It I am proud to look out over a room full of people whose work created the evidence base and framed the principles that have shaped three decades of progress in mental health policy. Through research, policy analysis, advocacy and powerful demonstrations, you have changed the course of history and set our country on a path that resonates with its best values.
This conference gives us an opportunity to look back over several decades of change in the landscape—how people think about mental illness and mental health, how individuals are treated, what treatments are available to them, and what remains to be done to achieve the vision of the President’s New Freedom Commission. That Commission offered a vision is of a society “where recovery is the expected outcome and where mental illness can be prevented or cured…a nation where everyone with a mental illness will have access to early detection and the effective treatment and supports essential to live, work, learn and participate fully in their community.”
I want to start the conversation about how to realize that vision and also reflect on MacArthur’s thirty year investment in the mental health field. 2008 is our 30th anniversary and, as we take stock of our contributions, the work in mental health stands out as one of our best programs. I want to take this opportunity to acknowledge the Foundation staff whose foresight and vision placed our work at leading edge of many important developments in the field, including the first program director, the late Bill Bevan, and former colleagues Denis Prager, Idy Gitelson, and Bob Rose, who is with us today. Bob led us to consider new ways of linking mind, body, and health. And I especially want to acknowledge Laurie Garduque and her role in helping the Foundation forge stronger links among research, policy and practice.
As a result of more than two decades of research led by the MacArthur research networks, we know what works. As a society, we have come a long way from the days when people with mental illness were warehoused in psychiatric institutions.
• There is now an array of effective treatments, both psychosocial and pharmaceutical, for even the most debilitating mental disorders.
• More Americans are receiving mental health care today – largely outside of institutional settings like state psychiatric hospitals.
• And that care is more likely to be covered by insurance, so the people who receive it have fewer out-of-pocket expenses.
Nevertheless, mental illness ranks first among illnesses that cause disability in the US, Canada, and Western Europe, with huge costs not only to the individuals and families who live with it, but to all of us. The direct costs of mental health treatment in the U.S. in 2001 were over $85 billion. And, that is just a fraction of the real cost to our economy. The indirect costs are even higher – at least $79 billion dollars, $44 billion in lost work days and lower performance from depression alone.
Virtually every sector of our society bears the burden of mental illness.
• Since the closing of many mental hospitals in the 1960s, the social welfare and criminal justice systems have become, by default, the primary sources of mental health care for adults.
• The education, child welfare and juvenile justice systems serve a similar role for children. Young people, like adults, often end up in trouble with the justice system because of behaviors associated with a mental disorder.
• Families pay an especially heavy toll, and not only in caregiving and isolation. Parents are sometimes compelled to relinquish custody of their children to the state, simply to get them the mental health services they need.
So, even though we are doing better, we have a long way to go before our mental health system is truly “well,” as economists Richard Frank and Sherry Glied have concluded in their analysis of mental health policy in the United States during the past half century.
As we chronicle our progress to date and challenges ahead, let me reflect on our journey together. When the Foundation first entered the field of mental health, three decades ago, we were nearly alone among private funders. It was a good fit for our mission: to foster lasting improvement in the human condition. Mental health is an inherent part of leading a fulfilling, productive life, and the need for improvement in the field was clear:
• The scientific understanding of mental health and mental illness was rudimentary.
• Effective treatments were in their infancy, and the vast majority of people were not receiving them.
• There was stigma and fear in society, and widespread inequities in policy and practice.
The Foundation started its work in mental health by addressing problems of fundamental fairness. We funded efforts to formalize civil and criminal justice standards, and we supported advocacy organizations like the Bazelon Center, the National Alliance on Mental Illness and the National Mental Health Association.
These early efforts had far-reaching effects.
We saw several court decisions upholding the rights of people with mental illness. The 1986 Supreme Court decision, Bowen v. City of New York, insured the eligibility of persons with severe mental illness to receive public benefits. In 1990, a Federal court decided, in Cason v. Housing Authority of Rochester, that people with mental illnesses could live in public housing under the Fair Housing Act. And, a class-action lawsuit, R.C. v. Hornsby, brought by the Bazelon Center, resulted in the 1991 landmark settlement that reformed the child welfare system in Alabama, where 40 percent of the children in state custody had emotional or behavioral disorders. Today, rather than languishing in institutions, more children are reunited with their families, supported by caseworkers and community-based services.
A series of laws took important steps toward that still-elusive goal of mainstreaming mental health. The Fair Housing Act amendments, the Americans with Disabilities Act, the federal Mental Health Parity Act and others share a goal of treating people with mental disorders and those with physical disabilities the same.
But it is difficult to formulate effective laws without a real understanding of the underlying science. As recently as 20 years ago, the evidence was thin. The Foundation sought a way to help build that base – not in an ivory tower, not in the narrow silos that are the common structure of academic research, but in a way that would link mental health with all the pertinent institutions of law and society.
