Here is another angle on concern about today's adolescents and young adults. It appears that the malaise affecting African American adolescents and young men stretches across racial boundaries at least somewhat. More young adult males live at home stalling the transition to adulthood. There certainly has always been some cultural spill over from African Americans to Caucasions. Part of the attraction of the "cool-pose culture" has been the admiration it creates even among whites.

But perhaps there is a bigger issue here. I suspect it's the economy and lack of adequate paying jobs that would enable young males to emancipate. This has to create a discouraged attitude among the young. Then I wonder if the new computer/internet generation has gotten lost in fantasy games more so than anyone has guessed, perhaps in part because of the lack of opportunities. If the American Dream is out of reach, then why get on with life at all? I certainly have seen this discouragement in individuals. Could it be pandemic?

WaPo

This phenomenon cuts across all demographics. You'll find it in families both rich and poor; black, white, Asian and Hispanic; urban, suburban and rural. According to the Census Bureau, fully one-third of young men ages 22 to 34 are still living at home with their parents -- a roughly 100 percent increase in the past 20 years. No such change has occurred with regard to young women. Why?

My friend and colleague Judy Kleinfeld, a professor at the University of Alaska, has spent many years studying this growing phenomenon. She points out that many young women are living at home nowadays as well. But those young women usually have a definite plan. They're working toward a college degree, or they're saving money to open their own business. And when you come back three or four years later, you'll find that in most cases those young women have achieved their goal, or something like it. They've earned that degree. They've opened their business.

But not the boys. "The girls are driven; the boys have no direction," is the way Kleinfeld summarizes her findings. Kleinfeld is organizing a national Boys Project, with a board composed of leading researchers and writers such as Sandra Stotsky, Michael Thompson and Richard Whitmire, to figure out what's going wrong with boys. The project is only a few weeks old, it has called no news conferences and its Web site ( http://www.boysproject.net ) has just been launched.

So far we've just been asking one another the question: What's happening to boys? We've batted around lots of ideas. Maybe the problem has to do with the way the school curriculum has changed. Maybe it has to do with environmental toxins that affect boys differently than girls (not as crazy an idea as it sounds). Maybe it has to do with changes in the workforce, with fewer blue-collar jobs and more emphasis on the service industry. Maybe it's some combination of all of the above, or other factors we haven't yet identified.

I've added an archive of resources for Health and Mental Health Professionals on Cultural Competency

Link here: http://dare-to-dream.us/cultural_diversity/

Let me know if you have some more resources and links I can add.

The NY Times published an article last week quoting some sobering statistics about inner city black youth. Six in 10 black men in their 30s who had dropped out of school had spent time in prison. Fifty percent of black youths don't finish high school. Unemployment for black high school dropouts has peaked at 72%.

Orlando Patterson, a professor of sociology at Harvard, wrote a courageous article in the NY Times today. Despite recent economic advances of other minorities and African American women, generations of African American young men continue to failed to integrate in the larger culture. He challenges the the traditional explanations of bad schools, discrimination and few jobs. He suggest the African American culture is a major contributing factor. The culture has evolved in just 145 years from the tortured history of slavery, through the oppression of "Jim Crow" laws to the "cool-pose culture" of today. That "cool-pose culture" raises boy's self-esteem as effectively as it locks him out of the mainstream opportunities.

A Poverty of the Mind - New York Times

So what are some of the cultural factors that explain the sorry state of young black men? They aren't always obvious. Sociological investigation has found, in fact, that one popular explanation — that black children who do well are derided by fellow blacks for "acting white" — turns out to be largely false, except for those attending a minority of mixed-race schools.

An anecdote helps explain why: Several years ago, one of my students went back to her high school to find out why it was that almost all the black girls graduated and went to college whereas nearly all the black boys either failed to graduate or did not go on to college. Distressingly, she found that all the black boys knew the consequences of not graduating and going on to college ("We're not stupid!" they told her indignantly).

SO why were they flunking out? Their candid answer was that what sociologists call the "cool-pose culture" of young black men was simply too gratifying to give up. For these young men, it was almost like a drug, hanging out on the street after school, shopping and dressing sharply, sexual conquests, party drugs, hip-hop music and culture, the fact that almost all the superstar athletes and a great many of the nation's best entertainers were black.

Not only was living this subculture immensely fulfilling, the boys said, it also brought them a great deal of respect from white youths. This also explains the otherwise puzzling finding by social psychologists that young black men and women tend to have the highest levels of self-esteem of all ethnic groups, and that their self-image is independent of how badly they were doing in school.

