Mental Health: HHS Leadership Needed to Coordinate Federal Efforts Related to Serious Mental Illness
Released: 2015-02-05T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: In 2013, about 10 million adults in the United States had a serious mental illness. The U.S. mental health care system includes a range of federal programs—across multiple agencies—for those with mental illness. Past efforts to develop a list of federal programs supporting individuals with serious mental illness have highlighted the difficulty of identifying such programs.

GAO was asked to provide information on federal programs that support individuals with serious mental illness. This report identifies (1) the federal programs that support individuals with serious mental illness; (2) the extent to which federal agencies coordinate these programs; and (3) the extent to which federal agencies evaluate such programs. GAO developed and administered a web-based questionnaire to eight federal agencies regarding program goals, target populations, services offered, evaluations, and coordination. GAO also interviewed agency officials.

section_title: What GAO Found
paragraphs: Agencies identified 112 federal programs that generally supported individuals with serious mental illness in fiscal year 2013. The majority of these programs addressed broad issues, such as homelessness, that can include individuals with serious mental illness. The programs were spread across eight federal agencies: Department of Defense (DOD), Department of Education, Department of Health and Human Services (HHS), Department of Housing and Urban Development, Department of Justice (DOJ), Department of Labor, Department of Veterans Affairs (VA), and the Social Security Administration. Thirty of the 112 programs were identified by the agencies as specifically targeting individuals with serious mental illness. Four agencies—DOD, HHS, DOJ, and VA—reported that they obligated about $5.7 billion for programs that specifically targeted individuals with serious mental illness in fiscal year 2013. Agencies had difficulty identifying all programs supporting individuals with serious mental illness because they did not always track whether or not such individuals were among those served by the program. Agencies also varied in which programs they identified because they had different definitions of what such a program might be. Such inconsistency limits the potential comparability across programs.

Interagency coordination for programs supporting individuals with serious mental illness is lacking. HHS is charged with leading the federal government's public health efforts related to mental health, and the Substance Abuse and Mental Health Services Administration is required to promote coordination of programs relating to mental illness throughout the federal government. In the past, HHS led the Federal Executive Steering Committee for Mental Health, with members from across the federal government. However, the steering committee has not met since 2009. HHS officials told us that the Behavioral Health Coordinating Council (BHCC) performs some functions previously carried out by the steering committee. The BHCC, however, is limited to HHS and is not an interagency committee. Other interagency committees were broad in scope and did not target individuals with serious mental illness. Staff for the majority of the programs targeting serious mental illness reported taking steps to coordinate with staff in other agencies. While coordination at the program level is important, it does not take the place of, or achieve the level of, leadership that GAO has previously found to be key to successful coordination and that is essential to identifying whether there are gaps in services and if agencies have the necessary information to assess the reach and effectiveness of their programs.

Agencies completed few evaluations of the programs specifically targeting individuals with serious mental illness. Of the 30 programs specifically targeting individuals with serious mental illness, 9 programs had a completed program evaluation, 4 programs had an evaluation underway, and 17 programs had no evaluation completed and none planned. However, agency officials said they engaged in other efforts—such as drawing on evidence in published literature—to ensure their programs were effective. GAO's prior work has shown the significance of both performance monitoring activities and program evaluations and noted the importance of formal program evaluations to inform program managers about the overall design and operation of the program.

section_title: What GAO Recommends
paragraphs: GAO recommends that HHS establish a mechanism to facilitate interagency coordination across programs that support individuals with serious mental illness. GAO also recommends that DOD, HHS, DOJ, and VA document which programs targeting individuals with serious mental illness should be evaluated and how often such evaluations should be completed. HHS disagreed with both recommendations. DOD, DOJ, and VA agreed with the second recommendation. GAO continues to believe the recommendations are valid as discussed in the report.

section_title: Letter
paragraphs: Mental illness is widespread in the United States. According to figures  from the Substance Abuse and Mental Health Services Administration  (SAMHSA)—an agency within the Department of Health and Human  Services (HHS)—an estimated 43.8 million—or 18.5 percent—of adults in  the United States suffered from a mental illness in 2013. Among those,  about 10 million—or 4.2 percent—of adults in the United States suffered  from a serious mental illness, which generally includes conditions such as  schizophrenia, bipolar disorder, major depression, and severe post- traumatic stress disorder (PTSD).issues. In 2013, approximately 10.7 percent of children—an estimated    Children also suffer from mental health  2.6 million—aged 12 to 17 years old experienced a period of major  depression.

The U.S. mental health care system includes a range of programs for  those with a mental illness, including programs addressing broad social  issues, such as homelessness, that can generally support individuals with  mental illness as well as other programs that are specifically targeting  people with mental illness. The federal government provides a range of  programs to support the needs of individuals with serious mental illness.  There have been efforts in the past to develop a list of the federal  programs and resources that are devoted to supporting and treating  individuals with serious mental illness, and some have highlighted the  difficulty of identifying all of the programs. For example, in 2013, the  Office of Management and Budget (OMB) collected information on the  federal activities and services that support individuals with mental illness;  however, OMB acknowledged that the information gathered did not  include a number of federal programs that address mental health as part  of broader activities and that there are also services or benefits provided  to individuals with mental illness that are not provided exclusively on the  basis of an individual’s mental illness.

Because of the size of the population affected and the complexity of  treating those with mental illness, coordinating and evaluating programs  that support these individuals is particularly important for meeting the  needs of this vulnerable population. Both Congress and the executive  branch have recognized the need for improved collaboration across the  federal government, and many of the meaningful results that the federal  government seeks to achieve require the coordinated efforts of  government agencies. Our prior work has highlighted some of the  approaches and key considerations for implementing interagency  collaborative mechanisms, such as defining outcomes; measuring  performance and ensuring accountability; and establishing leadership  approaches, among other things.role in agency strategic planning and in program management, providing  important feedback on both program design and execution.

Furthermore, evaluation can play a key  You asked us to provide information on how federal agencies support  programs for individuals with serious mental illness and ensure these  programs are meeting the needs of this population. This report identifies  (1) the federal programs that support individuals with serious mental  illness; (2) the extent to which federal agencies coordinate programs for  individuals with serious mental illness; and (3) the extent to which federal  agencies evaluate or monitor programs for individuals with serious mental  illness.

To identify federal programs supporting those with serious mental illness,  the extent to which federal agencies are coordinating, and the extent to  which federal agencies evaluate or monitor programs, we developed a  web-based questionnaire. The web-based questionnaire asked  questions about program goals, target populations, services offered,  performance information and evaluations, coordination, and funding in  fiscal year 2013. To determine which federal departments, agencies, and  other federal entities administer programs that support individuals with  serious mental illness, we reviewed existing documentation and reports  and interviewed advocacy groups and agency officials. Based on this  review and our interviews, we identified eight agencies frequently cited as  having relevant programs supporting individuals with serious mental  illness and administered the questionnaire to those agencies.supplemented the questionnaire responses with follow-up interviews and   We  questions to each of the agencies to obtain any additional information. To  assess the reliability of the information we received, we performed  internal reliability checks and conducted follow-up as necessary with  agency officials. As a result, we determined that the data used in our  report were sufficiently reliable for our purposes. See appendix I for more  information on our scope and methodology.

