Young Adults With Serious Mental Illness: Some States and Federal
Agencies Are Taking Steps to Address Their Transition Challenges 
(23-JUN-08, GAO-08-678).					 
                                                                 
The transition to adulthood can be difficult for young adults who
suffer from a serious mental illness, such as schizophrenia or	 
bipolar disorder. When these individuals are unsuccessful, the	 
result can be economic hardship, social isolation, and in some	 
cases suicide, all of which can pose substantial costs to	 
society. Due to concerns about young adults with serious mental  
illness transitioning into adulthood, GAO was asked to provide	 
information on (1) the number of these young adults and their	 
demographic characteristics, (2) the challenges they face, (3)	 
how selected states assist them, and (4) how the federal	 
government supports states in serving these young adults and	 
coordinates programs that can assist them. To do this work, GAO  
analyzed data based on national surveys, including the National  
Comorbidity Survey Replication (NCS-R), and administrative data  
from the Social Security Administration (SSA). GAO also reviewed 
published research; interviewed federal, state, and local	 
officials, as well as mental health providers, experts, and	 
advocacy groups; and conducted site visits in Connecticut,	 
Maryland, Massachusetts, and Mississippi --four states that focus
on this population. GAO did not make any recommendations. HHS	 
made comments intended to clarify the report and we made changes 
as appropriate. 						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-678 					        
    ACCNO:   A82485						        
  TITLE:     Young Adults With Serious Mental Illness: Some States and
Federal Agencies Are Taking Steps to Address Their Transition	 
Challenges							 
     DATE:   06/23/2008 
  SUBJECT:   Aid for the disabled				 
	     Community-based mental health services		 
	     Disability benefits				 
	     Disadvantaged persons				 
	     Employment assistance programs			 
	     Employment of the disabled 			 
	     Federal aid programs				 
	     Federal aid to states				 
	     Federal/state relations				 
	     Housing programs					 
	     Mental health					 
	     Mental health care services			 
	     Mental illnesses					 
	     Persons with disabilities				 
	     Policy evaluation					 
	     Program evaluation 				 
	     Surveys						 
	     Youth						 
	     Youth employment programs				 
	     Program coordination				 
	     Social programs					 
	     DOL Job Corps Program				 
	     Formula Grants Program				 
	     HHS John H. Chafee Foster Care			 
	     Independence Program				 
                                                                 
	     HUD Youthbuild Program				 
	     WIA Youth Activities Program			 

******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO Product.                                                 **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
******************************************************************
GAO-08-678

   

This text file was formatted by the U.S. Government Accountability 
Office (GAO) to be accessible to users with visual impairments, as part 
of a longer term project to improve GAO products' accessibility. Every 
attempt has been made to maintain the structural and data integrity of 
the original printed product. Accessibility features, such as text 
descriptions of tables, consecutively numbered footnotes placed at the 
end of the file, and the text of agency comment letters, are provided 
but may not exactly duplicate the presentation or format of the printed 
version. The portable document format (PDF) file is an exact electronic 
replica of the printed version. We welcome your feedback. Please E-mail 
your comments regarding the contents or accessibility features of this 
document to [email protected]. 

This is a work of the U.S. government and is not subject to copyright 
protection in the United States. It may be reproduced and distributed 
in its entirety without further permission from GAO. Because this work 
may contain copyrighted images or other material, permission from the 
copyright holder may be necessary if you wish to reproduce this 
material separately. 

Report to Congressional Requesters: 

United States Government Accountability Office: 
GAO: 

June 2008: 

Young Adults with Serious Mental Illness: 

Some States and Federal Agencies Are Taking Steps to Address Their 
Transition Challenges: 

GAO-08-678: 

GAO Highlights: 

Highlights of GAO-08-678, a report to congressional requesters. 

Why GAO Did This Study: 

The transition to adulthood can be difficult for young adults who 
suffer from a serious mental illness, such as schizophrenia or bipolar 
disorder. When these individuals are unsuccessful, the result can be 
economic hardship, social isolation, and in some cases suicide, all of 
which can pose substantial costs to society. 

Due to concerns about young adults with serious mental illness 
transitioning into adulthood, GAO was asked to provide information on 
(1) the number of these young adults and their demographic 
characteristics, (2) the challenges they face, (3) how selected states 
assist them, and (4) how the federal government supports states in 
serving these young adults and coordinates programs that can assist 
them. 

To do this work, GAO analyzed data based on national surveys, including 
the National Comorbidity Survey Replication (NCS-R), and administrative 
data from the Social Security Administration (SSA). GAO also reviewed 
published research; interviewed federal, state, and local officials, as 
well as mental health providers, experts, and advocacy groups; and 
conducted site visits in Connecticut, Maryland, Massachusetts, and 
Mississippi ï¿½four states that focus on this population. 

GAO did not make any recommendations. HHS made comments intended to 
clarify the report and we made changes as appropriate. 

What GAO Found: 

GAO estimates that at least 2.4 million young adults aged 18 through 
26ï¿½or 6.5 percent of the non-institutionalized young adults in that age 
rangeï¿½ had a serious mental illness in 2006, and they had lower levels 
of education on average than other young adults. The actual number is 
likely to be higher than 2.4 million because homeless, 
institutionalized, and incarcerated persons were not included in this 
estimateï¿½groups with potentially high rates of mental illness. Among 
those with serious mental illness, nearly 90 percent had more than one 
mental disorder, and they had significantly lower rates of high school 
graduation and postsecondary education. GAO also found that about 
186,000 young adults received SSA disability benefits in 2006 because 
of a mental illness that prevented them from engaging in substantial, 
gainful activity. 

Young adults with serious mental illness can have difficulty finding 
services that aid in the transition to adulthood, according to 
researchers, public officials, and mental health advocates. Because 
available mental health, employment, and housing services are not 
always suited for young adults with mental illness, these individuals 
may not opt to receive these services. They also can find it difficult 
to qualify for adult programs that provide or pay for mental health 
services, disrupting the continuity of their treatment. Finally, 
navigating multiple discrete programs that address varied needs can be 
particularly challenging for them and their families. 

The four states GAO visited help young adults with serious mental 
illness transition into adulthood by offering programs that provide 
multidimensional services intended to be age and developmentally 
appropriate. These programs integrate mental health treatment with 
employment and other supports. To deliver these services, states use 
various strategies. They coordinate across multiple state agencies, 
leverage federal and state funding sources, and involve young adults 
and their families in developing policies and aligning supports. 

The needs of young adults with serious mental illness have also 
received attention from the federal government, and agencies have been 
providing some support to states through demonstrations, technical 
assistance, and research. Federal agencies have also established bodies 
to coordinate programs to serve those with mental health needs, youth 
with disabilities, and youth in transition, which may help improve 
service delivery for young adults with serious mental illness, as well. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-678]. For more 
information, contact Cornelia M. Ashby at [email protected] or Cynthia A. 
Bascetta at [email protected]. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

More Than 2 Million Young Adults Have a Serious Mental Illness That Can 
Affect Their Education and Employment: 

Young Adults with Serious Mental Illness Face Challenges Accessing 
Appropriate Support: 

Selected States Provide Multidimensional Services to Young Adults with 
Serious Mental Illness Using Various Strategies: 

Federal Agencies Have Supported Demonstrations, Provided Technical 
Assistance and Research, and Formed Interagency Working Groups: 

Concluding Observations: 

Response to Agency Comments: 

Appendix I: Scope and Methodology: 

Appendix II: Federal Programs Identified by Bazelon as Helping Young 
Adults with a Serious Mental Illness (SMI): 

Appendix III: Evidence-Based Practices Promoted by SAMHSA: 

Appendix IV: Demographic Characteristics of Young Adults Aged 18-26, by 
Severity of Mental Illness, 2001-2003: 

Appendix V: Demographic Characteristics of Young Adults 18-26 Who 
Received SSA Disability Benefits Because of a SMI: 

Appendix VI: Selected Programs States Can Use to Target or Provide 
Comprehensive Services for Young Adults with SMI: 

Appendix VII: Overview of Programs for Young Adults with SMI in Four 
States: 

Appendix VIII: Comments from the Department of Health and Human 
Services: 

Appendix XIV: GAO Contacts and Staff Acknowledgments: 

Selected Bibliography: 

Related GAO Products: 

Tables: 

Table 1: Examples of Federal Programs That Can Provide or Fund Mental 
Health Services to Young Adults with Serious Mental Illness: 

Table 2: Examples of Federal Programs That Can Provide Educational or 
Employment-Related Services to Young Adults with Serious Mental 
Illness: 

Table 3: Examples of Federal Programs That Can Provide Housing Support 
to Young Adults with Serious Mental Illness: 

Table 4: Estimated Prevalence of Commonly Diagnosed Mental Illnesses 
among Young Adults Aged 18-26 with Serious Mental Illnesses: 

Table 5: Estimated Prevalence of Mental Disorders among Young Adults 
Aged 18-26 Receiving SSI or DI or Both Because of a Serious Mental 
Illness: 

Table 6: Estimated Education, Employment, and Income for Young Adults 
Receiving SSI or DI Because of a Serious Mental Illness Compared to the 
General Population of Young Adults with Serious Mental Illness: 

Figures: 

Figure 1: Estimated Prevalence of Mental Illness among Young Adults 
Aged 18 through 26 in 2006, by Severity: 

Figure 2: Rates of Education among Young Adults, Aged 18-26: 

Figure 3: Federal Coordination Efforts on Mental Health, Youth in 
Transition, and Transitioning Youth with Disabilities: 

Abbreviations: 

CMS: Centers for Medicare & Medicaid Services: 

CPS: Current Population Survey: 

DI: Disability Insurance: 

DOD: Department of Defense: 

DOJ: Department of Justice: 

DOT: Department of Transportation: 

DSM-IV: Diagnostic and Statistical Manual of Mental Disorders-Fourth 
Edition: 

HHS: Department of Health and Human Services: 

HUD: Department of Housing and Urban Development: 

IEP: individualized education program: 

NBS: National Beneficiary Survey: 

NCS-R: National Comorbidity Survey Replication: 

NIMH: National Institute of Mental Health: 

SAMHSA: Substance Abuse and Mental Health Services Administration: 

SSA: Social Security Administration: 

SSI: Supplemental Security Income: 

TIP: Transition to Independence Process: 

TRF: Ticket Research File: 

USDA: U.S. Department of Agriculture: 

VA: Veterans Administration: 

WIA: Workforce Investment Act: 

[End of section] 

United States Government Accountability Office:
Washington, DC 20548: 

June 23, 2008: 

The Honorable Pete Stark: 
Chairman: 
Subcommittee on Health: 
Committee on Ways and Means: 
House of Representatives: 

The Honorable Gordon Smith: 
Ranking Member: 
Special Committee on Aging: 
United States Senate: 

The transition from adolescence to adulthood is a challenging time in 
which individuals assume greater responsibility for their independence 
and make critical decisions about relationships and careers that affect 
them long into the future. While this transition can be difficult for 
all young adults, it is particularly so for those who suffer from a 
serious mental illness, such as acute schizophrenia or acute bipolar 
disorder. The interpersonal skills and sound judgment most needed 
during young adulthood are precisely those skills that can be impaired 
by a serious mental illness. Moreover, the severity of mental illness 
can vary over time, and experiencing severe episodes during this 
transition period can derail young adults from completing school or 
beginning a career. When young people with serious mental illness do 
not successfully transition to adulthood, the result can be economic 
hardship, social isolation, and in some cases suicide, all of which can 
pose substantial costs to society. 

