Mr. Chairman and members of the Commission, NAMI greatly appreciates the opportunity to provide testimony about the current state of treatment and services for people with severe mental illnesses and to offer recommendations for how these services can be improved. My name is Jim McNulty and I am the national President of NAMI.
NAMI was founded as a grassroots family advocacy movement in 1979 in Madison, Wisconsin. Today, NAMI has more than 220,000 consumer and family members nationwide dedicated to improving the lives of persons with severe mental illnesses. As a person diagnosed with bipolar disorder (manic-depressive illness), I am proud to serve as NAMI's President and proud that NAMI is the nation's "voice on mental illness" representing both consumers and family members.
Today, I can say that I am one of the lucky people who has had access to the services I need to achieve stability and recovery. This was not always the case. In 1987, when I was first diagnosed, my health insurance plan provided virtually no coverage for mental illness. I was forced to seek treatment from my primary care physician, who knew nothing about treating manic depression. The negative consequences on my life were traumatic and extreme. I lost my job, my home and my family. Were it not for the kindness of friends, I would have become homeless.
I tell you this to illustrate how fine the line can be for a person with mental illness between recovery, stability and dignity on the one hand and falling through the cracks on the other. The disability that many who suffer from schizophrenia, bipolar disorder, major depression, anxiety disorders and other severe mental illnesses experience is only partially due to the symptoms of these illnesses. In many cases, disability is attributable to circumstances surrounding severe mental illnesses, including extreme poverty, lack of services and supports, and pervasive stigma and prejudice. Thus, it is crucial that a comprehensive plan to improve services and outcomes for people with mental illnesses address these surrounding circumstances as well as specific treatment and service issues.
The Best of Worlds: In 2002, there is much cause for hope, because significant progress has been made in discovering effective treatments for serious brain disorders such as schizophrenia, bipolar disorder, major depression and many other mental illnesses. Significant progress has also been made in developing services that work in helping people with mental illnesses achieve recovery, independence and dignity in their lives. And, the consumer self-help movement has empowered consumers to take a significant role in developing and providing services and supports that make a big difference in their lives and the lives of others.
The Worst of Worlds: Unfortunately, the progress described in the preceding paragraph has not generally translated into better services for people living with severe mental illnesses. In fact, on any given day, fewer than half of all people suffering from schizophrenia, bipolar disorder (manic-depressive illness), major depression and other severe mental illnesses receive even minimally adequate treatment and services. Most children and adolescents in need of mental health services do not get them. Access to appropriate treatment is particularly limited for adults and youth with mental illnesses who are poor, African-American, or members of other cultural or ethnic minority groups.1
Non-Existent Community Systems of Care: In many parts of the country, there are literally no community-based systems of care for people with mental illnesses. Consumers must wait for weeks to get an appointment to see a psychiatrist. Case managers have huge caseloads and are frequently unable to provide timely services. Assertive community treatment programs, with proven effectiveness in addressing the needs of people with multiple and complicated needs, are unavailable in most places. In many communities, hospital beds for people in acute psychiatric crisis are virtually non-existent. Waiting lists for Section 8 housing and other affordable housing options are many years long. Finally, the budget crisis in the states places access to medications needed for recovery at risk.
Neglecting children and adolescents and their families: These problems are even worse for children and adolescents with mental illnesses. Tragically, loving families continue to be told that they must relinguish custody of a child with a mental illness to secure critically needed services. Families commonly encounter systems unwilling to serve their children or seeking to "pass the buck" to other systems.
Poverty is a significant factor and a major impediment to recovery: People with disabilities are among the poorest of all people in the nation. This is particularly true for people with mental illnesses. Many people with mental illnesses rely on Supplemental Security Income (SSI) as their sole source of income. Individuals living on SSI are (on average) living at 18.5% of median income. For the average SSI beneficiary, renting a modest one-bedroom apartment costs consumers 98% of their monthly income - pricing them completely out of the rental housing market.2
The cataclysmic consequences of lack of treatment and services: The consequences of failing to provide youth and adults with mental illnesses with necessary services are well documented - deaths, homelessness, incarceration in jails, prisons and juvenile justice systems and immeasurable suffering.
