1. MENTAL HEALTH Group D Trey Perez Heather Rawls DJ Reid

2. Agenda Mental health overview Previous Legislation Current Legislation Republican and Democratic views Policy and Fiscal Implications Proposed Legislation

3. What is Mental Health The meaning of being mentally healthy is subject to many interpretations rooted in value judgments, which may vary across cultures. Mental health should not be seen as the absence of illness, but more to do with a form of subjective well being, when individuals feel that they are coping, fairly in control of their lives, able to face challenges, and take on responsibility.

4. Defined by WHO Mental health is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity specific to the individual’s culture (WHO).

5. What is Mental Illness? Mental illness refers collectively to all diagnosable mental health problems that become “clinical,” that is where a degree of professional intervention and treatment is required. Generally, the term refers to more serious problems, rather than, for example, a mild episode of depression or anxiety requiring temporary help (WHO).

6. History of Mental Health Policy Mental health has been shaped by cultural changes and major social policies designed with other populations in mind as well as by the efforts of persons working in the mental health field itself. (Center For Mental Health Services)

7. History of Mental Health Policy There have been significant improvements in treatment, public attitudes, and services organization, and enormous growth in mental health insurance coverage, treatment resources, episodes of care, and research of all kinds in the past 50 years. –Systems have transitioned from largely psychotherapy for the affluent and custodial institutional care for all others, to a range of outpatient services, inpatient care in various settings, residential care, and housing alternatives

8. History of Mental Health Policy The change that is currently transforming mental health care –The introduction and growth of managed behavioral health care –The work of mental health professionals.

9. Mental Health Economy: Past and Present Resource allocation of mental health care has been decentralized over the past 35 years. –1950’s: 75 percent of episodes of treatment were provided by public mental hospitals –1990’s: less than a quarter of treatment episodes are provided by publicly owned mental hospitals

10. Mental Health Economy: Past and Present 1950’s through the 1970’s the mental health system operated as a planned economy. Today, there is a market for insurance, services, and management of mental health systems. –The majority of individuals in the United States acquire their mental healthcare from private providers who compete for customers.

11. Disparity of Mental Health Services With the emergence of dramatic structural changes in mental health services over the past 50 years, disparities have been created, with the biggest disproportion of services being available to children and seniors located in rural settings.

12. Child and Adolescent Mental Health The MECA Study (Methodology for Epidemiology of Mental Disorders in Children and Adolescents) estimated that almost 21 percent of U.S. children ages 9 to 17 had a diagnosable mental or addictive disorder associated with at least minimum impairment.

13. Children and adolescents age 9–17 with mental or addictive disorders, combined MECA sample, 6-month (current) prevalence* * Disorders include diagnosis-specific impairment and CGAS < or = 70 (mild global impairment)

14. Child and Adolescent Mental Health The mental disorders affecting children and adolescents include the following (NIMH) : –Attention Deficit Hyperactivity Disorder (ADHD, ADD): Attention Deficit Hyperactivity Disorder (ADHD, ADD)Attention Deficit Hyperactivity Disorder (ADHD, ADD) ADHD/ADD, is one of the most common mental disorders that develop in children. Characterized by impulsiveness, hyperactivity, and inattention. ADHD/ADD, is one of the most common mental disorders that develop in children. Characterized by impulsiveness, hyperactivity, and inattention. –Autism Spectrum Disorders (Pervasive Developmental Disorders) Autism Spectrum Disorders (Pervasive Developmental Disorders)Autism Spectrum Disorders (Pervasive Developmental Disorders) Autism Spectrum Disorders (ASD), also known as Pervasive Developmental Disorders (PDDs), cause severe and pervasive impairment in thinking, feeling, language, and the ability to relate to others. –Bipolar Disorder Bipolar DisorderBipolar Disorder Bipolar Disorder, also known as manic-depressive illness, is a serious medical illness that causes shifts in a person's mood, energy, and ability to function.

15. Child and Adolescent Mental Health –Borderline Personality Disorder Borderline Personality DisorderBorderline Personality Disorder Borderline personality disorder (BPD) is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. –Depression Depression Depression is a disorder that affects an individuals thoughts, mood, feelings, behavior, and physical health. –Eating Disorders Eating DisordersEating Disorders Eating disorders involve serious disturbances in eating behavior, such as extreme and unhealthy reduction of food intake or severe overeating, as well as feelings of distress or extreme concern about body shape or weight. –Childhood-Onset Schizophrenia Childhood-Onset SchizophreniaChildhood-Onset Schizophrenia Schizophrenia is a chronic, severe, and disabling brain disorder.