We conducted this performance audit from December 2013 to December  2014 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: Mental Illness
paragraphs: Mental illness is generally defined as a health condition that changes a  person’s thinking, feelings, or behavior and causes the person distress  and difficulty in functioning. The symptoms associated with a given type  of mental illness can vary in frequency and severity across individuals  and for each individual over time. Mental illnesses with particularly severe  symptoms can have a dramatic impact on an individual’s ability to  function in everyday life. The fatigue experienced by an individual with  major depressive disorder can be so severe that it is difficult to summon  the energy to work every day. The delusions associated with paranoid  schizophrenia can make it impossible to maintain stable personal  relationships with spouses, co-workers, or friends. Certain other mental  illnesses are known for the unpredictable and episodic nature of their  symptoms and the harmful effect this has on the ability to function  consistently over time. For example, individuals with bipolar disorder can  alternate between periods of mania, relative normalcy, and profound  depression.

section_title: Mental Health Care System
paragraphs: The services provided by the public mental health care system to  individuals with serious mental illness have changed over time.  Historically, state-run public mental health hospitals were the principal  treatment option available to them. By the 1960s, the reliance on inpatient  care was viewed as ineffective and inadequate because of patient  overcrowding, staff shortages, and other factors. At the same time,  improved medications and other interventions were reducing some of the  symptoms of mental illness and increasing the potential for more of these  individuals to live successfully in the community. A recovery-oriented,  community-based approach to mental health treatment has since  emerged. Under this approach, individuals are to receive services and  supports uniquely designed to help them manage their mental illness and  to maximize their potential to live independently in the community. These  services and supports are multidimensional—intended to address not  only mental illness but also employment, housing, and other issues.  When feasible, these multidimensional services are provided in what is  referred to as a “wrap-around” manner—that is, they are uniquely  targeted to the nature and extent of each individual’s needs. When  services are provided by multiple agencies, those agencies are to  coordinate their activities and funding so that the individual experiences  the services and supports seamlessly—as if from one system, not many.

section_title: Federal Mental Health Care Programs
paragraphs: The federal government provides a range of programs to support the  needs of individuals with serious mental illness, such as funding block  grants to community mental health organizations and providing supportive  housing programs for individuals with mental illness. The responsibility for  the administration and evaluation of these programs falls upon multiple  agencies, including Department of Defense (DOD), Department of  Education (Education), HHS, Department of Housing and Urban  Development (HUD), Department of Justice (DOJ), Department of Labor  (DOL), Department of Veterans Affairs (VA), and Social Security  Administration (SSA). Programs supporting individuals with serious  mental illness may or may not be specifically targeting that population.  For example, a program providing housing for homeless veterans may  provide support to individuals with serious mental illness because these  individuals make up a portion of the population of homeless veterans, but  the program is targeting homeless veterans rather than individuals with  serious mental illness.

SAMHSA, an agency within HHS, leads the federal government’s public  health efforts related to behavioral health, which includes mental health.  Specifically, SAMHSA administers behavioral health programs,  disseminates policies, information and data, and awards contracts and  grants to states, tribes, local governments, and other organizations,  including those that support individuals with serious mental illness.

section_title: Agency Coordination and Program Evaluation
paragraphs: Our prior work has noted the importance of coordinating and evaluating  programs. This is particularly important in the case of federal efforts to  support serious mental illness, given the size of the population affected  and the complexity of treatment. We have also reported on the  importance of coordination between federal agencies on issues of  national significance as a way to avoid fragmentation. Many of the  meaningful results that the federal government seeks to achieve require  the coordinated efforts of more than one federal agency and often more  than one sector and level of government. Our past work has identified a  range of mechanisms that the federal government uses to lead and  implement interagency coordination, including interagency groups  sometimes referred to as task forces, working groups, councils, or  committees.

In addition, for many years, we have reported that more frequent  evaluations of performance and results were needed for multiple federal  programs and activities. systematic study to assess how well a program or programs are working.

GAO, Government Efficiency and Effectiveness: Opportunities to Reduce  Fragmentation, Overlap, and Duplication through Enhanced Performance Management  and Oversight, GAO-13-590T (Washington, D.C.: May 22, 2013).

Evaluations answer specific questions about program performance and  may focus on assessing program operations or results. Evaluation can  play a key role in agency strategic planning and in program management,  providing important feedback on both program design and execution.  Program evaluation is closely related to performance measurement and  reporting. Performance measurement is the systematic ongoing  monitoring and reporting of program accomplishments, particularly  progress toward established goals or standards. The Government  Performance and Results Act of 1993 (GPRA), as expanded by the  GPRA Modernization Act of 2010, encourages federal agencies to  conduct evaluations by requiring them to include a schedule of future  program evaluations in their strategic plans and summarize their  evaluation findings when reporting on their performance goals, among  other things.

section_title: Eight Agencies Reported over 100 Programs That Can Support Individuals with Serious Mental Illness, but It Is Unlikely All Programs Were Identified
subsections: section_title: Agencies Identified 112 Programs That Can Support Individuals with Serious Mental Illness, 30 of Which Specifically Target This Population
paragraphs: Agencies identified 112 federal programs in fiscal year 2013—across  eight federal agencies—that can support individuals with serious mental  illness. These 112 programs conducted activities that can generally  support individuals with serious mental illness. For example, HUD’s  Continuum of Care program provided funding to nonprofit providers and  state and local governments to quickly find housing for homeless  individuals and families, among other services. See appendix II for a list  of the 112 federal programs identified as supporting individuals with  serious mental illness in fiscal year 2013.

The number and purpose of programs identified by agencies through our  questionnaire varied widely. DOD reported the largest number, a total of  34 programs, and HHS identified 33. Together, the agencies accounted  for more than half of the 112 programs. DOJ and VA also each reported  over 10 programs. Overall, many of the programs focused on the  provision of support services and a few programs focused on research or  surveillance. Programs that provided support services included those that  provided case management services such as SAMHSA’s Criminal and  Juvenile Justice Programs. These programs sought to divert individuals  with serious mental illness from the criminal justice system by providing  support services that connect the individual to behavioral health, housing,  and job placement services. DOD was the only agency that reported  prevention programs (13 programs) through the questionnaire, and three  agencies—DOD, HHS, and VA—reported treatment programs (16  programs). About a quarter of the programs—27 programs—were  identified as serving other purposes. For example, the Department of  Education included its Personnel Development program that awarded  grants to assist in ensuring adequate numbers of highly qualified special  education teachers and fully certified personnel to serve children with  disabilities, including children with serious emotional disturbance who  may have a serious mental illness. Table 1 provides the number of these  programs, by primary program purpose, within the eight federal agencies.

In addition to serving a variety of purposes the 112 programs that support  individuals with serious mental illness, served a variety of subpopulations,  ranging from children to homeless veterans. For example, DOJ  administered a program—the Second Chance Act Reentry Program—that  focused on adults and youth with co-occurring substance abuse and  mental health disorders during their confinement or court supervision. In  addition, DOL administered the Homeless Veterans Reintegration  program, which worked to meet the needs of homeless veterans by  reintegrating them into the workforce.