In 2002, a new national blueprint for addressing the comprehensive needs of people with severe mental illnesses is desperately needed. We must learn from the mistakes of the past, rethink the assumptions that led to the development of flawed policies and systems, and create mental health systems that respond in a humane and effective way to the people they are charged with serving.
NAMI offers the following preliminary recommendations to the Commission as it proceeds with developing its report.
1. Consolidate and Coordinate Services at Federal, State and Local Levels.
Children and adults with mental illnesses require multiple services over the course of their lives. These services may include psychiatric treatment, general medical/primary care treatment, assertive community treatment or intensive case management services, substance abuse counseling and treatment, vocational and psychiatric rehabilitation services, school-based/educational services, individualized in-home and community-based services for children and families, and housing assistance to name a few. For some people, all of these services may be crucial to attaining and maintaining recovery and maximum functioning.
Access to these multiple services is frequently impeded because responsibility for providing them is vested with different providers who are administered by different systems and are subject to different funding streams and rules. Additionally, the boundaries between public and private sector services have been increasingly blurred as public sector agencies have contracted with private organizations to provide and/or manage services. The fragmentation of services and systems has frequently bred inefficiency and impeded rehabilitation and recovery for individuals with mental illnesses.
There is widespread agreement in the field that close collaboration and coordination among diverse systems and providers is essential to achieving good outcomes in the treatment of people with severe mental illnesses. However, the best ways to achieve this goal are not as clear.
Public mental health agencies today must deal with a number of different federal funding streams with divergent, often conflicting rules, including Medicaid and Medicare, the mental health and substance abuse block grants (administered by one agency, SAMHSA, but subject to different rules), a number of different housing programs administered by HUD, SSI and SSDI (administered by the Social Security Administration), and federal vocational rehabilitation resources (administered by the Department of Education). In recent years, little progress has been made in simplifying or coordinating these federal programs in a way that maximizes service outcomes for people with mental illnesses.
In the late 1980's and early 1990's, a Federal Taskforce on Homelessness and Severe Mental Illness was created, consisting of representatives from virtually all federal agencies with responsibility for programs targeted for this population.6 The taskforce published a report, entitled Outcasts on Main Street , which set forth a comprehensive federal blueprint for responding to homeless individuals with severe mental illnesses and co-occurring substance abuse disorders.
Several of the recommendations in the report were adopted as innovative new programs, including HUD's Shelter Plus Care program (blending rental assistance and services) and the Access grants issued to states to test promising approaches to services integration in a number of communities. Perhaps even more importantly, the Taskforce fostered a spirit of cooperation among the federal agencies participating that translated into better coordination of services. Today, more than ten years later, it is time to create a similar strategic blueprint among key federal agencies impacting on the lives of people with mental illnesses.
Medicaid today constitutes between 40 and 50% of all spending on public mental health services, and this percentage is growing. Yet, state and county mental health agencies frequently have little control over Medicaid spending. These agencies must be given authority to integrate and blend Medicaid funds with other mental health resources (such as general state funds, federal block grant funds, etc.) to be effective in carrying out their responsibilities to organize and coordinate public mental health services for people with mental illnesses.
The prevalence of people suffering from co-occurring mental illnesses and addictive disorders is very high, particularly among children and adults at greatest risk. The research is clear that mental health and substance abuse treatment and services must be blended to effectively treat this population.7 Despite this, the availability of programs combining mental health and substance abuse treatment are in woefully short supply throughout the country. Many programs serving people with substance abuse disorders are not prepared or willing to treat people with co-occurring mental illnesses, and many programs serving people with mental illnesses are not prepared or willing to treat people with co-occurring substance abuse disorders.