I call this the Dionysian trap for young black men. The important thing to note about the subculture that ensnares them is that it is not disconnected from the mainstream culture. To the contrary, it has powerful support from some of America's largest corporations. Hip-hop, professional basketball and homeboy fashions are as American as cherry pie. Young white Americans are very much into these things, but selectively; they know when it is time to turn off Fifty Cent and get out the SAT prep book.

For young black men, however, that culture is all there is — or so they think. Sadly, their complete engagement in this part of the American cultural mainstream, which they created and which feeds their pride and self-respect, is a major factor in their disconnection from the socioeconomic mainstream.

Of course, such attitudes explain only a part of the problem. In academia, we need a new, multidisciplinary approach toward understanding what makes young black men behave so self-destructively. Collecting transcripts of their views and rationalizations is a useful first step, but won't help nearly as much as the recent rash of scholars with tape-recorders seem to think. Getting the facts straight is important, but for decades we have been overwhelmed with statistics on black youths, and running more statistical regressions is beginning to approach the point of diminishing returns to knowledge.

The tragedy unfolding in our inner cities is a time-slice of a deep historical process that runs far back through the cataracts and deluge of our racist past. Most black Americans have by now, miraculously, escaped its consequences. The disconnected fifth languishing in the ghettos is the remains. Too much is at stake for us to fail to understand the plight of these young men. For them, and for the rest of us.

Orlando Patterson, a professor of sociology at Harvard, is the author of "Rituals of Blood: Consequences of Slavery in Two American Centuries."

Here is a great post for parents from Dr. Deborah Serani.

1. Yelling: May be an effective way to vent frustration, but children of parents who yell often learn to tune it out. Results: The behavior does not change, and children learn to be hostile. Better: Stop. Ask what it would feel like to be yelled at. Most children respond better to calm, reasonable commands. Leave yelling for emergencies like “Look out for that car !”. . .“Don’t touch the barbecue!”

2. Demanding Immediate Compliance. Children and adults usually do not respond well to immediate demands. Such commands do not take into account how the person hearing the request may feel…what they are doing at that moment. Results: Commands that are demanded immediately are often tuned out, or blatantly refused. Better: Make a respectful but firm request. “At the next commercial, please hang up your jacket.”...... “When I come back from the bedroom, it’ll be time for us to go to get into pajamas”.

3. Nagging. Parents who nag are generally individuals who are not aware of how they communicate their demands. They also tend to be too lenient. “Did you clean your room yet ?”. This is not a command, this is a question. Results: children respond “no” to such a question. You then get more and more frustrated when the task is not complete. Better: Get you child’s full attention, and assert your request.

4. Lecturing And Advice Giving. Lecturing is fruitless. People have limited attention spans for monologues that have little interaction. A child’s ability to sustain attention during a lecture is even less. Children experience the least learning from lecturing and advice giving. Results: You child learns to tune you out the minute you get on the soapbox. Example: Lecturing a child about homework that is late, and what happens, how the teacher may feel, how you feel does not change behavior. Better: Ask a question that will illicit consequential thinking… “ What do you think happens if you keep bringing your homework in unfinished ?”. ...“ How does it feel to have to miss recess because you were fighting with a classmate?”. .... “ What do you think Daddy will say if he sees you’ve not taken care of your new toy?”.

5. Taking Anger Out On Kids. Over-reaction and outbursts of rage are all too commonplace in our stressful society. When you take your anger out on your child, you may say something that will stay with him for a long time. Results: Your child feels hurt, you feel hurt, everyone’s self esteem suffers. Better: Offer your child a heartfelt apology if you’ve lost your control and over-reacted. Children learn that talking about angry feelings is okay, and that Moms and Dads make mistakes. Even Better: If you find that you are over-reacting a good deal of the time, you may not be tending to your own needs. Go to the gym, take walks, take quiet time, find a supportive network.

6. Shaming And Belittling. Parents do not often realize that they may make remarks that leave their child feeling small, inadequate and less intelligent. “ Why are you acting like such a baby ?”… “ That’s the dumbest thing I have ever heard .”… “ I’m so sick and tired of you behaving like this.” Results: Loss of self-esteem, feelings of trust are effected. Better: Monitor your language and see how often you say positive things vs. negative things. Make sure that you are dealing adequately with your own needs. Make sure that your expectations are realistic for the kind of behavior you are looking for in your child.

