	Introduction

According to the federal Substance Abuse and Mental Health Services Administration (SAMHSA), in 2007 about 11% of adults (23.7 million) experienced serious psychological distress, such as anxiety and mood disorders, that resulted in functional impairment that impeded one or more major life activities. It is estimated that less than half of these individuals received mental health care due to various social, financial, and systemic barriers. Congress has been increasingly interested in transforming the mental health system in the aftermath of tragedies involving mentally ill individuals—such as the shootings at Columbine and Virginia Tech, which led to heightened public interest in the adequacy of the mental health care system. In the past decade, Congress passed two far-reaching laws on mental health care. The first law, the Children's Health Act, reauthorized the SAMHSA in 2000 and called for greater focus on the measurement of mental health care outcomes. The second law, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, expands federal requirements for mental health coverage and requires health insurers who choose to cover mental illness to provide mental health benefits on par with that for physical health. Mental illnesses are common in the United States. While there have been recent advances in treatment options, the delivery system and financing mechanisms have been slow to transform. Despite substantial investments that have enormously increased the scientific knowledge base and have led to developing many effective treatments, a commission established under President George W. Bush reported that many Americans were not benefiting from these investments. Each of the elements considered in this report—providers, settings, and financing—has implications for the quality of mental health care delivered. Federal entities that attempt to measure the quality of mental health care are those that provide for mental health care (VA, DOD, SAMHSA, HRSA, CMS) and the Agency for Healthcare Research and Quality (AHRQ). Access to competent mental health providers is scarce in rural areas and even some urban areas. Health insurance coverage of mental illness is often less comprehensive than that of physical illnesses. Mental health care is often not coordinated with other care that an individual may be receiving or may need. These reports are consistent in their recommendations for reforming the mental health care system. A crosswalk of the recommendations of the four federal reports mentioned above in the context of the issues facing the mental health care delivery system is included in the Appendix . Transformation of the mental health care system, in this view, would require incorporating in a timely fashion evidence-based practices as part of routine practice, resolving workforce shortage issues, ensuring access to care by removing financial barriers, coordinating mental health care with general health care and social services, and developing a way to systematically measure and improve the quality of care delivered. While each of these recommendations may result in some benefits, evidence suggests a comprehensive transformation of the mental health system could be necessary to ensure the availability and accessibility of quality mental health care to all individuals who need it.
In the past decade, four federal reports have offered insight into the nation's mental health care system and recommended a fundamental transformation of the system. According to these reports, transformation of the mental health care system would require timely incorporation of evidence-based practices in routine practice, resolution of workforce shortage issues, removal of financial barriers, coordination of mental health care with general health and social services, and systematic measurement and improvement of the quality of care delivered. While each of these recommendations may result in some benefits, the findings suggest that a comprehensive transformation of the mental health system could be necessary to ensure the availability and accessibility of quality mental health care to all individuals who need it.
In 2007 about 11% of adults (23.7 million) in the United States experienced serious psychological distress, such as anxiety and mood disorders, that resulted in functional impairment that impeded one or more major life activities. Different types of providers deliver care in a range of settings and are financed by various combinations of public and private payers. Congress has been increasingly interested in transforming the mental health system in the aftermath of tragedies involving mentally ill individuals—such as the shootings at Columbine and Virginia Tech, which led to heightened public interest in the adequacy of the mental health care system. Two federally funded efforts, one through the Agency for Healthcare Research and Quality (AHRQ) and the other through the Substance Abuse and Mental Health Services Administration (SAMHSA), attempt to measure the quality of mental health care on an annual basis. At this time, neither effort is adequately developed to guide the transformation of the system.
SAMHSA estimates that less than half of individuals with serious psychological distress receive mental health care due to various social, financial, and systemic barriers. While there have been advances in treatment options, the delivery system and financing mechanisms have been slow to transform and apply these findings in routine practice. For this reason, despite substantial investments that have increased the knowledge base about mental illness and have led to the development of many effective treatments, experts agree that many Americans are not benefiting from these investments. Mental health care is often not coordinated with other care that an individual may be receiving or may need. Access to competent mental health providers is scarce in rural areas and even some urban areas. Coverage for mental illness provided by private health insurance, Medicare and Medicaid, is sometimes less comprehensive than that for physical illnesses, negatively affecting access. In addition, some issues, such as social stigma around mental illness, and inadequate public awareness that mental health problems are treatable create disincentives for individuals to seek care. These issues affect both the access to, and the quality of, care delivered and, by consequence, the mental health outcomes achieved.
In the past decade, Congress passed two far-reaching laws on mental health care. The first law, the Children's Health Act, reauthorized the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2000 and called for greater focus on measurement of mental health care outcomes. The second law, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, expands federal requirements for mental health coverage. Congress could consider transformation of the mental health system as part of larger health care reform efforts.