NAMI is pleased that SAMHSA Director Charles Curie has prioritized removing barriers and creating incentives within the federal mental health and substance abuse block grants to integrate services for people with co-occurring disorders. Accomplishing this would be a significant step in the right direction. Additionally, NAMI believes that services providers on both the mental health and substance abuse sides must be required to develop plans for integrating mental health and substance abuse treatment for people with co-occurring disorders in order to receive federal block grant funds.
Still another step that can be taken is to establish cooperative agreements between state mental agencies and state housing authorities, such as setting aside Section 8 rental subsidies for people with mental illnesses. For example, state mental health agencies in several states have negotiated agreements with state housing authorities to establish priorities for people with mental illnesses being served with public mental health dollars.
Programs assuming responsibility for the full array of services for people with severe mental illnesses have demonstrated the best outcomes. For example, assertive community treatment (ACT) programs assume responsibility for all "core services" required by their clients, including housing.8 And, innovative approaches like multi-systemic therapy, a family and community-based treatment model for treating youth with mental health related needs and addictive disorders that blends and coordinates resources, have produced positive outcomes for youth and resulted in cost savings over time.
2. Implement assertive community treatment models to reduce hospitalizations, criminal incarceration and other psychiatric emergencies:
Research conclusively demonstrates that comprehensive and aggressive community services and supports, such as assertive community treatment (ACT)9 programs, lead to positive outcomes for people with severe mental illnesses, in terms of higher consumer satisfaction, reduced hospital admissions and reduced involvement with criminal justice systems.10 Unfortunately, these vital services are frequently lacking in many parts of the country.
Currently, 23 states fund assertive community treatment programs through the Medicaid Rehabilitation option.11 Other states have adopted the Rehabilitation Option but do not fund ACT or similar services through this option. The Federal Center for Medicare and Medicaid Services (CMS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) can play an important role by promoting ACT and other approaches with proven effectiveness in successfully serving people with the most severe mental illnesses and in encouraging adequate funding of these programs through the Rehabilitation Option or other appropriate options in Medicaid.
Additionally, state mental health agencies should be encouraged to invest general funds into ACT and other evidence based programs and into bridge funding for housing for individuals in these programs. While the costs of these services may be high in the short-run, in the long run, provision of these services decrease higher expenditures associated with hospitalizations, incarceration or other outgrowths of lack of services.
3. Create recovery oriented services, with particular emphasis on housing and employment.
Having a mental illness does not rob individuals of their desire for self-sufficiency and independence. In fact, it is well documented that employment is a critical component of recovery for people with these illnesses. However, most people with severe mental illnesses do not have access to employment. A 1990 study revealed that the employment rate for people with these brain disorders is 10 percent to 15 percent.12
Housing is just as important. Without a stable place to live, the value of other services for people with mental illnesses are significantly diminished. Stable housing is the foundation upon which recovery and independence are built and no service model will be effective in the long run if it is asked to reach consumers in homeless shelters and jails.
Our nation's affordable housing system has a relatively poor record of serving people with mental illnesses. In addition, the Department of Housing and Urban Development (HUD) has made little effort to understand the real implications and bitter reality of recent federal housing policies that have reduced the federally subsidized housing units available to people with severe mental illnesses and other disabilities.13
NAMI is appreciative that President Bush has emphasized the importance of maximizing the use of "tickets to work" for people with disabilities, including people with mental illnesses. In addition to addressing work disincentives in the SSDI and SSI programs, tickets to work also afford consumers with more autonomy to select vocational rehabilitation providers, an important step forward in view of the historically poor performances of many state vocational rehabilitation systems in serving people with mental illnesses. NAMI urges the Commission to consider additional steps that can be taken to afford consumers more choice in employment and vocational rehabilitation, and also steps that can be taken to promote consumer run businesses, consumer employment opportunities in state and local government, and other consumer employment initiatives.
In the housing arena, NAMI strongly encourages the active involvement of senior HUD officials in the work of the Commission. At a minimum, HUD should be asked to develop model guidelines, as well as technical assistance and training materials for state and local housing officials on the obligation to use affordable housing resources to serve adults with severe mental illnesses.