16. Reported Mental Health Concerns: Gender and School Level School Mental Health Services in the United States. 2006. http://projectforum.org/docs/SchoolMentalHealthServicesintheUS.pdf * School Mental Health Services in the United States. 2006. http://projectforum.org/docs/SchoolMentalHealthServicesintheUS.pdfhttp://projectforum.org/docs/SchoolMentalHealthServicesintheUS.pdf

17. The Tragedy Most children and adolescents with psychiatric disorders do not get the help they need. If left untreated, the physical, emotional, social and intellectual development of children with mental disorders will be severely stunted, if not crippled. These children are at a heightened risk for school failure and dropout, drug abuse, and many other difficulties - all of which can be prevented by timely evaluation and appropriate treatment.

18. Elderly Adult Mental Health Mental health issues affect seniors differently than other age groups due to loss, physical health concerns, and economic and social changes acting either individually or in combination. Up to 25% of people over the age of 60 experience some kind of mental illness, particularly depression.

19. Elderly Adult Mental Health The lack of attention to the mental health problems of the elderly may be attributed to: – ageism –inadequate training of health care providers – the shortage of geriatric specialists –the need for more knowledge and research,

20. Medicaid Coverage of Mental Health Treatment There are certain mental health services that are mandatory under federal law and must be offered to all Medicaid beneficiaries in all states. –Inpatient and residential treatment –Outpatient physician and hospital services –Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Requires coverage of all optional services when necessary for a child.

21. Medicaid Coverage of Mental Health Treatment Mandatory eligibility covers pregnant women and children up to age 6 in families with incomes up to 133 percent of the federal poverty level and older children up to 100 percent of poverty. States can opt to raise these income limits to 185% or 133% of poverty respectively. States also have the option to cover children who qualify for the State Child Health Insurance Program (S-CHIP), whose families can have incomes as high as 250 percent of poverty

22. Medicaid Coverage of Mental Health Treatment A large number of individuals with mental disorders on Medicaid are eligible because they receive federal disability benefits. Over a quarter of those receiving Supplemental Security Income (SSI) disability benefits, 1.4 million, are people with psychiatric disabilities. Generally, SSI recipients fall within the mandatory eligibility category.

23. Medicaid Coverage of Mental Health Treatment Medicaid also offers coverage of individuals who have high medical costs and who can qualify as “medically needy.” –These individuals must still meet the eligibility standards of some category of Medicaid (such as by being disabled), but need not meet the Medicaid income test –These individuals must still meet the eligibility standards of some category of Medicaid (such as by being disabled), but need not meet the Medicaid income test

24. Medicare Coverage of Mental Health Treatment Hospitalization: Medicare covers care in specialized psychiatric hospitals which only treat mental illness when in-patient care is needed for active psychiatric treatment. –pays for necessary in-patient hospitalization for up to 90 days per benefit period. Partial hospitalization programs offer intensive psychiatric treatment on an outpatient basis to psychiatric patients, with an expectation that the patient’s psychiatric condition and level of functioning will improve and that relapse will be prevented so that re-hospitalization can be avoided

25. Medicare Coverage of Mental Health Treatment Medicare covers needed diagnostic and treatment services provided by physicians, including psychiatrists, as well as clinical psychologists, social workers, psychiatric nurse specialists, nurse practitioners and physicians assistants. Medicare pays for home health services for individuals who require skilled care on a part-time or intermittent basis and who are confined to the home. People with mental health needs who meet these eligibility criteria are eligible for care in their home, even if they have no physical limitations

26. Medicare Coverage of Mental Health Treatment LIMITATIONS: –Reimbursement for certain psychiatric services differs from the usual Medicare reimbursement rules. Medicare Part B generally reimburses doctors at 80% of the approved amount; the patient pays the remaining 20% coinsurance amount. When a claim is for mental health services, Medicare makes an initial deduction of 37½ % before paying 80% of the charge. As a result, the Part B reimbursement is, on average, about 50% of the charge.

