NOTE: Charts and graphs for this chapter are listed in the right column of the page.

CHAPTER 11 - MENTAL HEALTH AND SUBSTANCE ABUSE

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FAST FACTS

• Each year, about one in four adults (26.2 percent) suffers from a diagnosable mental illness, according to National Institute of Mental Health.¹
• An estimated 22.3 million people were classified as substance dependent or substance abusers in 2007.² Substances abused range from alcohol, pain relievers and tranquilizers to hallucinogens, cocaine and heroin.
• In 2007, an estimated 29.4 million adults received any kind of mental health service during the past year.³
• An estimated 5.4 million adults needed mental health services but hadn’t received any mental health care in the past year.⁴
• The cost of care is cited most often by people who recognize that they need mental health treatment but don’t get it.⁵
• Alcohol is the most commonly abused substance, with an estimated 18.7 million people classified as abusing or dependent in 2007.⁶
• 3.9 million people aged 12 or older received any kind of treatment related to the use of alcohol or illegal drugs (about one-sixth of the number dependent or abusing).⁷
• On January 1, 2010, most group health plans began implementing a law putting mental health and substance abuse treatment on a parity with treatment of medical and surgical conditions.⁸

Increasingly, it seems, mental illness and substance abuse surface in news stories detailing erratic or unpredictable behavior, sometimes with violence as an added element.  Yet, on both individual and systemic levels, the story is more complex. Difficult as they may be to report, the complex stories are worth pursuing. By fostering a broader understanding of the issues, such stories can lead to policy changes that may ultimately result in more people getting the help they need.

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BACKGROUND: MENTAL ILLNESS

Each year, about one in four adults (26.2 percent) suffers from a diagnosable mental illness, according to National Institute of Mental Health. ⁹ The recession that began in 2008 could raise this percentage, since unemployment increases a person’s risk of mental health problems.¹⁰

In 2007, almost 30 million adults in the U.S. received mental health services during the previous 12 months (13.2 percent of the population aged 18+). Another 5.4 million adults had a need for such care, but did not receive any mental health services.¹¹

In 2003, $100.3 billion was spent in the U.S. to treat mental illness and $20.7 billion was spent to treat substance abuse, totalling 7.5 percent of the $1.6 trillion spent on all health care that year.¹² (See chart, “Spending for Mental Health Treatment.”) Mental illness also costs individuals and society in terms of lost productivity, lost earnings due to illness and social disruptions linked to mental problems.¹³

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In their severity, mental illnesses range from occasionally troubling to life-consuming. (Click here to see text box, “Major Categories of Mental Illness.”) To cope with temporary problems, such as depression following illness or a traumatic event, many people need only a short-term intervention.

But others experience more debilitating and long-lasting conditions that interfere with routine activities such as work, school, and family, and can require lifelong treatment. (See chart, “Adults Suffering Selected Mental Illnesses in a Given Year.”)

Effective, well documented treatments for mental illness and substance abuse have been developed and widely disseminated, including psychotherapy regimens, other psychosocial treatment and prescription medications.¹⁴

But a significant number of Americans do not have adequate access to treatment or do not take advantage of available help. The reason most often cited for not getting care was cost (43 percent). Other reasons mentioned were:

• “could handle the problem without treatment at the time” – 29 percent
• “health insurance did not cover enough treatment” –11 percent
• “concerned about confidentiality” – 11 percent
• “might cause neighbors/community to have a negative opinion” – 9 percent
• “might have a negative effect on job” – 9 percent.¹⁵

(For other reasons, see chart, “Reasons for Not Getting Care for a Mental Health Need.”)

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BACKGROUND: SUBSTANCE ABUSE

Substance abuse involves the overuse of common products such as alcohol, pain relievers and tranquilizers, and also illegal drugs such as cocaine and heroin. An estimated 22.2 million people were substance dependent or substance abusers in 2008.¹⁶ (There are technical definitions for both “substance abuse” and “substance dependence.”¹⁷ See the glossary for more.)