HUD should also be asked to develop model agreements between state and local housing agencies and state and local mental health authorities so that both establish clear and accountable goals for addressing chronic homelessness experienced by people with mental illness and ensuring access to all of HUD's programs.
HUD Secretary Martinez has already made progress on this effort with his initiative to end homelessness over the next decade. NAMI believes that this goal is reachable if HUD focuses its resources on development of permanent supportive housing (and ensures stable long term funding for rent subsidies). The evidence is clear that permanent supportive housing works and costs about the same as keeping someone chronically homeless.14
4. Provide inpatient and long-term care options for people who require them.
In recent years, inpatient treatment options for people with severe mental illnesses have disappeared in many communities as more and more emphasis has been placed on downsizing and closing hospitals.15 In some areas, hospital admissions are limited to those individuals who have deteriorated to the point of meeting criteria for involuntary hospitalizations. Hospital beds for voluntary patients are virtually non-existent. Requiring people seeking inpatient treatment to deteriorate to the point of possible dangerousness to self or others before inpatient treatment can occur is cruel and very poor public policy.
The decrease in inpatient treatment options also impact on people who require twenty-four hour services and supports. Recently, the New York Times documented in shocking detail the shameful living conditions in large adult care homes run by individuals more interested in making profits than providing quality services.16 Many of the individuals living in these facilities had previously been long-term residents of state hospitals in New York.
NAMI is very concerned that some states have responded to the needs of people with mental illnesses who require twenty-four hour services through placements in nursing homes, unlicensed board and care facilities, or other settings that are substandard and/or inappropriate. These placements are arguably no better or even worse than the institutional settings that preceded them.
We strongly support the principle set forth in the Olmstead case that people with mental illnesses should receive services in the most integrated setting appropriate to their needs. We do not support a return to the reliance on institutional placements that characterized mental health policy prior to de-institutionalization. However, inpatient psychiatric treatment for individuals requiring acute care should remain an essential component of a continuum of psychiatric services. Additionally, mental health systems must include humane residential options for individuals requiring twenty-four hour care or long-term services.
Since 1965, when Medicaid was enacted, Federal matching payments have been prohibited for IMDs for persons between the ages of 22 and 64. (IMDs are inpatient facilities of more than 16 bed whose patient roster is comprised of more than 51% people with mental illnesses).
In addition to limiting inpatient options for those who need them, NAMI believes that the IMD exclusion impacts adversely on access to comprehensive, community-based wrap-around services financed through Medicaid. Community-based wrap-around services for adults with mental retardation are frequently funded through Medicaid Home and Community Based waivers. These waivers are granted based on the notion that a facility bed can be converted to a community slot with no increased cost to Medicaid. However, these waivers are not available for adults under the age of 64 with mental illnesses because Federal Medicaid funds cannot be used to pay for inpatient treatment for these individuals due to the IMD exclusion.
5. Invest resources in educating health-care, criminal justice and other professionals about mental illness.
General practitioners and other non-psychiatric health care professionals are frequently the first to come into contact with children or adults manifesting symptoms of mental illnesses. In fact, the Surgeon General's report revealed that about one-third of all adults receiving treatment for mental health problems in the United States receive their treatment from general medical and/or human service providers, rather than specialty mental health providers.17 Involvement of non-specialty mental health providers in the provision of mental health services is even more significant for children. The Surgeon General's report revealed that the largest provider of mental health services to children and adolescents were school systems.18
Additionally, law enforcement, criminal justice and court personnel are increasingly coming into close contact with children and adults experiencing acute psychiatric symptoms. As stated above, police have become front-line respondents to people with severe mental illness in crisis. Lawyers and judges interact regularly with adults and children with mental illnesses in carrying out their responsibilities as well. Finally, correctional officers and medical personnel encounter and interact with youth and adults with mental illnesses with great frequency.
