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May 1, 2006
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The experts have shared their opinions multiple times—now let's take action

Many important lessons can be drawn from the unprecedented succession of landmark reports in the field in the past few years. First came the Surgeon General's 1999 report on mental health, which has had little lasting impact on mental healthcare's practice despite its historic proportions. Following this report was the World Health Organization's report on mental health in 2001, which hardly was noticed in the United States, let alone used to guide decision making. More recently, the President's New Freedom Commission on Mental Health issued its report; the federal Center for Mental Health Services and state mental health agencies have begun a process of transformation in response to this report. And this past November, the Institute of Medicine (IOM) issued Improving the Quality of Health Care for Mental and Substance-Use Conditions.

It is very important to consider why these prestigious reports have all been issued in such a short period. One obvious factor is that the mental health and substance use fields have come of age, with broad recognition that good behavioral health underpins all aspects of life. Another is that the mental health and substance use fields have not delivered effectively on their promise: Half of our fellow citizens with mental and substance use conditions still receive no care at all, and those who do almost always receive lesser quality care than we all know should be provided. These two factors are related. It is precisely because most people recognize that good mental and behavioral health are essential to good overall health that they are concerned about the inability of these fields to deliver high-quality care.

Although I could focus this commentary on either or both of these factors, I will instead examine a third—lack of scalability. Stated simply, lack of scalability means that these fields have not had the capacity to broadly implement key practices and systems demonstrated on a small scale to be efficient and effective. Hence, even though evidence exists that many practices would improve the quality of care, we have not implemented them on a national scale. This failure to broadly implement high-quality care has been a predominant rationale and justification for the landmark reports on these fields.


We have lacked national coordination to link excellent interventions, systems, procedures, etc., with appropriate financial incentives, training, and technical assistance and see the process through until new tools have been adopted broadly throughout the country. Local providers and managers have seen little reason to adopt new tools because quality improvement has not been part of their daily lexicon, and incentives have driven their attention elsewhere. No one person or group is to blame for this failure. Collectively, we all are guilty of not recognizing how to put the puzzle together.

A national quality improvement effort is essential if we are to free consumers and families from the shackles of mental illness and substance use problems, free them from dependency on our service systems, and free them to participate in community life. Right now, our suboptimal system does none of this. We have a few islands of excellence surrounded by an ocean of care as usual.

A Blueprint for Change

The IOM report is a road map to show us the way to improve quality. We need to understand the blueprint, and then build a new fully scalable system that reflects the principles of quality improvement.

The IOM report starts from an essential premise: Good-quality mental health and substance use care can be achieved only if the two types of care are coordinated with each other, and if both are coordinated with primary care. Lack of appropriate coordination allows the person to fall through the cracks. We all can recount examples of consumers who failed to achieve recovery because some of their major problems remained unaddressed (e.g., substance use for a mental health consumer or vice versa, or chronic physical problems). It's obvious that any of these problems can prevent effective community participation.

From mental health and substance use providers’ point of view, compelling economic reasons exist to achieve effective coordination. Each year, a larger and larger segment of mental health and substance use care is provided through primary care. A quiet revolution is under way on a daily basis, yet we are, at most, only peripherally aware of it.

The IOM's blueprint for change includes concrete action steps for most of the field's key groups: providers, program administrators, and state and national officials. These action steps focus on four key “tipping points”: financial reform, training for our human resources, implementation of effective care practices, and appropriate information technology to drive care coupled with performance measures.

Consumer leaders are crafting a set of key steps that consumers could take to promote the report's full implementation. The blueprint's successful implementation will depend in large measure on how well we can create a consumer- and family-directed recovery-oriented system. We need to promote this goal at every turn if we are to be successful.

A Call to Action

We have been called to action at least four times in the past few years. Yet we haven't heeded the call with zest. Let's not allow the same thing to happen with the new IOM report. Form a local community collaborative to implement the blueprint in your own community. National efforts are taking shape to provide necessary leadership and to forge strategies that address the recalcitrant problem of scalability. Join these national efforts when asked or, better yet, volunteer before you are asked. The future of mental health and substance use care depends on you.