While public mental health services are primarily administered by 
states, a variety of federal programs can assist young adults with 
serious mental illness as they transition to adulthood. Because of 
concerns about young adults with serious mental illness transitioning 
into adulthood, you asked us to provide information on (1) the number 
of young adults with serious mental illness and their demographic 
characteristics, (2) the challenges they face, (3) how selected states 
assist these young adults, and (4) how the federal government supports 
states in serving these young adults and coordinates federal programs 
that can assist them. 

To provide information on the number and demographic characteristics of 
young adults, which we define as individuals aged 18 through 26, with 
serious mental illness,[Footnote 1] we analyzed data from two surveys 
of individuals living in U.S. households: the National Comorbidity 
Survey Replication, 2001-2003 (NCS-R), a federally funded survey of 
mental illness, and the Census Bureau's 2006 Current Population Survey, 
Annual Social and Economic Supplement (CPS). We estimated the 
prevalence of serious mental illness using the NCS-R, which is based on 
interviews conducted from 2001 through 2003. We then applied that 
prevalence estimate to the number of young adults aged 18 to 26 
nationally in 2006, as estimated by the CPS, based on the assumption 
that rates of mental illness were relatively stable in this age group 
between 2001 and 2006. We also analyzed two Social Security 
Administration (SSA) datasets on individuals receiving disability 
benefits: the 2006 Ticket Research File (TRF) and the National 
Beneficiary Survey, 2004 (NBS).[Footnote 2] We assessed the reliability 
of data from the NCS-R, the CPS, and SSA and determined they were 
sufficiently reliable for the purposes of this report. We also reviewed 
published research on the extent of mental illness among the homeless 
and those involved with the criminal justice or foster care systems. 

To identify the challenges faced by young adults with serious mental 
illness, we reviewed published research as identified through a 
literature review of relevant journals, books, articles, and reports 
published since 1995. We also interviewed federal, state, and local 
officials during site visits to four states (see below), mental health 
providers, and experts in the field of transitional young adults and 
mental health. Finally, we interviewed advocacy groups, as identified 
throughout our review, that work with young adults and their 
caregivers. 

To describe how selected states are assisting young adults with serious 
mental illness, we visited four states that have implemented programs 
specifically focused on this population: Connecticut, Maryland, 
Massachusetts, and Mississippi.[Footnote 3] During the site visits, we 
met with officials from mental health agencies, other state agencies, 
private organizations involved in providing or advocating for services 
for this population, and, when possible, young adult consumers of 
mental health services. We selected these four states for our site 
visits because, after reviewing published research and interviewing 
federal and state officials, mental health researchers, and advocacy 
groups, we determined that they offered statewide or state-organized 
programs specifically focused on transition-aged youth with serious 
mental illness.[Footnote 4] 

To determine how federal agencies are supporting states and 
coordinating federal programs that can assist young adults with serious 
mental illness, we interviewed federal officials from agencies within 
the U.S. Department of Education (Education), Department of Health and 
Human Services (HHS), Department of Housing and Urban Development 
(HUD), Department of Justice (DOJ), Department of Labor (Labor), and 
SSA. We also reviewed documents pertaining to the activities and 
accomplishments of interagency coordination groups as well as funding 
and eligibility information on federal programs relevant to young 
adults with serious mental illness. See appendix I for a more detailed 
description of our methodology. We conducted our work from June 2007 
through June 2008 in accordance with generally accepted government 
auditing standards. 

Results in Brief: 

We estimate that at least 2.4 million young adults aged 18 through 26-
-or 6.5 percent of the 37 million non-institutionalized young adults in 
that age range--had a serious mental illness in 2006, and they had 
lower levels of education on average than other young adults. This 
estimate of 2.4 million is likely to be low because certain groups that 
may have high rates of mental illness, such as the institutionalized, 
were not included in the NCS-R. Nearly 90 percent of young adults with 
serious mental illness had more than one type of disorder. For example, 
32 percent of these young adults had a drug or alcohol-related disorder 
in addition to another type of mental disorder. We also found that, 
compared to young adults with no mental illness, those with serious 
mental illness have significantly lower rates of high school graduation 
(64 versus 83 percent) and continuation into postsecondary education 
(32 versus 51 percent). Our analysis of SSA data indicates that, in 
2006, about 186,000 young adults with serious mental illness received 
disability benefits because their mental illness was determined to be 
severe enough to prevent them from engaging in substantial employment. 
We were unable to identify the number of young adults with serious 
mental illness who were homeless or involved in the justice or foster 
care systems; however, evidence suggests that young adults in these 
groups have high rates of mental illness overall. 

Young adults with serious mental illness face several challenges, 
including finding services tailored to their specific needs, qualifying 
for adult programs that provide access to mental health services, and 
navigating multiple programs and delivery systems. Existing public 
mental health, employment, and housing programs are not necessarily 
tailored to their mental disability or age range, which may discourage 
these young adults from participating. For example, officials in three 
states we visited stated that Workforce Investment Act (WIA) youth 
centers could not provide the intense, customized support that young 
adults with serious mental illness need, and state officials also 
indicated that there are not enough permanent housing options tailored 
to this age group. With regard to access to mental health services, 
those who received free or low-cost services as children may not 
qualify for them as adults. According to the National Council on State 
Legislatures, states' clinical criteria for receiving public mental 
health services are generally narrower for adults than for children. 
Similarly, Medicaid income requirements are more stringent for adults, 
and differences in criteria for child and adult disability benefits 
from SSA can result in a loss of benefits during redetermination at age 
18 for youth who had received benefits as children. Finally, 
researchers and public officials cite the difficulty young adults with 
serious mental illness may have navigating the multiple discrete 
programs that may address their varied needs. 

The four states we visited--Connecticut, Maryland, Massachusetts, and 
Mississippi--have developed programs that offer multidimensional 
services designed for young adults with serious mental illness as they 
transition into adulthood. The services are intended to be age- 
appropriate and to address various needs, such as mental health care, 
vocational rehabilitation, employment, life-skills development, and, in 
some cases, housing. In Connecticut, the program initially focused on 
individuals referred from the Department of Children and Families, but 
it has since evolved to focus on a broader group of young adults with 
serious mental illness. This focus is similar to that of the other 
states' programs. The state programs vary in size, with some serving a 
relatively small number of young adults, and none have been 
systematically evaluated to determine their effectiveness. States have 
used a variety of strategies to provide these services to young adults 
with serious mental illness. One strategy has been to coordinate 
services across multiple state agencies by establishing formal referral 
processes or launching interagency task forces. This strategy can 
provide a bridge for individuals who were receiving services and 
supports from one agency as children and must transition to another 
agency in order to continue to receive those services and supports as 
adults. Another is to leverage resources by combining funds from 
federal and state sources. States have also used certain service 
delivery models promoted by the Substance Abuse and Mental Health 
Services Administration (SAMHSA) as evidence-based practices. One such 
practice, supported employment, assists young adults with obtaining and 
retaining competitive employment in the community as part of their 
mental health treatment. Another strategy has been to involve young 
adults with serious mental illness and their family members in 
developing policies and aligning services for these programs. 

The needs of young adults with serious mental illness have also 
received some attention from the federal government, which has, to some 
extent, supported state efforts to serve these young adults and is 
beginning to coordinate programs that can assist them. While we found 
that there are currently no federal programs that specifically target 
this population, SAMHSA and Education formerly sponsored the 
Partnerships for Youth in Transition program of 2002-2006 to foster 
state-funded programs for transition-age youth with serious mental 
illness. This initiative has yielded ongoing collaborative transition 
programs at several sites in five states: Maine, Minnesota, 
Pennsylvania, Utah, and Washington. An evaluation of the young adults 
participating in the programs suggests that there may be some positive 
outcomes for them, and SAMHSA plans to promote similar initiatives in 
other states. Federal agencies also fund other demonstration projects 
that support state and local efforts to provide or better coordinate 
existing services for transition-aged individuals, although these 
programs are not targeted to young adults who have a serious mental 
illness. In addition, federal agencies are providing some support to 
states and localities through technical assistance and research. For 
example, Labor's National Collaborative on Workforce and Disability for 
Youth provides technical assistance to One-Stop Centers to increase 
their capacity to serve individuals aged 14 through 25 who have 
disabilities, which include serious mental illness. Additionally, the 
National Institute of Mental Health (NIMH) is funding research on 
innovative strategies to better serve this population. In response to 
presidential concern about uncoordinated service delivery in the mental 
health and other related systems, several federal agencies have formed 
working groups to consider opportunities for collaboration among 
programs that involve mental health, youth in transition, or the needs 
of transitional youth with disabilities, although none are focused on 
young adults with serious mental illness. 

We provided a draft of this report to Education, DOJ, HHS, HUD, Labor, 
and SSA as well as draft sections concerning their states to 
Connecticut, Maryland, Massachusetts, and Mississippi. We received 
technical comments from all of the federal agencies and states, which 
we incorporated where appropriate, and general comments from HHS. In 
its general comments, HHS indicated that the report was pertinent and 
timely but expressed some confusion over our definition of serious 
mental illness and noted that the report's scope could be expanded in a 
number of ways. We clarified our definitions and noted that, while 
additional research could be beneficial, the scope of our report 
focused on the objectives and population agreed upon with our 
requesters. Written comments from HHS are included in appendix VIII. 

Background: 

Young adulthood is a critical time in human development. During this 
period, individuals transition into roles that they maintain long into 
the future. This transition can involve completing school; securing 
full-time employment; becoming financially independent; establishing a 
residence; entering into a stable, long-term relationship; and becoming 
a parent. To successfully accomplish these things, young adults must 
develop good interpersonal skills, sound judgment, and a sense of 
personal responsibility and purpose. 

