Part IV of a four-part series looking at the sorry state of treating the mentally ill — beyond warehousing people in institutions or prisons — and the tentative efforts to improve the situation. Part I looked at the scope of the problem and the downbeat assessments by experts; Part II examined how the severely mentally ill end up in prison instead of receiving help. Part III noted that some locales have good ideas but those are few and far between.
In Australia, if a 15-year-old boy starts hearing voices or even starts to skip school or act out in the classroom, a national program called Youth Pathways swings into action.
Teachers would identify the teen as at-risk and refer him to counselors, who would connect him and his family to mental health programs intended to provide treatment and support and keep him in school.
Unless he's lucky enough to have parents who can afford private psychiatric care, a 15-year-old boy in the United States who is hearing voices and acting out at school is likely to end up in a juvenile detention facility.
Youth Pathways is just one part of the Australian government's comprehensive National Action Plan on Mental Health, 2006-2011, which will spend nearly $5 billion over five years to improve the quality and availability of mental health services across the country.
Rooted in recognition during the late 1990s that Australian mental health services, like those in the United States, were underfunded and inadequate, the plan "provides a strategic framework that emphasizes coordination and collaboration between government, private and non-government providers, aimed at building a more connected system of health care and community supports for people affected by mental illness."
There are five primary areas of focus. They include promotion, prevention and early intervention, of which Youth Pathways is a part; integrating and improving the care system; participation of the mentally ill in the community and employment, including housing; increasing and improving training of the mental health work force; and coordinating the care that is provided by government and others. More than 145 separate initiatives are part of the plan.
"While most initiatives represent additional commitments to expand ongoing programs, many are new and take the delivery of services for people with mental illness into areas beyond the boundaries of traditional health care," a February 2008 progress report notes. "Key human service programs operating outside the system that have major responsibilities under the plan include housing, employment, education and correctional services."
Included in the strategy, and perhaps most important to the plan, are expected benchmarks and a timeline for accomplishing each one. A special committee is charged with making sure they are met.
It is this amalgamation of services that makes the Australian plan unique. While the 2002 President's New Freedom Commission on Mental Health in the United States identified similar needs, few if any of its recommendations have been implemented.
But services remain fractured and inconsistent, and the toll is significant medical and social costs. The mentally ill are more likely to be incarcerated, homeless and sick. Too many end up hurting themselves or others.
The entire mental health services conundrum in the United States needs to be viewed as a public health problem, which is what Australia has done, said Annmarie Cameron, executive director of the nonprofit Mental Health Association in Santa Barbara, Calif.
If programs could be coordinated and implemented nationwide, there would be significant savings, not to mention the mentally ill would receive the treatment they deserve.
E. Fuller Torrey, author of 11 books on severe mental illness, founder of the nonprofit Treatment Advocacy Center and director of the Stanley Medical Research Institute, believes the only thing that will create that change is to have more people in political and national office who understand mental illness from the perspective of family members.
"If I had one thing (I could do politically) and could make one appointment, I would appoint a head of the federal Medicare agency who has three family members who are seriously mentally ill, and then I would write federal policy that would provide funding, and measure the outcome, and provide programs, and measure the outcome," Torrey said. "We know that if you fund programs properly you can markedly decrease the mentally ill homeless, markedly decrease the mentally ill in jail and markedly decrease the hospitalization of the mentally ill."
Twenty years ago, the Treatment Advocacy Center surveyed mental health programs. For the most part, mental health care has deteriorated nationwide, Torrey said.
"A combination of several things. One is lack of leadership and burnout of the people who were doing it," Torrey said. "Part of the problem is the funding issue. If you want to do a really good job, you have to get the funding together from a lot of different sources." The bureaucracy can be crushing.
Politically, "it's just not been a priority. There's not a single governor who's made this a priority. It's a disgrace," Torrey said.
Similarly, no administration in recent history has been willing to make mental health reform a priority. While President George W. Bush's New Freedom Commission report noted the disastrous shape of the mental health system, no significant funding or program initiatives resulted from it.
Australia's long-term plan includes many of the program initiatives that mental health care professionals in the United States know about and would love to implement. But it requires coordination of services across a spectrum of needs: housing, employment, health care and preventing the mentally ill from ending up on the streets or in jail.
And it would require a commitment of dollars that would be possible only through a concerted effort on the part of all the states and the federal government, as in Australia.
In this country, funding for services for the mentally ill has declined or shifted from mental health services to the criminal justice system, where many of the nation's mentally ill individuals have ended up. Redirecting those dollars will require a major shift in priorities.
It's unclear how much the new Obama administration will be able to follow through on once the new president assumes the Oval Office in January. During his presidential campaign, Barack Obama's Web site included a position on mental health policies. NAMI, which asked the candidates to respond to a questionnaire on mental health issues, posted Obama's responses on its Web site.
Mental health isn't funded in part because people don't think that treatment can be effective, said Paul Erickson, medical director of mental health services at Cottage Health Care systems in Santa Barbara. If people had the idea that mentally ill people can recover with treatment, if they heard more about those successes, public support for mental health programs might grow, he said.
"Those are the kinds of stories people need to hear," Erickson explained.
Also, society needs to understand how truly dire the situation is in the United States.
"I have to fight every single time, every day, to try to get treatment for my patients," Erickson said.
He recounted how an oncologist friend who treats children has never had trouble raising money for his cancer patients — unless they are also mentally ill.
What's missing? "Political will and leadership," Erikson said. "There's a need for that. It really requires some champions, but that's very hard to come by."
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