And so the Foundation began an experiment in the organization of scientific research: a strategy that came to be known as MacArthur Research Networks. The networks are a way to promote intellectual collaboration across institutions and disciplines – to bring diverse perspectives, conceptual frameworks, and methods of investigation to bear on the most significant research questions in the field.
The first networks sought to increase the understanding of human development across the lifespan, and in particular the understanding of mental health and mental illness. As the concept evolved, later networks addressed the gap between science and practice. Seeking ways to improve access to effective mental health services, they examined how services are organized and delivered, and the policies that shaped the system. With science as a basis for policy and practice, we focused on three populations with the greatest need:
• People with depression, one of the most prevalent forms of mental illness, accounting for over half of all private insurance claims for mental illness.
• Children, where there is the biggest gap between research and practice, and for whom the delivery of services is fragmented across different settings.
• People with serious mental illnesses—schizophrenia, severe depression, and bipolar disorder—who are the most vulnerable because of their complex service needs, and whose visible presence contributes heavily to the stigma of mental illness.
The accomplishments of the networks have been substantial, and widely influential:
• Many of the networks’ research findings now define the state of the art. For example, challenging a longstanding stereotype, John Monahan and the Network on Mental Health and the Law showed that an increased risk of violence is associated not with mental illness itself but with the use of alcohol and drugs.
• The Network on Mental Health Policy Research demonstrated that covering mental illnesses like other illnesses – parity – adds very little to the cost of care. As a result, the federal government and 37 states have now enacted some form of parity legislation, eliminating discriminatory and unfair practices that result in limited coverage of mental health conditions, higher co-payments and deductibles, and lower annual and lifetime limits on benefits.
• There are evidence-based treatments for fully 80 percent of the problems children experience. However, most of these treatments have not made their way from research laboratories into everyday settings. John Weisz and his colleagues in the Network on Youth Mental Health Care have developed and tested in real-world settings a treatment model that addresses the barriers to adoption. The model combines clinical training and supervision with an electronic information system to guide treatment. California, New York, Massachusetts, and New Hampshire are interested in sharing the costs of a large-scale demonstration of the model’s effectiveness.
• Most patients with depression are seen by their primary care physicians for other medical conditions – often conditions, like backache and insomnia, which are a result of their depression. The Network on Depression and Primary Care, led by Allen Dietrich and John Williams, has created a cost-effective, easily applied system for helping these physicians recognize and treat depression in their patients. The Department of Defense has implemented the model on five U.S. military bases to help treat military personnel returning from Iraq and Afghanistan, and has plans to introduce the model to six more military bases later this year. The network has also worked with Aetna and Blue Cross Blue Shield, to bring that system to millions of patients across the U.S.
• In 1999, the U.S. Surgeon General issued its first report on mental health. Network members played a major role in that report; in a follow-up report on race, culture and ethnicity; and in the President’s New Freedom Commission on Mental Health. Howard Goldman served as scientific advisor for the first Surgeon General’s report, Jeanne Miranda held the position for the second report, Michael Hogan chaired the President’s Commission, and other network members contributed as writers, reviewers and consultants for all three reports.
I could go on but the point is clear. You should feel a great sense of accomplishment. Your research, model initiatives, legal challenges and policy advocacy have changed the way the country thinks about mental illness and the value of mental health care. Not only scientists, but doctors, insurance companies, policymakers, and the public now speak of fundamental fairness, evidence-based practice, resilience and recovery.
But, for all this progress, there is much more to do. We do not lament the decline of the large mental health institutions of the past. But what we today call the mental health system exists, generally unacknowledged, in our communities and institutions – our schools and workplaces, our jails and juvenile detention centers, our housing and social welfare systems. And as long as the mental health role of these institutions remains unacknowledged and unsupported, many people with mental illness will go without effective treatment – at great cost to them, their families, and their communities.
This is the unfinished agenda in mental health: to create a coherent and integrated system from these individual components – a system that is distributed but strong, accessible, accountable, and cost-effective—one that provides continuity of care to individuals and families.
Where do we begin? We can start wherever there are people with mental illness: in our schools, in the workplace, in the justice system, and in our communities.
The mission of our schools is to help all children learn and thrive. Yet when one student in a classroom has a behavior disorder, the teacher, that student and every other student deal with it every day.
One out of five schoolchildren has a mental illness that interferes with their ability to learn – and with their schools’ ability to serve all students. Half of all children with mental illness will drop out of school before completing high school. Many will end up in the juvenile justice system and incarcerated – at a cost of more than $60,000 a year.
There are alternatives and our schools need additional resources to employ them. Model programs, such as Multi-systemic Therapy have shown that it is possible to identify children with mental illness early and enroll them in a proven, family-centered treatment plan at a fraction of the cost of incarceration. With treatment, they can complete their education, dramatically improve their employment opportunities, and lead full, productive lives—and diminish the effects of their behavior on the prospects of others.
