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PROLOGUETransforming Federal PolicyThe delivery of mental health care services in the United States reflects the current fragmentation apparent throughout all of health care, with different responsibilities for federal, state, and local governments. The following three papers focus on the federal role—the need for more integrated care and more research to determine the most effective interventions. Robert Drake and colleagues look at the growing role that Social Security disability programs—both Social Security Disability Insurance and Supplemental Security Income—play in supporting America’s mentally ill. Although many of these beneficiaries want to, and could, work, features of these programs actually limit their ability to gain employment and be productive. Drake and his colleagues advocate for marrying the benefits to a program of "supported" employment, releasing enrollees from dependence and restoring their dignity. Audrey Burnam and her RAND colleagues navigate a very different landscape: that of mental health care for returning Iraq and Afghanistan veterans, particularly those with depression and post-traumatic stress disorder (PTSD). Both the Defense Department and the Veterans Health Administration have taken significant steps to improve care for those affected. Yet most veterans will actually seek care outside the military or VHA systems and back in their own communities, if at all. Burnam and colleagues make recommendations to grow community-based practitioners and train them to recognize and treat combat-related mental health conditions; to establish incentives for providers to improve treatments; and to have the government provide more assistance to help the states. Phillip Wang and colleagues from the National Institute of Mental Health examine the federal government’s role in funding comparative effectiveness research to test interventions against one another. They review the findings of three large randomized controlled trials testing older versus newer antipsychotic drugs in treatment of schizophrenia, as well as drug and psychosocial treatments for those with persistent depression and bipolar disorder. The trials did demonstrate some clear findings—most particularly that, as a class, the newer and more expensive psychotropic drugs did not work better than older generics. Yet they also reinforced the fact that individuals are highly variable and need tailored regimens, including behavioral interventions. Such trials, they conclude, should remain a core part of the federal contribution to advancing mental health.
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