson, Housing and Homelessness, Goleta, 

CA 

Stephen J. Bartels, M.D., Older Adults, Associate 

Professor of Psychiatry, Dartmouth Medical School, 

Lebanon, NH 

Eric Caine, M.D., Suicide Prevention, John Romano 

Professor and Chair, Department of Psychiatry, 

University of Rochester Medical Center, Rochester, 

NY 

Jean Campbell, Ph.D., Consumer Issues, Research 

Assistant Professor, Missouri Institute of Mental 

Health, St. Louis, MO 

Judith Cook, Ph.D., Employment and Income 

Supports, Professor and Principal Investigator, 

University of Illinois at Chicago, Chicago, IL 

King Davis, Ph.D., Cultural Competence and 

Children and Families, Professor, University of 

Texas, Austin, TX 

Miriam R. Davis, Ph.D., Interim Report and Final 

Report, Medical Writer and Consultant (LLC), Silver 

Spring, MD 

Stephen Day, Medicaid, Executive Director, 

Technical Assistance Collaborative, Inc., Boston, 

MA 

Richard Frank, Ph.D., Medication, Professor, 

Department of Health Care Policy, Harvard Medical 

School, Boston, MA 

Bob Friedman, Ph.D. Children and Families, 

Professor and Chair, Department of Child and 

Family Studies, Louis de la Parte Florida Mental 

Health Institute, University of South Florida, Tampa, 

FL 

Barbara Friesen, Ph.D., Children and Families, 

Director, Research and Training Center on Family 

Support and Children’s Mental Health, Portland 

State University, Portland, OR 

Howard Goldman, M.D., Ph.D., Evidence-Based 

Practices/Medication, Professor, Department of 

Psychiatry, University of Maryland School of 

Medicine, Baltimore, MD 

Rachel Guerrero, L.C.S.W., Children and Families, 

Chief, Office of Multicultural Services, State 

Department Mental Health, Sacramento, CA 

Pamela Hyde, J.D., Medicaid, Senior Consultant, 

Technical Assistance Collaborative, Santa Fe, NM 

Ethleen Iron Cloud-Two Dogs, Cultural 

Competence, Program Director, Oglala Sioux Tribe, 

Porcupine, SD 

Kerry Knox, Ph.D. Suicide Prevention (assisting 

Eric Caine), Department of Psychiatry, University of 

Rochester Medical Center, Rochester, NY 

Col. David Litts, M.D., Suicide Prevention, 

Associate Director for Suicide Prevention Resource 

Center, Washington, DC 

Ruby J. Martinez, Ph.D., Cultural Competence, 

Assistant Professor, School of Nursing, University of 

Colorado Health Sciences, Denver, CO 

Kenneth Minkoff, M.D., Co-occurring Disorders, 

Director of Integrated Psychiatric and Addiction 

Services for Arbour Health System, Medical Director 

of Choate Health Management Care, and Assistant 

Clinical Professor of Psychiatry at Harvard, Boston, 

MA 

Dennis Mohatt, M.A., Rural Issues, Senior Program 

Director, Mental Health Program, Western Interstate 

Commission for Higher Education, Boulder, CO 

John T. Monahan, Ph.D., Rights and Engagement, 

Professor, University of Virginia, Institute of Law, 

Psychiatry, and Public Policy, Charlottesville, VA 

Pat Mrazek, Ph.D., M.S.W., Children and Families, 

Mental Health Policy Consultant, Rochester, MN 

Sheila Pires, M.P.A., Children and Families, Partner, 

Human Service Collaborative, Washington, DC 

Ann O’Hara, Housing and Homelessness, Associate 

Director, Technical Assistance Collaborative, 

Boston, MA 
Steven P. Shon, M.D., Cultural Competence,

Medical Director, Texas Department of Mental 

Health and Mental Retardation, Austin, TX 

Henry Steadman, Ph.D., Criminal Justice, President, 

Policy Research Associates, Inc., Delmar, NY 

Susan Stefan, J.D., Rights and Engagement, 

Attorney, Center for Public Representation, Newton, 

MA 

Beth Stroul, M.Ed., Children and Families, Vice 

President, Management and Training Innovations, 

Inc., McLean, VA 

Jurgen Unutzer, M.D., M.P.H., Mental Health 

Interface with General Medicine, Principle 

Investigator and Director, IMPACT Study 

Coordinating Center, Health Services Research 

Center, UCLA Neuropsychiatric Institute, Los 

Angeles, CA 

Doug Ziedonis, M.D., M.P.H., Co-occurring 

Disorders, Associate Professor, Department of 

Psychiatry, UMDNJ - Robert Wood Johnson 

Medical School, Piscataway, NJ 

Research and technical support

Garrett Moran, Ph.D., Associate Area Director, 

Westat, Rockville, MD 

Susan Azrin, Ph.D., Senior Study Director, Westat, 

Rockville, MD 

Miriam Davis, Ph.D., Medical Writer and 

Consultant, Silver Spring, MD 

Howard Goldman, M.D., Ph.D., Professor, 

Department of Psychiatry, University of Maryland 

School of Medicine, Baltimore, MD 

Carolyn Boccella Bagin, M.Ed., Center for Clear 

Communication, Inc., Rockville, MD 
Acronyms

ACF Administration for Children and 

Families 

AD/HD Attention Deficit Hyperactivity 

Disorder 

ADA Americans with Disabilities Act 

BBA Balanced Budget Act 

CMHS Center for Mental Health Services 

CSAT Center for Substance Abuse 

Treatment 

CMS Center for Medicare and Medicaid 

Services 

DOJ U.S. Department of Justice 

EBPs Evidence-based Practices 

ED U. S. Department of Education 

FCTI Family Critical Time Intervention 

Model 

FDA U.S. Food and Drug Administration 

GAO General Accounting Office 

HCBS Home and Community-based 

Services 

HHS U.S. Department of Health and 

Human Services 

HIPAA Health Insurance Portability and 

Accountability Act 

HRSA Health Resources and Services 

Administration 

HUD U.S. Department of Housing and 

Urban Development 

IDEA Individuals with Disabilities 

Education Act 

IEP Individualized Education Program 

IMDs Institutions for Mental Diseases 

IOM Institute of Medicine 

NIH National Institutes of Health 

NIMH National Institute of Mental Health 

NSSP National Strategy for Suicide 

Prevention 

OCR Office for Civil Rights 

PTSD Post-traumatic Stress Disorder 

SAMHSA Substance Abuse and Mental Health 

Services Administration 

SSA Social Security Administration 

SSDI Social Security and Disability 

Income 

SSI Social Security Income 

TANF Temporary Assistance for Needy 

Families 

TMAP Texas Medication Algorithm Project 

TWWIIA The Ticket to Work and Work 

Incentives Improvement Act 

VA Department of Veterans Affairs 

VHA Veterans Health Administration 

WHO World Health Organization