Excellent models for educating these various professionals have emerged. For example, a number of NAMI affiliates organize or work with mental health and criminal justice professionals to organize training programs for criminal justice professionals, including police, judges, correctional officers and parole and probation.19 Additionally, several excellent educational programs on mental illness aimed at students and school personnel have been developed, including "Breaking the Silence" in New York and "Hope for Tomorrow" in Utah. Finally, NAMI has added a "Family to Family" provider training curriculum to its "Family to Family" family education curriculum.
The need for federal, state and local community support of these and other educational and training initiatives is clear. High School students throughout the United States are required to take Health Education courses as part of their core curricula. Units on mental illness should be required as part of these courses.
The need for education extends to judges, lawyers and other court personnel as well. In February, 2001, the Florida Supreme Court took a significant step by adding "mental illness awareness" to mandatory continuing legal education courses for all attorneys admitted to the Florida Bar.20 Other states, including North Carolina and Ohio, are considering similar steps. Judges and lawyers are called on everyday to address issues involving mental illnesses. Justice demands that they understand these illnesses.
6. Build a qualified and professional mental health workforce.
The supply of qualified mental health providers is abysmally low in far too many communities across the country. In some states, there are virtually no licensed psychiatrists in rural regions. For example, in New Mexico, only 18 psychiatrists practice outside the city limits of Albuquerque and Santa Fe.21 Qualified mental health professionals for treating children and adolescents with mental illnesses and older persons with mental illnesses are particularly in short supply.22
Workforce shortages impact in a very negative way on access to treatment for children and adolescents with mental illnesses and their families. For example, in Idaho, there is a shortage not only of child and adolescent psychiatrists but also pediatricians. Consequently, family practitioners are often thrust into the role of diagnosing and prescribing treatment for early onset mental illnesses.23 All too often, these physicians do not understand the basics about treating early-onset mental illnesses.
Attracting and retaining qualified individuals is also a big problem in other mental health professions. Community rehabilitation programs have a difficult time retaining social workers, rehabilitation counselors, case managers and other direct service staff because of low wages and low morale.
Aggressive steps must be taken to address these problems. For example, scholarships should be provided for psychiatrists, psychologists, and other mental health professionals who commit to providing services to people with mental illnesses in under-served regions.
Additionally, loan forgiveness programs should be established for those who serve for a particular period in under-served regions. And, psychiatrists, psychologists, and other mental health professionals serving people with severe mental illnesses should be provided with training and professional development opportunities whenever possible.
Wages paid to case managers, counselors and other important but traditionally inadequately compensated professionals should be sufficiently high to retain qualified and dedicated individuals in the field. Finally, consumers and family members should be employed in a variety of professional capacities in the mental health field.
Ensuring high quality and properly credentialed mental health providers will inevitably lead to better outcomes and improved lives for people living with mental illnesses.
7. Necessary steps must be taken to engage hard to serve individuals in treatment and services.
A great deal of controversy and discord surrounds discussions of how best to engage in treatment and services individuals with severe mental illnesses who need but are unwilling to participate in treatment. These discussions frequently dissolve into bitter debates about the utility of involuntary treatment interventions. NAMI believes that this issue is far more complicated than whether and when to treat people on an involuntary basis.
First, it is important to recognize that many consumers have had genuinely bad experiences with treatment systems. These experiences may include abuse and neglect in treatment settings, the failure of providers to listen to consumers and their treatment preferences, excessive use of seclusion and restraints for purposes of punishment and intimidation, and severe medication side effects. Improving conditions in treatment systems, training staff to treat consumers with respect and dignity, employing consumers as treatment and service providers, and minimizing aversive measures such as the use of restraints and seclusion are all important in convincing consumers to willingly engage in treatment and services.
Second, there are a number of steps that can be taken short of involuntary interventions to engage people in treatment. These include:
As a last resort, NAMI supports assisted outpatient treatment as a necessary intervention to engage in treatment individuals whose symptoms are so severe that they don't recognize their need for treatment. We emphasize that this should be a last resort and that use of the other techniques set forth above will significantly decrease although not eliminate the need for court-based interventions. We also emphasize that court-based procedures must include strict due process protections for individuals subject to them, including legal representation, notice, the right to present testimony in one's own behalf, and periodic review.
