1 page 3 hours Requirements: one page Mental Health Policy Can access to mental health services be improved? A n estimated 58 million American adults, or

1 page 3 hours Requirements: one page Mental Health Policy
Can access to mental health services be improved?

A
n estimated 58 million American adults, or one in

four, suffer from a diagnosable mental disorder.

Eleven million live with a serious mental illness,

such as schizophrenia, bipolar disorder or major

depression. Yet it can take years for some individuals to see a

mental health professional. Some don’t want help, but the majority

say treatment is often unaffordable. Others don’t know where to

go for treatment or say that insurance coverage isn’t adequate. The

contentious debate over gun control since the December massacre

at Sandy Hook Elementary School has been accompanied by a

less polarizing discussion about improving access to mental health

care. Still, some proposals have split mental health advocates, in-

cluding encouraging states to make court-ordered outpatient treat-

ment easier to obtain. In addition, critics say new definitions of

mental illnesses will lead to over-diagnosis. Meanwhile, insurers

and patient advocates struggle to interpret federal laws requiring

equal treatment of mental and physical illnesses.

I

N

S

I

D

E

THE ISSUES ………………..427

BACKGROUND …………….433

CHRONOLOGY …………….435

CURRENT SITUATION ……..440

AT ISSUE……………………441

OUTLOOK………………….443

BIBLIOGRAPHY…………….446

THE NEXT STEP …………..447

THISREPORT

Demonstrators support a decision to charge police
officers in Fullerton, Calif., in the beating death of a
schizophrenic homeless man, 37-year-old Kelly

Thomas. In January 2013 a judge declined to drop
charges against the three officers, who have pleaded

not guilty. Last year the city paid $1 million to
Thomas’ mother to settle her wrongful death civil suit.

CQResearcher
Published by CQ Press, an Imprint of SAGE Publications, Inc.

www.cqresearcher.com

CQ Researcher • May 10, 2013 • www.cqresearcher.com
Volume 23, Number 18 • Pages 425-448

RECIPIENT OF SOCIETY OF PROFESSIONAL JOURNALISTS AWARD FOR
EXCELLENCE � AMERICAN BAR ASSOCIATION SILVER GAVEL AWARD

90th
Anniversary

1923-2013

426 CQ Researcher

THE ISSUES

427 • Should states make iteasier to force the mentally
ill into treatment?
• Does the medical pro-
fession define mental illness
too broadly?
• Do insurers treat mental
and physical health equally?

BACKGROUND

433 Rise of State HospitalsUrbanization and population
growth gave rise to public
mental hospitals after 1800.

433 Shift to Community CareAfter the 1940s, community
mental health gained support.

434 Changing Federal PolicyThe Reagan administration
and Congress sought to
reduce disability payments.

437 Equal TreatmentThe Clinton and George
W. Bush administrations
sought to improve coverage.

CURRENT SITUATION

440 Integrating CareProposed legislation would
increase funding for men-
tal health centers.

442 Mental Health in SchoolsPresident Obama wants
better programs to identify
students’ mental illness.

OUTLOOK

443 Legislation in LimboRecent mental health mea-
sures have been tied to
stymied gun proposals.

SIDEBARS AND GRAPHICS

428 Government Funds MostMental Health Treatment
Medicaid, Medicare and other
programs paid 60 percent of
the total in 2005.

432 Cost Deters Many FromTreatment
Half say treatment is unafford-
able.

434 Mental Health PrescriptionsSoar
Medication orders more than
doubled from 1996 to 2008.

435 ChronologyKey events since 1843.

436 Shortage of Mental HealthProfessionals Cited
“It’s a huge problem, starting
with the child mental health
system.”

438 Police Trained to DealWith the Mentally Ill
More than 2,700 crisis teams
exist nationwide.

440 Young Adults Had MostSerious Mental Illness
Nearly 8 percent of young
adults had a serious mental
illness in 2011.

441 At Issue:Will the new mental-disorders
manual lead to over-diagnosis?

FOR FURTHER RESEARCH

445 For More InformationOrganizations to contact.

446 BibliographySelected sources used.

447 The Next StepAdditional articles.

447 Citing CQ ResearcherSample bibliography formats.

MENTAL HEALTH POLICY

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Mental Health Policy

THE ISSUES
F

our months after the
massacre of six adults
and 20 first-graders in

Newtown, Conn., Senate
Majority Leader Harry Reid,
D-Nev., took to the floor of
the chamber in early April to
make a deeply personal plea
for gun control legislation.
“Sometimes people in a fit

of passion will purchase a
handgun to do bad things with
it . . . even as my dad did —
killed himself,” said Reid. 1