A subset of the 112 programs—30 programs, or 27 percent—were  identified by agencies as specifically targeting individuals with serious  mental illness. These targeted programs were administered by five  agencies: DOD, DOJ, HHS, SSA, and VA. The primary purpose of the 30  targeted programs varied. Half of the targeted programs (15 programs)  provided support services, such as case management, to individuals with  serious mental illness. Ten of those programs were within HHS. Seven of  the targeted programs provided treatment services, with 6 of those  programs—administered by VA—providing treatment services to veterans  with serious mental illness. All targeted programs reported by HHS were  within SAMHSA, and focused on providing support services and technical   Table 2 provides the number of these programs, by primary  assistance.program purpose, within the five federal agencies that identified programs  specifically targeted towards individuals with serious mental illness.

In addition to serving a variety of purposes, the 30 programs that  specifically target individuals with serious mental illness, served a variety  of subpopulations, ranging from children and families to homeless  veterans. Over half of the targeted programs (16 programs) were  administered by three agencies—DOD, DOJ, and VA—and served  specific subpopulations; servicemembers, incarcerated or previously  incarcerated individuals, and veterans, respectively. Three of the targeted  programs (all within HHS) served children and/or families. The remaining  programs served adults.

Based on agency-reported information from the questionnaire, about   $5.7 billion was obligated for the 30 targeted programs in fiscal year  2013.and VA for treatment and support services (among other things) for   The majority of these funds—84 percent—was obligated by DOD  servicemembers, veterans and their families. HHS’s SAMHSA  obligations represented about 13 percent of total obligations for the 30  targeted programs. HHS officials noted that Medicaid is the largest  payer for services for individuals with serious mental illness and that  Medicare is also a significant payer for services for that population. The   See appendix  remaining funds were obligated for programs within DOJ.III for more information on the 30 targeted programs.

section_title: It Is Unlikely That Agencies Identified All Programs for Individuals with Serious Mental Illness
paragraphs: Agencies had difficulty identifying all programs supporting individuals with  serious mental illness because they did not always track whether or not  such individuals were among the population served by the program.  During follow-up interviews, officials from several agencies indicated that  they were unsure how many individuals with serious mental illness were  served by various programs. Specifically, some agencies noted that they  administered broad federal programs focusing on individuals with  disabilities that could serve individuals with serious mental illness. For  example, Education officials indicated that individuals with serious mental  illness could have been among individuals eligible to receive services  under their Centers for Independent Living program that provided  financial assistance to community-based centers for independent living.

However, Education officials were unsure the extent to which the program  served individuals with serious mental illness because that was not the  focus of the program and because individuals self-identify their disability,  which may include a serious mental illness. Similarly, the Disability  Employment Initiative administered by DOL served all people with  disabilities, including individuals with serious mental illness, but it was  unclear how many individuals with serious mental illness were served by  this program. Officials from agencies within HHS also noted that it is  possible that all of their programs could support individuals with serious  mental illness.

The inability of agencies to identify a comprehensive list or inventory of  programs for individuals with serious mental illness is problematic. The  GPRA Modernization Act of 2010 requires OMB to compile a  comprehensive list of all federal programs identified by agencies, and to  include the purposes of each program, how it contributes to the agency’s  mission, and recent funding information. However, as we reported  earlier this year, our initial review of these lists identified concerns about  the usefulness of the information being developed and the extent to which  it might be able to assist executive branch and congressional efforts to  identify and address fragmentation, overlap, and duplication. The lack of  such a list makes it more difficult for executive branch agencies and  Congress to determine whether proposed or existing programs are  duplicative.

In addition to difficulties in identifying a comprehensive inventory of  programs for individuals with serious mental illness, some agencies also  had difficulty identifying how much funding was obligated for programs  supporting individuals with serious mental illness. For example, HHS’s  National Institutes of Health identified all of its activities, including its  mental health activities as one program, Scientific Research. Officials  said they were able to identify funding amounts for individual research  studies related to certain illnesses that may be considered serious mental  illnesses, such as depression or schizophrenia. They noted that they were currently developing a method to categorize all research grants that  were related to serious mental illness. Similarly, DOJ’s Bureau of Prisons  identified three programs targeting individuals with serious mental illness  but could not provide the obligated funding amounts for the programs,  providing instead an amount that included all psychology services  programs, which included all of the Bureau of Prisons’ substance abuse  and mental health programs.

In addition, the number and scope of programs agencies identified is  likely incomplete and difficult to compare across agencies for a variety of  other reasons. Agencies varied widely in how they counted their  programs, resulting in inconsistencies among agencies, thus limiting the  potential comparability across programs. Some agencies identified  broad programs that included many activities; other agencies counted  each of these underlying activities as a separate program. For example,  within DOD, the Army included one program, the Behavioral Health  System of Care, which included a broad array of mental health and  substance abuse activities for servicemembers and their families. In  contrast, the Navy chose to list each comparable behavioral health  activity as a separate program. Furthermore, NIH identified only one  program, its Scientific Research program, which encompassed all of its  internal and external research project grants on topics ranging from  cardiovascular health to those grants related to mental illness.

Agencies also varied in how they defined their programs and in which  programs they chose to include. For example, DOD officials identified all  of their suicide prevention programs as those that support individuals with  serious mental illness, but SAMHSA officials did not initially include any of  their suicide prevention programs. They explained that these services  were not limited only to individuals with serious mental illness and served  a broader population. Subsequently, after further discussion with us,  SAMHSA included their suicide prevention programs among those that  can support individuals with serious mental illness. In another instance,  HUD and VA jointly administered the HUD-VA Supportive Housing  program, a specialized program aimed at providing housing and other  services to disabled veterans. VA officials indicated that this program was  targeting individuals with serious mental illness while HUD maintained  that the program was not targeting this population. Similar to these  challenges in identifying programs supporting individuals with serious  mental illness, our prior work has also found that agencies took various  approaches to defining their programs. This variation in definitions across  agencies can limit comparability among similar programs.

section_title: Interagency Coordination of Programs Supporting People with Serious Mental Illness Is Lacking
paragraphs: Agency-level committees that officials said allowed them to coordinate  efforts regarding mental health did not focus on, and took little action  specific to, serious mental illness. However, program staff for the majority  of the programs targeting serious mental illness reported taking steps to  coordinate with other program-level staff.
subsections: section_title: Committees Have Been Established for Interagency Coordination, but They Did Not Focus on, and Took Little Action Specific to, Serious Mental Illness
paragraphs: Interagency coordination for programs for individuals with serious mental  illness is lacking because agency-level committees do not focus  specifically on, and have taken little action regarding, serious mental  illness. While DOD, DOJ, HHS, SSA, and VA officials reported  establishing committees that they said allow them to coordinate efforts  regarding mental health across agencies, none of these committees were  focused specifically on serious mental illness.New Freedom Commission on Mental Health produced a report on the   In 2003, the President’s  fragmentation among programs for individuals with serious mental illness  and made recommendations to the federal government to better  coordinate services. In response, the Federal Executive Steering  Committee for Mental Health—led by HHS—was formed with high-level  representatives from DOD, DOJ, DOL, Education, HUD, SSA, VA, the  Department of Agriculture, and the Department of Transportation. In  2008, we reported that the committee had taken steps to coordinate  federal efforts by promoting access to employment services for young  adults with serious mental illness. However, the steering committee has  not met since 2009. HHS officials told us that the Behavioral Health  Coordinating Council (BHCC) performs some functions previously carried  out by the steering committee. The Secretary of HHS established the  BHCC in 2010 to bring together members from agencies within HHS to  focus on behavioral health issues, but the council did not include officials  from other federal agencies. Moreover, the BHCC has focused mainly on  substance use issues, rather than mental health.