7. Setting Up Traps. Parents who tend to be punitive and authoritative try to catch their children in a lie to prove a point. Example: “ You overhear a phone conversation that your child is having regarding smoking cigarettes. A trap -setter says, “ Do you or your friends smoke ?”. The child says, “ No.”. The parent insinuates, “Then what was that conversation?”. “Did you put your toys away?” “Then what is this mess here?!”. Result: You have a defensive child who learns to lie and conceal, and mistrust others. Better: Straight forward inquiry. “ I overheard you talking on the phone about something that concerns me. Let’s find some time to talk about .”.... “ I see you’ve not put your toys away, let’s clean up together”. Not everything children say or write is true. You need to explore all concerns in an up-front manner.

8. Imposing Excessive Guilt. Parents who come from dysfunctional homes may make the mistake of implying that their children are responsible for circumstances in their life. Example, “ Why do you always upset your father?”… “I devote my life to you, and now you do this !”. “If you loved me, you would do this.” Results: A child comes to feel responsible for the problems in the house. Better: Learn other ways to express your feelings constructively, and without guilt . Parents who experience this may need to examine their co-dependent tendencies.

9. Physical Punishment. The purpose of discipline - from the word disciple - is to teach. This is never accomplished with physical force according to research. Results: Children who are hit as a means of punishment learn hostility and resentment instead of respect. The behavior that was inappropriate is not prevented from re-occurring, and damage is done to the parent-child relationship. Physical punishment tends to run in families. If you routinely hit your children as a method of discipline, you may need to examine your own childhood. Better: Alternative skills are needed so that enhancement of parent-child bond can occur, and so discipline instills respect and learning.

10. Coercion. This is the use of physical force to get your child to do what you want. Example: Pushing your child into the doctor’s office… or dragging a frightened child to school. With coercion, the parent is generally asserting a need to control, rather than responding to the child’s feelings. Results: Children often resist this kind of intervention. Self esteem suffers. Better: Help your child express his/her feelings. “ Is something scary about going to the doctor?”. “Is there something at school that bothers you?”. Recommended: Give your child a choice such circumstances. “ Do you want me to hold your hand when we go into the doctor’s office?”. “Do you want me to talk to your teacher at school?”. Choices give the child a sense of control over the situation, but leaves no question that he/she is going to the doctor, or to school.

References
~ The Bottom Line Magazine
~ Windell, James. A Sourcebook for 50 Fail-safe Techniques for Parents. Collier Books, New York.

Washington Post got the story about the study on depression all wrong yesterday. Now half of blogdom is blathering about the misinformation.

Results of the STAR*D Part 1 Depression study by funded by NIMH was published in January in the American Journal of Psychiatry. Yesterday, the report on STAR*D Part 2 of the study was released, but requires a subscription. The press release summarizing the results is at the NIMH site.

I found two reports in the press about the study. The Washington Post got it all wrong.

Antidepressants fail to cure the symptoms of major depression in half of all patients with the disease even if they receive the best possible care, according to a definitive government study released yesterday.

[...]Although the study showed that patients who do not respond well to one drug could be helped by another, the results are "discouraging for several reasons," Rubinow said in an editorial published in the New England Journal of Medicine, which also published the study.

It is troubling that large numbers of patients continued to have problems, he said. Additionally, he noted that the drugs used in the study -- Celexa, Wellbutrin, Zoloft and Effexor -- work in very different ways yet had roughly equal effectiveness when it came to treating depression. This suggests that the underlying brain mechanisms of depression are far more complicated than simple notions of a single chemical imbalance.

Thomas Insel, director of the National Institute of Mental Health, which funded the study, emphasized that patients should seek -- and stick with -- treatment. "The glass is half full from our perspective," he said. But "the glass is half empty in that we need to come up with better treatments in the future."

I seriously doubt the psychiatrists they interviewed were "disappointed" with the results. As the research reports states quiet persuasively, the results were in fact "robust". The measurement of success in this study was "remission". That means ALL symptoms were gone. Most drugs are approved for use in treating depression based on improvement in symptoms. Remission is the highest standard of improvement there can be. The LA Times did a much better job of relating the story.

American Journal of Psychiatry

The remission rates (28% for HAM-D; 33% for QIDS-SR) were robust and similar to rates found in uncomplicated, non-chronic symptomatic volunteers enrolled in placebo-controlled, 8-week, randomized, controlled trials with SSRIs (4). These remission rates were better than those found in efficacy studies among patients with chronic depression (22%) (9), possibly because of a number of factors discussed below, including the use of measurement-based care and the clinical research coordinators.