More than 38,000 people
committed suicide in 2010,
the latest year of available data,
nearly half with guns. Nine in
10 who take their lives have
a diagnosable mental illness,
most often depression or a
substance abuse disorder, ac-
cording to the National Insti-
tute of Mental Health (NIMH),
a government research insti-
tute in Bethesda, Md. 2

After Newtown, Congress
swiftly held hearings on gun
control and on mental health
care, despite the fact that the mental-
ly ill account for a tiny fraction of gun
crimes. While mental health advocates,
researchers and scientists were wary
about tying discussions about the frag-
mented mental health care system to
the gun control debate, they wel-
comed the chance to advocate for bet-
ter access to diagnosis, treatment and
support services.
“The burden of mental illness is enor-

mous,” Thomas Insel, director of the
NIMH, told lawmakers a month after
Newtown. An estimated 58 million
American adults, or one in four, suffer
from a diagnosable mental disorder in
any given year, and it takes a decade,
on average, for them to make contact
with a mental health professional, said

Insel. More than 11 million of those
adults suffer from serious mental ill-
ness, including schizophrenia, bipolar
disorder and major depression, and for
them the average delay in treatment is
five years. “That is five years of in-
creased risk for using potentially life-
threatening, self-administered treatments,
such as legal or illicit substances, and
even death,” said Insel. 3

Experts disagree on how to fix the
country’s broken mental health sys-
tem. Proposed legislation to improve
access by pumping more federal Med-
icaid money into community mental
health centers, which treat more than
8 million low-income people a year,
has some bipartisan support in Con-
gress. But calls by families for states

to make it easier to force the
mentally ill into treatment are
generating spirited opposition
from civil liberties groups.
Meanwhile critics complain
that the American Psychiatric
Association’s latest manual of
psychiatric disorders, released
this month, will do nothing
to stop over-diagnosis of men-
tal illness.
The bipartisan Excellence in

Mental Health Act would set
new standards of care at com-
munity mental health centers.
It includes a list of mandated
services and requires better in-
tegration of treatment for men-
tal illness and substance abuse;
provides more Medicaid dol-
lars for centers meeting those
standards and funds the mod-
ernization of existing centers
and construction of new ones.
Sen. Debbie Stabenow, D-

Mich., author of the Senate
version of the bill, estimated
that it would allow commu-
nity mental health centers to
treat an additional 1.5 million
people each year. 4

“As we’ve listened to peo-
ple on all sides of the gun debate,
they’ve all talked about the fact that we
need to address mental health treatment,
and that’s what this does,” Stabenow
said in mid-April as the Senate prepared
to vote on the bill as an amendment
to gun control legislation. 5 But gun
control legislation failed, and the vote
on the Excellence in Mental Health Act
was shelved.
“Today, our nation’s community men-

tal health centers are simply stretched
too thin and struggling to provide es-
sential services,” said Linda Rosenberg,
president and CEO of the Washington-
based National Council for Communi-
ty Behavioral Healthcare, a nonprofit
association of 2,000 providers that sup-
ports the bill.

BY BARBARA MANTEL

G
e
tt
y
I
m
a
g
e
s/
P
ri
m
e
f
o
r
T
h
e
W
a
sh
in
g
to
n
P
o
st
/M
a
x
W
h
it
ta
k
e
r

Janett Massolo of Reno, Nev., holds a photo of her
daughter Shannon on March 22, 2013. Using her

father’s handgun, Shannon committed suicide when she
was 15 years old. Nine out of 10 people who take their
own lives have a diagnosable mental illness, most often
depression or a substance-abuse disorder. More than

38,000 people committed suicide in 2010,
nearly half with guns.