27. Medicare Coverage of Mental Health Treatment It is recommended that individuals need to consider carefully how to supplement their Medicare coverage –Medigap policy –Retiree health policy –Through Medicaid

28. Previous Legislative Efforts: Keeping Families Together Act of 2007 To amend the Public Health Service Act to establish a State family support grant program to end the practice of parents giving legal custody of their seriously emotionally disturbed children to State agencies for the purpose of obtaining mental health services for those children. Introduced by Rep. Jim Ramstad (R-MN3) PURPOSE: To assist States in eliminating the practice of parents giving custody of their seriously emotionally disturbed children to State agencies for the purpose of securing mental health care for those children Referred to the House Committee on Energy and Commerce

29. Previous Legislative Efforts: Mental Health Parity Act of 2007 To amend the Public Health Service Act with respect to mental health services for elderly individuals. Introduced by Sen. Pete V. Domenici (R-NM) STATEMENT OF PURPOSE- To provide parity between health insurance coverage of mental health benefits and benefits for medical and surgical services. Referred to Committee on Health, Education, Labor, and Pensions

30. Previous Legislative Efforts: Seniors Mental Health Access Improvement Act of 2007 To amend the Social Security Act to provide for the coverage of marriage and family therapist services under part B of the Medicare Program, and for other purposes. Introduced by Rep. Edolphus Towns (D-NY). –Co-Sponsored by Rep. Charles W. Pickering (R-MS3) Effective: The amendments made by this Act apply with respect to services furnished on or after January 1, 2008.

31. Bill S. 633 of the 110 th Congress Title “Working Together for Rural Access to Mental Health and Wellness for Children and Seniors Act” –Introduced by Sen. Norm Coleman (R-MN) –February 15, 2007 –Referred to Committee on Health, Education, Labor, and Pensions

32. Findings In rural areas, where specialized mental health services are scarce, accessing mental health professional services is difficult. Rural primary care providers have experienced an increase in mental health issues recently Surgeon General estimates 21% of children experience mental health systems, which left untreated can lead to school failure, drug abuse, and often incarceration The Department of Health and Human Services estimates 1 in 5 children and adolescents have diagnosable disorders, yet close to 80% receive no help

33. Findings continued… Few schools have the resources and funding available to implement a full range of mental health interventions Mental health is a fundamental cornerstone to ensure children have the opportunity to be successful in school Promoting and expanding telemental health collaborations to strengthen delivery of mental health services in remote and underserved areas is needed Telemental health is effective at diagnosing and treating mental health disorders and can provide better access and care to rural areas –Telemental health is the use of videoconferencing or similar means of electronic communication to provide mental health services

34. Grant Program Continued… Amount of Funding: The Secretary shall award a grant to a State under this section in an amount that is based on the respective number of critical access hospitals (as defined in section 1861 (mm)(1) of the Social Security Act (42 U.S.C. 1395x(mm)(1)) in the State as such compares to the total number of critical access hospitals in all States that are awarded grants under this section

35. Purpose Provide assistance to rural schools, hospitals, and communities through collaborative efforts to secure progressive and innovative systems to provide mental healthcare access and treatment for youth, seniors, and families Increase access to elementary and secondary schools to mental health services in rural areas through the use of a mobile health services van program Increase access to individuals of all ages to mental health services in rural areas by utilization of telemental health services established in the areas

36. Grant program State grants shall be awarded by the Secretary of Health and Human Services for the purpose of issuing subgrants to carry out the purposes of this act Eligibility: States shall be deemed eligible by submitting an application with all pertinent information required, establishing a lead agency, and submitting a state plan

37. State Lead Agency The governor of each state shall be responsible for selecting a Lead agency (other than the State Office of Rural Health) to administer the State programs The lead agency shall administer directly or through other agencies the awarded funding The lead agency will also be responsible for forming the state plan which will coordinate the expenditures in consultation with state and local representatives of educational agencies, rural mental health providers, and the state hospital association

38. The State Plan 1. Establish lead agency 2. Assure that the state will use funding in the following areas: 1.Provide mobile van services for elementary and secondary education students 2.Provide telemental health services to individuals of all ages in rural areas, and cover all administrative costs associated with these grant recipients 3. Assure that the grant benefits will be available throughout the entire state 4. Assure the lead agency will consult mental health providers and state hospital associations to assess appropriate fund utilization

39. Eligibility Located in or serving a rural area Government owned or non-profit hospital Community mental health facility Primary care clinic Other non-profit agency providing mental health services Selection will be based on an applicants need to improve mental health care access within a community and the extent to which it will serve rural low-income populations. All applicants must submit a comprehensive outline of all procedures, evaluations, measurements, and must keep a record and reports available to the Secretary at all times for oversight.