There are several other interagency committees according to agency  officials, but these committees were generally broader in scope and did  not specifically focus on individuals with serious mental illness. (See   table 3 for several examples of such committees that are currently  operational.) For example, DOD, HHS, and VA lead the Interagency Task  Force on Military and Veterans Mental Health to provide support to  veterans, servicemembers, and their families. Agency officials told us the Interagency Task Force has undertaken efforts that were broadly  related to mental health such as expanding capacity for mental health  treatment, but have taken few actions specifically targeting serious mental  illness. Similarly, HHS officials reported that the U.S. Interagency Council  on Homelessness—formed to coordinate the federal response to  homelessness—has worked to improve access to behavioral health  services in an effort to address chronic and veteran homelessness.  Accordingly, the work of this committee might affect individuals with  serious mental illness, but the committee did not specifically focus on the  unique needs of this population. Only one of the identified committees— HHS’s BHCC—had plans to establish a subcommittee devoted to  addressing serious mental illness. It is also important to note that the  formation of this subcommittee was only recently announced during the  course of our work. SAMHSA officials said that the new subcommittee  under the BHCC will have an explicit focus on addressing serious mental  illness, and that they expected this group to have an initial meeting in  early 2015 to establish a direction for its forthcoming efforts. However,  consistent with the BHCC, the subcommittee is only expected to  coordinate within HHS, not across federal agencies.

Agency officials cited few specific actions taken by the coordination  committees to address the needs of individuals with serious mental  illness. For example, according to agency officials, the Psychological  Health and Traumatic Brain Injury committee, co-chaired by DOD and VA,  worked to implement the Integrated Mental Health Strategy, which the  agencies jointly developed to address the mental health needs of  servicemembers and veterans. However, VA officials said that none of  the elements of this strategy or actions the committee has taken were  specific to serious mental illness.

Although SAMHSA is charged with promoting coordination across the  federal government regarding mental illness, its efforts to lead  coordination—specifically on serious mental illness—across agencies  have been lacking. According to SAMHSA’s enabling legislation, as  amended, it is required to promote coordination of programs relating to  mental illness throughout the federal government. In addition,  SAMHSA’s 2011-2014 strategic plan acknowledges the need for  coordination, noting that no single program, either within HHS or  anywhere else in the federal government, can solve the problems of  homelessness, joblessness, educational challenges, and community  cohesion for people with mental illness, including those with serious  mental illness. Despite SAMHSA’s recognition of the need to  coordinate, such coordination related to serious mental illness has been  largely absent across the federal government. Further, our previous work  has demonstrated the value of interagency coordination when it is  supported by agency leadership. Without such coordination and support,  agencies do not have the necessary information to assess the reach and  effectiveness of their programs or to determine whether or where there  may be gaps or overlap in services for individuals with serious mental  illness.

section_title: Staff of Most Programs Specifically Targeting Individuals with Serious Mental Illness Reported Some Coordination
paragraphs: Although coordination specific to serious mental illness was lacking  among interagency committees, staff who completed questionnaires  regarding individual programs reported that they coordinate with their  counterparts in other programs both within and across agencies.  Specifically, staff from 90 percent of the programs targeting serious  mental illness (27 of 30 programs) reported coordinating with their  counterparts in other programs.

Program staff reported via the questionnaire and in follow-up responses  that they coordinated with other programs in the same agency. For  example, according to SAMHSA officials, program staff from the mental  health homelessness programs in SAMHSA’s Center for Mental Health  Services coordinated with staff in SAMHSA’s Center for Substance Abuse  Treatment in order to conduct a national evaluation of SAMHSA’s  homeless programs. This evaluation is a coordinated effort within  SAMSHA to compare effectiveness of programs and models of service  delivery such as those used by the Projects for Assistance in Transition  from Homelessness program, which funded services in both community  mental health and co-occurring alcohol and drug treatment. In another  example, program staff from SAMHSA’s Primary and Behavioral Health  Care Integration program—a program that addresses the primary care  needs of individuals with serious mental illness in an integrated  community mental health center setting—reported collaborating with  HHS’s Health Resources and Services Administration to jointly fund a  training and technical assistance center. According to staff for this  program, the cooperative agreement targeted both the Primary and  Behavioral Health Care Integration program grantees and the Health  Resources and Services Administration’s community health centers and  has supported trainings, curricula development, and webinars.

In addition, program staff reported via the questionnaire and in follow-up  responses that they have coordinated with programs in other agencies.  Program staff from SAMHSA’s Criminal and Juvenile Justice programs,  for example, told us that they met quarterly with program staff for DOJ’s  Bureau of Justice Assistance Justice and Mental Health Collaboration  program. They said that they strategized the use of resources at these  meetings. While coordination at the program level is important to ensure  that program staff are aware of the efforts of staff for other programs, it  does not take the place of, or achieve the level of leadership, that we  have noted in past work is key to successful coordination. Where  programs to address an issue are spread across multiple agencies—as  we have found they are in the case of serious mental illness—interagency  coordination at the agency level can minimize the potential for duplication  and overlap that could reduce the efficiency of federal programs. See  appendix IV for more information on the coordination mechanisms and  activities reported by program staff.

section_title: Agencies Have Evaluated Less than One-Third of the 30 Programs Targeted for People with Serious Mental Illness
paragraphs: Agencies completed few evaluations of the 30 programs that specifically  targeted individuals with serious mental illness. Specifically, as of  September 2014, 9 programs had a completed program evaluation,   4 programs had an evaluation underway, and 17 programs had no  evaluation. (See fig. 1.)

Of the 9 completed program evaluations, 7 were completed by SAMHSA  and 2 were completed by DOD. DOJ, SSA, and VA had not completed  any evaluations for their targeted programs. Evaluations for both targeted  DOD programs and two of the targeted SAMHSA programs were  completed in 2013. Of the remaining 5, all of which are HHS’s SAMHSA  programs, 1 was completed in 2010, 2 were completed in 2011, and 2  were completed in 2014.

We found that these completed evaluations gave an overall assessment  of the program, examined its strengths and weaknesses, and provided  recommendations for improvement. For example, SAMHSA contracted  with the Human Services Research Institute—a consulting and research  firm—to conduct an evaluation of the Protection and Advocacy for  Individuals with Mental Illness (PAIMI) program. Human Services  Research Institute’s 2011 evaluation report found that the program was  successful in giving those with psychiatric disabilities a voice in the  exercise of their rights, among other things. However, the report also  found deficiencies in the program, such as insufficient training for federal  program and contract officials regarding PAIMI requirements and frequent  difficulties gaining access to at-risk individuals in residential settings.  SAMHSA provided us with information about how the agency has  addressed the deficiencies outlined in the PAIMI evaluation.