428 CQ Researcher

But Rosenberg criticized President
Obama, whose fiscal 2014 budget,
submitted to Congress in April, did not
include funding for the proposed legis-
lation. “I am extremely disappointed
that the White House has not em-
braced the Excellence Act, which would
increase access and early intervention
in communities around the country,”
said Rosenberg. 6

The White House budget does call
for $130 million in funding for other
mental health proposals, including
$55 million to train teachers and other
adults to recognize the signs of men-
tal illness in students and to help them
refer students, when necessary, for
services. The proposed budget also
includes $50 million in tuition sup-
port to help train an additional 5,000
social workers, counselors and other
mental health professionals to address
critical shortages in many parts of the
country. 7

Some professional groups said the
money was welcome but far too little.
“While we applaud President Obama’s
budget proposal, it doesn’t come close

to restoring the drastic cuts in funds
for mental health services that have
been imposed over the last several
years,” said Robert Cabaj, chair of the
Council on Advocacy and Government
Relations at the American Psychiatric
Association, a medical society in Ar-
lington, Va. 8

Spending on mental health care to-
taled $113 billion in 2005, before ad-
justment for inflation, according to the
latest available data, about twice the
amount spent a dozen years earlier.
(See graphic, above.) The money went
mostly toward prescription drugs and
outpatient treatment. Nevertheless men-
tal health spending as a share of total
health care outlays has been slipping;
it was 6.1 percent in 2005, down from
7.2 percent in 1986.
Private insurance has picked up an

increasing portion of mental health ex-
penditures, accounting for 27 percent
in 2005, up about 6 percentage points
from a dozen years earlier. Patients’ out-
of-pocket expenditures remained at
roughly 12 percent, and the federal gov-
ernment’s share was not much changed

either, at about 28 percent. States’ share
of mental health spending, however,
dropped from 35 percent in 1993 to
30 percent in 2005 and is likely to have
dipped further since. 9

The deep recession that officially
began in December 2007 and ended
in June 2009 took a huge toll on state
finances, and states cut approximate-
ly $5 billion in public mental health
spending from 2009 through 2013, ac-
cording to the National Association of
State Mental Health Program Directors
in Alexandria, Va. Over the same pe-
riod, demand for publicly financed in-
patient and outpatient mental health
services rose 10 percent.
“Those cuts have had a devastating

impact on access to services for peo-
ple,” says Ronald Honberg, national di-
rector for policy and legal affairs at
the National Alliance on Mental Illness
(NAMI), an advocacy group in Ar-
lington, Va. “It’s helped to further pre-
cipitate a system that is responding to
emergencies rather than doing ongo-
ing care and prevention.”
The number of state psychiatric

hospital beds fell by about 4,500 —
9 percent of total capacity — between
2009 and 2012. Outpatient services
have suffered as well. “In my own
state of Arizona, virtually all state-only
funded behavioral health services *
have been dramatically reduced or
eliminated over the last few years,”
Laura Nelson, chief medical officer
of the Arizona Department of Health,
told Congress last year. “Over 4,600
children have lost behavioral health
services. Nearly 6,300 adults lost ac-
cess to substance abuse treatment
services. 10

“Due to mental health cuts, we are
simply increasing emergency depart-
ment costs, increasing acute care costs
and adding to the caseloads in our
criminal and juvenile justice systems
and correction systems,” said Nelson.

MENTAL HEALTH POLICY

Government Funds Most Mental Health Treatment

Mental health spending in 2005, the latest year for which data are
available, totaled $113 billion, about 60 percent of it paid by Medicaid,
Medicare or other government sources. Private insurers
paid nearly 30 percent. Mental health
accounted for about 6 percent
of total health spending.

