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PROLOGUEEvolution In State PolicyThe passage in 2008 of federal mental health parity legislation has garnered much attention, but comparably significant developments have occurred at the state level as well. These changes have built on the trend away from institution-centered treatment toward community-based care. The papers that follow show how several states have begun the challenging process of developing the infrastructure and payment systems to advance care in the community—and balancing the civil liberties of mental health "consumers" against the broader public safety. It’s a poignant reality that sometimes only tragedy will prompt overdue policy change. Richard Bonnie and colleagues chronicle changes afoot in Virginia, where the deadly 2007 shootings at Virginia Tech spurred an ongoing reform process. Among other measures, the state has taken steps to improve its emergency evaluation of mentally ill patients in the community—but as yet has made only a "down payment" on expanding community-based treatment capacity. A Perspective by Michael Hogan and Lloyd Sederer offers further insight from New York State. There, a recent state task force created in the wake of a wave of violence found casual and poorly coordinated care to be the root of the problem. It recommended, among other measures, a new system of "clinical alerts" to identify those at risk of decompensation and violence. Turning to California, Saul Feldman describes how the famously tax-averse state managed to pass a voter initiative for a "Millionaires Tax" dedicated to community-based mental health care. The initiative is a major work in progress, but it has already resulted in the creation of affordable housing projects earmarked for mentally ill homeless people in some major cities. Finally, Jeffrey Swanson and coauthors examine the fact that in New York, African Americans are more likely than whites to be involuntarily committed for out-patient care. Whether this is good or bad depends on one’s perspective: Is it better to be treated as an outpatient than to be hospitalized—or is mandatory treatment even at the outpatient level an unnecessary infringement on civil liberties?
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