In addition, the Army Deputy Chief of Staff conducted an evaluation of the  Army National Guard Psychological Health program in 2013. The  evaluation recommended that the program demonstrate that the services  delivered were responding to a specific need of its target population— Army National Guard and Army Reservists—and noted that it is unclear  whether the program is reaching Reservists. The evaluation also found  that the program adhered to its quality standards and effectively solicited  customer feedback.

Four of the 30 programs targeting individuals with serious mental illness  reported having evaluations underway that were scheduled for completion  after September 2014. The SSA Homeless with Schizophrenia  Presumptive Disability program is scheduled for completion in December  2014, the SAMHSA Projects for Assistance with the Transition from  Homelessness program and Mental Health Homelessness Prevention  programs are scheduled for completion in 2016, and the DOD Air Force  Air National Guard Psychological Health program is scheduled for  completion in 2017.

The remaining 17 programs targeting individuals with serious mental  illness had not completed a program evaluation. This included all 3 DOJ  programs, all 8 VA programs, 2 DOD programs, and 4 HHS programs.  (See table 4.) Our prior work has shown that program evaluations  address specific questions about program performance and may focus on  assessing program operations or results. These evaluations can play a  key role in agency strategic planning and in program management,  providing important feedback on both program design and execution.  Although our past work has found that some program evaluations can be  expensive, the relatively few evaluations completed among programs  targeted for individuals with mental illness is a concern because without  meaningful and timely evaluations, agencies may lose opportunities to  identify improvements in federal government efficiency and effectiveness,  and because comprehensive evaluations can be key to coordinating and  streamlining federal programs.30 programs and their evaluation status.

section_title: Conclusions
paragraphs: Individuals with serious mental illness can face significant challenges  getting the services they need. Agencies identified a wide range of federal  programs—across multiple agencies—that can support individuals with  serious mental illness. Although staff in programs targeting serious  mental illness reported taking steps to coordinate their individual  programs, coordination efforts among agency leadership to address  serious mental illness are lacking. The absence of this high-level  coordination hinders the federal government’s ability to develop an  overarching perspective of its programs supporting and targeting  individuals with serious mental illness. Although SAMHSA—the agency  within HHS that is required to promote coordination of programs relating  to mental illness throughout the federal government—has made some  effort to coordinate on mental health broadly, it has shown little leadership  in coordinating federal efforts on behalf of those with serious mental  illness. Without stronger leadership from HHS to coordinate an integrated,  interagency approach, it is difficult to attain the type of high-level  perspective needed to determine whether there are gaps in services. For  example, federal agencies reported difficulty even identifying which  programs can support this vulnerable population. Stronger HHS  leadership can also help ensure that agencies have the necessary  information to assess the reach and effectiveness of their programs for  individuals with serious mental illness. The new subcommittee within  HHS’s BHCC may provide a useful starting point to facilitate this  coordination around serious mental illness; however, the subcommittee is  new and the BHCC is limited to HHS and is not an interagency  committee.

We have also reported many times on the importance of conducting  formal program evaluations to inform program managers on the overall  design and operation of the program and ensure that the program’s  objectives are being met. Although about $5.7 billion was obligated by 4  agencies—DOD, HHS, DOJ, and VA—to support federal programs  specifically targeting individuals with serious mental illnesses, less than  one-third had a completed program evaluation. The public health, social,  and economic impact of serious mental illness, coupled with the  constrained fiscal environment of recent years, highlights the need to  ensure that federal programs efficiently and effectively use their  resources to support the complex needs of individuals with serious mental  illness.

section_title: Recommendations
paragraphs: To understand the full breadth of federal programs and the scope of  federal resources expended on programs supporting those with serious  mental illness, we recommend that the Secretary of HHS establish a  mechanism to facilitate intra- and interagency coordination, including  actions that would assist with identifying the programs, resources, and  potential gaps in federal efforts to support individuals with serious mental  illness.

To help determine if programs are effective at supporting those  individuals with serious mental illness, we recommend that the  Secretaries of Defense, Health and Human Services, Veterans Affairs,  and the Attorney General—which oversee programs targeting individuals  with serious mental illness—document which of their programs targeted  for individuals with serious mental illness should be evaluated and how  often such evaluations should be completed.

section_title: Agency Comments
paragraphs: We provided a draft of this report to DOD, DOJ, DOL, Education, HHS,  HUD, SSA, and VA for review and comment. DOD, HHS, SSA, and VA  provided written comments, which are reprinted in appendixes VI, VII,  VIII, and IX. DOJ, Education, HHS, and HUD provided technical  comments on this report that we incorporated as appropriate. Although  our report does not include recommendations directed to SSA, it said it  agreed with our report. DOL had no comments on the report.

Our first recommendation was directed to HHS exclusively. HHS did not  concur with this recommendation, which calls for the agency to establish  a mechanism to facilitate intra- and interagency coordination. HHS noted  that funding for SAMHSA is largely allocated to specific programs by  Congress and thus improving coordination should include coordination at  the Congressional level. HHS also stated that the recommendation was  not supported because coordination was already occurring at the program  level and there was not a specific need identified by agencies,  stakeholders, or individuals with serious mental illness that more  coordination was necessary.

The report acknowledges that coordination at a program level is important  but notes that it cannot take the place of coordination at higher levels that  would provide the perspective needed to assess the reach and  effectiveness of all of the federal government’s programs targeting  individuals with serious mental illness. In addition, as we note in the  report, SAMHSA’s own enabling legislation, as amended, includes a  requirement to promote coordination of programs relating to mental  illness throughout the federal government, and its own strategic plan  recognizes the need for coordination as well. In addition, our past work  has highlighted the importance of interagency coordination supported by  agency leadership. In light of these other sources demonstrating the  importance of interagency coordination beyond the program staff level to  the agency level, we believe our recommendation is appropriate and well- supported.

In addition, HHS expressed concern that we excluded Medicare and  Medicaid from our scope, stating that this omission was unexplained and  that it created inconsistencies in our findings because we included  treatment and support services funded by DOD and VA. However, as we  stated explicitly throughout the report, we excluded health benefit  programs including Medicare, Medicaid, and TRICARE. The purpose of  this report was to provide information on programs supporting individuals  with serious mental illness beyond those of reimbursement. As a result,  we do not believe it creates the inconsistencies stated by HHS. However,  the draft included an estimate of spending on mental health services by  Medicaid and Medicare to help address HHS’s concern.

Our second recommendation on conducting program evaluations was  directed to DOD, DOJ, HHS, and VA. HHS did not concur with this  recommendation, while DOD, DOJ, and VA agreed. While HHS said that  performance measurement is important, it stated that program evaluation  is only one method of measurement and suggested that the report places  undue importance on program evaluations in particular. In the report we  acknowledge that there are other efforts to monitor performance and  program effectiveness, including the performance and outcomes targets  in SAMHSA’s strategic plan, but as the report states, this type of ongoing  monitoring cannot take the place of a program evaluation. In addition,  HHS expressed concern that the report focused on completed  evaluations, noting that some program evaluations provide interim results  while still underway. In the report we acknowledge 2 HHS programs that  have program evaluations underway. Therefore, we believe we have  appropriately characterized the current status of the agency’s program  evaluations.