8. Empower consumers and families to drive treatment and recovery options.
The term "consumer" is a misnomer when applied to people with mental illnesses. Being a consumer connotes choice, namely the ability to select from an array of services and supports that work best for the particular individual. The unfortunate reality is that most mental health systems are not structured this way at all. Consumers generally have little choice and little role in selecting service providers or helping to shape the design and operation of service delivery systems. Sometimes consumers and their families learn that services do not exist at all.
Research demonstrates that consumers who participate in self-help programs achieve better outcomes in terms of reporting fewer symptoms and fewer hospitalizations.24 Peer education and support programs, such as NAMI's In Our Own Voice and Peer to Peer are effective tools for educating and empowering consumers to take more active roles in making fundamental decisions about their own treatment and in helping to design systems of care.
The same principal applies to programs for family members. NAMI's Family to Family program has empowered thousands of family members across the country to take more active roles as public educators, advocates and in support of family members who suffer from mental illnesses.
Programs like these should be encouraged and supported throughout the country. So too should the active participation of consumers and family members on Mental Health Advisory Councils, Medicaid Advisory Councils, and other bodies with significant roles in shaping mental health and healthcare policies and priorities.
9. Develop anti-stigma guidelines for the media and work with consumer and family organizations to use these guidelines as advocacy tools.
Every day, we see examples of stigma against people with mental illnesses perpetrated by the media. Just last week, a headline in The Trentonian of Trenton, New Jersey, provided a shocking reminder of just how pervasive this stigma is. A story about a fire at the local psychiatric hospital was accompanied by the headline "ROASTED NUTS".25 Local advocates were outraged and flooded the newspaper with calls, emails and letters of protest. The next day, the person responsible for the headline wrote a front page apology. Nevertheless, it is hard to believe in 2002 that a headline so patently offensive and stigmatizing could have passed muster with the chain of command at the newspaper and found its way into print. Unfortunately, examples of stigma promulgated by the media and others continue to abound.
Guidelines must be developed to better inform the print and broadcast media about how to report on mental illness. For example, the National Institute of Mental Health (NIMH) is currently working with the Annenberg School of Journalism at the University of Pennsylvania to develop guidelines for the media in reporting on suicides. It is very difficult to make progress in changing the hearts and minds of the public about mental illnesses in the face of stigmatizing media portrayals of mental illness. Hence, the importance of national standards and guidelines.
A Presidential Commission on Mental Health was last convened in 1978. The report of that Commission led to passage of the Mental Health Systems Act, a comprehensive blueprint for improving community-based mental health treatment and services for people with mental illnesses. Unfortunately, many of that Commission's recommendations were never fully implemented.
Today, 25 years later, a new Presidential Commission has been convened and is poised to develop a comprehensive plan for improving services for people with mental illnesses. The timing is right, because the development of such a plan is desperately needed. NAMI's grassroots membership stand ready to assist as the Commission moves forward on its important mission. Thank you again for the opportunity to submit this testimony.
1 Wang, P.S., Demler, M.S., and Kessler, R.C., "Adequacy of Treatment for Serious Mental Illness in the United States," American Journal of Public Health, Vol. 92, # 11, 92-98 (2002).
2 Technical Assistance Collaborative and Consortium for Citizens with Disabilities Housing Taskforce, Priced Out in 2000: The Crisis Continues, 2001.
3 Council of State Governments, "Criminal Justice/Mental Health Consensus Project," page 4.
4 Shaffer, D. and Craft, L., "Methods of Adolescent Suicide Prevention," Journal of Clinical Psychiatry, 60 (Suppl. 2) 70-74 (1999).
5 Angst, J., et al., "Suicide Risk in Patients with Major Depressive Disorder," Journal of Clinical Psychiatry, 60 (Suppl. 2), 57-62 (1999).