40. Fund Utilization Mobile vans –Offset all costs incurred after Dec. 31, 2007 –Purchase or lease of vehicle –Repairs and maintenance –Purchase or lease of communication equipment –Education and training of staff using the van –Professional staff employment

41. Fund Utilization Continued… Telemental health services –Offset all costs incurred after Dec. 31, 2007 –Purchasing, leasing, maintaining, and repairing all telemental health equipment –Telecommunications, utility, and software upkeep and purchase –Education and training to telemental health service staff –Professional staff employment

42. Limitations $10,000,000 in appropriations for the program for each fiscal years 2008 to 2010 Each subgrant shall not exceed $300,000 for one fiscal year The Secretary shall review and monitor State compliance with the requirements of this section and the State plan and will be able to suspend payments to states if compliance is not satisfactorily met

43. Republicans vs. Democrats

44. Issues with mental healthcare Parity of mental health care Major issue is that mental health is not cost beneficial Mental health problems cost too much since they are chronic Myth? What about heart disease, diabetes, asthma? Chronic physical diseases. Substance abuse and rehabilitation Should treatment medications be covered by Medicare/Medicaid?

45. Democrats

46. Democratic Party view on mental health Want healthcare to be available and affordable to everyone and provided by the state Democrats believe that mental healthcare is needed for veterans. War costs are not just bullets and guns, but taking care of returning veterans both physically and mentally.

47. Republicans

48. Republican view on mental healthcare Increase the number of citizens with health insurance Make private insurance more affordable Move away from government funding Limit mental healthcare by providers, especially Medicare and Medicaid

49. Republicans (cont.) “senior House Republicans and business groups are staunchly opposed to the deal” -Deal was to include coverage of mental healthcare in insurance “The compromise would outlaw disparities in coverage between mental and physical illness under group health plans sponsored by employers with more than 50 workers”

50. Similarities Both consider mental health as an important part of a healthy life Both parties want to end discrimination in the work place (insurance discrimination) Both want equitable mental healthcare 98% of Americans think mental health should be covered by insurance 83% of Republicans and 92% of Democrats want equitable health insurance 89% of both employees AND employers want mental health care coverage

51. Similarities (cont.) “That movement has galvanized Congress. Senators Pete V. Domenici, Republican of New Mexico, and Paul Wellstone, Democrat of Minnesota, have, for more than five years, led a campaign to translate the idea of parity into law.” -- Robert Pear, New York Times Dec. 2001

52. Similarities (cont.) ''It's a real battle,'' Mr. Specter said Bush says people should have the access to the care they need. But is concerned with increasing costs of healthcare Dilemma

53. Policy and Fiscal Implications

54. The Presidents New Freedom Commission on Mental Health: Achieving the Promise, Transforming Mental Health Care in America (2003) Final report by President Bush’s Freedom Commission on Mental Health Recognizes the critical role schools can play in the continuum of mental health services Emphasizes building a mental health system that is evidence-based, recovery- focused and consumer- and family-driven

55. Freedom Commission on Mental Health 15 member commission appointed by Bush in 2003 to examine the Mental Health System in the U.S. Over the course of a year through public hearings, site visits, written and oral testimony from experts, and comments and concerns received through the Internet the committee concluded “the system was in shambles.” Analysis of all the reports and findings suggested that the only way to create an effective and efficient mental health system was to fundamentally transform the system.

56. Findings of the Commission The principle findings emphasized the mental health systems need to be equivalent to the public health system –better access for all, equity in treatment and funding, and a reduction of stigma. MHS was built around a delivery and payment system instead of the needs of MHS recipients and their families, frequently resulting in unsatisfactory outcomes. The public mental health system failed to employ evidence-based practices or the newest technologies and the commission confirmed that a person’s race, ethnicity, or geographical location could compromise his or her access to services. The Commission recommended the creation of a comprehensive mental health plan in each state.

57. New Freedom Commission on Mental Health (NFC) Focusing on State activities related to six goals for transforming mental health systems from the President’s New Freedom Commission Report.