Spending on Mental Health
Treatment by Payer, 2005

2.6%
Other private sources

27%

Private
insurance

29.8%
State

28.4%
Federal

12.2%

Out-of-pocket

Source: “National Expenditures for Mental Health Services and Substance Abuse
Treatment, 1986-2005,” Substance Abuse and Mental Health Services Administration,
Tables 74 & 75, pp. 201-202, http://hcfgkc.org/sites/default/files/documents/MHUS_
2010_part3_508.pdf

* Behavioral health services refers to mental
health as well as substance abuse services.

May 10, 2013 429www.cqresearcher.com

For example, in a survey of more than
6,000 hospital emergency depart-
ments, 70 percent reported boarding
psychiatric patients for hours or days,
and 10 percent reported boarding
such patients for weeks while staff
looked for psychiatric beds. 11 And ac-
cording to a recent report, the per-
centage of inmates in New York City
jails with mental health problems rose
from 24 percent in 2005 to 33 per-
cent in 2011. 12

Sheriff Brian Gootkin, who super-
vises 48 deputies in Gallatin County,
Mont. — an area twice the size of
Rhode Island — blamed reductions in
community mental health funding for
a significant jump in psychiatric emer-
gencies that his force must handle.
“Every deputy that is diverted to the
Montana State Hospital or even to a
local hospital is not on patrol main-
taining public order and deterring
crime,” Gootkin complained. 13

The 2010 Patient Protection and Af-
fordable Care Act — the sweeping
health care system overhaul champi-
oned by Obama — will add to the
demand for mental health services as
it extends health coverage to more
than 30 million Americans, including
an estimated 6 million to 10 million
with mental illness.
Against that backdrop, here are some

of the issues that lawmakers, advo-
cates, mental health professionals and
people with mental illness and their
families are debating:

Should states make it easier to
force the mentally ill into treat-
ment?
On March 19, 2005, Roger Scanlan

of Allentown, Pa., diagnosed with schiz-
ophrenia and off his medications, killed
his parents with a knife and then took
his own life by cutting his throat. Five
years later, his brother, Michael, testi-
fied on behalf of proposed legislation
in Pennsylvania to make it easier for
courts to order outpatient treatment of
the mentally ill.

“I always knew when he wasn’t
taking his meds,” Scanlan said of his
brother. “He would become very pas-
sionate about government, religion, and
then he would believe that he was
the second coming of Christ or Moses
or some other biblical figure.”
“Everyone from crisis, the Allentown

Police Department, his doctors, they
all knew the pattern. We, as a fami-
ly, we couldn’t intervene to help him.
We couldn’t get him off the street. We
were told that Roger had rights,” said
Scanlan. “What rights did my mother
and father have?” 14

The legislation died in committee
in 2010. But since the Newtown mas-
sacre, families and a prominent ad-
vocacy group favoring easing rules for
court-ordered treatment have renewed
their campaign, testifying before Con-
gress and at state forums. Civil liber-
ties groups and other mental health
advocates are strongly opposed, say-
ing patients should not be forced into
treatment.
Forty-four states allow courts to

order outpatient treatment of mental-
ly ill people who have a history of
not complying with treatment, which
is sometimes referred to as assisted
outpatient treatment or AOT. Most
states require the person to be an im-
minent danger to self or others. For
example, in Pennsylvania, a court can’t
order treatment unless the person com-
mitted or tried to commit serious
harm to self or others within the past
30 days. 15

But 10 states have less stringent cri-
teria. For example, New York’s Kendra’s
Law, named for a young woman pushed
to her death in front of a subway train
in 1999 by a schizophrenic man off
his medications, does not require ev-
idence of recent harm. A New York
court can order outpatient treatment
for someone who is not complying
with mental health treatment if non-
compliance led to hospitalization or
confinement in a mental health unit
in a jail or prison at least twice in the

last three years or to serious or at-
tempted serious violent behavior in
the past four years. 16