As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the Secretary of Health  and Human Services, the Secretary of the Department of Defense, the  Secretary of the Department of Education, the Secretary of the  Department of Housing and Urban Development, the Attorney General of  the United States, the Secretary of the Department of Labor, the  Commissioner of Social Security, the Secretary of the Department of  Veterans Affairs, and to other interested parties. In addition, the report will  be available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please   contact me at (202) 512-7114, or kohnl@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of our report. Key contributors to this report are listed in   appendix X.

section_title: Appendix I: Scope and Methodology
paragraphs: This appendix describes the methodology for developing, administering,  and analyzing a web questionnaire for eight federal departments,  agencies, and other entities to gather information on programs supporting  individuals with serious mental illness or serious emotional disturbance,  including any evaluation and coordination efforts undertaken related to  those programs.
subsections: section_title: Identification of Federal Agencies
paragraphs: To identify federal agencies that may have programs supporting  individuals with serious mental illness or serious emotional disturbance,  we reviewed the programs and agencies highlighted in the President’s  New Freedom Commission on Mental Health “Major Federal Programs  Supporting and Financing Mental Health Care,” reviewed our prior  reports, other documents, such as reports from the Bazelon Center for  Mental Health Law, and interviewed advocacy groups and agency   Based on this review and our interviews, there were eight  officials.agencies that were cited frequently as having programs supporting  individuals with serious mental illness, and we included those agencies in  our review:

Department of Defense (DOD)

Department of Education (Education)

Department of Health and Human Services (HHS)

Department of Housing and Urban Development (HUD)

Department of Justice (DOJ)

Department of Labor (DOL)

Department of Veterans Affairs (VA), and

Social Security Administration (SSA).

section_title: Identification of Programs
paragraphs: To identify federal programs that support individuals with serious mental  illness or serious emotional disturbance, we developed definitions to  provide some clarity on the programs that should be included in our  review. To develop these definitions, we examined applicable federal  requirements, our prior work, and interviewed advocacy groups and  federal officials. We defined the key terms as follows:

Program: A federal program, activity, or initiative may include, but is  not limited to, (1) grants to state, local, tribal, nonprofit, or research  entities, (2) contracts with service providers, or (3) services directly  provided to beneficiaries by the federal agency itself. This does not  include health benefit programs—such as Medicaid, Medicare, or  TRICARE—that reimburse providers for various mental health  services.

Serious mental illness: Adults who currently have, or at any time in  the past year had, a diagnosable mental, behavioral, or emotional  disorder (excluding developmental and substance use disorders) of  sufficient duration to meet certain diagnostic criteria, as specified  within the Diagnostic and Statistical Manual (DSM), that resulted in  serious functional impairment, substantially interfering with or limiting  one or more major life activities. Serious mental illness may also  include individuals with a specific diagnosis, for example, individuals  diagnosed with schizophrenia, schizoaffective disorder, bipolar  disorder, or major depression.

Serious emotional disturbance: Children and adolescents from birth  up to age 18 who currently or at any time during the past year had, a  diagnosable mental, behavioral, or emotional disorder of sufficient  duration to meet diagnostic criteria specified within the DSM that  resulted in functional impairment, which substantially interferes with or  limits the child’s role or functioning in family, school, or community  activities. Serious emotional disturbance may also be a condition  exhibiting one or more characteristics—such as a general pervasive  mood of unhappiness or depression—over a long period of time and  to a marked degree that adversely affects a child’s educational  performance as defined in the Individuals with Disabilities Education  Act implementing regulations.

We adopted these definitions to focus our review on programs that either  directly administer or fund programs for the seriously mentally ill, as well  as programs that may support a broader population likely to include those  with serious mental illness. Given the wide range of programs included in  this review, we relied on the federal agencies to identify the programs that  met the criteria above. When necessary, we discussed these criteria with  the agencies. For example, SAMHSA officials did not initially include any  of their suicide prevention programs, submitting instead only those  programs that were specifically targeted for individuals with serious  mental illness. After several discussions, SAMHSA officials provided the  names of 12 additional programs, including their suicide prevention  programs that can provide general support to individuals with serious  mental illness. However, SAMHSA officials did not identify the primary  purpose or provide additional information on these more broadly focused  programs.

We received requests from several agencies to eliminate some of their  programs from our review for various reasons. For example, Navy and  Marine Corps program staff included their substance abuse programs in  their responses to the questionnaire. After discussions with DOD, we  determined that since these programs focus on substance abuse rather  than mental health they should be removed. We ultimately determined  that it was appropriate to remove 13 programs from our review. In total,  112 programs were included in our final analysis.

section_title: Developing and Administering the Web- Based Questionnaire
paragraphs: We developed a web-based questionnaire to collect detailed information  on federal programs that support individuals with serious mental illness or  serious emotional disturbance for fiscal year 2013. It included questions  on program goals, target groups served, evaluations conducted, and  coordination activities with other federal agencies. In addition, the  questionnaire asked agencies to identify which of these programs were  specifically targeted for individuals with serious mental illness. We then  verified this information through follow-ups with the agencies. Finally, the  questionnaire also collected data on program obligations—defined as  definite commitments that create a legal liability of the government for the  payment of goods and services ordered or received—for fiscal year 2013.  In some cases, we could not obtain data on funds obligated for these  programs because agency officials told us that they did not report  budgetary data at this level, among other reasons.

To minimize errors arising from differences in how questions may be  interpreted, we conducted pretests with HHS and Education in February  2014. We made appropriate revisions and our final questionnaire was  sent to several knowledgeable agency officials within each of the eight  agencies. These officials were responsible for coordinating with the  appropriate program staff to ensure we received completed  questionnaires for these programs. Within the eight agencies, we  received responses from program staff that were operating programs  relevant to our purposes. The questionnaire was available from March  2014 to June 2014. In total, we received 44 completed questionnaires  from program staff within the eight agencies. All eight agencies  responded, for a 100 percent response rate. We also made telephone  calls to officials and sent them follow-up e-mail messages, as necessary,  to clarify their responses or obtain additional information.

We used standard descriptive statistics to analyze responses to the  questionnaire. Because this was not a sample survey, there were no  sampling errors. To minimize other types of errors, commonly referred to  as nonsampling errors, and to enhance data quality, we employed survey  design practices in the development of the questionnaire and in the  collection, processing, and analysis of the questionnaire data.

To reduce nonresponse, another source of nonsampling error, we sent  out e-mail reminder messages and phone calls to encourage officials to  complete the questionnaire. In reviewing the questionnaire data, we  performed checks to identify inappropriate answers. We further reviewed  the data for missing or ambiguous responses and followed up with  agency officials when necessary to clarify their responses. As a result, we  determined that the data used in this report were sufficiently reliable for  our purposes.

section_title: Determining the Extent of Coordination
paragraphs: To assess coordination efforts among the higher levels of agency  leadership, we reviewed information gathered through the questionnaire  and interviewed agency officials from the agencies represented among  the 30 programs—that is, those identified as targeting individuals with  serious mental illness—regarding interagency committees established to  facilitate coordination and collaboration. To determine the organizational  structure, mission, and the actions taken by these committees, we also  reviewed relevant interagency committee documents such as  membership rosters, meeting agendas, and meeting minutes.