58. 1) Organization and Structure Component: to whom the SMHA commissioner/director is accountable; responsibility for a variety of mental health services, including State mental hospitals, community mental health programs, and forensic programs; ways in which community-based mental health services are funded 2) Policy Component: Contains information on priority clients and mandates for core services; other service system requirements, standards, and future directions; activities relating to downsizing, closing, or consolidating State mental hospitals; privatizing components of the public mental health system; and major legal issues involving the SMHA

59. 3) Client Component: Contains aggregated data characterizing individuals served by the SMHA in State mental hospitals and community-based programs. 4) Services Component: Describes the nature of the service system supported by each SMHA in three broad areas. (1) SMHA service system issues include the types of services offered by the SMHA in State hospitals and community programs, the definitions of these services, linkages of services among institutions and communities, and the role of different services within the SMHA’s desired service system. (2) Linkages to other State services systems include information about the linkages between the SMHA mental health system and other State agencies that provide services for individuals with mental illness. (3) Information on the implementation of various evidence-based practices by SMHAs is a new focus in this component.

60. 5) Forensic Component: Contains information about the organization and delivery of services to forensic clients by the SMHA and the relationship of the SMHA to the criminal justice systems in each State. 6) Workforce Component: Staffing levels of State-operated and State-funded mental health services provider organizations; minority workforce issues; client to staff ratios; recruitment, training, and retention of staff; salary levels; and workers’ compensation.

61. 7) Financial Component: Includes the forms and information necessary to complete the annual SMHA-controlled Revenues and Expenditures Study plus information about the resources available to the SMHAs and the States to fund the delivery of mental health services. 8) Managed Behavioral Health Care: The use of managed care to deliver public mental health services, the roles of Medicaid waivers, and how traditional SMHA-funded providers interact with managed care organizations.

62. 9) Research and Evaluation Component: Organizational locus of the research and evaluation functions and their funding and staffing levels. 10) Information Management Component: Current status of the information management function and its development over time. The component provides for a systematic compilation of the organizational placement of information management functions, the level of integration of these functions, and their funding and staffing.

63. The Need for Early Intervention 3-5% of school age children diagnosed with ADHD 13% of kids 9-17 diagnosed with variety of anxiety disorders

64. Most Frequent Reported Barriers to Mental Health Services Financial Constraints of Families –Lack of Insurance –Inability to afford private pay services Limited school and community-based resources

65. “No Child is Left Behind.” With effective school- wide programs, support and funding, many teachers could strengthen their focus on the academics, problem- solving and critical thinking skills essential for students to acquire and spend less time managing difficult behaviors.

66. What are our schools doing to help? 87% of schools reported providing behavioral/emotional assessments, behavior management consults and crisis intervention as primary mental health services, only 59% of schools reported using curriculum-based programs to enhance social and emotional functioning 15% reported conducting school-wide screening for behavioral or emotional problems. If schools placed greater focus on school-wide behavior prevention and social-emotional early intervention programs, perhaps there would be less need for individually focused services of behavior assessments, management consultations and crisis intervention.

67. Burden of Disease Data developed by the massive Global Burden of Disease study conducted by the World Health Organization, the World Bank, and Harvard University, reveal that mental illness, including suicide, accounts for over 15 percent of the burden of disease in established market economies, such as the United States. Global Burden of Disease studyGlobal Burden of Disease study

68. Controlling costs Public mental hospitals have been reduced or downsized from 560,000 resident patients in 1955 to fewer than 60,000 clients today, despite sizable population growth. Most acute inpatient care is now in general hospitals; and although case-mix and co-morbidity are more complex, average length of stay has fallen steadily to less than 10 days, and continues to fall. In the period 1988 to 1994, some 12.5 million days were reduced in mental hospital care with only small compensation in days of care in the general hospital sector (Mechanic, McAlpine, & Olfson, 1998). The introduction of managed care in the private sector has reduced expenditures of some large corporate purchasers by as much as 30–40 percent, with most of these reductions achieved by large reductions in average length of stay (Feldman, 1998; Mechanic & McAlpine, 1999).

69. Socioeconomic status has one of the strongest associations with the prevalence of mental disorders Social policies have a major role in making treatment available. Persons with serious and persistent mental illness remain perhaps the most disadvantaged and neglected group in our society and suffer from the failures of American health care policy. Decision processes do not sufficiently sensitize the seriousness and complexity of mental illness, and the patients with the most severe illnesses appear to do worse under present managed care arrangements as compared to fee-for- service practice.

70. Out of Sight, Out of Mind, Yet Expensive A Justice Department study estimated that in midyear 1998, there were more than 280,000 persons with mental illness in jails and prisons, and more than a half million more on probation (Ditton, 1999).

71. Olmstead vs. L. C: a possible solution? (ADA) and the U.S. Supreme Court decision which required the State of Georgia to provide community care to persons with mental illnesses and mental retardation who could function in such less restrictive settings without placing an undue burden on the State or requiring that the State establish a particular type of program.