[...]Several baseline features were associated with higher remission rates, including lower baseline severity; being Caucasian, female, better educated, and more highly paid; and having private insurance, fewer concurrent general medical and psychiatric disorders, better pretreatment physical and mental function (12-item Short-Form Health Survey physical and mental sub-scales), greater life satisfaction, and a shorter current episode. Taken together, greater illness severity and psychiatric and general medical co-morbidity as well as less social support are likely associated with lower remission rates for citalopram. These findings are consistent with some of the previous studies that reported lower response rates to antidepressants in subjects with greater baseline symptom severity and longer current episodes (19, 25, 63-67).

[...]In our sample, being married or living with someone appeared to have a positive effect on the overall remission rates; married or cohabiting patients met criteria for treatment response with greater frequency than single participants. Although Hagerty and Williams (68) found that patients living alone were more likely to drop out of treatment, our findings indicate that participants who were unmarried or living alone did not drop out early and yet had lower remission rates. Not all studies have found social support to be a significant predictor of treatment outcome (69, 70), but most have suggested social support and, even more specifically, marital status as positive predictors of response.

The kinds of factors associated with lower rates of remission are complicating factors, many of which are addressed appropriately with psychotherapy, skills training and social support. Unfortunately, the newspapers miss both points entirely.

The important finding in the STAR*D Part 2 study was that persistence in seeking a combination or a change in medication increased remission rates. If one counts each medication trial as 6-8 weeks and add to this 12 to 16 weeks or more for psychotherapy to address complicating factors like anxiety, a history of mistreatment, abuse or trauma or substance abuse, it's reasonable to expect at least 16 weeks of concerted, persistent and painful effort to make progress with a resistant depression. Many sufferers are tempted to give up after the first attempt at treatment.

As the LA Times quoted the study's lead psychiatrist:

"Hang in there," said Dr. A. John Rush of the University of Texas Southwestern Medical Center, who led the trials, which are reported today in the New England Journal of Medicine. "For the depressed person, it may not matter so much what drug is being prescribed, but that the person moves forward and keeps trying," he said. MORE

Mental Notes had a great post a few days ago listing the kinds of indications to look for in understand if your child is suffering from a serious problem. Behavior can mean many things, often because of the context of situation. You may need help to figure out what needs the attention.

I will take issue with one of his assertions. While it is true that a full assessment takes a lot of time and there is very little incentive from the doctor's perspective to do the full diagnostic and medicating as a trial is a widely used method of diagnostics, I'd advocate for the full evaluation before medicating. There are too many stories of "kids like zombies" floating around to say nothing about this.

Bring your child to a mental health professional who will take a full 45 to 60 minute evaluation, or more to determine a diagnostic of ADHD. I've known several clinicians in my community who will take 2 to 3 sessions to do a complete background including some standardized tests. I think that is justified. There is indications that behavior therapy is as or more effective than medication alone.

Hyperactivity is way over-diagnosed. I think it is because it is hard to come up with the right diagnosis amongst the differential diagnoses for behavior problems in a seven minute interview. Easier to try the psychostimulant, and then if it does not work, do the longer work-up. Attention Deficit Hyperactivity Disorder isn't even the most common cause of behavior problems.

Here are a few of the most common reasons (ie, the differential diagnosis) for behavior problems:

Stress at home. Children are very sensitive to the worries of their parents. Often parental worries become worries for the child, as well. Some children are not very good at talking about their worries, so they show as behavior problems at school. A good evaluation of behavior problems includes asking about family stress.

Learning Disorders. When a child gets frustrated because school work is too hard for him he will often let us know by having behavior problems. Children who are being evaluated for hyperactivity should be tested for learning disorders, as well.

Depression. Children with severe depression (some folks call this "clinical depression") are not always sad and mopey. Often they "tell" us that they are depressed through bad behavior. A child and adolescent psychiatrist can help decide if the behavior is a symptom of depression.

Teacher-child conflict. In my experience this is very, very rare. But one time while visiting a classroom, a teacher with her back to the classroom went on and on about all the talking going on behind her, convinced that it was my patient doing the talking. But I was watching right over her shoulder, and my patient never said a word the whole time! Even though it's unusual, sometimes a child and a teacher just don't "hit it off."

Here is a very interesting research article about a link between depression and later victimization by domestic abuse. While, I don't find this surprising, it's gratifying to see connections that have the potential to influence the focus of psychotherapy.