The transition from child to adult roles can be a challenging one, and 
evidence suggests that this period has become longer and more complex 
over the years. During the 1950s, young people often completed their 
education and secured employment, married, and became parents all in 
their early 20s. Since then, the economy has grown increasingly 
information-driven, while wages have declined and the cost of living 
has increased, when adjusted for inflation. Consequently, young adults 
require greater technical skills and education to support themselves 
and may alternate living in an educational setting, with their 
families, or independently well into their adult years. 

Mental Illness and Disability: 

As they transition to adulthood, some young people may experience a 
mental illness, which is generally defined as a health condition that 
changes a person's thinking, feelings, or behavior and causes the 
person distress and difficulty in functioning.[Footnote 5] Some young 
adults develop their mental illness during childhood, while it is 
typical for others, such as individuals with schizophrenia, to 
experience the onset of symptoms as young adults.[Footnote 6] Although 
research shows that 50 percent of mental disorders begin by age 14, 
[Footnote 7] it can take several years for the illness to be detected 
and appropriately treated. Early detection and treatment of mental 
disorders can result in a substantially shorter and less disabling 
course of mental illness. 

The symptoms associated with a given type of mental illness can vary in 
frequency and severity across individuals and for each individual over 
time. Mental illnesses with particularly severe symptoms can have a 
dramatic impact on an individual's ability to function in everyday 
life. The fatigue experienced by an individual with major depressive 
disorder can be so severe that it is difficult to summon the energy to 
work every day. The delusions associated with paranoid schizophrenia 
can make it impossible to maintain stable personal relationships with 
spouses, co-workers, or friends. Certain other mental illnesses are 
known for the unpredictable and episodic nature of their symptoms and 
the harmful effect this has on the ability to function consistently 
over time. For example, individuals with bipolar disorder can alternate 
between periods of mania, relative normalcy, and profound depression. 
For a young adult, such unpredictable mood swings can stymie progress 
in securing and maintaining a job or beginning and sustaining a long- 
term relationship. 

Individuals with mental illnesses who have particularly severe symptoms 
can qualify for certain federal supports. The Alcohol, Drug Abuse, and 
Mental Health Administration Reorganization Act of 1992 uses the term 
serious mental illness to identify individuals whom states are allowed 
to treat using federal dollars from the Community Mental Health Block 
Grant program.[Footnote 8] In response to the requirements of this Act 
that HHS develop a definition, SAMHSA defined "adults with a serious 
mental illness" as those who are: "age 18 and over, who currently or at 
any time during the past year, have had a diagnosable mental, 
behavioral, or emotional disorder of sufficient duration to meet 
diagnostic criteria specified within DSM-III-R, that has resulted in 
functional impairment which substantially interferes with or limits one 
or more major life activities." [Footnote 9] These major life 
activities can be basic living skills, such as eating or bathing; 
instrumental living skills, such as maintaining a household; or 
functioning in social, family, or vocational/educational contexts. 
States are free to establish more restrictive eligibility guidelines 
for their treatment population in several ways: by narrowing the list 
of qualifying diagnoses, specifying the length of time the individual 
must have had symptoms, or requiring that individuals function below a 
certain level. As a result, the criteria used by states to qualify 
adults for public mental health services can vary. 

Some individuals with a serious mental illness may be unable to work 
because of their impairments. These individuals aged 18 or older may 
qualify for Supplemental Security Income (SSI) or Disability Insurance 
(DI) provided by SSA if they can demonstrate that their mental illness 
results in the inability to engage in any kind of substantial gainful 
activity and has lasted or can be expected to last at least 12 months. 
[Footnote 10] DI pays benefits related to prior earnings to those with 
a work history sufficient to obtain insured status. Children can 
receive DI benefits based on their parent's work history.[Footnote 11] 
SSI provides cash benefits for those who have limited or no work 
history and whose income and assets fall below certain levels. Children 
can receive SSI benefits if they have a qualifying disability 
themselves. Individuals may receive concurrent payments from both DI 
and SSI if their work history qualified them to receive DI payments but 
their income and assets--including the amount of their DI payments-- 
were sufficiently low that they also qualified to receive SSI payments. 
In fiscal year 2006, approximately 8.6 million individuals received DI 
payments and 6.9 million received SSI payments, for a total of $126.4 
billion in benefits paid out over the course of the year. 

Public Mental Health System: 

Many people with serious mental illness receive treatment through the 
public mental health system, which serves as a safety net for those who 
are poor or uninsured or whose private insurance benefits run out in 
the course of their illness. State mental health departments have 
primary responsibility for administering the public mental health 
system. In doing so, they serve multiple roles, including purchaser, 
regulator, manager, and, at times, provider of mental health services. 
Services are delivered by state-operated or county-operated facilities, 
nonprofit organizations, and other private providers. The sources and 
amounts of the public funds that mental health departments administer 
vary from state to state but usually include state general revenues and 
funds from Medicaid and other federal programs. 

The services provided by the public mental health system to individuals 
with serious mental illness have changed over time. Historically, state-
run public mental health hospitals were the principal treatment option 
available to them. By the 1960s the reliance on inpatient care was 
viewed as ineffective and inadequate because of patient overcrowding, 
staff shortages, and other factors. At the same time, improved 
medications were reducing some of the symptoms of mental illness and 
increasing the potential for more individuals to live successfully in 
the community. A recovery-oriented, community-based approach to mental 
health treatment has since emerged. Under this approach, individuals 
are to receive services and supports uniquely designed to help them 
manage their mental illness and to maximize their potential to live 
independently in the community. These services and supports are to be 
multidimensional--intended to address not only mental illness but also 
employment, housing, and other issues. When feasible, these 
multidimensional services are provided in what is referred to as a 
"wrap-around" manner--that is, they are uniquely targeted to the nature 
and extent of each individual's needs. When services are provided by 
multiple agencies, those agencies are to coordinate their activities 
and funding so that the individual experiences the services and 
supports seamlessly--as if from one system, not many. 

Federal Programs That Can Assist Young Adults with Serious Mental 
Illness: 

Services and supports relevant to young adults with serious mental 
illness that are funded or provided by federal programs include mental 
health treatment, education and employment assistance, housing, and 
income support. In all, the Judge David L. Bazelon Center for Mental 
Health Law (Bazelon) identified 57 relevant programs in 2005. (See app. 
II.) These programs are administered by a variety of agencies, 
including DOJ, HHS, Education, HUD, Labor, SSA, and U.S. Department of 
Agriculture (USDA). 

Programs Funding Mental Health Services: 

The federal government funds mental health services that are provided 
by programs administered by state agencies. Table 1 lists five examples 
of such programs. 

Table 1: Examples of Federal Programs That Can Provide or Fund Mental 
Health Services to Young Adults with Serious Mental Illness: 

Department: HHS; 
Program: Community Alternatives to Psychiatric Residential Treatment 
Facilities Demonstration Grants Program; 
Purpose: Five-year demonstrations to help provide alternatives to 
psychiatric residential treatment facilities for children up to age 21 
and allow coverage of a comprehensive package of community-based 
services for these youths such as 24-hour support and crisis 
intervention, respite care for families and after-school support 
programs. 

Department: HHS; 
Program: Community Mental Health Services Block Grant Program; 
Purpose: Provide mental health services to people with serious mental 
illness. 

Department: HHS; 
Program: Comprehensive Community Mental Health Services for Children 
with Serious Emotional Disturbances; 
Purpose: Promote more effective ways to organize, coordinate, and 
deliver mental health services and supports for youth up to age 22 and 
their families. 

Department: HHS; 
Program: Medicaid--Medical Assistance Program, Title XIX; 
Purpose: Improve access to health care for low-income individuals and 
those in certain groups. 

Department: HHS; 
Program: Projects for Assistance in Transition from Homelessness; 
Purpose: Provide mental health and related services to homeless 
individuals with a serious mental illness. 

Source: GAO analysis. 

[End of table] 

In particular, Medicaid and the Community Mental Health Block Grants 
are major sources of federal funding for mental health services for 
young adults with serious mental illness. Medicaid is a health 
insurance program for certain groups of low-income individuals, 
including elderly and disabled individuals and children.[Footnote 12] 
Funded jointly by the federal government and the states, and 
administered federally by the Centers for Medicare & Medicaid Services 
(CMS), Medicaid is the primary federal payer for public mental health 
services provided by states. In order to receive federal Medicaid 
funding, states are required to provide certain broad categories of 
services, such as inpatient and outpatient hospital services and 
physician care. Reflecting their medical focus, Medicaid mental health 
services have traditionally been provided by physicians, including 
psychiatrists, who work at hospitals, clinics, and other institutions. 
While Medicaid will cover services provided to individuals in 
facilities with 16 or fewer beds, the program specifically excludes 
coverage provided in large state-run psychiatric institutions for 
adults aged 22 through 64. States may choose to provide certain 
optional categories of services. For example, states may use the 
Medicaid "rehabilitation option" to cover a broad range of services 
related to rehabilitation from a mental illness or other condition or 
disability.[Footnote 13] States may also participate in certain 
Medicaid demonstration programs that allow them greater flexibility in 
the services they choose to cover. Medicaid spending by the federal 
government and the states totaled $317 billion in 2006. 

To supplement the Medicaid program, CMS administers several smaller 
grant programs that states can use to fund improvements to their mental 
health systems. For example, CMS established Medicaid Infrastructure 
Grants to support state efforts to enhance employment options for 
people with serious mental illness and other disabilities. States may 
use these grants to plan and manage improvements to Medicaid 
eligibility determination and service delivery systems or to improve 
coordination between the state Medicaid program and employment-related 
service agencies. Nearly $43 million was available to states under this 
grant program in fiscal year 2008. CMS also administers Real Choice 
Systems Change Grants to help states and others build the 
infrastructure that will result in improvements in community-integrated 
services and long-term care supports for individuals with long-term 
illnesses and disabilities, such as serious mental illness. The goal of 
the program is to help these individuals live in the most integrated 
community setting suited to their needs, have meaningful choices about 
their living arrangements, and exercise more control over their 
services. Nearly $14 million was awarded to states under this grant 
program in fiscal year 2007. 

Through the Community Mental Health Services Block Grant program and 
other federal grant programs, SAMHSA funds mental health services that 
can be used by states to assist young adults with serious mental 
illness. The block grants are allocated to states according to a 
statutory formula that takes into account each state's taxable 
resources, personal income, population, and service costs. In order to 
receive the funding, states are required by SAMHSA to provide data on 
the mental health services provided including demographic information 
annually to SAMHSA on the number of individuals treated by the state's 
mental health system. In addition, states are required to maintain 
statewide planning councils that include consumers, family members, and 
mental health providers to oversee the mental health system. In fiscal 
year 2007, SAMHSA provided $401 million in block grants to states. 
According to a SAMHSA official, this made up an average of between 1 
percent and 2 percent of each state's budget on community-based mental 
health services. SAMHSA also administers smaller targeted grants to 
support state mental health services and initiatives. 