72. Mental Healthcare Provider Rural Incentive Act

73. Target Groups ChildrenSeniors Medicare recipients Undeserved/low income Those on Medicaid

74. Rationale and Purpose Improve access to mental health care in rural communities. Incentives for doctors to work in rural settings

75. Mechanism Mental health doctors/psychiatrists will commit to work in a rural community for a minimum of two years. They must commit at least 12 hours per week for 50 weeks of the year in a rural community mental health clinic or facility. In return, doctors will be offered grants 1. Categorical grant - for up to 4 years of work - Must be spent to repay loans 2. Block grant - Meant to provide doctor with startup capital for private practice or clinic.

76. Mechanism Lead Agencies will determine the communities that will qualify as “rural” and areas that qualify doctors for these incentives Lead Agency established from Bill S. 633 - Working together for rural access to mental health and wellness for children and seniors act

77. Financing Up to $100,000 in Categorical Grant –Approx. $25,000 per year for first four years in qualifying rural setting –Must be used to repay loans used for educational purposes

78. Financing Up to $100,000 in other grants for fulfilling rural work obligation to help with “start up” costs. –$20,000 block grant minimum Can be used as doctor sees fit; i.e. pay off additional debt, start up practice, etc. –Up to $100,000 in project-like grant for private uses To be used for establishing practices in rural communities Larger grants will be given on an as-needed basis (for example in those communities where startup costs may be higher) but will not exceed $100,000

79. Financing Services rendered will be covered by Medicare, Medicaid, and private insurance –Mental Health Parity Act of 2007 (S. 558), states that all insurance must provide equity in the care and treatment of mental and physical illnesses –“the financial requirements applicable to such mental health benefits are no more restrictive than the financial requirements applied to substantially all medical and surgical benefits covered by the plan”

80. Outcomes Increase access to mental health care for populations in rural settings To eliminate healthcare (particularly mental healthcare) disparities among rural and urban and suburban communities –Provide better care and treatment for the children, seniors and impoverished populations

81. Summary Eliminate disparities for mentally ill in rural areas by encouraging psychiatrist and other mental health related physicians to work in these settings Incentives are monetary in forms of grants to pay off loans and to provide capital to establish local practice in a rural community

82. References Treatment of Children with Mental Disorders. 2006. http://www.nimh.nih.gov/publicat/adhd.cfm School Mental Health Services in the United States. 2006. http://projectforum.org/docs/SchoolMentalHealthServicesintheUS.pdf http://projectforum.org/docs/SchoolMentalHealthServicesintheUS.pdf Mental Health, United States 2000: Chapter 7. 2000. http://mentalhealth.samhsa.gov/publications/allpubs/SMA01- 3537/chapter7.asp http://mentalhealth.samhsa.gov/publications/allpubs/SMA01- 3537/chapter7.asp Mental Health, United States 2000: Chapter 8. 2000. http://mentalhealth.samhsa.gov/publications/allpubs/SMA01- 3537/chapter8.asphttp://mentalhealth.samhsa.gov/publications/allpubs/SMA01- 3537/chapter8.asp. http://mentalhealth.samhsa.gov/publications/allpubs/SMA01- 3537/chapter8.asp Geriatric Mental Health Foundation. http://www.gmhfonline.org/gmhf/consumer/factsheets/depression_latelife.ht ml http://www.gmhfonline.org/gmhf/consumer/factsheets/depression_latelife.ht ml

83. Republican And Democratic Voters Overwhelmingly Support Fair Mental Health Insurance Coverage. Medical News Today. Jan 16, 2007. http://www.medicalnewstoday.com/medicalnews.php?newsid=60847 http://www.medicalnewstoday.com/medicalnews.php?newsid=60847 Democrats Working to Expand Veterans Mental Health Care. Democratic National Committee. 2007. http://www.democrats.org/a/2005/06/democrats_worki.php http://www.democrats.org/a/2005/06/democrats_worki.php Making Healthcare Affordable for Everyone. Republican National Committee. 2007. http://www.gop.com/Issues/HealthCare/. http://www.gop.com/Issues/HealthCare/ The Olmstead Decision. March 22, 2007 http://www.workworld.org/wwwebhelp/the_olmstead_decision.htm The National Institue of Mental Health. 2007. NIMH.gov Mental Health, United States 2000: Chapter 7. 2000. http://mentalhealth.samhsa.gov/publications/allpubs/SMA06-4195/chapter11.asp References