Unmitigated Mission Creep: MHSA fails to stick to the mission of serving individuals with serious mental illness

When campaigning for Proposition 63, Senator Steinberg and mental health trade association head, Rusty Selix promised voters the funds would help people with serious mental illness.

“This measure will provide mental health services to people who need it most.” (emphasis added)
Darrell Steinberg, March 23, 2004

 “And (voters) didn’t want (Proposition 63) to fund all mental health, only people that had severe mental illness.”
Rusty Selix

Proposition 63 Findings and Declarations differentiated between mental illnesses and serious mental illnesses

Mental illnesses are extremely common; they affect almost every family in California. They affect people from every background and occur at any age. In any year, between 5% and 7% of adults have a serious mental illness as do a similar percentage of children — between 5% and 9%. Therefore, more than two million children, adults and seniors in California are affected by a potentially disabling mental illness every year. 

Proposition 63 made clear it was to help get services to people with serious mental illnesses:

Purpose and intent:  To “define serious mental illness among children, adults and seniors as a condition deserving priority attention…to reduce the long-term adverse impact on individuals, families and state and local budgets resulting from untreated serious mental illness…To expand…programs have already demonstrated their effectiveness in providing …medically necessary psychiatric services, and other services, to individuals most severely affected by or at risk of serious mental illness.”

There is little controversy as to who has “serious” mental illness. Proposition 63 and virtually all government agencies and non profits use roughly 5-9% of the population because they all rely on the National Institute of Mental Health (NIMH) the pre-eminent research arm of the US Government that addresses these issues. 5-9% is also supported by other research.(FN1) NIMH estimates overall 5% have “Serious Mental Illness” and breaks it down by diagnosis as follows:

Schizophrenia (NIMH defines all schizophrenia as “severe”)                1.1% of the population
The subset of major depression called “severe, major depression”       2.0% of the population
The subset of bipolar disorder classified as “severe”                             2.2% of the population
Total “severe” mental illness by diagnosis:                                      5.3% of the population

The above are overall figures. Within certain age groups NIMH research shows up to 8% have serious mental illness. This accounts for the 5-9% figure used in the legislation.

In spite of the above, MHSA funds are being used on people who may have any type of mental health problem rather than those with serious mental illness as required by the legislation. Worthy and unworthy social service programs started masquerading as mental health programs to make them eligible for funding. Tutoring, unemployment, bullying initiatives, crime reduction, bad marriages, prostitution, were all defined as mental health issues eligible for funding.

Prevention and Early Intervention (PEI) Funds must serve seriously ill

Legislative Language
(a)     The State Department of Mental Health shall establish a program designed to prevent mental illnesses from becoming severe and disabling. The program shall emphasize improving timely access to services for underserved populations.
(b) The program shall include the following components:

(1) Outreach to families, employers, primary care health care providers, and others to recognize the early signs of potentially severe and disabling mental illnesses.
(2) Access and linkage to medically necessary care provided by county mental health programs for children with severe mental illness, as defined in Section 5600.3, and for adults and seniors with severe mental illness, as defined in Section 5600.3, as early in the onset of these conditions as practicable.
(3) Reduction in stigma associated with either being diagnosed with a mental illness or seeking mental health services.
(4) Reduction in discrimination against people with mental illness.

Discussion: The purpose  is “to prevent mental illness from becoming severe and disabling”. It is not “to prevent mental illness” (which we don’t know how to do) or “improve mental health”. Outreach may only be to “recognize the early signs of potentially severe and disabling mental illnesses” not to recognize the signs of poor mental health, bad grades, potential unemployment. The outreach must be narrowly targeted. The responsibility to provide “access and linkage” is only to provide access and linkage “to medically necessary care” and even then, it is only for people who are already “with severe mental illness”. It does not prioritize “access and linkage” to non-medical care, or to people without “severe mental illness”. Stigma activities are limited to those that affect ‘being diagnosed with mental illness” or seeking services. The bulk of misdirected PEI funds are being driven through the ‘stigma’ requirement. CalMHSA, MHSAOC, county behavioral directors justify massive spending that does not focus on ‘serious mental illness’ by saying it ‘reduces stigma’ or discrimination. Most of that spending is unjustified and little of it is being done ‘cost-effectively’

(c) The program shall include mental health services similar to those provided under other programs effective in preventing mental illnesses from becoming severe, and shall also include components similar to programs that have been successful in reducing the duration of untreated severe mental illnesses and assisting people in quickly regaining productive lives.

Discussion: This does allow funds to be used for people with “mental illness” (20% of population) versus 5-9% who have “serious mental illness”. However, the funds may only be expended to prevent that mental illness “from becoming severe”. It also allows funding to reduce the duration of “untreated severe mental illness” (i.e., provide treatment). MHSAOC, county behavioral health directors, CalMHSA, MHA and others have read the last phrase “assisting people in quickly regaining productive lives” as freeing them from the responsibility to spend the money only on those with ‘severe mental illness’

(d) The program shall emphasize strategies to reduce the following negative outcomes that may result from untreated mental illness: (1) Suicide. (2) Incarcerations.  (3) School failure or dropout.  (4) Unemployment.  (5) Prolonged suffering. (6) Homelessness. (7) Removal of children from their homes.

Discussion: This paragraph allows funding to reduce 1-7 only insofar as they result from “untreated mental illness”.  Both conditions must be met: 1. Untreated mental illness and 2. One of the seven outcomes. MHSAOC, CA DMH, county behavioral health directors, MHA, NAMI, and others have used this provision to provide services that reduce the seven bullet points to people without mental illness.

(e) In consultation with mental health stakeholders, the department shall revise the program elements in Section 5840 applicable to all county mental health programs in future years to reflect what is learned about the most effective prevention and intervention programs for children, adults, and seniors.

Discussion: Many of the “most effective programs” for people with serious mental illness are not receiving funding. The best known would be Assisted Outpatient Treatment (Laura’s Law). The Department of Justice and all research shows it reaches those with “serious mental illness” and reduces arrest, incarceration, homelessness, suicide, suffering and other outcomes.  


FN1. 1. United States Public Health Service Office of the Surgeon General (2001). Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: Department of Health and Human Services, U.S. Public Health Service. 2. Department of Health and Human Services: Substance Abuse and Mental Health Services Administration (2002). National Household Survey on Drug Abuse: Volume I. Summary of National Findings; Prevalence and Treatment of Mental Health Problems. 3. Kessler, R. C., Berglund, P. A., Bruce, M. L., Koch, J. R., Laska, E. M., Leaf, P. J. et al. (2001). The prevalence and correlates of untreated serious mental illness. Health Services Research, 36, 987-1007