To assess coordination efforts at the program level, we used information  gathered through the questionnaire to identify which of the 112 programs  at the eight agencies included in our review had coordinated with other  programs in an official capacity. Finally, we interviewed agency officials  and reviewed relevant documentation related to the reported program- level coordination.

section_title: Assessing Evaluations
paragraphs: We used information gathered through the questionnaire to determine  whether the eight agencies included in our review had begun or  completed evaluations for any of their 112 programs. For the 30 programs  that the agencies identified as targeting those with serious mental illness,  we asked the agencies for copies of the most recent completed program  evaluations. We reviewed the information provided to us to determine  whether it met our definition of a program evaluation and, for each  completed program evaluation, we reviewed its objectives and scope.  Furthermore, we interviewed agency officials about factors affecting the  lack of program evaluation. We also reviewed agency documents and  interviewed agency officials to identify whether the agencies took other  steps to help ensure that their programs are effective, such as whether  the agencies used other methods—such as collecting outcome  measures—to monitor their programs.

section_title: Appendix II: List of Programs That Can Support Individuals with Serious Mental Illness Identified by Eight Federal Agencies
paragraphs: Homeless with Schizophrenia Presumptive Disability  Work Incentives Planning and Assistance  General Outpatient Mental Health Services  Intensive Community Mental Health Recovery  Mental Health Residential Rehabilitation Treatment  Primary Care Mental Health Integration  Psychosocial Rehabilitation and Recovery Center  Re-Engaging Veterans with Serious Mental Illness  Specialized Homeless Services  Specialized Post-Traumatic Stress Disorder  Therapeutic and Supported Employment Services  the Department of Education to the Administration for Community Living at the Department of Health  and Human Services, envisioning an orderly transition period to effectuate the transferred authorities.  Pub. L. No. 113-128, tit. IV, §§ 491, 503(e), 506(d), 128 Stat. 1425, 1695, 1701-1705 (July 22, 2014).

section_title: Appendix III: List of Programs Specifically Targeting Individuals with Serious Mental Illness Identified by Eight Federal Agencies
subsections: section_title: Program name

section_title: Baseline Psychological Testing for Recruits
paragraphs: A screening program completed  during basic military training at Joint  Base San Antonio to identify mental  health and behavioral problems.

Selected Air Force medical  treatment facilities are outfitted with  interactive virtual reality systems for  use in enhanced exposure therapy  between behavioral health providers  and patients suffering from  conditions such as post-traumatic  stress disorder (PTSD), mild  traumatic brain injury, addictions,  phobias, and anger management  issues.

Air National Guard  Psychological Health Program  Provides assessment services,  ensures continuity and engagement  in treatment, and prevents  servicemembers from falling  through the cracks. This program  does not provide direct treatment  services.

Psychological Health Program  Provides assessment services,  ensures continuity and engagement  in treatment, and prevents  servicemembers from falling  through the cracks. This program  does not provide direct treatment  services.

This is a 10-week comprehensive  residential treatment program for  Active Duty members with combat  related stress disorders, including  PTSD. Includes evidence-based  treatment such as cognitive  processing therapy, along with  psychopharmacological  interventions and complementary  alternative treatments.

Distributes funding to eligible states  and territories for a variety of mental  health prevention and treatment  services; planning; administration;  and educational activities under the  state plan for comprehensive  community-based mental health  services for children with serious  emotional disturbance and adults  with serious mental illness.

Children and youth  (birth to age 17),  adults (age 18-64)

Provides support for technical  assistance to facilitate the  restructuring of the mental health  system by promoting consumer  directed approaches for adults with  serious mental illness.

Criminal and Juvenile Justice  Diverts individuals with serious  mental illness from the criminal  justice system by providing support  services that connect the individual  to behavioral health, housing, and  job placement services.

Provides comprehensive services  focusing on outreach, engagement,  intensive case management, mental  health services, substance abuse  treatment, benefits support, and  linkage to permanent housing.

Supports state and local  governments creation or capacity  expansion of evidence-based  practices addressing the prevention  of mental illness; trauma-informed  care; screening, treatment and  support services for military  personnel; and housing and  employment support.

Expands behavioral health services  to individuals who are at risk for or  have serious mental illness and/or  co-occurring substance use  disorder and are at risk or living with  HIV/AIDS. Supports programs that  develop or expand behavioral  health and primary care networks in  order to reduce the impact of  behavioral health problems, HIV risk  and HIV-related health disparities.

section_title: Agency
paragraphs: Program description  Funds the coordination and  integration of primary care services  into publicly-funded community  behavioral health settings. The  program encourages grantees to  engage in necessary partnerships,  expand infrastructure and increase  the availability of primary health  care and wellness services to  individuals with mental illness.

Population  served  Adults, elderly   (age 65 or older)

Supports services and resources to  people with serious mental illness,  including those with co-occurring  substance use disorder, who are  experiencing homelessness or at  risk for homelessness. Provides  funds for community-based  outreach, case management,  screening and diagnostic treatment,  alcohol or drug treatment, and a  limited set of housing services.

Provides grant awards to support  protection and advocacy systems  designated by the governor of each  state or mayor of the District of  Columbia. These systems monitor  compliance with the Constitution  and federal and state laws within  public and private residential care,  treatment facilities, and non-medical  community-based facilities for  individuals with serious mental  illness, children, and youth.

Supports the creation of  developmentally appropriate local  systems of care to improve  outcomes of youth and young adults  with serious mental health  conditions. The grants fund  integration of local systems with  state, tribal, or territorial levels in  areas such as education,  employment, housing, mental health  and co-occurring disorders, and  decrease contacts with the juvenile  and criminal system.

Young adults   (ages 16-25)

section_title: Agency
paragraphs: Fiscal year 2013  obligations  2,093,606  driven organizations to enhance  statewide service system capacity.  Promotes skill development,  business management, and  partnership building as part of the  recovery process for mental health  consumers.

Provides information, referrals, and  support at the state and local level  to families who have a child with a  serious emotional disturbance.

Supports broad-scale operation,  expansion and integration of  systems of care to improve  behavioral outcomes of children and  youth with serious emotional  disturbances and their families.

An intensive residential substance  abuse treatment program providing  services for inmates with co- occurring substance use disorders  and serious mental illnesses. The  program is 9-months, unit-based,  and offers cognitive-behavioral  interventions in a modified  therapeutic community setting.

Mental Health Step Down Unit  Offers an intermediate level of care  for inmates with serious mental  illness who do not require inpatient  treatment, but lack the skills to  function independently in a general  population prison. Programs  operate as modified therapeutic  communities and utilize cognitive  behavioral treatments, cognitive  rehabilitation, and skills training.

A unit-based residential psychology  treatment program that focuses on  inmates with serious mental illness  and a primary diagnosis of  Borderline Personality Disorder.  Uses evidence-based treatments to  increase time between disruptive  behaviors and increase pro-social  skills, and aims to prepare inmates  for transition to less secure prison  settings or promote successful  reentry to society.

section_title: Program name

section_title: Homeless with Schizophrenia Presumptive Disability
paragraphs: Aims to remove barriers to  supplemental security income for  individuals who have been  diagnosed with schizophrenia or  schizoaffective disorder who are  known to be homeless by helping  them through the application  process and providing presumptive  disability payments.

Provides veterans with serious  mental illness intensive recovery- oriented mental health services in  their home and community that  enable them to live in the  community of their choosing.  Connects veterans with a team that  may include peer specialists, social  workers, psychologists and  physicians.