Part of SAMHSA's activities related to the block grant program are to 
promote specific practices--known as evidence-based practices--in 
mental health treatment. SAMHSA considers a practice evidence-based if 
it has been validated by research, such as clinical trials with 
experimental designs, and if it reflects expert opinion. On its Web 
site, SAMHSA provides toolkits for five types of evidence-based 
practices that states can use to design their programs. These five 
practices are Illness Management and Recovery, Assertive Community 
Treatment, Supported Employment, Family Psychoeducation, and Co- 
Occurring Disorders: Integrated Dual Disorders Treatment. (See app. III 
for details about these practices.)[Footnote 14] SAMHSA is also 
promoting research on evidence-based practices in a number of other 
areas, including supported education, and plans on providing toolkits 
or other informational materials for these as well. A condition for 
receiving Community Mental Health Services Block Grant funds is that 
states are required by SAMHSA to report on whether they are using the 
evidence-based practices. In addition, states can use Medicaid funds to 
pay for certain services associated with the use of evidence-based 
practices.[Footnote 15] 

Education and Employment-Related Programs: 

Other federal programs fund educational and employment-related supports 
through states, localities, or other groups to individuals with a 
mental health disability. (See table 2): 

Table 2: Examples of Federal Programs That Can Provide Educational or 
Employment-Related Services to Young Adults with Serious Mental 
Illness: 

Department: Education; 
Program: Rehabilitation Services--Vocational Rehabilitation Grants to 
States; 
Purpose: Provide vocational rehabilitation services to persons with 
disabilities who are interested in seeking employment. 

Department: Education; 
Program: Individuals with Disabilities Education Act, Part B, Grants to 
States, Formula Grant Program; 
Purpose: Provide special education and related services to children 
with disabilities to ensure they have available a free appropriate 
public education and to prepare them for further education, employment, 
and independent living. 

Department: HHS; 
Program: Chafee Foster Care Independence Program; 
Purpose: Help current and former foster care youth achieve self- 
sufficiency through education, employment, financial management, 
housing, counseling, and other support. 

Department: HHS; 
Program: Chafee Education and Training Vouchers Program; 
Purpose: Provide vouchers to foster care youth adopted after age 16 or 
certain former foster care youth through funds of up to $5,000 per year 
for postsecondary education and training. 

Department: Labor; 
Program: Job Corps; 
Purpose: Education and job training program for at-risk youth to 
prepare them for stable, long-term employment. 

Department: Labor; 
Program: Workforce Investment Act (WIA) Youth Activities; 
Purpose: Provide workforce training, educational activities, and 
leadership development opportunities to low-income youth. 

Department: Labor; 
Program: YouthBuild; 
Purpose: Provide disadvantaged youth with opportunities for employment, 
education, leadership development, and training through the 
construction and rehabilitation of permanent affordable housing for 
homeless individuals and low-income families. 

Source: GAO analysis. 

[End of table] 

Through special education programs funded with federal dollars in part, 
students through age 21 with emotional disturbances and students with 
other disabilities with behavioral and emotional components can receive 
an individually tailored program of specialized instruction and support 
services set out in an individualized education program (IEP).[Footnote 
16] On the basis of decisions of the student's IEP team, students can 
receive such services as psychological services, counseling and social 
work services, and job coaching (as part of services supporting the 
transition of a student to post-school activities). 

Another example of a program that provides educational and employment- 
related supports is Labor's WIA Youth Activities program, which funds 
efforts related to workforce training, education attainment, community 
involvement, and leadership development for low-income individuals aged 
14 to 21 who have difficulty completing their education or securing or 
maintaining employment. Once they are determined to be WIA eligible, 
youth receive an assessment of their academic level, skills, and 
service needs. Local youth programs then use the assessment to create 
individualized service strategies, which lay out employment goals, 
educational objectives, and necessary services. In 2006, Labor received 
approximately $940 million in funding appropriated for WIA youth- 
related activities. 

Education's Rehabilitation Services Administration provides grants to 
assist state vocational rehabilitation agencies in providing employment-
related services for individuals with disabilities, including 
individuals with serious mental illness. Vocational rehabilitation 
agencies assist individuals in pursuing gainful employment commensurate 
with their abilities and capabilities. Money for vocational 
rehabilitation is allotted to states and territories according to a 
formula, and over $2.8 billion was appropriated to states in 2007. 

Finally, current and former foster care youth can receive services up 
to the age of 21 through the Chafee Foster Care Independence program. 
This program funds independent living, education, and training and 
gives states the flexibility to extend Medicaid coverage for former 
foster care youth up to age 21. Federal funding associated with these 
activities totaled $140 million in 2006.[Footnote 17] However, we have 
found that there are critical gaps in mental health and housing 
services for foster youth and that states were serving less than half 
of their eligible foster care population through their programs. 
[Footnote 18] 

Programs That Provide Housing Supports: 

Other programs provide housing supports. (See table 3.) These programs 
range in scope, targeting low-income people generally to vulnerable 
groups specifically, such as the disabled or the homeless. 

Table 3: Examples of Federal Programs That Can Provide Housing Support 
to Young Adults with Serious Mental Illness: 

Department: HHS; 
Program: Runaway and Homeless Youth Grant Program; Purpose: 
Provide street-based educational and prevention services and outreach 
to homeless and runaway youth who have been subjected to, or are at 
risk of being subjected to, sexual abuse, prostitution, or sexual 
exploitation. 

Department: HUD; 
Program: Public and Indian Housing; 
Purpose: Provide and operate cost-effective, decent, safe, and 
affordable dwellings for lower -income families. 

Department: HUD; 
Program: Section 8 Housing Choice Vouchers; 
Purpose: Assist very low-income families to afford decent, safe, and 
sanitary rental housing. 

Department: HUD; 
Program: Shelter Plus Care; 
Purpose: Provide rental assistance to persons with disabilities 
(primarily those with serious mental illness, chronic problems with 
alcohol or drugs or both, acquired immunodeficiency syndrome, or 
related diseases) and their families in connection with supportive 
services funded from other sources. 

Department: HUD; 
Program: Supportive Housing Programs; 
Purpose: Develop supportive housing and services that will allow 
homeless persons to live as independently as possible. 

Department: HUD; 
Program: Supportive Housing for Persons with Disabilities; 
Purpose: Allow very low-income persons with disabilities to live as 
independently as possible in the community in affordable housing. 

Source: GAO analysis. 

[End of table] 

More Than 2 Million Young Adults Have a Serious Mental Illness That Can 
Affect Their Education and Employment: 

We estimate that at least 2.4 million young adults had a serious mental 
illness in 2006. This estimate is likely to be low because it is based 
on a survey that did not include individuals who were homeless, 
institutionalized, or incarcerated--populations that likely suffer high 
rates of mental illness. Most young adults with serious mental illness 
suffer from multiple disorders, and relative to young adults with no 
mental illness, they have significantly lower rates of high school 
graduation and postsecondary education. Our analysis also found that 
about 186,000 young adults received disability benefits from SSA in 
2006 because their mental illness was so severe that they were found to 
be unable to engage in substantial gainful activity. Finally, although 
we were unable to identify the number of young adults with serious 
mental illness who were homeless or involved in the justice or foster 
care systems, research suggests that these groups have high rates of 
mental illness overall. 

At Least 2.4 Million Young Adults Had a Serious Mental Illness in 2006, 
and Many Suffered from Multiple Disorders and Did Not Graduate from 
High School: 

According to our analysis of the NCS-R, an estimated 2.4 million young 
adults aged 18 through 26 had a serious mental illness in 2006-- 
approximately 6.5 percent of the estimated 37 million young adults 
living in U.S. households.[Footnote 19] We estimate that another 9.3 
million--25.3 percent--had a moderate or mild mental illness, and that 
overall, nearly one in three young adults experienced some degree of 
mental illness in 2006. (See fig. 1.) 

Figure 1: Estimated Prevalence of Mental Illness among Young Adults 
Aged 18 through 26 in 2006, by Severity: 

[See PDF for image] 

This figure is a pie-chart depicting the following data: 

No mental illness: 68.2%; 
Moderate or mild mental illness: 25.3%; 
Serious mental illness: 6.5%. 

Source: GAO analysis of the National Comorbidity Survey Replication 
(NCS-R), 2001-2003. 

[End of figure] 

Because of limitations in the populations surveyed by the NCS-R, our 
estimated prevalence of serious mental illness among young adults in 
2006 is likely to be low. Because only individuals living in households 
and campus housing were included in the sample population, individuals 
who were institutionalized, incarcerated, or homeless are not included 
in NCS-R data.[Footnote 20] Research has shown that young adults in 
these populations may have significant rates of serious mental illness. 
The NCS-R may also under-represent the prevalence of serious mental 
illness because some individuals may not have reported what they 
believe will be viewed as socially unacceptable behaviors or may have 
chosen not to participate in the survey at all.[Footnote 21] Finally, 
the NCS-R does not attempt to measure the prevalence of schizophrenia 
and other nonaffective psychotic disorders, and for this reason, may 
only represent a subset of those who would be considered by SAMHSA to 
meet the criteria for having a serious mental illness.[Footnote 22] 

Our analysis of the NCS-R indicates that certain disorders were most 
common among the young adult population aged 18 through 26 with serious 
mental illness. Specifically, we found that six mental disorders 
affected more than 25 percent of young adults with serious mental 
illness. The most prevalent of these was intermittent explosive 
disorder, and the other five were major depressive disorder, specific 
phobia, bipolar disorder, alcohol abuse, and social phobia.[Footnote 
23] (See table 4.) We also found that nearly all young adults with 
serious mental illness were diagnosed with more than one mental 
disorder. Specifically, 89 percent had two or more diagnoses and 56 
percent had four or more.[Footnote 24] For example, 20 percent of 
individuals with the most common diagnosis, intermittent explosive 
disorder, were also diagnosed with bipolar disorder, while 39 percent 
were also diagnosed with alcohol abuse. Results of the survey also 
suggest that about 32 percent of young adults with a serious mental 
illness had a co-occurring diagnosis of alcohol or drug abuse or 
dependence along with at least one other mental disorder.[Footnote 25] 

Table 4: Estimated Prevalence of Commonly Diagnosed Mental Illnesses 
among Young Adults Aged 18-26 with Serious Mental Illnesses: 

Disorder (past 12 months): Intermittent explosive disorder; 
Characterization of disorder: Discrete episodes of a failure to resist 
aggressive impulses that result in serious violent acts or destruction 
of property; 
Percent with disorder[A]: 45. 

