After years of spending cuts to mental health programs, lawmakers have begun to boost funding for the most effective approaches

Horrific violence committed by people who are mentally ill has reignited state policy debates over gun control. But it also, much less visibly, has been the catalyst behind concerted action on another front: mental health care.

Over the past two legislative sessions, at least 36 state legislatures have increased generalfund appropriations for inpatient and outpatient mental health care for children, adolescents and adults. And nearly every state has enacted new laws in areas ranging from jaildiversion strategies to schoolbased behavioral health services to programs aimed at reducing the stigma of mental illness. Thirty state policy initiatives enacted in 2013 received the goldstar "best practices" designation by the National Alliance on Mental Illness.

From the mass killings at Sandy Hook Elementary School to the most recent shootings at Florida State, the gunmen had severe mental disorders that went unnoticed, untreated or unreported.

The Sandy Hook tragedy in December 2012, in particular, "opened up the eyes of governors and state legislators around the country that mental health has been cut enough," says Andrew Sperling, director of legislative advocacy with the National Alliance on Mental Illness. "We've seen largely bipartisan agreement that there are gaps in the public mental health system, and recognition that cutting mental health care has severe downstream consequences."

Former Colorado Representative Cheri Gerou (R), who served on the Joint Budget Committee, agrees. "I think it's clear that we haven't done enough, and we're coming to understand the value of better approaches to prevention, intervention and treatment," she says. She supported a 13.5 percent increase in the general fund appropriation for mental health services, to "make Colorado a healthier state," she says.

Up From Years of Cuts

Sperling and others are quick to point out that recent funding increases are dwarfed by the $4.35 billion reduction in mental health care budgets that states made collectively between 2008 and 2012.

The Texas Legislature, for example, boosted mental health spending in the 2013-15 budget by more than $250 million, or about 15 percent-the largest such increase in the state's history. But "even with the new money," says Texas Representative Garnet Coleman (D), a champion of mental healthcare reform, "our percapita funding for mental health is below what it was in 1999, and we've slipped from 43rd to 48th in the nation."

Coleman says that mental health spending in Texas "really began to get whacked every year, starting in 2003. We were cutting programs and services even when we didn't need to."

Coleman laments the fact that Texas is among the states that declined to opt into Medicaid expansion-which would have increased mental health insurance coverage-calling it "a real missed opportunity. It means we're going to have to do a lot more in terms of indigent care."

Connecting the Dots

Although shootings spurred some legislative action on gun reform and mental health, there's little independent research on the relationship between gun violence and mental health. Certain psychiatric illnesses have been linked to an increased risk for violence, but a compelling body of research suggests that the vast majority of people with mental disorders do not commit violent acts. People with mental illness, in fact, are actually more likely to be the victims of violent crime than the perpetrators.

Coleman, for one, decries the extent to which mental illness and gun violence have been linked-a connection that runs the risk of further stigmatizing and deterring people from seeking help for fear they will be viewed as deranged and violent, he says.

A recent report by Columbia University's 2x2 Project, which focuses on public health issues, noted a 2013 Gallup poll showing a majority of Americans now believe the biggest cause of gun violence is not easy access to guns, but the failure of the mental health system to identify individuals who pose danger to others.

"The connection between mental illness and guns has crowded out the issue of gun control," authors of the report wrote. "Although there are many reasons to invest more resources in our mental health system, there is little evidence that focusing on mental health screening-especially at the expense of gun control-will prevent shootings."

Coleman agrees. "This is politics, pure and simple-not policy," he says. "When increased spending on mental health doesn't lead to a reduction in gun violence, I think we're going to see a lot of pressure to retrench."

Comprehensive Packages

Senator Charles Schwertner (R), who chairs the Texas Senate'sCommittee on Health and Human Services, says that although the growing alarm over incidents like Sandy Hook played a role in legislators' decision to increase mentalhealth spending, "the things we're funding are not tailored just to preventing gun violence." Targets for funding include peersupport groups for veterans, crisis intervention, reducing waiting lists, creating alternatives to incarceration, expanding community mental health centers, developing supportive housing and employment. "It's a really transformative package," he says.

In the wake of the Sandy Hook shootings, Connecticut legislators in the spring of 2013 also approved a comprehensive package of bills weaving together mental health, school safety and gun control. The new laws target assault weapons but also include a wide range of mental health care initiatives focused on early identification and intervention and on mental health literacy.

The package also created a new statewide Children's Mental Health Task Force and broader public information campaigns, mandatory training for teachers and other school employees in how to spot and report signs of mental disorders in children, and a major study of incarcerated youth with mental health problems.

The four other states that tightened gun laws-Colorado, Delaware, Maryland and New York-also made background checks mandatory and placed stricter limits on assault weapons and highcapacity magazines. In addition, Arkansas, New York and Tennessee passed "duty to warn" laws, requiring mental health professionals to notify law enforcement officials about patients they believe might be a danger to society.

New Policies and Practices

In its recent report on mental health legislation enacted in 2013, the National Alliance on Mental Illness grouped state initiatives into a number of categories and identified notable efforts in each category:

Mental Health System Improvement. Colorado lawmakers allocated $18.5 million to create a single, statewide mentalhealth crisis hotline, establish five aroundtheclock crisis centers, increase the number of psychiatric beds, and develop housing alternatives for people with mental illnesses. Oregon legislators appropriated $67 million to expand psychiatric residential treatment programs and promote children's mental health. The California Legislature earmarked $143 million to add hundreds of new crisis and triage positions to the mentalhealth workforce. And in Utah, lawmakers passed a new law aimed at integrating programs that address mental health, physical health and substance abuse.