Provides residential rehabilitation  and treatment services for veterans  with mental health and substance  use disorders, medical conditions  and psychosocial needs, such as  homelessness and unemployment.  The program addresses the goals of  rehabilitation, recovery, and  community integration. It provides  specific treatment for mental health,  substance use disorders and  medical conditions.

Supports recovery and integration  into the community for veterans with  serious mental illness and severe  functional impairment. Includes  individual assessment and  curriculum planning, skills training  classes, family education programs,  psychiatric services, compensated  work therapy, and case  management services.

section_title: Agency
paragraphs: Program description  Identifies veterans with  schizophrenia or bipolar disorder  who have received care but have  been lost to follow-up (no outpatient  visits and no inpatient visits of more  than 2 days) for at least 1 year.  Contact information of identified  veterans are sent to a social worker  or psychologist at VA medical  centers and community outpatient  clinics who make efforts to locate,  contact, assess the needs, and  invite the veterans to return to care.

Provides a range of inpatient and  outpatient treatments for veterans  diagnosed with military-based  PTSD. These services use  psychotherapies and  psychopharmacology. Examples of  specialty PTSD inpatient treatment  are: Domiciliary PTSD, Women’s  Trauma Recovery Program.  Specialty PTSD outpatient  treatment includes Substance Use  PTSD and Women’s Stress  Disorder Treatment Team.

A continuum of recovery-oriented  vocational rehabilitation programs  that help veterans with mental  health disabilities (including  individuals with co-occurring  physical disabilities) and a history of  occupational dysfunction overcome  barriers to employment and return  to the workforce.

A continuum of care designed to  assist eligible homeless veterans  and veterans at risk for  homelessness. Services include  homelessness prevention and rapid  re-housing; assistance to veterans  involved with the justice system;  community case management; and  employment assistance.

section_title: Agency
paragraphs: Program description  Provides services to veterans with  acute and severe emotional and/or  behavioral symptoms that may  cause a safety risk to the self or  others, and/or may result in  severely compromised functional  status, including veterans with  serious mental illness. Programs  provide a range of intensive clinical  services (e.g., close safety  monitoring, close medication  management) and frequent group  therapy and psychoeducation.

section_title: Appendix IV: Questionnaire Responses on Coordination for Programs Targeting Individuals with Serious Mental Illness
paragraphs: Program staff in the 30 programs targeting individuals with serious mental  illness reported using a variety of coordination mechanisms and activities  when working with other programs both within and across agencies. As  reported by program staff, the most frequent program-level coordinating  mechanisms used were participating in an intra- or interagency committee  or taskforce (11 programs) or developing or sharing tools that facilitate  collaboration—for example, shared databases (10 programs). (See fig. 2.)

Referral of patients or clients was the most frequently cited coordination  activity for programs targeting individuals with serious mental illness (see  fig. 3). For example, program staff for the Department of Justice’s Bureau  of Prisons’ Dual Diagnosis Residential Drug Abuse Program received  referrals after inmates have been pre-screened by Bureau of Prisons’  Designations and Sentence Computations Center. Involving other  agencies in strategic planning was the second most commonly reported  coordination activity by program staff (12 programs).

section_title: Appendix V: Status of Evaluations of Federal Programs Targeting Individuals with Serious Mental Illness, as of September 2014
subsections: section_title: Program name
paragraphs: (Y/N)

section_title: Program name
paragraphs: (Y/N)

section_title: Appendix VI: Comments from Social Security Administration

section_title: Appendix VII: Comments from the Department of Defense

section_title: Appendix VIII: Comments from the Department of Veterans Affairs

section_title: Appendix IX: Comments from the Department of Health and Human Services

section_title: Appendix X: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Staff Acknowledgments
paragraphs: In addition to the contact above, Tom Conahan, Assistant Director;  Carolyn Fitzgerald; Cathy Hamann; Jacquelyn Hamilton; Mollie Hertel;  Hannah Marston Minter; Vikki Porter; Michael Rose; and Joanna Wu  made key contributions to this report.


Question-summary annotations: questions: question: What agencies are responsible for programs supporting mental health?
answer: HHS is charged with leading the federal government's public health efforts related to mental health, and the Substance Abuse and Mental Health Services Administration is required to promote coordination of programs relating to mental illness throughout the federal government.
child_questions: question: How does this differ from past distribution of responsibility?
answer: In the past, HHS led the Federal Executive Steering Committee for Mental Health, with members from across the federal government. However, the steering committee has not met since 2009. HHS officials told us that the Behavioral Health Coordinating Council (BHCC) performs some functions previously carried out by the steering committee. The BHCC, however, is limited to HHS and is not an interagency committee.

question: What issues did GAO find with other interagency committees?
answer: Other interagency committees were broad in scope and did not target individuals with serious mental illness.
child_questions: question: What steps have agencies taken to amend these issues?
answer: Staff for the majority of the programs targeting serious mental illness reported taking steps to coordinate with staff in other agencies.
child_questions: question: What issue did AGO find with this approach?
answer: While coordination at the program level is important, it does not take the place of, or achieve the level of, leadership that GAO has previously found to be key to successful coordination and that is essential to identifying whether there are gaps in services and if agencies have the necessary information to assess the reach and effectiveness of their programs.

questions: question: What did GAO find regarding the completion of program evaluations for agencies targeting individuals with mental illness?
answer: Agencies completed few evaluations of the programs specifically targeting individuals with serious mental illness. Of the 30 programs specifically targeting individuals with serious mental illness, 9 programs had a completed program evaluation, 4 programs had an evaluation underway, and 17 programs had no evaluation completed and none planned.
child_questions: question: How did agencies justify this lack of evaluations?
answer: However, agency officials said they engaged in other efforts—such as drawing on evidence in published literature—to ensure their programs were effective.

question: What issues did GAO find with this lack of evaluations?
answer: GAO's prior work has shown the significance of both performance monitoring activities and program evaluations and noted the importance of formal program evaluations to inform program managers about the overall design and operation of the program.

questions: question: What was GAO asked to do?
answer: GAO was asked to provide information on federal programs that support individuals with serious mental illness.

question: What does this report discuss?
answer: This report identifies (1) the federal programs that support individuals with serious mental illness; (2) the extent to which federal agencies coordinate these programs; and (3) the extent to which federal agencies evaluate such programs.
child_questions: question: How did GAO collect data for this report?
answer: GAO developed and administered a web-based questionnaire to eight federal agencies regarding program goals, target populations, services offered, evaluations, and coordination. GAO also interviewed agency officials.

questions: question: What does GAO recommend DOD, HHS, DOJ, and VA do?
answer: GAO recommends that HHS establish a mechanism to facilitate interagency coordination across programs that support individuals with serious mental illness. GAO also recommends that DOD, HHS, DOJ, and VA document which programs targeting individuals with serious mental illness should be evaluated and how often such evaluations should be completed.
child_questions: question: How did HHS respond to these recommendations?
answer: HHS disagreed with both recommendations.

question: How did DOD, DOJ, and VA respond to these recommendations?
answer: DOD, DOJ, and VA agreed with the second recommendation.

question: How did GAO respond to the agencies' disagreement?
answer: GAO continues to believe the recommendations are valid as discussed in the report.