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Bush unveils mental health action plan New York

Jeanne Lenzer

President Bush has unveiled a federal action agenda for mental health in the United States, aimed at helping more patients to live in the community and removing some of the stigma of mental illness. It also recommends screening some groups of people for mental disorders.

The agenda, which is based on the earlier recommendations of the New Freedom Commission on Mental Health (BMJ 2003;327:248), has been praised by a number of organisations, including the American Psychiatric Association and the National Alliance for the Mentally Ill. But critics say the agenda includes the promotion of unproved screening examinations and a controversial treatment algorithm, known as the Texas medication algorithm project (TMAP) (BMJ 2004;328:1458).

One of the central goals of the action agenda—to help people with mental disabilities to live in the community, hold jobs, and participate in community life—has won widespread support. Other action agenda projects include outreach to educate the public about depression in men, because many men don’t seek help; suicide prevention initiatives; help for young people in the juvenile justice system to get jobs; projects to help parents avoid relinquishing custody of children with mental health problems; and the promotion of "toolkits" to provide mental health professionals with evidence based advice.

The federal plan is being coordinated by the Substance Abuse and Mental Health Services Administration, which is part of the Department of Health and Human Services in Rockville, Maryland. Mark Weber, spokesman for the administration’s Center for Mental Health Services, said that roughly $24bn (£13bn; €20bn) would be made available annually for the reforms. The cash is not all new money but includes funds for existing projects, which will be brought into the federal plan. He said the action agenda is the result of "unbelievable cooperation and collaboration" among the agencies that will ensure a "coordinated approach to treat mental health in a way that is unprecedented."

One of the projects endorsed by the commission and incorporated into the plan is the TMAP. Mr Weber said the algorithm is a plan for best practice. But Stefan Kruszewski, a psychiatrist who exposed the overprescribing of psychotropic drugs to young people in state custody in Pennsylvania (BMJ 2004;329:69), criticised the federal action agenda for adopting the TMAP.

He said, "TMAP was marketed as a guide to safer and more effective [psychotropic] drugs than the cheaper, existing medications." But he said that the drugs promoted by the algorithm are neither safer nor more effective. "The newer atypical antipsychotics and SSRIs [selective serotonin reuptake inhibitors] have positive features, but these are often overshadowed by their negative effects, such as obesity, diabetes, and suicidality."

He added that the algorithm was launched "with considerable contributions from multiple drug companies to support an advantage to high priced, on-patent [drugs] made by the same drug companies that were underwriting TMAP."

Robert Sheehan, a member of the National Council for Community Behavioural Healthcare, said in evidence to Congress earlier this month that budget cuts threatened to undermine the components of the agenda which supported self care and case management. Budget reconciliation legislation that will slash roughly $10bn from mental health services was expected to clear the House Committee on Energy and Commerce and the Senate Committee on Finance as the BMJ went to press.

A controversial scheme in the original proposals of the New Freedom Commission on Mental Health to screen US citizens "of all ages" has been modified in the new mental health agenda. The agenda’s formulators now say they do "not recommend mandatory nor universal screening for mental health problems."

But one of the steps in the agenda is the launch of the National Action Alliance for Suicide Prevention, a "public-private partnership," whose role includes support for organisations such as the Suicide Prevention Resource Center (www.sprc.org/whatweoffer/factsheets/columbia-teenscreen.pdf ). This centre promotes programmes such as TeenScreen, which was developed by Columbia University and which is being used across the US. The TeenScreen programme encourages the "universal" voluntary screening of all teenagers and has given away free cinema tickets to students to encourage them to discuss and possibly come forward for screening (www.teenscreen.org /).

Details of the federal action agenda are at www.samhsa.gov/Federalactionagenda/NFC_TOC.aspx