Doris Fuller, executive director of the
Treatment Advocacy Center, a nonprofit
based in Arlington, Va., wants states to
model their laws on New York’s. Making
it easier for courts to order outpatient
treatment would help the small subset
of people known in the mental health
world as “frequent flyers,” says Fuller.
“Many of them don’t acknowledge that
they are ill or they don’t know that
they are ill,” she says. Court-ordered
treatment, which is monitored and
carries penalties for failing to take re-
quired medication, is needed to stabi-
lize people until they voluntarily com-
ply with treatment, she says.
Many states rarely use their court-

ordered outpatient treatment laws, and
Fuller wants that to change as well.
“California has a law similar to Kendra’s
Law, but there are 58 counties in Cali-
fornia and at this point, only one
county has opted in and another has
a pilot program,” says Fuller. The same
is true in Texas, she says, where courts
in Dallas County have started using
the state’s outpatient treatment law
more frequently. “But then you have
other counties that aren’t using it for
whatever reason,” she continues. “The
local mental health officials haven’t
gotten on board, [and] there are con-
cerns about what it will cost.”
Patient-rights groups strongly object

to looser criteria for or greater use of
court-ordered outpatient treatment.
“These laws [such as New York’s
Kendra’s Law] are based on specula-
tion,” says Debbie Plotnick, senior di-
rector of state policy at Mental Health
America, a national advocacy group
for people with mental illness based
in Alexandria, Va. Mental health dis-
orders are episodic, she says. “People
could have been in the hospital with-
in the past three years and doing very
well now in the community. You can-
not say they are likely to be a danger
to self or others.”

430 CQ Researcher

The problem is not that the seri-
ously mentally ill are refusing treat-
ment, say Plotnick and others. “We
have interventions that are effective for
the people that the Treatment Advo-
cacy Center claims cannot be reached.
The problem is that those interven-
tions are not available for those who
need them,” because of a lack of in-
surance and funding, says Ira Burnim,
legal director at the Washington-based
Judge David L. Bazelon Center for Men-
tal Health Law.
These interventions include support

provided by trained peers (people liv-
ing successfully with mental illness);
supported housing staffed by mental
health workers; and so-called assertive
community treatment or ACT, in which
a team consisting of a psychiatrist,
nurse, social worker, employment
counselor and a case worker provides
highly individualized services to an
individual at home.
“Another missing element of com-

munity care that is sorely lacking around
the country is the presence of a cri-
sis center that can take people in for
brief periods of time, arrange hospi-
talization if needed and is available
24/7,” says Michael Hogan, New York
state’s commissioner of mental health
until retiring late last year.
But Fuller says making treatment

and support services more widely avail-
able is not enough if people in crisis
refuse to use them. “You could liter-
ally park people who are actively psy-
chotic on the front door of the best
service center in the country, and if
they don’t think they are sick, they
are not going to [voluntarily] walk
through that door and access those
services.”
Plotnick rejects that argument. “I’m

saying we should give people services
upstream before they reach a crisis.
We have to help them before they are
in that stage,” she says.
The largest and latest study of the

impact of Kendra’s Law was published
four years ago. It compared people’s

experience under court-ordered out-
patient treatment with their prior expe-
rience, controlling for other factors. 17

“Overall, under assisted outpatient
treatment, people were less likely to
get hospitalized, more likely to receive
appropriate medications for their con-
dition, less likely to be arrested, and
generally functioned better, with no
apparent effect of feeling coerced,” as
long as individuals were under court
order for at least six months, says Mar-
vin Swartz, a psychiatry professor at
Duke University and the study’s prin-
cipal investigator. The study found that
these improvements were sustained
once the court order expired.
“It makes sense because a Kendra’s

Law order pushes you to the top of
the line,” says Burnim. “They got bet-
ter because they got access to much
better services, not because of the
court order.”
In fact, unlike other states with as-

sisted outpatient treatment, New York
created a new stream of funding to ad-
minister Kendra’s Law and also plowed
money into expanding services for those
who have a serious mental illness.
But Swartz says his study showed

that the court order itself conferred
benefits. In one analysis, the researchers
looked at people who were receiving
intensive treatment from a team of
professionals without a court order
and with a court order. “We found that
people under court order did better,”
says Swartz.
Hogan says there could be anoth-

er explanation. Under court-ordered
outpatient treatment, government
watchers monitor the professional team
delivering services, and, as a result,
the quality of the treatment may have
simply been better, he says.