Alcohol is the most commonly abused substance, with an estimated 18.3 million people aged 12 and older classified as abusing or dependent on alcohol in 2008 (7.3 percent of the population aged 12+).¹⁸ Among illicit drugs, marijuana is abused most often (4.2 million people abusing or dependent).¹⁹ An estimated 3.1 million people were dependent on, or abused, both alcohol and drugs.²⁰

A relatively small number of substance abusers get treatment. In 2008, 4.0 million people aged 12 or older received any treatment related to the use of alcohol or drugs.²¹ Among those who received treatment, a majority (55 percent – 2.2 million) got treatment at a self-help group. The next most commonly mentioned treatment site was an outpatient rehabilitation facility (38 percent – 1.5 million).²²

Substance abuse and dependence vary considerably with age and gender. Among all people in the U.S. aged 18 to 25, one out of five (20.8 percent) was classified as substance dependent or substance abusing in 2008.

In contrast, 7.0 percent of those older than 25 were abusers or dependent.²³ The rate for males is about twice as high as for females.²⁴

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CO-OCCURRING CONDITIONS

A significant number of individuals suffer from more than one problem at the same time, such as mental illness and substance abuse, or mental illness and a chronic health condition. For instance, in 2008, 2.9 million people suffered at least one major depressive episode in the past year and also abused, or were dependent on, alcohol or drugs.²⁵

Individuals with schizophrenia have a significant rate of diabetes, in part due to side effects of their medications.²⁶ Such co-occurring conditions contribute to the fact that people with serious mental illness die, on average, 25 years earlier than the general population. Their increased morbidity and mortality are largely due to treatable medical conditions, researchers say, caused by modifiable risk factors such as smoking, obesity, substance abuse, and inadequate access to medical care.²⁷

The World Health Organization (WHO) has pointed out the need to address these problems in a coordinated way. As WHO’s 2008 World Health Report puts it: “Addressing co-morbidity – including mental health problems, addictions and violence – emphasizes the importance of dealing with the person as a whole.”²⁸
Among the estimated 5.4 million adults with both serious psychological distress and substance dependence or abuse, only about one in 10 got both mental health care and specialty treatment for substance abuse.²⁹

Studies suggest that some individuals with mental illness “self-medicate” with alcohol or drugs. A 2008 study found that almost a quarter of those with mood disorders such as major depression or bipolar disorders used alcohol or drugs to relieve symptoms.³⁰

Before enactment of health reform legislation, it was reported that more than a third of people with mental illnesses (34 percent) were uninsured – twice the rate in the population as a whole.³¹ This is one reason many suffering from mental illnesses don’t get the medical care they need for other disorders. Some other reasons include: fearfulness or lack of motivation on the part of the patient, discomfort on the part of providers, and inadequate funding and fragmentation of services within the health care system as a whole.³²

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MOST RECENT LEGISLATION AFFECTING MENTAL HEATH AND SUBSTANCE USE DISORDER POLICY

Implementation of “Parity” Law
Well over a decade of advocacy by the mental health and substance abuse communities finally resulted in passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addictions Equity Act in October 2008. (See box for details.) Interim regulations issued to implement the law have engendered a new set of controversies, however, as consumers and managed care organizations grapple over parity’s reach. Even after they become final, it is likely that questions about the scope of services covered by the law will only be answered in court.  Still, the law is now in effect, and all policies issued after July 1, 2010 must be in compliance with it.

Implementation of Patient Protection and Affordable Choice Act
In contrast to past attempts at health reform, coverage for mental health and substance use conditions was written into the health reform law of 2010 from its earliest drafts.  Treatment for mental health and substance abuse conditions was included in the essential benefits package required for health policies to be sold through the new health insurance exchanges beginning in 2014, for example, and, in general, the new law fully incorporated the parity law (see above). 

Perhaps surprisingly  to those outside the mental health field, many general provisions of the new law reform benefit people with mental health or substance use disorders.  The elimination of coverage exclusions due to pre-existing conditions, for example, will make insurance available to Americans who have been denied coverage because of their histories of mental health or substance abuse treatment. (See the health reform chapter for details.) Similarly, the expansion of Medicaid holds the potential to bring millions with substance use or mental health disorders into the treatment system, while the extension of coverage under parents’ policies to offspring under the age of 27 will mean many facing the onset of mental illness will be covered at this critical moment in their lives. 

These changes in policy will likely mean tremendous upheaval for the care and treatment system – really a patchwork of systems – that has developed under the rules in place for many years.  Questions abound, among them:  How many of those newly eligible will seek treatment?  How will provider agencies integrate with the general healthcare field?  Will there be capacity to meet growing demand?

