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Nation Receives a D for Mental Health Care:

NAMI’s Grading the States Report as an Effective Tool for Criminal Justice Advocates  


The National Alliance on Mental Illness (NAMI) has released a new report, Grading the States, assessing the nation's public mental health care system for adults and finding that the national average grade is a D.

Fourteen states improved their grades since NAMI's last report card three years ago. Twelve states fell backwards. Oklahoma showed the greatest improvement in the nation, rising from a D to a B. South Carolina fell the farthest, from a B to a D. However, the report comes at a time when state budget cuts are threatening mental health care overall.

NAMI's grades for 2009 include six Bs, 18 Cs, 21 Ds and six Fs, based on 65 specific criteria such as access to medicine, housing, family education, and jail diversion.

To read the full report, go to  To contact your state Governor or legislators about the contents of the report, click here.

Criminal Justice Findings

As a part of the 65 criteria used to grade each state, NAMI evaluated several measures related to the criminalization of people with mental illness. Most information was gleaned from a survey of state public mental health authorities, and confirmed through various fact-checking procedures.  NAMI divided this information into four categories, and criminal justice related measurements were included in Category IV: Community Integration and Social Inclusion.  As a whole, the nation scored a D on Category IV, indicating that in most states, people with mental illness are still housed in jails and prisons with few alternatives to incarceration.

The report notes innovations in many states, with advocates promoting police Crisis Intervention Teams, mental health courts and other jail diversion programs; and re-entry programs.  Most states have some of these programs, but few have strong state level leadership from the public mental health authority or other state agency.

In addition, most states do not have policies that suspend rather than terminate Medicaid benefits during incarceration, and restore them upon release. Such policies are important to ensure that people re-entering after incarceration have access to life-saving medical care, which reduces their risk of further incarceration.

Each state report card includes detailed information about state support for CIT, mental health courts, re-entry programs, and Medicaid benefits restoration, including whether the state scored below or above the national average. Advocates can use this information, in conjunction with the state narratives, to help push governors, legislators and local officials to make reducing criminalization a priority in their states and communities. Many NAMI state organizations have prioritized de-criminalization and welcome collaboration with their partners in the criminal justice community. To find your state or local NAMI, visit

Other Findings

State by state, this assessment of our nation’s public mental health services finds that we are painfully far from the high-quality system we envision and so desperately need. While some states are making consistent efforts to improve, the great majority are making little or no progress. NAMI’s principal finding is clear: the state of mental health services in this country is simply unacceptable.

While the nation earned a D overall, there are certainly some improvements across the country to be noted:

  • Fourteen states increased their overall score over the past three years; one more state earned a B; and two fewer states failed outright.
  • In many cases, NAMI found state mental health agencies making valiant efforts to improve systems and promote recovery despite rising demand for services, serious workforce shortages, and inadequate resources.
  • Many states are adopting better policies and plans, promoting evidence-based practices, and encouraging more peer-run and peer-delivered services.

But these improvements are neither deep nor widespread enough to improve the national average. The grades for almost half the states (23) remain unchanged since 2006, and 12 states have fallen behind.

The top-performing states—and there were only six of them—received a B grade. Yet even these states are hardly in a position to celebrate since there is no doubt that many of their residents living with serious mental illnesses are not receiving the services and supports they need. Further, while the “B states” scored better than others on a series of measures, their performance shares a critical limitation with all the states: they do not know what share of people in need their systems serve, or how well people fare once they are served. It is a tragic reality that no state in the nation is able to pass this true test of a mental health system’s performance.

As in 2006, the majority of states earned a C or a D grade (18 and 21 states, respectively). These states present a mix of strengths and weaknesses as their category-specific grades reveal. Finally, NAMI finds that public mental health care systems in six states are failing outright—in few of the categories we examined are they performing at even the lowest acceptable levels. These six failing states include South Dakota, which chose not to participate in the survey.

Without a significant commitment from our nation’s leaders—in Washington, among governors, and in state legislatures—state mental health agencies will continue to struggle to provide even minimally adequate services to people living with serious mental illnesses.

To read the complete findings of the report, click here

Policy Recommendations

The report contains five policy recommendations for putting the nation’s public mental health system on a path to maximum efficiency and effectiveness. 

Increase public funding for mental health care services.
It is well documented that failure to provide adequate mental health services and supports increases costs to other systems, such as corrections, emergency rooms, and public benefit programs. The recently signed federal economic stimulus bill will provide states with badly needed federal assistance to fund Medicaid. Additionally, some states have found innovative ways to generate new revenues for mental health services, such as re-allocation of resources, dedicated taxes such as sales taxes, mental health trust funds and other means.  The report provides specific examples of these innovations.   

Improve data collection, outcomes measurement and accountability.
Improvements in data collection and outcomes measurement are essential to making the case for more funding. Data collection must be standardized, with increased use of electronic health information technology.  Additionally, the federal government, particularly the Substance Abuse and Mental Health Services Administration (SAMHSA), should exert stronger leadership in developing meaningful outcome measures and enforcing good data reporting by state mental health agencies, all of which receive federal funds.

Integrate mental and physical health care.
Studies document that people with serious mental illnesses die on average 25 years younger than the rest of the population and have a higher risk of serious medical problems.  Although some states have started projects to better integrate mental and physical healthcare, coordination between mental health and primary care systems is generally very poor.  Positive steps such as co-locating mental health and healthcare practitioners at community health and mental health centers, ongoing screening for diabetes and hypertension, increased use of health and wellness programs, and smoking cessation programs should be implemented.

Promote recovery and respect.
People with serious mental illnesses often have negative experiences with the treatment system, including disrespectful or abusive treatment, victimization, or services that do not take into account a person’s cultural or language background.  Civil rights violations remain rampant in some inpatient psychiatric treatment facilities.  The use of peer counselors and peer specialists as service providers is a promising practice that should be more fully embraced.  Additionally, states should prioritize efforts to provide services that are culturally and linguistically competent.  Finally, adequate resources must be directed to federal agencies such as the U.S. Department of Justice charged with investigating civil rights violations and enforcing civil rights protections in inpatient treatment facilities.

Increase services for people with serious mental illnesses who are most at risk.
Acute care psychiatric beds and crisis stabilization services are significantly lacking for people who are most vulnerable, including those whose symptoms may prevent them from recognizing their need for treatment.  The federal Medicaid Institutions for Mental Diseases (IMD) exclusion serves as a barrier both to accessing inpatient treatment and re-directing resources into community services and should be eliminated.  Additionally, states should implement a full range of strategies to improve adherence to treatment, including   Assertive Community Treatment programs, peer supports, psychiatric advance directives, motivational strategies such as the LEAP program, and assisted outpatient treatment (AOT).

To read the full policy recommendations section, click here.