[показать] News from MacArthur December 16, 2005

Mental Health in America

Signs of Progress and Challenges Ahead

A Promising Moment

MacArthur's Focus on Mental Health

A Closing Thought

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Mental Health in America—Bringing the Best of Research to Practice and Policy

When the MacArthur Foundation was established in 1978, one of the first
issues we addressed through our grantmaking was how to improve the way
this nation provides for the treatment and care of people with mental illness.

When we first took on the issue, we were surprised at how little was
known about effective treatments. So our first ventures were in research, in
an effort to identify and fill gaps in knowledge about the origins and
course of mental illness and the biological, psychological, and social factors
that promote healthy, successful development across the lifespan.

Today the research base and body of knowledge about mental illness has
vastly expanded, with much of that work supported by MacArthur’s
investment of more than $305 million. The central issues now concern
the ways in which services are organized and delivered and the policies
that shape the delivery system. The mental health care system is astonishingly fragmented, with financing split between the public and private
sectors.
And it has been transformed, for better and worse, through the emergence
of managed care.

No longer is there a question about whether effective treatments for
mental illnesses exist. They do. The challenge now is to move past
the barriers to seeking and receiving treatment and to bring the results of
research to the service of those in need around the world. To that end MacArthur has provided assistance to the World Health Organization and
the World Bank to make mental health a higher priority in their public
health work.

Today MacArthur’s grantmaking in the field of mental health focuses on
the goal of improving access to effective and efficient mental health
services by helping to move the most promising advances from research into
policy and practice.

In this issue of the MacArthur Foundation’s newsletter we discuss the
extent of the challenge posed by mental illness, the opportunity to
improve treatment and care and, of course, the work supported by the
MacArthur Foundation in an effort to help address one of this country’s
most pressing public health needs.

As always, we welcome your comments.

Jonathan F. Fanton
President
Signs of Progress and Challenges Ahead

Mental illness is as real and as burdensome – to the individual and
society – as any other illness or infirmity. Thanks to breakthroughs
in just the last quarter century, mental illnesses are as amenable to
treatment as other medical conditions. The treatments offer good value
for the cost in terms of decreased disability, improved functioning,
greater productivity, and less personal distress.

While much of this newsletter will focus on problems to be addressed,
it is worth reviewing the progress made over the past 25 years in the
field of mental health. There has been much progress, but much hard work
lies ahead. According to a landmark report on mental illness issued by the
U.S. Surgeon General in 1999, the vast majority of people with mental
disorders still do not receive effective treatment.

When people who need mental health care do not receive it, the cost to
individuals and their families, their communities, and to society is
enormous. For individuals and families the cost is measured largely in
terms of pain and suffering and the inability to function in the home
or workplace. The stigma of mental health adds isolation, distrust, and
discrimination to the burden. For other social systems the impact of
mental illness is destabilizing. The criminal justice system, the
juvenile justice system, child welfare, and the system for social
welfare have each become major sources of care for children and adults with
mental illness.

It is clear that improving access to mental health treatment and
services would lift a huge burden from individuals and from society. Part of
the solution requires untangling the extraordinarily complex organization
and financing of the U.S. mental health system.
A Promising Moment to Focus on Improving Mental Health Care

There is no question about the challenges involved in addressing the
nation’s mental health needs. But a sense of opportunity outweighs
pessimism. In just the last few years several factors have combined to
change the debate about providing mental health services to all who
need them, including two mental health care bills signed by President Bush
in 2004:

The Garrett Lee Smith Memorial Act, which provides funds for mental
health interventions to prevent suicide.

The Mentally Ill Offender and Treatment Act, which authorizes $50
million in federal grants to states to support pre- and post-booking
mental health interventions.

Recognizing that the time is ripe for change, many organizations have
come together to form the Campaign for Mental Health Reform, with the
objective of advancing mental health as a national priority. These groups, many
of them receiving funding from MacArthur, are helping build a base of
evidence, practical knowledge, and tools that can be used to inform
effective law, policy and practice. Participants in the Campaign
include the Bazelon Center for Mental Health Law, National Alliance for the
Mentally Ill, National Mental Health Association, and National
Association of State Mental Health Organizations.
The MacArthur Foundation’s Focus on Mental Health

MacArthur's Focus on Research
An Emphasis on Removing Barriers to Treatment
Focus Populations
Education and Communication

The MacArthur Foundation’s grantmaking in the field of mental health
has taken place in two phases. The first was designed to fill in the
knowledge base. Today it focuses on bringing knowledge to practice,
primarily through an impact on policy.

