Psychiatr News April 21, 2006
Volume 41, Number 8, page 8
© 2006 American Psychiatric Association
States Get Disappointing Marks on MH Report Card
Rich Daly
NAMI's ranking of the mental health care system in 48 states identifies
a broad range of service availability and treatment quality.
State public mental health care systems generally earn poor-to-failing
grades in terms of the mental health care they offer their residents,
according to a national "report card" issued by the National
Alliance on Mental Illness (NAMI). But the report also hailed some states'
innovative efforts and commitment to mental health care in the face of budget
shortfalls.
The report assessed mental health care accessibility, affordability, and
quality in all but two states and rated the majority with Ds or Fs. Colorado
and New York officials declined to participate so were left without a
grade.
The grades were based on how well each system met a series of 10 elements,
which included comprehensives services and support, access to acute and
long-term treatment, and sufficient funding.
"These are things we value and think people should actually
have," said Kenneth Duckworth, M.D., NAMI's medical director. "The
report says the programs should be accountable to the consumers who use
it."
The two highest-scoring states—Ohio and Connecticut—were
praised for innovative uses of jail-diversion programs and bilingual services,
respectively. Conversely, Connecticut was chided for long emergency room wait
times for hospitalization, while Ohio was criticized for lacking a mental
health care parity law. Both states received a "B" in the
report.
Michael Fitzpatrick, NAMI's executive director, said the highest rankings
stemmed in part from those states' "consistency of vision over
time," the use of consumer feedback, and a regular examination of
program outcomes. An "A" is possible when a state meets the
"B" goals and provides a comprehensive range of programs, he
said.
Although the report examined each state's efforts in specific areas, such
as the provision of supportive and affordable housing to those recovering from
mental illness, its emphasis was on what new initiatives each state was
trying.
Jeffrey Geller, M.D., a member of the APA Council on Social Issues and
Public Psychiatry and incoming Area 1 trustee, said the report did an
excellent job with an impossible task. The approach was limited because it
largely depended on the states to assess their own efforts, which leaves the
findings highly vulnerable to personal slant, he said.
The report's findings were also based in part on a "test
drive," in which the report's contributors used a series of questions
they believed would provide them with a clear picture of mental health
services in the states. The reports also were based in part on interviews with
consumer and family advocates, as well as legal and policy experts on their
perspectives of each state's system.
The report, Geller said, did an excellent job of highlighting the overall
poor level of care the states provide for their citizens with mental
illness.
The list of state innovations may provide less incentive for other states
to improve their programs, however, than "putting in their face the
disgraceful way they treat those with mental illness," Geller said.
Among the eight states given failing grades, Iowa was praised for its
establishment of the statewide Technical Assistance Center for Evidence-Based
Practices to promote their use in mental health care.
"There are some good things happening, even in abysmal states,"
Duckworth said.
The report described another failing state, Kansas, as a place where good
intentions exist but the rhetoric often doesn't match reality. The state was
criticized for lagging in the decriminalization of mental illness and lack of
access to acute inpatient treatment. The report's authors were also puzzled as
to why the state lacks an Assertive Community Treatment (ACT) program, one of
the oldest and most effective evidence-based practices and a critical
component in a comprehensive mental health system.
The report criticized Iowa for a lack of effort to expand access to
services for people who have severe mental illness and live in rural
jurisdiction, which are the vast majority of the state's jurisdictions.
The report examined only the public mental health systems of the states
because they fund the majority of mental health care, and even affluent
residents with serious mental illness are statistically likely to require some
care in the public system eventually.
The report identified some hopeful trends, including the increasing use of
jail-diversion programs. The report noted that the effort's importance is
underscored by research that estimates that 16 percent of the nation's
inmates, or 300,000 people, suffer from serious mental illness.
Another growing trend is the provision of services by peers, who may offer
case management, drop-in centers, and outreach programs.
Some innovative mental health program financing has been adopted by states,
according to the report, such as California's Proposition 63 initiative in
2004, which provides a stable, significant source of revenue for mental health
services through a so-called millionaire's tax.
NAMI representatives said they hoped the report might serve to educate
state officials and legislators, who may not realize or remember that cuts to
vital services for people with mental illnesses raise rather than reduce the
overall costs to society. The issue is especially important this year with
states slated to cut billions of dollars from their Medicaid systems, which
pay for 50 percent of the mental health services that states administer. Some
Medicaid changes under consideration are likely to impact people with mental
illness.
Among the Medicaid options Congress recently approved for states is the
institution of higher copayments.
"Copays for mental health services discourage people from seeking
help," Duckworth said.
Some states were hailed for their efforts to bolster their Medicaid mental
health programs, even in the face of a reduced federal financial commitment to
the state and federal partnership.
Although the report found few states have increased their mental health
funding in recent years, it cautioned that additional funds only benefit
mental health care consumers when they flow through effective and efficient
treatment and assistance programs. The skepticism of some administrators and
legislators toward mental health care may be justified if evidenced-based and
emerging best practices are not emphasized by mental health professionals,
Duckworth said.
The report praised the efforts in this area by the federal Substance Abuse
and Mental Health Services Administration and the National Association of
State Mental Health Program Directors.
The grades are the first follow-up of NAMI's previous mental health systems
"report card" issued 15 years ago. NAMI plans to rate the states
again in three years.
The report is posted online at
<www.nami.org/grades>.
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