Disorder (past 12 months): Major depressive disorder; 
Characterization of disorder: Prolonged feelings of sadness, 
worthlessness, or irritability, often accompanied by behavioral 
changes, such as decreased energy or apathy; 
Percent with disorder[A]: 32. 

Disorder (past 12 months): Specific phobia; 
Characterization of disorder: Irrational fear associated with a 
specific object or situation; 
Percent with disorder[A]: 32. 

Disorder (past 12 months): Bipolar disorder[B]; 
Characterization of disorder: Mood swings ranging from high periods of 
mania to low periods of severe depression; 
Percent with disorder[A]: 28. 

Disorder (past 12 months): Social phobia; 
Characterization of disorder: Extreme anxiety in social situations; 
Percent with disorder[A]: 28. 

Disorder (past 12 months): Alcohol abuse; 
Characterization of disorder: Pattern of repeated alcohol use resulting 
in adverse consequences; 
Percent with disorder[A]: 26. 

Source: National Institutes of Health, DSM-IV, and GAO analysis of the 
NCS-R, 2001-2003. 

[A] All diagnoses were based on criteria specified in the DSM-IV for 
mental disorders occurring within the past 12 months, and all estimates 
are subject to a sampling error of within plus or minus 8 percentage 
points, with the exception of intermittent explosive disorder (plus or 
minus 13 percentage points), alcohol abuse and social phobia (plus or 
minus10 percentage points). The NCS-R measured rates of mental illness 
in U.S. households, and did not include individuals who are 
institutionalized, incarcerated, or homeless. 

[B] The NCS-R provides separate prevalence estimates for bipolar I and 
bipolar II disorder. For the purposes of this analysis, we added the 
estimates together to derive the prevalence of bipolar disorder 
generally. 

[End of table] 

Young adults with serious mental illness had significantly lower rates 
of high school graduation than other young adults, according to our 
analysis of demographic information in the NCS-R. Specifically, the 
percentage of young adult respondents with serious mental illness who 
graduated high school was significantly lower than the percentage of 
those with moderate, mild, or no mental illnesses. Additionally, the 
percentage of young adult respondents with serious mental illness who 
continued their education after high school was also significantly 
lower than the percentage of those with moderate, mild, or no mental 
illness. (See figure 2.) 

Figure 2: Rates of Education among Young Adults, Aged 18-26: 

[See PDF for image] 

This figure is a multiple vertical bar graph depicting the following 
information: 

Rate of education: graduated high school; 
Serious mental illness: 64%; 
Moderate or mild mental illness: 81%; 
No mental Illness: 83%. 

Rate of education: Postsecondary education; 
Serious mental illness: 32%; 
Moderate or mild mental illness: 46%; 
No mental Illness: 51%. 

Source: GAO analysis of the National Comorbidity Survey Replication 
(NCS-R), 2001-2003. 

Note: Differences in estimates of education between young adults with 
serious mental illness and young adults with moderate, mild, or no 
mental illness are statistically significant at the 5 percent 
significance level and are subject to a sampling error of within plus 
or minus 12 percentage points. The NCS-R measured rates of mental 
illness in U.S. households and did not include individuals who are 
institutionalized, incarcerated, or homeless. 

[End of figure] 

Young adults with serious mental illness also had lower rates of 
employment than other young adults, although the differences were not 
statistically significant, according to our analysis of the NCS-R. 
Specifically, 63 percent of young adults with serious mental illness 
reported they were currently employed, versus 68 percent of those with 
a mild or moderate mental illness and 71 percent of those with no 
mental illness. Results of other studies, however, suggest that 
unemployment is a common problem for young adults with serious mental 
illness. For example, an analysis of the 1994--95 National Health 
Interview Survey on Disability found an employment rate of 34 percent 
among working-age adults with mental health disabilities, versus 79 
percent among adults with no disability.[Footnote 26] In addition, the 
President's New Freedom Commission on Mental Health stated in its 2003 
report that only one in three persons with a disability resulting from 
mental illness is employed.[Footnote 27] (See app. IV for more detailed 
demographics of young adults with serious mental illness compared to 
those with moderate, mild, or no mental illness.) 

About 186,000 Young Adults Had a Mental Illness So Severe That They 
Received Disability Benefits from the SSA in 2006: 

In 2006, about 186,000 young adults had a mental illness that was 
severe enough that they received disability payments from SSI, DI or 
both, meaning that they were found to be unable to engage in 
substantial, gainful activity because of their illness, according to 
our analysis of the TRF. The 186,000 individuals who received benefits 
in 2006 represented just under a quarter of all young adults who 
received SSI or DI that year and do not include individuals who receive 
benefits because of abnormalities in cognition or intellectual 
functioning, such as mental retardation or autism.[Footnote 28] Of 
these young adults, about 67 percent received payments through SSI 
only, nearly 9 percent received payments from DI only, and 24 percent 
received concurrent payments from both programs. Among those receiving 
SSI payments, nearly 60 percent first became eligible before the age of 
18. 

The mental illnesses that were most common among young adults receiving 
payments from SSI, DI, or both for serious mental illness include 
schizophrenic, paranoid, and other functional psychotic disorders and 
affective mood disorders, such as depression or bipolar disorder. (See 
table 5.) 

Table 5: Estimated Prevalence of Mental Disorders among Young Adults 
Aged 18-26 Receiving SSI or DI or Both Because of a Serious Mental 
Illness: 

Disorder: Affective mood disorders; 
Percent with disorder: 46. 

Disorder: Schizophrenic, paranoid, and other functional psychotic 
disorders; 
Percent with disorder: 33. 

Disorder: Anxiety disorders; 
Percent with disorder: 8. 

Disorder: Personality disorders; 
Percent with disorder: 5. 

Disorder: Other mental disorders; 
Percent with disorder: 8. 

Source: GAO analysis of SSA's Ticket Research File, 2006. 

Note: This analysis does not include those who receive disability 
benefits because of abnormalities in cognition or intellectual 
functioning, such as mental retardation or autism, or those whose 
eligibility has not been redetermined after turning 18. 

[End of table] 

These young adults receiving SSI or DI or both scored lower on certain 
socioeconomic indicators than the general population of those with 
serious mental illness. Specifically, when we compared SSI and DI 
recipients with serious mental illness with their counterparts from the 
NCS-R, we found that the SSI and DI recipients had lower rates of high 
school graduation and employment. (See table 6.) In addition, while 59 
percent of those receiving disability payments reported having ever 
worked, only 15 percent reported being currently employed. This 
compares with an estimated 63 percent rate of employment for those in 
the NCS-R.[Footnote 29] Finally, we found that SSI/DI recipients also 
had a lower average annual household income than all young adults with 
serious mental illness represented in the NCS-R. (See app. V for more 
detailed demographic analysis of young adults enrolled in SSI and DI 
due to serious mental illness.) 

Table 6: Estimated Education, Employment, and Income for Young Adults 
Receiving SSI or DI Because of a Serious Mental Illness Compared to the 
General Population of Young Adults with Serious Mental Illness: 

Characteristic: Graduated high school; 
SSI and DI recipients: 52%; 
All with a serious mental illness: 64%. 

Characteristic: Currently employed; 
SSI and DI recipients: 15%; 
All with a serious mental illness: 63%. 

Characteristic: Average annual household income; 
SSI and DI recipients: $20,685; 
All with a serious mental illness: $45,667. 

Source: GAO analysis of SSA's National Beneficiary Survey, 2004, for 
estimates for SSI and DI recipients, and the National Comorbidity 
Survey Replication (NCS-R), 2001-2003, for estimates of all young 
adults with a serious mental illness. 

Note: Our analysis of SSI and DI recipients does not include those who 
receive disability benefits because of abnormalities in cognition or 
intellectual functioning, such as mental retardation or autism. All 
estimates are subject to a sampling error of within plus or minus 12 
percentage points for estimates from the NCS-R and plus or minus 7 
percentage points for estimates from the NBS. 

[End of table] 

The number of young adults whose mental illness is severe enough to 
qualify for SSI or DI is likely to be higher than the 186,000 who were 
receiving disability payments in 2006 for two reasons. First, there 
could be some number of individuals who suffer from a serious mental 
illness who do not apply for SSI or DI or complete the application 
process. The process of proving eligibility requires the submission of 
medical records to document the medical nature of the mental illness, 
probable duration of the symptoms, and the degree of impairment the 
illness imposes, as well as proof of income for SSI eligibility--a 
process that might prove too difficult for those with a serious mental 
illness.[Footnote 30] The second reason the 186,000 might not represent 
all who could qualify for disability benefits is that, according to SSA 
officials, some individuals who have a serious mental illness may be 
receiving benefits because of another disability, such as mental 
retardation, or a physical disability.[Footnote 31] Our analysis of SSA 
administrative data found about 100,000 young adults whose primary 
disability was not a serious mental illness had a secondary diagnosis 
of a mental illness, which may have been severe enough, by itself, to 
qualify the individual for disability benefits. These individuals were 
therefore not included in our count of 186,000. 

The Number of Young Adults with Serious Mental Illness Who Are Homeless 
or Involved in the Justice or Foster Care Systems is Unknown, Although 
Research Suggests Their Rates of Mental Illness May Be High: 

We were not able to estimate the number of young adults in certain 
vulnerable populations who have a serious mental illness, although the 
available research suggests that rates of mental illness are high in 
these groups. These vulnerable populations include young adults 
transitioning out of the foster care system--who may have limited 
family support for their struggle with serious mental illness--and 
young adults who become homeless or incarcerated. The NCS-R does not 
include individuals who are homeless or incarcerated, and although 
individuals in foster care are included, they are not specifically 
identified as such in the data. Additionally, a review of literature on 
homelessness and the justice and foster care systems yielded no studies 
that produced national estimates of the number of such young adults in 
those groups. Studies that examine mental illness in those groups 
either do not yield estimates specific to young adults or do not 
measure serious mental illness in a consistent way that can be compared 
across groups. 

Although the prevalence of serious mental illness has not been studied 
in these young adult populations nationally, available research 
suggests that their rates of mental illness may be high. With respect 
to young adults in foster care, a national survey that included 464 
individuals aged 12 to 17 who had been placed in foster care found that 
they were about four times more likely to have attempted suicide in the 
preceding year when compared to those never placed in foster care. In 
addition, they were about three times more likely to have experienced 
significant anxiety and mood symptoms, such as depression or mania. 
[Footnote 32] Research also indicates that mental health problems among 
foster care children may persist into adulthood. For example, the 
Northwest Foster Care Alumni Study, which assessed 659 adults aged 20 
through 33 in Oregon and Washington who had been in foster care as 
children, found that over half had experienced symptoms of one or more 
mental disorders in the previous year, and 20 percent had symptoms of 
three or more mental disorders.[Footnote 33] The study compared these 
results to results from the NCS-R for adults in the same age range, 
which found that only three percent of adults in that age range had 
symptoms of 3 or more disorders in the previous year. 

