This issue of the Journal begins a series on mental health in the mainstream of public policy, examining the past and future of mental health policy and research. The past decade has seen the publication of a Surgeon General’s report on mental health (1) and a set of reports from the President’s New Freedom Commission on Mental Health (2, 3). Yet more than ever there is a need to take stock of where mental health policy sits in the mainstream of broader public policy.
Considering people with mental health problems as well as their needs is a comparatively new topic for mainstream public policy. Until a few decades ago, almost all considerations of mental health policy focused on the specialty mental health service systems of psychiatric hospitals and community mental health centers. In the past, individuals with severe mental disorders were segregated from the rest of the health care system and lived their lives mostly disconnected from the mainstream of society and its institutions and public policies. With the movement toward deinstitutionalization and community care, individuals with even the most severe and persistent mental disorders came to live in our neighborhoods and interact with our broader social institutions (4).
In their book Better But Not Well: Mental Health Policy in the United States Since 1950, Frank and Glied (5) concluded that the mental health of the general public in the United States has improved steadily over the past half century. With the exception of a group of those who are most impaired, including some who are homeless and chronically unemployed, people with mental disorders are better off than ever before, using mental health services and participating in the mainstream of society. Even some who are most impaired have access to a broad array of social services and agencies, compared with conditions 50 years ago, when individuals with severe mental disorders often spent many years in specialized institutions for mental illness. Today, they are involved in the mainstream of society and derive benefits from its diverse institutions. They receive services from—and occasionally create special challenges for—the welfare system, housing providers, schools, adult and juvenile criminal justice systems, and the general health care system, where much mental health care occurs. The following are statistical data pertaining to the impact of mental illness on society:
In 2005, 27% of individuals <65 years old who received Supplemental Security Income (SSI) and 38% of Social Security Disability Insurance (SSDI) beneficiaries were eligible to receive benefits because of a mental impairment (6).
More than 200,000 adults who are incarcerated in state and federal prisons demonstrate the signs and symptoms of a mental disorder (7).
Juvenile detention centers have spent $200 million on children who could benefit instead from community mental health services (8).
People with mental illness constitute approximately 30% of the population of homeless individuals, particularly those who are persistently undomiciled (5).
These statistics underscore the critical role of mainstream programs in the lives of people with mental illness. Mental health issues are a part of broad public policy—occasionally recognized as such but often hidden and poorly understood.
Mental health policy has evolved over the past century through a series of incremental steps guided by scientific advances and supported by an ideology of community integration and participation (4). Federal, state, and local mental health policies are now manifestations of employment and welfare policies, criminal justice policy, education and juvenile justice policies, and general health policy. The drive for health insurance parity is an example of mental health becoming part of the mainstream of health care financing policy. At times, however, there remains a need for exceptionalist policies that treat individuals with mental disorders differently (5). For example, exceptionalism may be appropriate in the design of special education services or programs to encourage employment among disabled populations, while standard health insurance coverage and cash assistance might work equally well for people with mental disorders and those with other needs.
Consistent with this shift, the recent presidential commission on mental health produced a series of reports, including a final report and recommendations for policy “transformation” in mental health (3), which touched upon a wide array of public policies. There are reports on criminal justice, housing, mental health and schools, employment and income support, Medicaid, rural mental health, interface with general medical care, and implementation of new technologies and evidence-based practices (9–18). The recommendations, however, tend to be modest and limited, even as they call upon a transformation of policies outside of traditional mental health agencies as well as within government and private sector mental health organizations.
The shift of mental health from exceptionalism to the mainstream has not been fully reflected in the mental health research agenda. The program of research in mental health services that began in the 1980s and was sponsored by the National Institute of Mental Health (NIMH) (19) focused almost entirely on specialty mental health services, such as psychiatric hospitals and inpatient units in general hospitals, mental health clinics, specialist providers, and community mental health centers. The New Freedom Commission recommended only studies investigating the causes of mental illness, boldly focusing on eliminating those causes completely. A recent report from NIMH (20) outlined a “road ahead” for research on mental health services but did not address the content of such studies and did not establish a policy research agenda.
The mental health policy research agenda presented in this series of articles, by contrast, focuses instead on mainstream social policies. These are policies that affect agencies where individuals with mental disorders create special opportunities and challenges—where they need and use services. The articles in this series focus on the following eight significant areas of public policy:
Ethnic and racial disparities
Governance and stewardship
Each article retrospectively examines one of these areas and identifies key issues in which mental health plays a role. The articles review what is known; then they look ahead at prospects for research to fill the gaps in our knowledge and understanding of the important issues discussed. Throughout this series, we use the general term “mental illness” and the specific term “mental disorder” to include all mental health and behavioral conditions, including substance use disorders. The first article in this issue of the Journal, by Jeanne Miranda, Ph.D., et al., examines mental health care in the context of health care disparities experienced by minorities in our population (21).