MacArthur's Focus on Research
When entering the mental health field about 25 years ago with a focus
on filling in the gaps in knowledge, MacArthur created interdisciplinary
research networks designed to focus on specific areas of research.
MacArthur networks have developed research instruments and clinical
tools that are standards in the field. Topics and approaches pioneered by
the networks have become mainstream. The network model has been adopted by others, including federal research initiatives at the National
Institutes of Health and the National Science Foundation.

The MacArthur Research Network on Mental Health and the Law
One of those networks, The MacArthur Research Network on Mental
Health and the Law, focuses on the competence of people with serious mental
illness to make decisions such as accepting or refusing treatment, how
patients come to experience the receipt of treatment as “coercive,”
and the relationship between mental disorder and violence. Under
director Dr. John Monahan of the University of Virginia, the Network
broke new ground on the issue of mental illness and violence,
providing compelling evidence that an increased risk of violence is
associated not with mental illness, but with the use of alcohol and
drugs. The finding, which challenged a longstanding stereotype, has
shifted practice and policy perspectives and is playing a prominent
role in advocacy and public education efforts to reduce the stigma of
mental illness.

The Initiative on Depression and Primary Care
Another project funded by the MacArthur Foundation, The Initiative
on Depression and Primary Care, devised education interventions to help
primary care physicians do a better job of diagnosing and treating
depression, one of the most important reasons people visit their
primary care physician in the first place. The researchers developed
the Three Component Model (3CM), a way of improving depression
management in health care organizations. The Department of Defense is
working with the Initiative to develop a pilot program to use with
soldiers returning from Iraq and Afghanistan. The Three Component
Model is being implemented by several large medical groups, a regional
health insurance plan, and a statewide Medicaid program. Recently,
one of the nation’s largest insurers, Aetna, announced it has adopted
the model to improve depression treatment. Research by the
Initiative on Depression and Primary Care shows that 60 percent of
those treated with the 3CM experience a 50 percent decrease in
symptoms after three months compared with 37 percent who receive usual
care.

Today the MacArthur Foundation’s grantmaking in mental health reflects
the scientific advances in the field, the complex structure of the nation’s
mental health system, and the impact of managed care. The strategy
focuses on the goal of improving access to effective and efficient
mental health services by helping to move the most promising advances from
research into policy and practice.

An Emphasis on Removing Barriers to Receiving Treatment
The size and complexity of the mental health system in the country present many barriers to access. As the cost of health care continues to rise, and mental health services are increasingly viewed as discretionary, there is a growing risk that the remarkable progress in finding effective treatments will drift further out of reach for the majority of those who suffer from mental illness.

There are two types of barriers to access to mental health services.
Some are barriers to seeking treatment such as the stigma of mental illness.
Others are barriers to receiving treatment, usually financial,
organizational, or a combination of the two. Lack of insurance and the
complexity of the mental health system are two examples.

The MacArthur Foundation’s strategy is focused upon the barriers to
receiving treatment because they are the ones that can be overcome by
changes in law and policy and which can affect the greatest number of
people.

Focus Populations
Grants in the field of mental health focus on the general population;
three specific subgroups: people with depression, children, and people
with serious mental illesses; and to support education and
communication.

The Mental Health Needs of the General Population
Grants to three organizations form the core of MacArthur’s work
designed to help the general population. The Research Network on
Mental Health Policy Research was originally formed by the Foundation
to address policy changes under managed care and their effects on the
mental health system’s performance and outcomes. During the course of
its work, the Network found that the major policy challenge today is
to improve the quality of care not only in traditional mental health
care settings, but also in service sectors—education, criminal and
juvenile justice, primary care, social welfare, housing—outside its
boundaries. Its work is aimed at encouraging the implementation of
evidence-based practice, improving mental health benefits in public
and private financing arrangements; and ensuring fairness and equity
in the management of mental health benefits. In an indication of the
impact of this work, federal mental health parity legislation became
law in 1996 and 37 states now have their own mental health parity
provisions.