MedlinePlus

Young women who had significant depression symptoms as teenagers were 86 percent more likely than their non-depressed peers to report serious partner violence 5 years later. This association still held after a number of potential risk factors, such as race, parents' education and history of childhood abuse from a caregiver, were taken into account. MORE

I have always associated victimization with low self-esteem. Low self-esteem has often seemed to relate to an increased risk of depression. Certainly, victims of abuse often are also depressed. But to find a connection of adolescent depression with double the risk of future victimization is a strong association.

Self-esteem has been one of those difficult to measure constructs, many because one would think that a person would know if they liked themselves or not. In my experience, people are often out of touch with themselves to the extent that what they want to believe is what they believe, rather than what is actually the truth. Self-esteem needs to be defined as set of behaviors in certain circumstances, such as acquiescence vs. assertiveness in intimate relationships.

Now it would make sense that a person who is depressed would been more likely to miss cues of potential danger. People who are depressed typically devalue their own opinions and would seem more likely to dismiss intuitions suggesting they are not safe that might allow them to protect themselves. They also are more likely to see fewer alternatives after the abuse has occurred. They would also be more likely to blame themselves for the abuse or believe that they deserve nothing better. Add low self-esteem to depression and the possibilities grow dramatically for victimization. A very interesting question is what is the relationship between low self-esteem as defined above and DSM IV TR criteria for depression and risk for recurrence.

Here is an example of putting this knowledge immediately into therapeutic practice. David Markham puts it this way:

As a psychotherapist working with depressed teens and depressed adults, I often encourage these women to find their voice and become more assertive. I kiddingly say "You can either be sad or be mad, and I think getting mad and saying, 'I'm not going to take this any more, or do this any more' is a step in the right direction in fighting off the depression."

This is a cross-posted comment to this article in THOUGHTS From the HEADoc.

I have witnessed first hand our Mental Health Centers insidiously disappear under the name of reform. The State Hospitals are next on the chopping block. Our citizens have been totally eliminated from knowledge of what is really happening with that situation. Also first hand, I watched the jail population become almost exclusively of those with mental illnesses and chemical dependence, effectively keeping those people from public site for the most part.

Most people don't appreciate the severity of the drug culture and how deeply it has penetrated our society at least until a family member becomes affected. It is no longer a ghetto problem only. Maybe my view of the situation is skewed because of the concentrations of populations I've worked with. The main difference I really have seen is that the blacks are treated in jail and most whites are treated outside of jail for the exact same problems. This situation seems to give the impression to the general public that all is well. Doctors are basically divided into two groups. The largest group are those who take no risk and treat no patient with history of high risk behaviors. The smaller group of physicians are those who haven't learned to join the larger group yet. I learned this difficult lesson over the past year. There is essentially no protection for a solo practitioner who will see higher risk patients. Like a sitting duck, that practitioner may be targeted by pharmacists and those sociopathic doctor shoppers I have written about many times before.

I have felt like Mudbone, many times, guarding the levy. The levy is weakening every day. The public in the valley are dry and unknowing. The politicians on the hill are dry and really don't give a damn. The levy is going to break and the people will feel the force of the metaphorical water. Many will drown. I must accept that it is not my purpose to address social issues because there are just too many and those in control at this time are indifferent, at best, to such issues.

I understand your discouragement. I've been there myself. After 30 years in this business, I find myself still shocked by the stories of deprivation, abuse and trauma I hear too regularly. I've come to accept that I have little influence on the big picture. I take my swings in the political sphere, but I have to retreat from there and focus on what I can do or I risk falling into a dark hole as deep as some of my clients'.

I figure I impact the world one person at a time. So I do the best I can with those who care to listen long enough to benefit. I celebrate and take credit for those that succeed. I quickly let go of those who are "falling elephants". With all those people out there who have benefited, I figure I have had more impact on the world than most people do. I'm grateful that my job is interesting, challenging and never boring. I learn something new everyday. And I meet some incredible people. And I learn who I don't want to know and how to protect myself from them.

I'm not sure I'd want to work as a solo practitioner in a high risk setting. That population demands a team approach. Solo practitioners really do have to limit their practice. There is no shame in that. It's good for the practitioner and the client.

I work as a team member in a partial hospital program in a large public hospital in the inner city (an endangered species, I know). It is probably the closest thing there is to an ideal setting for therapy with high risk individuals. The program model quickly weans out those who are not serious about changing their lives. We see them all, 2/3s don't make it by self-selection. A few are kicked out. Those that stick it out are forever changed. Many crack, meth, alcohol and heroin addicts actually make it. People who have suffered deep trauma often find peace. And I see my share of people with lots of potential and skills as well, many with their first time in treatment. I feel very fortunate to witness the beginning of their metamorphosis.