Mental Health and Substance Use Disorders and Health Information Technology
The American Recovery and Reinvestment Act of 2009 (ARRA) authorized more than $30 billion for the expansion of health information technology in this country.  This expenditure is seen as a key investment in greater efficiency and improved medical care and is a cornerstone of the health reform effort now underway.  For the mental health and substance abuse treatment communities, however, this initiative is a reminder of the still uncertain space they occupy in the broader health care environment, since the opportunities for HIT funds in the behavioral health sphere appears limited.

Advocates are dismayed that exclusion from ARRA funding of HIT may allow walls to rise that may prevent meaningful integration of care for adults with serious mental illness and with medical complications resulting from the high rate of substance abuse among people with many chronic conditions.  At the same time, many point out that the behavioral health field has long claimed a greater need than other medical sectors for the maintenance of privacy and confidentiality for patient-specific information, and some continue to fear that poorly designed HIT policy could lead to erosion of these guarantees. 

Mental health and substance abuse issues affecting the military and their families
Much is yet to be learned about the effects of the conflicts in Iraq and Afghanistan on members of the military and their families.  Among other things, these conflicts have brought multiple deployments for many, including members of the National Guard and Reserves, who may not have anticipated their prolonged absences from civilian life.  The conflicts affect not only those  on active duty exposed to violence and death, fear and uncertainty while in combat zones, but also the families left at home who  have also been shaken from their safe routines. 

Suicide, depression, anxiety, post-traumatic stress disorder, and the abuse of alcohol and drugs among military members have received considerable coverage as the conflicts have dragged on. But as we have seen with previous wars, the full range of effects may not become apparent for years.  Military and civilian leaders are attempting to find answers to these problems, but it remains unclear what success they are having. Can the military culture accommodate efforts to build resilience or to develop interventions for those already scarred?  Can civilian mental health and substance abuse treatment systems adapt to serve those whose disorders stem from military service?  Who is responsible for the families – including the families of the “citizen soldiers” in the Guard and Reserves?

State Budget Problems
With all but two states facing budget shortfalls in FY 2010, the economic recession has taken a significant toll on the ability of public mental health and substance abuse treatment systems to maintain the level of services they have traditionally provided.  With demand for services increasing (see above), systems in most states have been faced with difficult choices. 

Typically, states experience budget shortfalls for two years or more after a recession is said to have ended. So most anticipate the present fiscal crisis to continue through FY 2012 or later. States have made cuts across a range of services, even though  some mental health agencies have been able to prevent even deeper cuts through increased reliance on Medicaid – especially thanks to the increased Federal match made available through ARRA.³³  

The Future of the “Specialty” System
Historically, care for Americans with serious mental illnesses has been provided and funded through dedicated state mental health agencies.  These agencies have evolved over time from custodians of huge state mental hospitals that once housed and employed thousands, into contracting and regulating bureaucracies that are much less visible in state government organizational charts.  While their role and functions have changed over time, state mental health agencies have retained responsibility for a population frequently shunned by the broader health and social welfare systems; state mental health agencies have provided a safety net for a population long relegated to separate but unequal status in our society.

Some now believe the need for distinct state mental health agencies may one day disappear. With passage of mental health parity and health reform legislation creating a pathway for the integration of mental health with overall health, it is possible to see a day when operation of a separate public mental health system may no longer be necessary. ³⁴

TIPS FOR REPORTERS 

• Your editor or assignment editor may feel uncomfortable discussing mental illness or may feel that your audience would rather read about something else. You can gently point out that there  is a large gap between the number of people affected by mental health and substance use disorders and the number who get help.  News stories, especially those with “real people,” can encourage readers or viewers to get help instead of trying to “tough out” a truly debilitating mental problem. (See the Patrick Kennedy example in the third tip below.)
  
• Like any field, the mental health and substance abuse communities are home to experts with ideologies or interests that may color their views or the information they provide.  Prominent voices in the field represent provider and industry associations, professional guilds, patients’ rights supporters, and advocates of involuntary treatment, to name a few.  The pharmaceutical industry’s support of both academic research and advocacy has received some press attention in recent years, and debate over its influence continues.  All of that noted, there is consensus with the community on the majority of policy issues.  The lesson, as with any reporting, is to determine and acknowledge the ties that may influence any expert consulted for a story on mental health or addiction.
  