The Bazelon Center for Mental Health Law works through policy
analysis and advocacy to advance policies and secure public resources for
mental health services and supports. And the National Mental Health
Association engages in advocacy and policy activities through its
network of 340 state affiliates.

People with Depression
Through the Initiative on Depression and Primary Care the
foundation seeks to enhance the quality of care received by patients with
depression seen in primary care settings.

Mental Health Needs of Children
Children are the group for which there is the largest gap between
research and practice, and for whom the delivery of services is most
fragmented across different settings. There are two objectives for
this area of work: to identify evidence-based treatments and make them
practical for use in real-world settings; and to develop strategies
that promote the adoption and implementation of interventions that
have been shown to be effective. The primary recipient of MacArthur
support for this work is the Research Network on Youth Mental Health
Treatment. The Network focuses on the gap between state-of-the-art,
evidence-based treatment and what is typically delivered in practice.
Its objectives are to identify scientifically validated treatments,
make them practical for use in clinical settings, and develop
strategies to encourage and facilitate their implementation – bringing
appropriate, effective, and efficient care to young people with mental
illness.

People with Serious Mental Illnesses
Those who suffer from illnesses such as schizophrenia, severe
depression, and bipolar disorder have complex service needs and the
very visible signs of their disorders contribute heavily to the stigma
of mental illness. Policy battles are underway in many states between
those who are for and those who oppose legally-mandated adherence to
treatment in the community. The Research Network on Mandated
Community Treatment is building the base of knowledge about this
issue from a broad range of perspectives: medical, psychological,
economic, legal, political, and ethical.

There is growing interest across the country in what are known as
psychiatric advance directives (PADs), in which a person would
indicate a treatment preference before being incapacitated by mental
illness. In addition to research on PADs by the Network on Mandated
Community Treatment, a grant was awarded to Duke University for a
joint project with the Bazelon Center for Mental Health Law to develop
a computer-based resource for people throughout the country seeking
the most up-to-date information and tools to use in implementing a
PAD.

Education and Communication
The Foundation also supports efforts to put new knowledge into the
hands of consumers, advocates, practitioners, and policymakers. The National
Mental Health Association, for example, uses Foundation funding to
provide education and training so that its affiliates can participate in
state-level health care reform activities. The Washington-based
National Health Policy Forum focuses on Congressional staff and federal agency officials. The Bazelon Center for Mental Health Law is a leader in
protecting the rights of people with mental disabilities by securing
public resources that enable them to lead productive lives.

The Foundation has funded over the years the journal Health Affairs to
support coverage of many mental health matters, including a special
issue each year on mental health policy. Public radio, with its influential
listening audience, broadcasts on 200 stations a weekly program called
The Infinite Mind. The program seeks to dispel myths and stereotypes about
mental illness by educating the public about the scientific and medical
advances in understanding the brain, behavior, and the treatment of
mental disorders.
A Closing Thought

The Foundation’s work in mental health has taken place during a period
of 25 years in which there has been unprecedented progress in the field.
We note with pride that people and organizations receiving MacArthur
support have been involved in many significant developments in mental health
over that period of time.

MacArthur’s research networks have helped shape the mental health
policy debate for 25 years. Research network members served as writers,
consultants, and reviewers for three of the most significant federal
mental health policy reviews: the Surgeon General’s report in 1999, a
follow-up report on race, culture and ethnicity in 2001, and the
President’s New Freedom Commission on Mental Health in 2003. These
efforts will frame the debate and ensure that sound research drives
mental health policy today and in the future.

It would be easy to fall into the trap of thinking that with so much
pressure on budgets at the state and federal level that little can
happen in the field of mental health. We prefer to take the opposite view.
The opportunity exists to restructure the mental health system in a way
that will greatly improve access to and delivery of care.

The current system, with its many cost centers and duplication of
effort, is ready for reform. It is not a matter of politics or ideology, but
merely of what is right and just for individuals and for our society.
The knowledge so carefully gained about how to treat mental illness should
be put to use helping people through new, more effective service delivery
models that are suited to the economic, political, and social environment of today.
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