Mental illness is reported to be widespread in the United States. An estimated 43.8 million people—18.5 percent of adults in the United States—suffered from a mental illness in 2013, according to the 2013 National Survey on Drug Use and Health administered by Substance Abuse and Mental Health Services Administration (SAMHSA). Among those, about 10 million people—4.2 percent of adults in the United States—suffered from a serious mental illness, which generally includes conditions such as schizophrenia, bipolar disorder, major depression, and severe posttraumatic stress disorder. The federal government provides a range of programs for those with a mental illness, including programs addressing broad social issues, such as homelessness, that can generally support individuals with serious mental illness as well as other programs that specifically target people with serious mental illness.
For the purposes of this report section, GAO defines individuals with serious mental illness as adults who currently or at any time in the past year have had a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) of sufficient duration to meet certain diagnostic criteria, as specified within the Diagnostic and Statistical Manual of Mental Disorders, that resulted in serious functional impairment, substantially interfering with or limiting one or more major life activities. Individuals with serious mental illness may also include those with a specific diagnosis; for example, individuals diagnosed with schizophrenia, schizoaffective disorder, bipolar disorder, or major depression. In addition, GAO defined individuals with serious emotional disturbance as children and adolescents from birth up to age 18 who currently or at any time during the past year have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the Diagnostic and Statistical Manual of Mental Disorders that resulted in functional impairment, which substantially interferes with or limits the child’s role or functioning in family, school, or community activities. Throughout this report section, when GAO refers to programs generally supporting or specifically targeting individuals with serious mental illness, it is referring to programs supporting or targeting individuals with either serious mental illness or serious emotional disturbance.
In a December 2014 report, GAO found that 112 federal programs across eight federal agencies—Department of Defense (DOD), Department of Education, Department of Health and Human Services (HHS), Department of Housing and Urban Development, Department of Justice, Department of Labor, Social Security Administration, and Department of Veterans Affairs(VA)—were supporting individuals with serious mental illness in fiscal year 2013. The purposes and populations served by these programs varied widely, from the provision of support services, such as case management, to research, and from children to incarcerated adults. A subset of these programs—30 programs administered by five agencies—were identified by agencies as specifically targeting individuals with serious mental illness. Across these 30 programs, the agencies reported obligations of about $5.7 billion for fiscal year 2013. Half of the 30 targeted programs—across four agencies (DOD, Department of Justice, HHS, and VA)—identified the same primary program purpose, the provision of support services to individuals with serious mental illness. With multiple agencies involved in administering the many programs supporting individuals with serious mental illness, the potential exists for overlapping or duplicative efforts.
According to SAMHSA’s enabling legislation, as amended, it is required to promote coordination of programs relating to mental illness throughout the federal government. In addition, SAMHSA’s 2011-2014 strategic plan acknowledges the need for coordination, noting that no single program, either within HHS or anywhere else in the federal government, can solve the problems of homelessness, joblessness, educational challenges, and community cohesion for people with mental illness, including those with serious mental illness.
Although SAMHSA recognizes the need to coordinate, such coordination related to serious mental illness has been largely absent. While agencies said they participate in committees that could allow them to coordinate efforts regarding mental health, these committees do not focus specifically on, and have taken little action regarding, serious mental illness. For example, the Secretary of HHS established the Behavioral Health Coordinating Council (BHCC) in 2010 to bring together members from agencies within HHS to focus on behavioral health issues, but the council did not include officials from other federal agencies. The BHCC had six subcommittees that addressed selected topics, and three of these subcommittees specifically address substance use. One of the six subcommittees has done work that was related to serious mental illness, based on information HHS provided on recent actions taken by the BHCC. SAMHSA officials said that they had plans to establish a subcommittee within the BHCC devoted to addressing serious mental illness and that they expected this group to have an initial meeting in early 2015. However, consistent with the BHCC, the subcommittee is only expected to coordinate within HHS, not across federal agencies.