• Many people with mental health or substance use disorders are motivated to seek help when they learn that prominent people are working to overcome similar problems.  For example, Rep. Patrick Kennedy (D-R.I.) has been open about his struggles with depression, alcoholism and addiction to prescription pain medication, saying “I hope my openness…and my acknowledgement that I need help will encourage others to get help if they need it.”³⁵   In the same vein, actress Glenn Close has worked with many mental health organizations to create Bring Change 2 Mind.org (bringchange2mind.org) to attack the stigma associated with mental illness. It’s worth asking whether the expert you are interviewing has a personal connection with mental illness or substance abuse, such as a family member who needed and sought care.
  
• Where can you find people with mental illnesses who are willing to be interviewed? Try the national office or your state affiliate of Mental Health America or the National Alliance on Mental Illness. Also check out the Bazelon Center for Mental Health Law (www.bazelon.org) for access to people with serious mental disorders and information on other mental health policy issues.
  
• There are mental health and substance agencies in every state. For a list, check the website of the National Association of State Mental Health Programs – www.nasmhpd.org – and the National Association of State Alcohol and Drug Abuse Directors – www.nasadad.org.
  
• Check out articles on mental health and reducing stigma written by the Rosalynn Carter Mental Health Journalism Fellows. 

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STORY IDEAS 

• Advocates often point to higher levels of unemployment, homelessness, and arrests as outcomes of cuts to state budgets for mental health and substance abuse services.  Representatives of the criminal justice system, local businesses, and others also frequently see a connection between diminished access to mental health and substance abuse services and greater pressure on other public sectors.  If states reduce funding for mental health and substance abuse services, questions inevitably arise: Is this merely cost-shifting from one public sector to another? Will funding lost to the mental health and substance abuse treatment systems ever be recaptured when revenues increase?
   
• A number of cities, including Los Angeles, Seattle and Miami, have concluded that homeless people who are mentally ill should have secure housing before they can benefit from services for their mental problems.³⁶ Nationally, the movement is called “Housing First.”³⁷ With some history now behind it, how well  it is this idea working – for individuals and communities?
  
• History history is filled with examples of advances in civilian life that have military roots.  Many would say that racial desegregation, for example, had its start in the military.  One outcome of the current conflicts in Iraq and Afghanistan could  be improvement in our society’s approach to  mental health and substance use disorders and an end to the discrimination for seeking treatment.Will progress on this front be discernible in coming years?
  
• How are mental health and substance abuse services being integrated into general health care?  Has the extension of coverage made possible by recent legislation resulted in more access to treatment for people with mental health and substance use disorders?

ENDNOTES

¹ National Institute of Mental Health. “The Numbers Count: Mental Disorders in America.” (www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america.shtml#Intro).

² Substance Abuse and Mental Health Services Administration. “Results from the 2007 National Survey on Drug Use and Health: National Findings.” See Section 7.1 titled “Substance Dependence or Abuse.” (www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.cfm#TOC).

³ Substance Abuse and Mental Health Services Administration. “Results from the 2007 National Survey on Drug Use and Health: National Findings.” See subsection titled “Mental Health Service Use and Unmet Need for Mental Health Care among Adults” in Section 8.1. (www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.cfm#TOC).

⁴ Substance Abuse and Mental Health Services Administration. “Results from the 2007 National Survey on Drug Use and Health: National Findings.” See subsection titled “Mental Health Service Use and Unmet Need for Mental Health Care among Adults” in Section 8.1. (www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.cfm#TOC).

⁵ Substance Abuse and Mental Health Services Administration. “Results from the 2007 National Survey on Drug Use and Health: National Findings.” See Figure 8.7(www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.cfm#TOC).

⁶ Substance Abuse and Mental Health Services Administration. “Results from the 2007 National Survey on Drug Use and Health: National Findings.” See Section 7.1 titled “Substance Dependence or Abuse.” (www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.cfm#TOC).

⁷ Substance Abuse and Mental Health Services Administration. “Results from the 2007 National Survey on Drug Use and Health: National Findings.” See section 7.2 titled “Past Year Treatment for a Substance Use Problem.” (www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.cfm#TOC).