School-based Programs and Services. Texas now requires training for K12 teachers and staffto recognize and respond to signs of mental health disorders in students. Utah requires school districts to offer annual seminars to parents on mental health, including depression and suicide prevention. Maryland, Minnesota and Rhode Island passed initiatives aimed at strengthening the link between schools and behavioral health programs.

Suicide Prevention. Kentucky established mandatory training requirements in suicide assessment and treatment for social workers, family therapists, professional counselors, psychologists and occupational therapists. Alaska, Oklahoma, Utah and Washington also approved new funding for suicide prevention.

Criminal Justice. Following the lead of a dozen or so other states, Arizona laid the groundwork for creating special courts for defendants with mental illnesses. Missouri created a veterans' treatment court to handle cases involving substance abuse or mental illness among current or former military personnel. South Dakota will allow judges to consider treatment options when imposing a sentence if a defendant who is a veteran or military service member pleads guilty or no contest. Montana revised its probation and parole system to work more effectively with prisoners who have a serious mental illness. Minnesota established a working group to examine juvenile justice and mental health. Texas will require local mental health authorities to create jaildiversion strategies that shiftpeople with serious mental illness out of the criminal justice system and into treatment.

Community Mental Health. Pennsylvania has earmarked funding for communitybased programs that integrate preventive care, disease management, behavioral health and pharmacy services. Texas and Minnesota approved initiatives aimed at broadening choices and increasing access to housing and employment opportunities for people who are mentally ill. Michigan allocated funds for comprehensive, homebased mental health services and a pilot program for highintensity care management.

Telemedicine. Idaho, Indiana and Utah approved legislation allowing the delivery of mental health services via twoway video and other communication technology. The goal is to increase access to specialized mental health care in rural areas, address workforce shortages and integrate physical and mental health care.

While lauding these and other efforts on the part of states, the report emphasized that it will take strong and sustained efforts in coming years to rebuild public mentalhealth systems "to provide children, youth and adults with the mental health care they need to stabilize, recover and live healthy lives," the report concluded.

Mental Health First Aid: A New Grassroots Strategy

Few people know how to help someone who is developing a mental illness and even fewer know where to turn when such illnesses result in a crisis. That's the idea behind Mental Health First Aid, which aims to equip adults and young people with skills to recognize, manage and prevent mental illness.

Designed along the lines of traditional first aid and CPR courses, the first aid curriculum comes with custom features to adapt to all kinds of audiences-from teachers, ministers and child welfare workers to law enforcement officials and emergency first responders.

A growing network of certified instructors-currently 4,800 in all 50 states-provides the smallgroup, eighthour training that includes lessons, roleplaying and other exercises, and a range of informational material. The training costs $50 to $75, but is available free of charge in many cases.

Since 2008, more than 70,000 Americans have undergone training, says Betsy Schwartz, vicepresident of public education and strategic initiatives at the National Council for Behavioral Health. That number is expected to increase significantly over the next few years because of growing support from state policymakers, she says. As of mid2014, 12 states had appropriated funds to grow the network of certified instructors and/or pick up the tab for teachers, school counselors, police officers and certain other groups to receive the training.

That's important, says George DelGrosso, CEO of the Colorado Behavioral Healthcare Council, because until now, the program in his state had been piecemeal, relying largely on donations and on the efforts of cashstrapped community mental health centers. "Now we have the funds to do it right," he says.

DelGrosso says when he met with members of the legislature's Joint Budget Committee last spring, he sensed "a strong commitment to doing a better job of identifying and helping people suffering from depression, substance abuse and other problems at an earlier stage. The focus was on what we can do to empower people, and help families and communities heal."

One of the things that former Representative Cheri Gerou (R) says appealed to her was the ripple effect of a program like Mental Health First Aid. "Once you can help someone cope better and live a better life, it makes life better for everyone around them," Gerou says.

The committee approved $1 million in support for the first aid training throughout Colorado over the next two years. Other states that have put money on the table are Arizona, Connecticut, Illinois, Indiana, Maryland, Michigan, Minnesota, Nebraska, New York, Texas and Washington.

Mental Health First Aid was developed by a husbandwife team of mental health professionals in Australia in the mid2000s, and to date has been replicated in the U.K., Canada, Finland, China, Singapore and 20 other countries.

A growing body of research suggests that the training is effective in several areas: increasing assistance to those in need, including establishing connections to professional help; reducing misinformation and stigmatizing attitudes; and decreasing the social isolation of those living with mental illness.

Suzanne Weiss, a freelancer based in Denver, is a frequent contributor to the magazine.

Additional Resources

NCSL Resources

Mental Health Professionals' Duty to Warn

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Other Resources

State Legislative Tool Kit: Mental Health First Aid, The National Council for Behavioral Health

TABLE OF CONTENTS

Up From Years of Cuts

Connecting the Dots

Comprehensive Packages

New Policies and Practices

Mental Health First Aid: A New Grassroots Strategy

Additional Resources

CONTACT

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