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By President E. Fuller Torrey, M.D. 
bio - interview - printable PDF version

Commission Report Offers Little for Severest Mental Illnesses 

Recommendations ignore people who are in crisis

Arlington, VA - The President's New Freedom Commission on Mental Health squandered an opportunity to be a unique champion for those most severely impacted by these devastating diseases - a group that uses a disproportionate amount of public services, particularly crisis care. The final report of the Commission portrays a nation whose system for helping those with severe mental illness is in shambles - but then ignores the people who are the most ill.

No report can cover everything, and much of what is suggested is commendable. But seemingly overwhelmed by the need to be politically correct, this Commission left out the people who needed them most, ignored powerful tools proven to save lives and money, and reinforced harmful stereotypes about recovery and stigma. Many mental health advocates are praising the report for its assessment of the system - we find it sad that because there is such a low bar for success with such reports, none wants to mention the important things that were omitted.

Failure to recommend tools, like assisted outpatient treatment, proven to save lives.

The report is adamant that treatments and services shown to be successful through research should be used, not languish. Yet the commissioners then gloss over tools like police training, mental health courts, and commitment laws, especially assisted outpatient treatment.

Adopting and utilizing assisted outpatient treatment is a proven way to meet the Commission's goal to disseminate and apply proven treatments to mental health care delivery. The Commission's hesitancy to address this treatment mechanism is especially astonishing given the results from instituting such measures. For instance, in New York, of those placed in six months of assisted outpatient treatment, 77% fewer were hospitalized, 85% fewer experienced homelessness, 83% fewer were arrested, and 85% fewer were incarcerated.

Failure to recognize major problems, like the Medicaid IMD exclusion, because of funding.

Despite listing as a goal the elimination of disparities in mental health services, the Commission failed to even mention the Medicaid IMD exclusion, reform of which is critical to making high-quality treatment available to low-income people with severe mental illnesses.

The Medicaid IMD exclusion is one of the most discriminatory healthcare policies on the books - the federal government does not reimburse states for Medicaid-eligible people with severe mental illnesses who are in state psychiatric hospitals, although it does for medical and psychiatric treatment in most other settings. This 1965 policy has been largely responsible for the massive closings of state psychiatric hospitals, which discharged patients from their Medicaid ineligible facilities to nursing homes and the community, where Medicaid reimbursement was available. 

Failure to recognize that a major factor in stigma is lack-of-treatment crimes.

The Commission recognized that stigma is an important problem for people with severe psychiatric disorders. It lowers their self-esteem; contributes to disrupted family relationships; and adversely affects their ability to socialize, obtain housing, and become employed. But any national campaign to reduce stigma will be completely undone with each headline touting a violent crime by someone who is not receiving treatment.

In fact, the Commission report actually ignores one of the most remarkable findings from the 1999 Surgeon General's Report on Mental Health, that "the perception of people with psychosis as being dangerous is stronger today than in the past.." The report concluded that "Stigma was expected to abate with increased knowledge of mental illness, but just the opposite occurred: stigma in some ways intensified over the past 40 years even though understanding improved."

The most effective way to reduce stigma is not a public information campaign - it is to help people BEFORE they become a headline. Yet absent from the report are interventions for those crises that directly lead to headline-making tragedies. These tragedies won't go away by ignoring them; they will go away by treating the cause.

Failure to dispel the myth that everyone with a severe psychiatric disorder can fully recover.

The idea that people can recover from mental illness by sheer will alone is illogical, has no basis in research, and is a cruel message to send to the many consumers struggling with these brain diseases.

The implication that failure to fully recover is because the person who is sick failed to have a strong-enough faith in recovery is akin to suggesting that happy thoughts can cure a broken leg. This perspective implies that the person with the brain disease is somehow at fault.

Although the Commission's focus on full recovery is understandable and recovery for all is a laudable long-term vision, it is important to remember that recovery is not currently possible for every person who has a severe psychiatric illness.

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