Tens of millions of Americans will experience depression, panic attacks, or some other form of mental illness this year. Of these, 6.8 million will suffer from the most severe forms such as schizophrenia and bipolar (manic-depressive) disorder. Countless jobs will be lost and lives will be put on hold as individuals and their families struggle to cope with the chaos and heartbreak of mental illness. Some of those with mental illness will attempt suicide, and many will be successful. In 1996, 500,000 Americans visited emergency rooms as a result of suicide attempts; 31,000 of those who attempted suicide died.
Many legislators and policymakers are seeking a way to address these critical problems. To do so effectively, however, they must better understand the nature of mental illness, as well as strategies for making mental health services more effective.
Mental illness is defined as "a biopsychosocial brain disorder characterized by dysfunctional thoughts, feelings, and/or behaviors that meet diagnostic criteria." Policymakers should differentiate between serious mental illness such as schizophrenia that requires treatment on a priority basis and less severe problems such as caffeine intoxication that can best be addressed with indigenous community resources.
Serious mental illness (SMI) is defined as (1) all cases of schizophrenia; (2) severe cases of major depression and bipolar disorder; (3) severe cases of panic disorder, obsessive-compulsive disorder, and post-traumatic stress disorder; (4) severe cases of attention deficit/hyperactivity disorder; and (5) severe cases of anorexia nervosa. Clinical symptoms and standard treatments for each of these eight serious mental illnesses are presented, as well as estimates of the number of Americans who currently suffer from each.
A person struggling with serious mental illness deserves effective care, whether provided through private insurance or public funds. Although many people receive the care they need, many others receive care that is far from effective and cycle endlessly in and out of mental health services that miss their mark. Policymakers seeking to reform and improve the nation's mental health services should consider the following issue areas.
Little information is gathered as to how well a given treatment works for a given person receiving care. Most mental health management information systems in the public and private sectors simply list demographics and services provided. Instead, providers should measure and document the actual outcomes of care provided. Regular use of standardized outcome measures would help transform mental health services into an evidence-based practice, improve the overall quality of care, and ensure that ever greater numbers of people with SMI can function productively in their home communities.
Coverage and access to services for serious mental illness should be on a par with coverage and service access for physical illnesses. A challenge in providing parity will be to determine which of the mental illnesses should be designated for full coverage.
Safeguarded Outpatient Commitment.
Inpatient commitment occurs when a court determines (through evaluation) that a person with SMI is at risk to hurt himself or others, and therefore needs psychiatric hospitalization. Currently, once a person has been successfully treated and is discharged from a psychiatric hospital, the court has no say over whether that person remains in treatment. Cessation of treatment, especially of medications, is the primary cause of relapse after discharge, and outpatient commitment was conceived to address this problem. The basic concept is that hospitalized persons with SMI could be given an opportunity for early discharge, contingent on their agreement to remain in treatment in their home community. Those who did not abide by this agreement could be re-hospitalized, or perhaps required to attend a day treatment program, for treatment stabilization without new commitment hearings. Such authority should be used only when absolutely necessary and only when it is clearly in the best interest of the person receiving care. Safeguards such as review and appeals options, and adequate community services, must be in place for this policy to succeed. Consideration should also be given to related concepts, such as "advance directives" stipulating preferred care.
Parental Approval for Children's Treatment.
Parents and local authorities do not always agree on how to respond to the mental health needs of children and adolescents. A way must be found to safeguard parental rights and authority while ensuring that the needs of children and adolescents who are suffering from serious mental illness are met. This balance has proven to be difficult to achieve.
Who Use Mental Health Services in the Process of Reform.
Over the past two decades, increasing numbers of people with serious mental illness have begun to speak out against the "broken" mental health system. There are no more passionate advocates for reform than those who have suffered from ineffective care. Any effort at results-oriented reform must include substantial, ongoing input from those who will benefit the most--the "consumers" of mental health services.
To meet the mental health care needs of Americans, policymakers should have a basic understanding of the range of mental illnesses, their treatments, and policy implications, as well as a means to identify the most serious mental illnesses for priority care. They also need to become informed on strategies for improving inadequate care. Such knowledge may then spark a much-needed national dialogue on reforming mental health services, so that persons with serious mental illness may live and work successfully in their home communities. These are the critical first steps in an ongoing effort to ensure that effective treatment is provided for all persons with serious mental illness and to promote the well-being of these individuals, their communities, and the nation.
Timothy A. Kelly, Ph.D., a licensed clinical psychologist, is a Visiting Research Fellow at the George Mason University Institute of Public Policy and formerly served as the Commissioner of Virginia's Department of Mental Health, Mental Retardation, and Substance Abuse Services.