In the workplace, we see a cost of $44 billion from lost productivity due to absenteeism and disability associated with depression. Employers struggle to provide appropriate assistance to those with mental illness, while maintaining a safe and efficient workplace for all their employees. These costs are at least in part avoidable. For example, in one project supported by MacArthur, spending less than $500 per patient on effective mental health treatment reduced time depressed by more than a month and increased time at work by four weeks in a two-year time frame
Evidence-based treatment can keep people with mental illness connected to their work and family, again at a fraction of the cost to society. But in addition to improving access to effective care, we need policies that will allow individuals to maintain their employment – at whatever level is possible for them and works for the employer—without losing the benefits that allow them to receive that care.
In the justice system, we encounter the nation’s large and growing prison population, which suffers from mental illness at three to four times the rate of the general population. The reason is simple. Behaviors caused by untreated mental illness get people in trouble with the law. In fact, the criminal justice system has become one of the nation’s largest providers of mental health services – a revolving door of incarceration, ineffective treatment, and recidivism. The justice system struggles to deal with a population for which it was not designed or equipped to help.
It does not have to be this way. Ideally, people with mental illness will receive treatment before they wind up in jail. But for those who do enter correctional systems, there are also answers. Evidence shows, for example, that we can decrease recidivism among juvenile offenders by dealing with their mental health needs early in their encounter with the system. And, among adults, recidivism declines when ex-offenders participate in re-entry programs that address mental health and substance abuse.
In our communities, more than two million adults in the U.S. have at least one episode of homelessness in a year; 46 percent of these individuals have had a mental health problem within that year. Serious mental illness is especially common among those who are chronically homeless. The lack of affordable housing, and complex procedures to apply for it, are major contributors to homelessness. But affordable housing alone is not the answer for everyone. Many people with mental illness also need flexible, individualized support services to sustain them in their housing.
This solution also is cost effective. One study found that for each person placed in permanent supportive housing, the public saved $16,000 a year compared to their previous costs for mental health, corrections, Medicaid, and public institutions and shelters.
So what is the bottom line?
• The examples I have just offered should make it clear that an investment in mental health, across many public spheres, offers a good return – in human fulfillment, in social benefits, and in economic terms. In other words, an investment in an individual in trouble or in need often redounds to the benefit of the larger society as well.
• We have learned that the unfinished agenda is not just a mental health agenda. It is an agenda for the nation – for mainstream institutions and funders and policymakers – for all of us here today.
After 30 years, the Foundation’s support for mental health reflects that evolution—from a targeted focus on mental health research, law and policy to a more distributed strategy that addresses mental health needs where they occur—in schools, communities and the justice system, indeed in every area of our US grantmaking.
Here are just a few examples.
In the schools, we are supporting MDRC to evaluate and perform a rigorous cost benefit analysis of Foundations of Learning, a demonstration in 60 Head Start classrooms in Chicago of the impact of a mental health professional in the classroom – how their presence affects the teacher, individual students and the progress of other students as they move into elementary school and beyond.
In our communities, MacArthur is working across the country on preservation of affordable rental housing, including supportive housing programs. In our Chicago-based New Communities Program, with its focus on the revitalization of 16 neighborhoods, every one of the communities makes mental health treatment and services a top priority. Our comprehensive prisoner reentry program—Safer Return—is paying special attention to the mental health needs of returning ex-offenders. The program starts in prison with counseling and job training that continues when the ex-offender returns home. The communities have organized welcome home panels that connect ex-offenders to social services, faith and civic organizations, job possibilities, and mental health services.
Most significantly, in the justice system, improving mental health services is a central strategy in every state in Models for Change, our national juvenile justice systems reform initiative. The work involves an investment of more than $11 million dollars to develop innovative approaches to identify and treat youth with mental health needs in the juvenile justice system and to promote widespread adoption of those measures across the country.
An “action network” of eight states (Illinois, Pennsylvania, Louisiana, Washington, Colorado, Connecticut, Ohio and Texas) is committed to demonstrating measurable progress and improvement on two critical issues—diverting youth with mental health needs from the earliest points of contact with the juvenile justice system and improving the ability of police, probation officers, and counselors to work effectively with those youth.
In all our domestic programs we are finding willing partners eager to apply research evidence and models that work. We are at an inflection point in the long journey to achieve a society that makes real the lofty rhetoric the New Freedom Commission. We need to engage all segments of society, all affected institutions and organizations, indeed all individuals who stand to benefit from a fair and compassionate approach to mental health.
Clifford Beers understood that a century ago when he wrote:
“How unobtrusively history writes itself: the crucial moments are not the loud triumphs or the catastrophes, but moments…quiet and undramatic, when a light is struck in the minds of [people] and a purpose is set on its way”
I am honored to look at an assembly of people who have lit the light that has set a purpose on its way: universal access to mental health treatment wherever and whenever needed.
I salute you for your past achievements and for your determination to turn our high aspirations into reality. Thank you.