Keep the faith. The world needs more of you.

A British mental health advocacy organization came up with a provocative way to challenge the stigma of mental illness. They commissioned a sculpture of Winston Churchill in a straitjacket. The British Prime Minister, who led the British people through WWII, is widely considered a heroic figure inspiring honor, persistence against overwhelming odds, and unbending will. Many have taken exception to what they consider to be a undignified association. Churchill suffered from depression, an experience he called his "black dog."

Rethink .org

Rethink severe mental illness today (September 14) defied an official ban to protest at the “last taboo” of mental health stigma and start a debate on how to overcome it. The charity had planned to unveil a “black dog” statue of former Prime Minister Winston Churchill in a straitjacket in London's Trafalgar Square to draw dramatic attention to the stigma surrounding mental ill-health.

But the statue, emblazoned with a “prejudice, ignorance and fear” sash, was banned. Instead, the statue is taking to the road and touring central London in defiance of the ban, imposed by the Greater London Authority, which controls access to Trafalgar Square.

Rethink chief executive Cliff Prior said: “Mental illness is the last taboo. People deny it, try to hide it and hide from it. We are determined to break out of the straitjacket and challenge prejudice, ignorance and fear wherever they appear.

I admire their creativity and courage to face the consequences of controversy for a good cause. Let's hope it helps!

Abuse in relationships is way too common, often because we are not taught when we are young to identify relationships going awry. If you are in a relationship that sounds like this, consider the wisdom of continuing.

The Sacramento Bee

He wants to spend an excessive amount of time alone with you and he encourages you to flake on your friends, ditch school or skip practice. It can seem like a romantic gesture, but it's not. One partner's insistence on being the sole focus of the other's time and attention is a key warning sign of abuse, as the victim is slowly isolated from family, friends and favorite activities, experts say.

He scrutinizes every detail of your life, including your friends, your hangouts and even your wardrobe. His controlling attitude means your cell phone is constantly in use, since he's always checking up on you. "In the early stages it gets misread as, 'Well, gosh, they care about me so much, they care about every little thing I'm doing,' " says Linda Hoos, an attorney for Break the Cycle. But it's not a measure of his affection, Hoos says, it's a way to assert his control.

Even if you've never so much as flirted with another guy since you started dating, he's always accusing you of cheating.

More here.

Cutting taxes can only mean one thing for people suffering from mental illness, there will be fewer and less quality in the services available. This is true for the public system certainly, but it is also likely to spread extensively into the private system. Public dollars tend to account for a significant part of the business for even the private mental health provider. Fewer dollars will mean a continued exodus of providers from direct service. Salaries have fallen hehind the market for master and doctoral level practitioners. That can only mean fewer new providers coming into the field, and more exiting the field for more lucrative opportinuties.

The mentally ill account already for at least 25% and more likely 50% or more of the homeless in this country. That number can only go up as the services decline. Many working people end up disabled because they can't find sufficient services to help them put their lives together. Many of the homeless are disabled with too much pride to ask for help.

We as a country can do better than that. The complete report is available at the link. A report card chart with all the states is at this link.

NAMI.org

We live in a time where people with serious mental illness are at increased risk. State systems are under tremendous financial strain. As this report goes to press, actions that are being considered in Congress are likely to do more harm than good. Sadly, the promise of community mental health remains unfulfilled.

In 1990, NAMI released its last state ratings report. It described a system of services that, despite enormous
expenditure of resources, was not “even minimally acceptable.” It detailed great regional and state variations in
the existing system of care. Sixteen years later, mental illnesses cause more disability than any other class of
medical illness in America. Recent reports from the U.S. Surgeon General, President Bush’s New Freedom
Commission, and the Institute of Medicine describe well a “system in shambles” and the “chasm” between
promise and performance.

Simply put, treatment works, if you can get it. But in America today, it is clear that many people living with
the most serious and persistent mental illnesses are not provided with the essential treatment they need. As a result, they are allowed to falter to the point of crisis The outcome of this neglect and lack of will by policymakers
remains often horrendous. The number of people with serious mental illness incarcerated in jails and prisons is on
the rise. Emergency room use is increasing. The availability of housing is being threatened. Increasingly, access
to effective treatments is being limited by many state governments.