Studies also suggest high rates of mental illness among young adults 
who are homeless. For example, an Urban Institute study based on the 
National Survey of Homeless Assistance Providers and Clients estimated 
that 46 percent of homeless individuals aged 20 through 24 had 
experienced a mental health problem in the prior year.[Footnote 34] 
Another study of 432 homeless young people in Los Angeles found that 63 
percent of those aged 19 through 24 currently had depressive symptoms 
and 38 percent had attempted suicide at some point in their lives. 
[Footnote 35] 

Finally, studies have found that young adults involved in the criminal 
justice system have high rates of mental illness. According to two 
national surveys conducted by the Bureau of Justice Statistics, 62.6 
percent of young adults aged 24 or younger in state prisons had a 
mental health problem in 2004, and 70.3 percent of those in local jails 
had a mental health problem in 2002.[Footnote 36] Further, a multi- 
state survey funded by DOJ's Office of Juvenile Justice and Delinquency 
Prevention found that about 70 percent of youth involved with the 
juvenile justice system had at least one mental health disorder, and 27 
percent had a severe mental health disorder in 2006.[Footnote 37] 

Young Adults with Serious Mental Illness Face Challenges Accessing 
Appropriate Support: 

According to researchers, public officials, and advocates, young adults 
with serious mental illness can have difficulty finding services 
tailored to their needs, qualifying for adult programs, and navigating 
multiple programs and delivery systems. While these young adults need a 
range of support services, the existing public mental health, 
employment, and housing programs are not necessarily tailored to their 
disability or their stage of life, which may lead them to forgo 
services entirely. Further, young adults who received free or low-cost 
mental health services as children generally face different, and 
sometimes more stringent, eligibility requirements as adults. Finally, 
federal officials and researchers have recognized the difficulties this 
group and their families have in navigating the broad array of programs 
that can help meet their needs. 

Public Services Are Often Not Tailored to the Needs of Young Adults 
with Serious Mental Illness: 

Although appropriate mental health services are a key to achieving 
independence, researchers and officials told us that these services are 
often not tailored to the age-related needs of the young adult 
population. We have previously reported that directors of programs 
serving youth aged 14 through 24 have difficulty finding adequate age- 
appropriate mental health services for their clients.[Footnote 38] A 
national expert has noted that adult mental health service providers in 
one state, for example, were generally not trained in adolescent 
development and so were unprepared to treat young adults with serious 
mental illness who tend to be relatively psychosocially immature. 
[Footnote 39] Officials in three of the states we visited similarly 
reported a need for better training among mental health providers in 
issues related to young adults. Other researchers have noted that group 
therapy should involve members in the same age range, given that young 
adults' self-esteem can depend significantly on peer acceptance. 
However, young adults are often referred to group-oriented treatment 
that may include mainly older adults who do not share their transition-
age issues and is therefore often inappropriate for them, according to 
mental health advocates with whom we spoke.[Footnote 40] 

While young adults with serious mental illness can benefit from a 
variety of employment programs, these programs are also not necessarily 
tailored to the particular needs of this population. For example, state 
officials in three of the four states we visited told us that WIA Youth 
centers in those states often lack the expertise to help young adults 
with serious mental illness find appropriate employment because these 
centers generally do not have the capacity to provide the intensive and 
customized support these individuals need. Labor officials told us 
that, as a result, WIA staff often refer youth they believe have mental 
illness to vocational rehabilitation programs. However, according to 
federal officials, vocational rehabilitation programs have been 
traditionally used by those with physical disabilities and are also not 
always designed to meet mental health needs.[Footnote 41] Advocates 
working with young adults in most states we visited likewise noted that 
the vocational rehabilitation services available to the youth they work 
with have not been responsive to their mental health-related issues. 
Similarly, officials in one state noted that service providers for 
students with disabilities at colleges and universities often lack the 
expertise and training to support students with serious mental illness. 
[Footnote 42] 

Finally, while researchers noted that young adults with serious mental 
illnesses experience difficulty living independently and in some cases 
finding housing, officials in all of the states we visited cited the 
inability to find appropriate housing as a key problem for this 
population. Specifically, they noted that there are not enough 
permanent housing options that are targeted to this age group. 
Supportive housing--which often includes a comprehensive set of 
supports such as job training and mental health services--is 
recommended by SAMHSA as a resource for those with mental illness. 
However, officials in all states we visited said there was a lack of 
such housing available. Additionally, where supportive housing is 
available, it is not necessarily geared to young adults. For example, 
HUD officials reported that the median age of the head of households 
receiving HUD supportive housing is 47. One service provider explained 
that if housing options are not geared to their age group, young adults 
with serious mental illness may end up homeless. 

Researchers and advocates have noted that if services are not suited to 
their age or disability, young adults with serious mental illness may 
choose not to participate. Young adults are particularly sensitive to 
the stigma associated with receiving treatment for their symptoms, and 
SAMHSA has reported that they have the lowest "help-seeking behavior" 
of any age group.[Footnote 43] Furthermore, as they age into the adult 
mental health system, their parents are generally no longer responsible 
for their mental health treatment, and these young adults then have the 
option to decline treatment. In Massachusetts, for example, a state 
official found that, in one locality, more than half of the young 
adults who had received mental health services as children chose not to 
receive them as adults. She attributed this to a lack of services 
geared to their disability and age. 

Differences in Eligibility Criteria between Child and Adult Systems 
Pose Challenges: 

Researchers and state officials we spoke with noted that young adults 
who once received public mental health services, Medicaid, or SSI or DI 
as children face different and sometimes more restrictive eligibility 
requirements for these programs as adults. They added that 
ineligibility for these adult programs can end established 
relationships with mental health professionals or otherwise disrupt 
receipt of mental health services. 

Qualifying for free or low-cost mental health services is often more 
difficult for adults than children. The National Conference of State 
Legislatures found that, among state programs, the clinical criteria 
for receiving adult public mental health services are generally 
narrower for adults than for children.[Footnote 44] Another study has 
found that in 2001 adult and child mental health policies were 
different in 34 states, and in 31 of those states, the range of 
qualifying disorders was more limited for adults than for children. 
[Footnote 45] Specifically, in half of the states with different 
criteria, the adult requirement was more restrictive by virtue of 
citing fewer specific diagnoses to qualify. Similarly, in most states 
children can qualify for Medicaid---the major federal funder of public 
mental health services---at higher household income levels than adults, 
who must also meet other categorical eligibility criteria. In these 
states, a young person previously covered by Medicaid as a child who 
becomes an adult risks losing access to the mental health treatment and 
psychiatric rehabilitation services covered by the program. Advocates, 
state officials, and researchers all cited the loss of Medicaid 
benefits because of different eligibility requirements between children 
and adults as a challenge for young adults with serious mental illness. 

When youth receiving SSI are evaluated using adult rules for SSI within 
one year of turning age 18, as required by law, they also find that the 
adult eligibility criteria are different and can result in a cessation 
of payments. This can also lead to a loss of Medicaid eligibility. SSA 
officials told us that 25 percent of youth who received SSI because of 
a mental health--related condition do not qualify for SSI once they 
turn 18. Advocates working with these young adults and their families 
in the states we visited cited this loss of SSI benefits as a key 
concern for young adults with serious mental illness in their 
transition to adulthood. SSA officials indicated that the loss of 
benefits for these young adults resulted partly from the fact that 
certain mental disorders that are considered disabling to children are 
not applicable to adults.[Footnote 46] For example, adult disorders 
that qualify for SSI do not include eating disorders and attention 
deficit hyperactivity disorder. However, SSA officials told us that 
they are currently working on revising some of the criteria for mental 
health impairments so that the criteria for children and adults are 
more closely aligned. 

Navigating Multiple Programs and Systems Can also Present Challenges: 

Because young adults with serious mental illness usually have a number 
of needs requiring multiple supports, they can find it difficult to 
receive all the services they need when programs are administered by 
different agencies with varying eligibility requirements. Given their 
multiple needs, a coordinated set of benefits is important for a 
successful transition to adulthood. Labor recently reported, however, 
that there is no single system that guides youth, in general, through 
the process of becoming productive, self-sufficient adults and that 
existing services for them are uncoordinated.[Footnote 47] Bazelon has 
similarly found that the programs serving young adults with mental 
illness have varying age and income requirements and may use different 
definitions of mental illness, which can make it difficult to obtain 
multiple services.[Footnote 48] In addition, according to state 
officials with whom we visited, program staff may not collaborate with 
or notify one another of the service plans they develop for clients. 
For example, the director of a mental health advocacy organization in 
Massachusetts told us that when a young person has a serious mental 
illness and the secondary school is involved, the staff at the school 
will typically not speak with the young person's doctor or Medicaid 
provider in order to coordinate behavior plans or more fully understand 
the particular mental illness. 

Navigating the varying eligibility requirements and service plans of 
multiple programs across a number of delivery systems can be difficult 
for anyone, but young adults with serious mental illness may have fewer 
interpersonal and emotional resources with which to do so. Mental 
health advocates told us that because young adults with serious mental 
illness tend to be involved in different service delivery systems, 
their parents or other caring adults must often operate as their de 
facto case worker, attempting to organize and coordinate various 
services. However, researchers and family advocates have also found 
that a major challenge for these parents and caring adults is their 
need for information related to availability of supports. For example, 
one researcher found that families wanted information related to the 
young adults' condition and treatment, available community resources, 
and supports for caregivers and that they generally reported feeling 
overwhelmed by the complexity of the system of agencies and 
organizations. 

Selected States Provide Multidimensional Services to Young Adults with 
Serious Mental Illness Using Various Strategies: 

Recognizing the challenges faced by young adults with serious mental 
illness, the four states we visited--Connecticut, Maryland, 
Massachusetts, and Mississippi--have designed programs with 
multidimensional services to help them transition into adulthood. 
States have used various strategies to provide these services. They 
include broadening eligibility criteria for mental health services, 
employing some of the evidence-based practices promoted by SAMHSA, 
coordinating efforts across multiple state agencies, leveraging federal 
and state funding sources, and involving consumers and family members 
in developing policies and aligning services. 