Does the medical profession de-
fine mental illness too broadly?
No laboratory tests exist to help

mental health professionals diagnose
and treat mental illness. That absence
is a huge disadvantage for psychiatry,

according to Allen Frances, former chair
of the psychiatry department at Duke
University, and “it means that all of our
diagnoses are now based on subjective
judgments that are inherently fallible
and prey to capricious change.” 18 As
a result, the psychiatric profession has
cast the net too broadly, capturing both
those with mental disorders and those
without, he says.
Frances is an outspoken critic of the

forthcoming fifth edition of the Diag-
nostic and Statistical Manual of Men-
tal Disorders (DSM), to be published
this month by the American Psychiatric
Association (APA). (See “At Issue,” p. 441.)
First published in 1952, the DSM clas-
sifies mental disorders, describing their
symptoms and listing the number and
duration of symptoms needed to make
a diagnosis. The task force overseeing
the newest iteration, the DSM-5, “gave
their experts great freedom, and the ex-
perts have used that freedom to do what
experts always do, which is try to ex-
pand their area of interest,” says Frances.
But the manual’s supporters reject

that view. “We developed DSM-5 by
utilizing the best experts in the field
and extensive reviews of the scientif-
ic literature and original research, and
we have produced a manual that best
represents the current science and
will be useful to clinicians and the
patients they serve,” said Dilip Jeste,
APA president and chief of geriatric
psychiatry at the University of Cali-
fornia, San Diego. 19

The diagnostic manual has drawn
criticism since its origin and has be-
come increasingly controversial as its
influence has grown. It “shapes who
will receive what treatment,” said Mark
Olfson, a Columbia University psychi-
atry professor not involved in the re-
vision. “Even seemingly subtle changes
to the criteria can have substantial ef-
fects on patterns of care.” 20 There have
been plenty of not-so-subtle changes
over the years, including an expansion
of the number of diagnoses from 106
in the first edition to 297 in DSM-4. 21

MENTAL HEALTH POLICY

May 10, 2013 431www.cqresearcher.com

Critics of the version due to be pub-
lished this month come from outside
and inside the profession. Frances, in
fact, was the chair of the task force
for DSM-4, published in 1994. He points
to a new diagnosis included in the
DSM-5 as just one example of what
he says is wrong.
It’s called Disruptive Mood Disregu-

lation Disorder (DMDD), and it’s an
attempt to reduce the
number of young chil-
dren who increasingly
are diagnosed with
bipolar disorder and
medicated with pow-
erful antipsychotic
drugs. DMDD is a di-
agnosis for irritable chil-
dren who have been
having “severe recur-
rent temper outbursts
that are grossly out of
proportion in intensity
or duration to the sit-
uation.” 22

“The threshold for
DMDD is high and
children must meet
several diagnostic cri-
teria,” David Kupfer,
chair of the DSM-5 task
force and head of the
psychiatry department
at the University of
Pittsburgh, says in an
email. The outbursts
must occur three times
a week on average
and have been present
for at least a year.
But “in real life, it

will be kids with tem-
per tantrums who will
get the diagnosis,” says Frances. “So
instead of reducing the risk of exces-
sive medication, I think this greatly in-
creases it. If you want to attack the
excessive diagnosis of bipolar disor-
der in children, you should have big
warnings in the bipolar section that
this is being terribly over-diagnosed in

kids, explain why and explain what
should be done.”
Several other changes to the diag-

nostic manual also are raising hack-
les. In the DSM-4, an individual griev-
ing the loss of a loved one could not
be diagnosed with major depressive
disorder (MDD) unless symptoms per-
sist for at least two months. For all
other individuals, the threshold for a

diagnosis of MDD is lower. Symptoms,
such as sadness, loss of interest, loss
of appetite, trouble sleeping and re-
duced energy, need last only two weeks
before a diagnosis can be made.
The DSM-5 removes the exclusion

for bereavement. Its elimination “shows
that psychiatry has no idea how to

define what’s normal, what’s abnormal
and how to differentiate between them,”
said Allan Horowitz, author of The
Loss of Sadness and a sociology pro-
fessor at Rutgers University in New
Jersey. “One …

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