⁸ Mental Health America (2008). “Fact Sheet: Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.” (www.nmha.org).

⁹ National Institute of Mental Health. “The Numbers Count: Mental Disorders in America.” (www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america.shtml#Intro).

¹⁰ Artazcoz, Lucía; Benach, Joan; Borrell, Carme; Cortès, Immaculada (2004). “Unemployment and Mental Health: Understanding the Interactions Among Gender, Family Roles, and Social Class.” American Journal of Public Health, January, Vol. 94, No. 1, p. 82. (www.ajph.org/cgi/reprint/94/1/82.pdf).

¹¹ Substance Abuse and Mental Health Services Administration. “Results from the 2007 National Survey on Drug Use and Health: National Findings.” See subsection titled “Mental Health Service Use and Unmet Need for Mental Health Care among Adults” in Section 8.1. (www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.cfm#TOC).

¹² Levit, Katharine; Kassed, Cheryl; Coffey, Rosanna, and others (2008). “Future Funding For Mental Health And Substance Abuse: Increasing Burdens For the Public Sector.” Health Affairs Web Exclusive, Oct. 7, Exhibit 1, p. w515. (www.healthaffairs.org).

¹³ See, for instance, Kessler, Ronald; Heeringa, Steven; Lakoma, Matthew, and others (2008). “Individual and Societal Effects of Mental Disorders on Earnings in the United States: Results from the National Co-Morbidity Survey ReplicationAmerican Journal of Psychiatry, 165: 703-711, June. (http://ajp.psychiatryonline.org/cgi/content/abstract/165/6/703). See also: Mental Health America. “Mental Health Matters to America.” (http://www1.nmha.org/access/mentalhealthmatters.cfm).

¹⁴ For mental illness, there are three established forms of psychotherapy and six major categories of pharmacological treatment, including antipsychotics, antidepressants and anti-anxiety drugs. For substance abuse, treatments frequently combine psychotherapy and medications such as buprenorphine (for opioid use), and naltrexone and acamprosate (for alcohol abuse). These drugs, developed relatively recently, join methadone and disulfiram as effective treatments, and are frequently offered in conjunction with counseling, peer support and aftercare. See: Institute of Medicine (2006). “Improving the Quality of Health Care for Mental and Substance-Use Conditions” Chapter 1, p. 29-33; Mental Health: A Report of the Surgeon General, (1999). Chapter 2, Overview of Mental Illness and Introduction to Range of Treatments. (www.surgeongeneral.gov/library/mentalhealth/chapter2/sec6.html); Join Together Web site (www.jointogether.org/keyissues/medications/treatment-medications-readmore.html).

¹⁵ Substance Abuse and Mental Health Services Administration. “Results from the 2008  National Survey on Drug Use and Health: National Findings.” See Figure 8.9. (http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.cfm#8.1.11).

¹⁶ Substance Abuse and Mental Health Services Administration. “Results from the 2008 National Survey on Drug Use and Health: National Findings.” See subsection titled “Substance Dependence or Abuse” in Section 7.1. (http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.cfm#7.1).

¹⁷ See section B.4.3 at Substance Abuse and Mental Health Services Administration. “2008 National Survey on Drug Use & Health: National Results, Appendix C, Key Definitions.” U.S. Department of Health and Human Services. (http://www.oas.samhsa.gov/nsduh/2k8nsduh/AppB.htm).

¹⁸ Substance Abuse and Mental Health Services Administration. “Results from the 2008 National Survey on Drug Use and Health: National Findings.” See subsection titled “Substance Dependence or Abuse” in Section 7.1.

¹⁹ Substance Abuse and Mental Health Services Administration. “Results from the 2008 National Survey on Drug Use and Health: National Findings.” See Figure 7.2. (www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.cfm#TOC).

²⁰ Substance Abuse and Mental Health Services Administration. “Results from the 2008 National Survey on Drug Use and Health: National Findings.” See subsection titled “Substance Dependence or Abuse” in Section 7.1. (http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.cfm#7.1).