6 The federal agencies participating on this taskforce included the Department of Health and Human Services, the Department of Justice, the Department of Housing and Urban Development, the Department of Veterans Affairs, the Department of Education and the Department of Labor.
7 According to the Surgeon General's report, 41 to 65% of people with an addictive disorder also have a lifetime history of at least one mental illness, and about 51% of those with one or more mental illnesses also have a lifetime history of an addictive disorder. The rates of co-occurring illnesses are highest in the 15 to 24 year old age group. U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General, 167 (1999).
8 Many ACT programs maintain general housing funds to pay rental and other housing costs until more permanent funding comes through.
9 ACT programs create fixed points of responsibility for providing ongoing treatment, rehabilitation and support services to individuals with severe mental illnesses. These programs are characterized by integrated service approaches, small consumer to staff ratios, expanded service hours, mobile crisis management, and coordinated treatment team planning, communications and service delivery.
10 See, e.g., Lang, M., et al, "Clinicians' and Clients' Perspectives on the Impact of Assertive Community Treatment," Psychiatric Services , 50:1331-1340, 1999; McHugo, G.J., et al, "Fidelity to Assertive Community Treatment and Client Outcomes in the New Hampshire Dual Diagnosis Study," Psychiatric Services, 50:818-824, 1999; Borland, A., et al, "Outcome of five years of continuous intensive case management," Hospital and Community Psychiatry, 40, 369-376, 1989.
11 Bazelon Center for Mental Health Law, "Recovery in the Community: Funding Mental Health Rehabilitation Approaches under Medicaid," November, 2001.
12 National Institute on Disability and Rehabilitation Research, Strategies to Secure and Maintain Employment for People with Long-Term Mental Illnesses, 3 (1992); National Alliance for the Mentally Ill, Legacy of Failure: The Inability of the Federal-State Vocational Rehabilitation System to Serve People with Severe Mental Illnesses, 10 (1997).
13 Since 1992, Public Housing Authorities and owners of assisted housing properties have been able to designate housing as "elderly only" and thereby exclude non-elderly people with disabilities. The Technical Assistance Collaborative estimates that as many as 273,000 affordable housing units have been lost to people with disabilities.
14 See http://intranet.csh.org/publications/NYNYcoststudy.pdf.
15 See, e.g., Schanche, D., "For More Georgians, Disorders Mean Time In Jail, Not Treatment Centers, Macon Telegraph , January 27, 2002; Shipley, S., "Locked in Suffering: Kentucky's Jails and the Mentally Ill; Judge Ordered Immediate Hospitalization but Officials Clashed Over Procedures, Time Frames," Louisville Courier-Journal, February 26, 2002.
16 Levy, C.J., "Voiceless, Defenseless and a Source of Cash," The New York Times, 4/30/2002.
17 U.S. Department of Health and Human Services, "Mental Health: A Report of the Surgeon General," 408, 1999.
18 Id.; see also, Shaffer, D., et al., "The NIMH Diagnostic and Interview Schedule for Children, version 2.3," Journal of the American Academy of Child and Adolescent Psychiatry, 35, 865-877, 1996.
19 See e.g. Turnbaugh, D., "Curing Police Problems with the Mentally Ill," The Police Chief, 52, 1999.
20 For more information, see www.puebloadvocacy.com/50states/vickers
21 Bonnie R. Rubin, "Psychologists Seek Rx Power", Chicago Tribune, 4/7/2002.
22 Surgeon General's Report, Id at 455.
23 Personal communications with Ann Kirkwood of NAMI Boise-Idaho.
24 Galanter, M., "Zealous Self Help Groups as Adjuncts to Psychiatric Treatment: A Study of Recovery, Inc.," American Journal of Psychiatry, 145, 1248-1253, 1988.
25 Baldwin, T. and Levine, J., "Roasted Nuts", The Trentonian, Wednesday, July 10, 2002.
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