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

Letter

Background

Mental Illness

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.

Mental Health Care System

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.

Federal Mental Health Care Programs

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.

Agency Coordination and Program Evaluation

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.

Eight Agencies Reported over 100 Programs That Can Support Individuals with Serious Mental Illness, but It Is Unlikely All Programs Were Identified

Agencies Identified 112 Programs That Can Support Individuals with Serious Mental Illness, 30 of Which Specifically Target This Population

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.

It Is Unlikely That Agencies Identified All Programs for Individuals with Serious Mental Illness

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.

Interagency Coordination of Programs Supporting People with Serious Mental Illness Is Lacking

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.

Committees Have Been Established for Interagency Coordination, but They Did Not Focus on, and Took Little Action Specific to, Serious Mental Illness

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.

Staff of Most Programs Specifically Targeting Individuals with Serious Mental Illness Reported Some Coordination

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.

Agencies Have Evaluated Less than One-Third of the 30 Programs Targeted for People with Serious Mental Illness

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.

Conclusions

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.

Recommendations

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.

Agency Comments

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.

Appendix I: Scope and Methodology

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.

Identification of Federal Agencies

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).

Identification of Programs

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.

Developing and Administering the Web- Based Questionnaire

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.

Determining the Extent of Coordination

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.

Assessing Evaluations

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.

Appendix II: List of Programs That Can Support Individuals with Serious Mental Illness Identified by Eight Federal Agencies

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).

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

Program name

Baseline Psychological Testing for Recruits

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.

Agency

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)

Agency

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.

Program name

Homeless with Schizophrenia Presumptive Disability

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.

Agency

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.

Agency

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.

Appendix IV: Questionnaire Responses on Coordination for Programs Targeting Individuals with Serious Mental Illness

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).

Appendix V: Status of Evaluations of Federal Programs Targeting Individuals with Serious Mental Illness, as of September 2014

Program name

(Y/N)

Program name

(Y/N)

Appendix VI: Comments from Social Security Administration

Appendix VII: Comments from the Department of Defense

Appendix VIII: Comments from the Department of Veterans Affairs

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

Appendix X: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

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.