²¹ Substance Abuse and Mental Health Services Administration. “Results from the 2008 National Survey on Drug Use and Health: National Findings.” See subsection titled “Past Year Treatment for a Substance Abuse Problem” in Section 7.1. http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.cfm#7.1

²² Substance Abuse and Mental Health Services Administration. “Results from the 2008 National Survey on Drug Use and Health: National Findings.” See section 7.2 titled “Past Year Treatment for a Substance Use Problem.” (http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.cfm#7.2).

²³ Substance Abuse and Mental Health Services Administration. “Results from the 2008 National Survey on Drug Use and Health: National Findings.” See subsection titled “Age” in Section 7.1. (http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.cfm#7.1.2).

²⁴ Substance Abuse and Mental Health Services Administration. “Results from the 2008 National Survey on Drug Use and Health: National Findings.” See subsection titled “Gender” in Section 7.1. (http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.cfm#7.1.3).

²⁵ 14.3 million adults had at least one major depressive episode in 2008. Of these, 20.3 percent were also dependent on, or abused, alcohol or illicit drugs, yielding 2.9 million individuals with both problems. Source: Substance Abuse and Mental Health Services Administration. “Results from the 2008 National Survey on Drug Use and Health: National Findings.” See subsections “Prevalence of Major Depressive Episode among Adults” and “Major Depressive Episode and Substance Use and Dependence or Abuse among Adults” in Section 8.1. (http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.cfm#8.1.7).

²⁶ Dixon, Lisa; Weiden, Peter; Delahanty, Janine, and others (2000). “Prevalence and correlates of diabetes in national schizophrenia samples. Schizophrenia Bulletin, 26, pp. 903-912. (http://schizophreniabulletin.oxfordjournals.org/cgi/reprint/26/4/903).

²⁷ National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council (2006), “Morbidity and Mortality in People with Serious Mental Illness.” pp. 4-ff. (http://www.nasmhpd.org/general_files/publications/med_directors_pubs/Mortality%20and%20Morbidity%20Final%20Report%208.18.08.pdf)

²⁸ World Health Organization (2008). “The World Health Report 2008: Primary Health Care – Now More Than Ever.” pp. 8-9. (www.who.int/whr/2008/whr08_en.pdf).

²⁹ Substance Abuse and Mental Health Services Administration. “Results from the 2007 National Survey on Drug Use and Health: National Findings.” See subsection titled “Mental Health Care among Adults with Co-Occurring Serious Psychological Distress and Substance Use Disorders” in Section 8.1. (www.oas.samhsa.gov/nsduh/2k7nsduh/2k7Results.cfm#TOC).

³⁰ Bolton, James; Robinson, Jennifer; Sareen, Jitender (2008). “Self-medication of mood disorders with alcohol and drugs in the National Epidemiologic Survey on Alcohol and Related Conditions.” Journal of Affective Disorders, Nov. 11. (www.sciencedirect.com).

³¹ Emmet, William (2009). “Testimony by William Emmet, Director, Campaign for Mental Health Reform, Senate Health, Education, Labor, and Pensions, Committee.” January 22, p. 3. (http://help.senate.gov/Hearings/2009_01_22/Emmet.pdf).

³² Emmet, William (2009). “Testimony by William Emmet, Director, Campaign for Mental Health Reform, Senate Health, Education, Labor, and Pensions, Committee.” January 22, pp. 3-4. (http://help.senate.gov/Hearings/2009_01_22/Emmet.pdf).

³³ National Association of State Mental Health Program Directors Research Institute, Inc. (2010), “The Impact of the State Fiscal Crisis on the Public Mental Health System”, Congressional Briefing, February 24, 2010, (http://www.nri-inc.org/reports_pubs/2010/NRI_SMHA_Budget_2010.pdf)

³⁴ “Will We Need a Separate Mental-Health System in the Future?”, The Wall Street Journal, WSJ.com, April 15, 2010, 2:40 PM ET

³⁵ USA Today (2006). “Rep. Patrick Kennedy to enter drug rehab.” May 4. (www.usatoday.com/news/washington/2006-05-04-kennedy-crash_x.htm)

³⁶ Hinton, Mick (2008). “Funding gives boost to homeless project.” Tulsa World, July 5. (www.tulsaworld.com)

³⁷ National Alliance to End Homelessness. “Housing First.” (www.endhomelessness.org/section/tools/housingfirst).