States We Visited Have Programs Providing Multidimensional Services to 
Young Adults: 

The four states we selected for review have developed programs that 
provide multidimensional services to young adults with serious mental 
illness.[Footnote 49] Administered by their respective mental health 
agencies, these programs are implemented at the local level generally 
by mental health authorities, non-profit organizations, and community- 
based mental health providers. In addition to health care services, the 
programs provide a range of services intended to be age and 
developmentally appropriate, including vocational rehabilitation, 
employment, life-skills development, and, in some cases, housing. These 
four states try to tailor these services so that, to the extent 
possible, young adults receive services appropriate for each 
individual's transition needs[Footnote 50]. They also try to integrate 
the services so that young adults do not have to navigate multiple 
discrete programs. Tailoring and integrating services are both central 
tenets of the wraparound approach. In Connecticut, the young adult 
program initially focused on individuals referred from the Department 
of Children and Families, but has since evolved to focus on a broader 
group of young adults with serious mental illness.[Footnote 51] This 
focus is similar to that of the other states' programs. 

The young adult programs administered by these four states vary in the 
number of young adults with serious mental illness that they serve and 
have not yet been systematically evaluated for their effectiveness. For 
example, in state fiscal year 2007, Connecticut's specialized program 
for young adults with serious mental illness aged 18 through 25 served 
716 individuals, or about 27 percent of the 2,615 young adults with 
serious mental illness receiving mental health services from the state 
mental health agency. State officials explained that not every young 
adult needs the kinds of intensive services provided under the state's 
specialized program for young adults but added that many more young 
adults could benefit from the program than are currently being served. 

In 2007, Massachusetts's young adult program served all of the 
approximately 2,600 young adults aged 16 to 25 with serious mental 
illness in the state's mental health system, providing one or more 
services, including case management, housing, employment, education, 
and peer mentoring. A smaller number received a variety of other mental 
health and social services. Although most of the states' young adult 
programs have existed for more than five years, none of the states have 
systematically collected data on outcomes to evaluate the effectiveness 
of their programs. State officials said that their budget resources are 
limited and they have focused on providing services. (See app. VII for 
a description of the four state programs.) 

States We Visited Use a Number of Strategies to Provide Services: 

In the four states we visited, state officials described a variety of 
strategies they have used to provide multidimensional services to young 
adults with serious mental illness. The strategies include broadening 
eligibility criteria for mental health services, employing evidence- 
based practices promoted by SAMHSA, coordinating efforts across 
multiple state agencies, leveraging federal and state funding sources, 
and involving consumers and family members in developing policies and 
aligning services. 

Broadening Eligibility Criteria for Mental Health Services: 

Maryland has chosen to broaden eligibility criteria for mental health 
services for young adults beyond the medical necessity criteria 
established for adults with serious mental illness. Specifically, 
Maryland generally limits its comprehensive adult mental health 
services to individuals with certain diagnoses and functional 
limitations, but state officials have approved eligibility for young 
adults who do not meet all the criteria. Maryland officials told us 
they aim to identify and treat individuals so that they can become 
meaningful community participants rather than becoming dependent on the 
service system. They said that state services target young adults who 
are in or at risk of out-of-home placement, such as in residential 
treatment centers. Many of these young adults have histories of severe 
trauma, have limited community living skills, and have increased 
psychotic symptoms. 

Employing Evidenced-Based Practices: 

Another strategy is to deliver multidimensional services using evidence-
based practices promoted by SAMHSA. Although these evidence-based 
practices have not been empirically tested specifically on the young 
adult population, states we visited are using some of them. Some of 
these practices involve bringing integrated mental health and social 
services to the young adults living in the community rather than 
expecting them to navigate multiple discrete programs on their own. For 
example, Massachusetts and Connecticut have used the Assertive 
Community Treatment model, which employs an interdisciplinary team of 
psychiatrists, social workers, and nurses to provide psychiatric, 
rehabilitation, and other support services in the community 24 hours 
per day.[Footnote 52] In this model, team members collaborate to tailor 
services on an individual basis, taking into account cultural 
diversity.[Footnote 53] Assertive Community Treatment services are 
designed for individuals who have the most serious symptoms of mental 
illness and greatest impairment in functioning. They often come to the 
program in crisis or upon release from inpatient psychiatric care. In 
Massachusetts, the Assertive Community Treatment services are available 
in various locations throughout the state, including in three sites in 
the Southeastern Area that specifically target these services for young 
adults. Connecticut uses this treatment model in some of its young 
adult program sites, often to serve those leaving foster care and the 
juvenile justice system. 

Connecticut, Maryland, and Massachusetts provide another evidence- 
based practice--supported employment--to assist young adults with 
serious mental illness. Based on the principle that work is 
therapeutic, supported employment programs are designed to help 
individuals work in competitive jobs in the community while receiving 
mental health treatment and rehabilitation services. These programs 
focus on rapid job placement in competitive employment. Once the 
individual is working, the program provides supports to retain 
employment. In Maryland, for example, the state mental health agency 
and the state vocational rehabilitation agency approved 30 evidenced- 
based supported employment programs available for young adults with 
serious mental illness, although these are not uniformly distributed 
across the state.[Footnote 54] According to state officials, these 
programs help individuals find and maintain meaningful jobs that are 
consistent with the individual's preferences and abilities. 

In addition, Connecticut has been providing a type of support that 
SAMHSA is beginning to explore as a potential evidence-based practice-
-supported education for young adults with serious mental illness who 
enroll in higher education. The Connecticut mental health agency 
provides funding for a supported education counselor at one of the 
state universities, who provides case management services, acts as a 
liaison between the university's disability office and the student with 
mental illness, and helps students work with relevant university staff 
to get appropriate accommodations for their mental illness in the 
classroom or during exams. This counselor serves also as an information 
resource for the student's parents, university faculty, and personnel 
that work with the young adult, as well as local mental health 
authorities and other key persons in the mental health system across 
the state.[Footnote 55] 

Coordinating Services across State Agencies: 

Agencies in states we visited are also coordinating to develop policy 
and provide multidimensional services. Agencies coordinate client 
referral, eligibility determination, and service delivery. These 
coordination efforts help address eligibility gaps between the children 
and adult mental health systems and ease service delivery so that young 
adults do not have to navigate multiple discrete programs. 

* Formal Referral Process across Agencies: This strategy can provide a 
bridge for individuals who were receiving services and supports from 
one agency as children but must transition to another agency in order 
to continue to receive those services and supports as adults. In 
Connecticut, many young adults are formally referred to the Connecticut 
mental health agency by the state agency responsible for foster care, 
juvenile justice, and youth mental health services. A cooperative 
agreement between the two agencies specifies appropriate candidates for 
the state mental health agency's young adult program, the process for 
providing services to them by both agencies during the transition 
period, and the agencies' respective funding responsibilities. 
Transitioning youth are referred as early as possible, generally at age 
16, to allow state mental health agency officials to develop 
appropriate plans. These referrals are made on a monthly basis. 

* Integrated Eligibility Determination and Service Delivery: Maryland's 
mental health agency has a formal arrangement with the state's 
vocational rehabilitation agency to integrate eligibility determination 
and service delivery processes. Under a cooperative agreement signed by 
the two agencies in 2007, individuals determined eligible by the mental 
health agency are also determined eligible by the vocational 
rehabilitation agency for supported employment services. The two 
agencies have automated their eligibility determination processes to be 
simultaneous. Once approved for services, individuals receive 
assistance finding and keeping a job and managing their mental illness 
in the workplace. Services are provided by not-for-profit supported 
employment programs that hire employment support specialists, according 
to a state mental health official. 

* Use of Statewide and Local Interagency Task Forces: In 2003, 
Mississippi's mental health agency created an interagency Transitional 
Services Task Force to develop policies and identify resources 
appropriate for young adults with serious mental illness aged 14 
through 25.[Footnote 56] The task force monitors the implementation of 
the state's young adult program at its two current sites and hopes to 
eventually present the results of an evaluation to justify expansion of 
the program statewide. At the local level, Mississippi established 
Multidisciplinary Assessment and Planning Teams, comprised of local 
officials from various state agencies and advocates that meet and 
review cases that include individuals aged 14 to 21 transitioning from 
the child to adult mental health systems, as well as other young adults 
considered high-risk. Currently operating in 33 of 82 counties in the 
state, the teams coordinate delivery of various services including 
mental health, education, vocational rehabilitation, and health care 
services.[Footnote 57] They have some flexible funds for providing 
additional multidimensional services, such as housing, tutoring, school 
uniforms, and in-home respite care. 

Leveraging Federal and State Funding Resources: 

Another strategy is to leverage federal and state funds to finance 
programs for young adults with serious mental illness. The four states 
we visited use Medicaid to pay for mental health services approved by 
CMS in the states' Medicaid plans, such as those provided in a 
physician's office, at an outpatient clinic, or rehabilitation program 
in the community. To varying extents, three of the four states-- 
Maryland, Massachusetts, and Mississippi--use Medicaid's rehabilitation 
option to pay for additional services[Footnote 58] that can support a 
young adult's recovery from mental illness. These services, which are 
provided to address daily problems related to community living and 
interpersonal relationships, may include psychiatric rehabilitation 
program services, symptom management, and counseling.[Footnote 59] 
Further, some of these states have used certain CMS grants to help 
cover some expenses of their young adult programs. For example, 
Mississippi targeted the Real Choice Systems Change grant that it 
received from CMS in 2001 to develop a "person-centered planning" 
approach for delivering services to young adults with serious mental 
illness.[Footnote 60] The grant concluded in 2004, but the state is 
using its own funds to provide these services in two of its local 
mental health centers and to provide training related to this approach. 
In addition, all four states we visited use their own funds to pay for 
mental health and other services for individuals in their young adult 
programs that are not eligible for Medicaid or who are Medicaid-
eligible but receive services not covered under Medicaid.[Footnote 61] 
Examples of such services include housing and transportation costs. 

In addition, states we reviewed used funds from other federal programs 
to provide various transition services to eligible youth through their 
young adult programs. In the case of Maryland, this involves "braided 
funding" for supported employment services. Braided funding refers to 
the integration of funding streams from multiple agencies so that the 
individual receiving services experience a seamless array of services. 
For example, various components of supported employment services are 
funded by Maryland's mental health agency, Maryland's vocational 
rehabilitation, and Medicaid. Maryland's mental health agency and 
Maryland's vocational rehabilitation agency have a cooperative 
agreement that outlines the funding components. In addition, Maryland 
requires individuals in its public mental health system, including 
young adults, to apply for SSI or any other applicable public benefit 
in order to receive income assistance (to pay for housing and 
insurance) to pay for services, according to a state mental health 
official. In the development of its young adult program, Maryland also 
uses part of its CMS Medicaid Infrastructure Grant to consult with 
experts on funding strategies and to implement the web-based mental 
health and vocational rehabilitation eligibility system. 

