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Commentary   |    
Conclusion: Mental Health in the Mainstream of Public Policy
Howard H. Goldman, M.D., Ph.D.; Sherry A. Glied, Ph.D.; Margarita Alegria, Ph.D.
Am J Psychiatry 2009;166:1215-1216. doi:10.1176/appi.ajp.2008.08040585

As the articles in this series on mental health in the mainstream of public policy have demonstrated, mental health policy is no longer limited to a segregated enclave under the direction of a specialized bureaucracy. It has moved into the mainstream across a wide range of public policy dimensions. The goal of this series of articles on mental health policy has been to examine the ways in which a better understanding of the role of mental health in various areas of mainstream public affairs might result in better public policy for everyone. Each of the articles explored the challenges posed for the administration and organization of public programs and policies for individuals with mental illness and discussed how mainstream policies may affect these individuals. Specifically, we have been concerned with the ways in which better mental health policy—informed by new mental health policy research—will mean focusing broad public policy studies on the special problems of individuals with mental disorders.

This approach would represent a marked shift in the way mental health policy has been studied in the past. This shift is apparent in the outcomes that would be the focus of such a research agenda. Rather than examining mental health-specific outcomes, such as rates of return to the hospital or improvement in symptoms, the focus of this new direction for mental health policy research should be on the outcomes of the “host” system: how to help individuals with mental disorders perform better in their roles as tenants, students, and citizens. The dependent variables we should focus on are residential stability, academic performance, and labor force participation for individuals with mental disorders living in our communities.

There remains room for exceptionalism—policies directed specifically toward those with mental illness. Many of the articles discussed the tension between research on special policies of mental health exceptionalism and on mainstream public policies. For example, while gaining access to mainstream housing resources is critical to community integration, inmates with mental health disorders need specialty mental health services if they are to be appropriately placed and properly treated in the criminal justice system (exceptionalism).

Raising issues of mental health in the context of mainstream policy programs also challenges our understanding of these programs. Implicit in this vision is an idea of social institutions reminiscent of the progressive era. Mainstream institutions, such as schools and prisons, once intended to produce better citizens rather than simply teaching students and incarcerating felons. Social institutions have moved away from these broad goals and now just wish to be able to meet their primary objectives. However, the articles in the Journal suggest that they cannot accomplish these narrower goals without addressing the special needs of some individuals under their charge. Early intervention to address the needs of people with mental disorders may once again be seen as logical public policy in host service systems, although for a very different reason. The goal today is not to use these various institutions to improve the mental health of the society but to address mental illness so that various social agencies and institutions can carry out their primary missions more effectively.

These changes present new opportunities for public policy research. Each of the articles in the series suggested a new research agenda for different areas of public policy.

Governmental agencies such as the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the Substance Abuse and Mental Health Services Administration have dominated mental health policy-related research funding for most of the post-World War II era. A specific focus on rigorous policy research waned when NIMH, NIDA, and NIAAA returned to the administrative structure of the National Institutes of Health after years under a separate agency (1). Some mainstream health policy agencies, such as the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, have sponsored some mental health policy research. In recent years, agencies such as the Social Security Administration and the National Institute of Justice also have initiated some research. There is a need for these agencies to partner with each other and with other government agencies to fund the proposed new mental health policy research agenda.

For the past three decades, private foundations have been at the forefront of sponsoring mental health policy research, particularly the John D. and Catherine T. MacArthur Foundation and the Robert Wood Johnson Foundation. These foundations funded the investigators involved in writing this policy perspective. Other foundations have been involved in related work, but it has been difficult to get new major funding sources to make a commitment to this new area of policy research.

From whatever source, governmental or private, dedicated funding will be needed to address the research recommendations of the articles presented in this public policy series. Reliable research support would produce policy analyses for the benefit of policy makers, managers, and service providers and the public.

All of the proposals discussed in the articles in this series require interdisciplinary research among investigators with knowledge of the important role of mental health in specific public policy domains. Interdisciplinary research can be promoted by interagency collaboration and commitment to funding joint policy studies. This would bring the funding together with individuals most knowledgeable about the current and future policy issues and teams of investigators who could implement the needed policy studies. The MacArthur Foundation Network on Mental Health Policy Research came to these conclusions after more than a decade of interdisciplinary research and study. Within the network, we created a culture of evidence-based policy analysis, which in turn suggested to the end users of our work the need for evidence-based policy making.

While looking backward, the foregoing articles in this series have presented a research agenda for the future. As supporters of mental health policy research come and go, as they change priorities, we believe that it is imperative that they recognize that mental health policy is fundamental to public policy.

1.Grob GN, Goldman HH: The Dilemma of Federal Mental Health Policy. Piscataway, NJ, Rutgers University Press, 2006
 

Address correspondence and reprint requests to Dr. Goldman, Editor, Psychiatric Services, 1000 Wilson Blvd., Suite 1825, Arlington, VA 22209; psjournal@psych.org (e-mail). Commentary accepted for publication November 2008 (doi: 10.1176/appi.ajp.2008.08040585).

The series on mental health in the mainstream of public policy is the product of collaboration between experts in various areas of broad social policy and experts in mental health policy. It was sponsored by the John D. and Catherine T. MacArthur Foundation Network on Mental Health Policy Research and a grant from the Robert Wood Johnson Foundation.

Dr. Goldman is affiliated with the Department of Psychiatry, University of Maryland School of Medicine, Potomac, Md.

The authors report no financial relationships with commercial interests.

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References

1.Grob GN, Goldman HH: The Dilemma of Federal Mental Health Policy. Piscataway, NJ, Rutgers University Press, 2006
 
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