Although staff in these programs targeting serious mental illness reported taking steps to coordinate their individual programs, GAO found that coordination efforts among agency leadership to address serious mental illness are lacking. While coordination at the program level is important, it does not take the place of, or achieve the level of, leadership that GAO has previously found to be key to successful coordination. The absence of this high-level coordination hinders the federal government’s ability to develop an overarching perspective of its programs supporting and targeting individuals with serious mental illness. Without interagency coordination supported by agency leadership, agencies do not have the necessary information to assess the reach and effectiveness of their programs or to determine whether or where there may be gaps, overlap, or duplication in services for individuals with serious mental illness.
The majority of these funds—84 percent—were obligated by DOD and VA for treatment and support services (among other things) for servicemembers, and veterans and their families. GAO’s review excluded programs that may reimburse providers for mental health services, such as Medicaid and Medicare or TRICARE. The Office of Management and Budget reported that federal spending on mental health services generally through Medicaid—a joint federal and state health care program—and Medicare was approximately $40 billion for fiscal year 2012.
Substance Abuse and Mental Health Services Administration, Leading Change: A Plan for SAMHSA’s Roles and Actions 2011-2014, HHS Publication No. (SMA) 11-4629 (Rockville, Md.: 2011). SAMHSA has also released their strategic plan for 2015-2018: Substance Abuse and Mental Health Services Administration, Leading Change 2.0: Advancing the Behavioral Health of the Nation 2015-2018, HHS Publication No. (PEP) 14-LEADCHANGE2, 2014 (Rockville, Md.: 2014).
To understand the full breadth of federal programs and the scope of federal resources expended on programs supporting those with serious mental illness, GAO recommended in December 2014 that HHS—which includes SAMHSA—establish a mechanism to facilitate intra- and interagency coordination across programs that support individuals with serious mental illness.
The information contained in this analysis is based on findings from the product listed in the related GAO product section. To identify federal programs supporting those with serious mental illness, the extent to which federal agencies are coordinating, and the extent to which federal agencies evaluate or monitor programs, GAO developed a web-based questionnaire. The web-based questionnaire asked questions about program goals, target populations, services offered, performance information and evaluations, coordination, and funding in fiscal year 2013. GAO identified eight agencies frequently cited as having relevant programs supporting individuals with serious mental illness and administered the questionnaire to those agencies. The eight federal agencies selected for the web-based questionnaire were DOD, Department of Education, HHS, Department of Housing and Urban Development, Department of Justice, Department of Labor, Social Security Administration, and VA. GAO supplemented the questionnaire responses with follow-up interviews and questions to each of the agencies to obtain additional information.
Table 5 in appendix V lists the programs GAO identified that might have similar or overlapping objectives, provide similar services, or be fragmented across government missions. Overlap and fragmentation might not necessarily lead to actual duplication, and some degree of overlap and duplication may be justified.
We defined a federal program as a program, activity, or initiative that may include, but is not limited to, (1) grants to state, local, tribal, nonprofit, or research entities; (2) contracts with service providers; or (3) services directly provided to beneficiaries by the federal agency itself. We excluded health benefit programs—such as Medicaid, Medicare, or TRICARE—that may reimburse for various mental health services.
In commenting on the December 2014 report on which this analysis is based, HHS did not concur with this recommendation to establish a mechanism to facilitate intra- and interagency coordination, citing the coordination that was already occurring at the program level. GAO acknowledged that coordination at the program level is important but noted that it cannot take the place of coordination at higher levels that would provide the perspective needed to assess the reach and effectiveness of all of the federal government’s programs targeting individuals with serious mental illness.
GAO provided a draft of this report section to HHS for review and comment. HHS did not provide comments on this issue.
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Agencies identified 112 federal programs that generally supported individuals with serious mental illness in fiscal year 2013. The majority of these programs addressed broad issues, such as homelessness, that can include individuals with serious mental illness. The programs were spread across eight federal agencies: Department of Defense (DOD), Department of Education, Department of Health and Hum...