In addition to federal funds leveraged at the state level, some local 
state agencies obtain services for their clients from other federally 
funded programs. Officials from one service provider in Massachusetts 
told us that their organization works with state housing authorities to 
secure HUD's Section 8 Rental Voucher Program for adults who were 
previously homeless.[Footnote 62] When we conducted our site visit, the 
provider was using 10 such vouchers to serve 20 to 30 young adults, 
according to this provider.[Footnote 63] State officials said that this 
was an important initiative by this provider because states find it 
particularly difficult to obtain appropriate housing for young adults 
with serious mental illness who have criminal records. In Maryland, 
although the state mental health agency does not work directly with the 
state WIA Office, a local provider in its young adult program works 
with local WIA offices in two counties to coordinate employment 
services for young adults with serious mental illness. This provider 
stations case managers at these counties' WIA One-Stop Centers to help 
young adults with serious mental illness with tasks such as identifying 
job opportunities or scheduling interviews.[Footnote 64] 

Involving Young Adults and Their Families: 

Another strategy is to involve young adults and family members in 
developing policy and delivering and evaluating services. The 
Massachusetts mental health agency established a statewide Youth 
Development Committee in 2002 to focus on individuals aged 16 through 
25 with serious mental illness. Committee membership includes young 
adults, parents, state child and adult mental health agency 
representatives, transition experts, and other professionals. Co- 
chaired by young adults with serious mental illness, the committee has 
engaged in a strategic planning process and meets every month to 
discuss progress in the field. The Committee has young adult 
representatives from all areas of the state, and these representatives 
report on progress related to supported employment, housing, and 
transition age youth case management in their areas. They also discuss 
Massachusetts's implementation of the Transition to Independence 
Process (TIP) system and identify emerging staff training needs 
associated with Motivational Interviewing and the TIP model. TIP is an 
approach that delivers individualized-tailored services to youth and 
young adults with serious mental illness by involving them in defining 
and achieving their employment, education, and community-life goals. 
[Footnote 65] The state also has a Youth Leadership Academy, which 
young adults attend to build peer networks and social connections and 
obtain information on key topics such as substance abuse prevention and 
health insurance. 

Federal Agencies Have Supported Demonstrations, Provided Technical 
Assistance and Research, and Formed Interagency Working Groups: 

The needs of young adults with serious mental illness have also 
received some attention from the federal government, which has, to some 
extent, supported state efforts to serve them through demonstrations, 
technical assistance, and research. In response to presidential concern 
about uncoordinated service delivery in the mental health and other 
related systems, several federal agencies have formed working groups to 
consider opportunities for collaboration among programs that involve 
mental health, youth in transition, or the needs of transitional youth 
with disabilities.[Footnote 66] 

One Former Federal Demonstration Project Developed Transition Programs 
That Continue in Five States and States Can Use Other Federal Programs 
to Provide or Coordinate Services: 

SAMHSA, in collaboration with Education, funded local services through 
the Partnerships for Youth in Transition demonstration aimed at 
developing local programs and assisting young adults with serious 
mental illness as they transition to adulthood.[Footnote 67] A total of 
$9.4 million was awarded over 4 years to several sites in Maine, 
Minnesota, Pennsylvania, Utah, and Washington. The demonstrations were 
intended to be self-sustaining and, although funding ended in 2006, 
sites in Pennsylvania, Utah and Washington have continued the program 
in total and aspects of the program continue in Minnesota and Maine. 
Pennsylvania, for example, has continued to operate a program serving 
young adults aged 14 through 25 in two economically disadvantaged 
communities. In these communities, young adults with serious mental 
illness continue to be involved in planning and implementing activities 
and serve on review panels and state-level advisory boards. These 
communities also use transition facilitators who work with young adults 
to help determine their goals and how local services can assist them. 

SAMHSA officials stated that this demonstration project resulted in 
positive outcomes that they would like other states to achieve. A 
preliminary evaluation of 193 program participants conducted by the 
National Center on Youth in Transition at the University of South 
Florida suggests that there may be some positive outcomes, such as 
employment, for participants from the program after 1 year.[Footnote 
68] While the Partnerships for Youth in Transition demonstration ended 
in 2006, SAMHSA officials indicated they are considering continuing 
similar work and looking for opportunities to use the data and lessons 
learned from this demonstration to help states better serve young 
adults with serious mental illness. 

While we found that there are currently no federal programs that target 
this population, agencies fund other demonstration projects that 
support state and local efforts to provide or better coordinate 
existing services for transition-age individuals. For example, SSA's 
Youth Transition Demonstration funds programs at ten sites that help 
youth aged 14 through 25, who receive or may qualify for SSI, 
transition from school to employment. SSA officials stated that mental 
illness is the primary disabling condition of 23 percent of the Youth 
Transition Demonstration enrollees. SSA developed alternative SSI rules 
only for the participants in this program that included extending their 
eligibility for SSI beyond age 18, even if the recipient does not meet 
SSI adult eligibility criteria. While not targeted to young adults with 
serious mental illness, CMS also offers a number of Medicaid 
demonstration waivers or options that can help states pay for services 
for this population. For example, the Community Alternatives to 
Psychiatric Residential Treatment Facilities Demonstration Grant 
Program has awarded 5-year grants to 10 states aimed at preventing 
youth up to age 21 from entering psychiatric residential treatment 
facilities. This demonstration can cover the cost of a comprehensive 
package of community-based services for these youth, such as 24-hour 
support and crisis intervention, respite care for families, and after- 
school support programs. Additional federal programs that can be used 
by states to serve young adults with serious mental illness are 
described earlier in this report, as well as included in appendix VI. 

Federal Agencies Provide Technical Assistance and Fund Research: 

Currently, some federal agencies provide technical assistance on 
promising practices that can help states coordinate services for young 
adults with serious mental illness as they transition to adulthood. 

* SAMHSA's Center for Mental Health Services contracts with two 
nonprofit organizations to operate the Technical Assistance Partnership 
for Child and Family Mental Health. The Partnership facilitates 
collaboration among government officials, organizations, and community 
leaders to develop and implement systems of care. SAMHSA officials told 
us the Partnership has recently begun to provide information on the 
specific needs and issues pertinent to young adults with serious mental 
illness and resources on child welfare youth in transition. 

* The National Collaborative on Workforce and Disability for Youth, 
funded by Labor's Office of Disability Employment Policy, provides 
technical assistance to One-Stop Centers to increase their capacity to 
serve youth aged 14 through 25 with disabilities, including those with 
serious mental illness. For example, according to Labor officials, 
Florida used this resource to enable its workforce development system 
to better assist youth with disabilities as they transition to 
adulthood. Recognizing the uncoordinated service delivery systems that 
youth must navigate, the Collaborative also published a resource guide 
for workforce practitioners and policy makers. The guide is designed to 
promote an understanding of how to serve youth with mental health needs 
and provides information on overcoming obstacles to better coordinate 
services across delivery systems for young adults with serious mental 
illness.[Footnote 69] 

With regard to federal support for research in this area, NIMH awarded 
a $1.1 million grant in 2007 to four research projects examining 
innovative strategies to provide services to youth with serious mental 
illness. According to NIMH, while evidence-based and traditional 
treatment models have been developed and tested for use with younger 
children and adults, evidence-based interventions and services have not 
been empirically tested on young adults or systematically adapted for 
this specific age group. The goal of three of the research projects is 
to assess the impact of tailoring existing treatment models to the 
needs of transition-aged youth. For example, one researcher is planning 
to adapt an established family-focused intervention approach for 
juvenile offenders to one that gives youth offenders with serious 
mental illness more control of their treatment and targets age-relevant 
social, work, and independent living skills. Another project examines 
young adults' use of primary care, mental health services, and 
psychotropic medications, as well as their overall mental health care 
costs. Agency officials told us information could help inform future 
research and strategies that promote continuity of care for young 
adults with serious mental illness as they transition to adulthood. 
[Footnote 70] 

Federal Interagency Groups Are Beginning to Coordinate Mental Health 
Services and Services for Youth in Transition and Youth with 
Disabilities: 

Although there are no federal interagency coordination efforts that 
focus exclusively on young adults with serious mental illness, three 
independent multiagency groups were recently formed to consider 
opportunities to coordinate federal programs and could address the 
needs of this group. According to agency officials, while efforts are 
not coordinated across these three groups formally, they have similar 
agency and staff participation. Figure 3 lists these groups, their 
target population, goals, and participating agencies. 

Figure 3: Federal Coordination Efforts on Mental Health, Youth in 
Transition, and Transitioning Youth with Disabilities: 

[See PDF for image] 

This figure is a table depicting the Federal Coordination Efforts on 
Mental Health, Youth in Transition, and Transitioning Youth with 
Disabilities, as follows: 

Group: Federal Executive Steering Committee on Mental Health; 
Target Population: Individuals with Mental Illness; 
Goal: Implement recommendations of the Presidentï¿½s New Freedom 
Commission on Mental Health to better coordinate federal services; 
Member Agencies: 
DOD: Member agency; 
DOJ: Member agency; 
DOL: Member agency; 
DOT: Member agency; 
ED: Member agency; 
HHS: Lead agency; 
HUD: Member agency; 
SSA: Member agency; 
USDA: Member agency; 
VA: Member agency. 

Group: Shared Youth Vision Federal Collaborative Partnership; 
Target Population: Transitioning Youth; 
Goal: Strengthen communication and coordination among federal youth 
serving agencies; 
Member Agencies: 
DOD: Not a member; 
DOJ: Member agency; 
DOL: Lead agency; 
DOT: Member agency; 
ED: Member agency; 
HHS: Member agency; 
HUD: Member agency; 
SSA: Member agency; 
USDA: Not a member; 
VA: Not a member. 

Group: Federal Partners in Transition Workgroup; 
Target Population: Transitioning Youth with Disabilities; 
Goal: Preparing youth with disabilities for employment; 
Member Agencies: 
DOD: Not a member; 
DOJ: Member agency; 
DOL: Lead agency; 
DOT: Member agency; 
ED: Member agency; 
HHS: Member agency; 
HUD: Not a member; 
SSA: Member agency; 
USDA: Not a member; 
VA: Not a member. 

Source: GAO analysis. 

Note: National Council on Disability and U.S. Equal Employment 
Opportunity Commission also participate in the Federal Partners in 
Transition Workgroup. Corporation for National and Community Service 
also participates in Shared Youth Vision Federal Collaborative 
Partnership. 

DOD = Department of Defense; DOT = Department of Transportation; VA = 
Veterans Administration. 

[End of figure] 

While interagency groups have been tasked with coordinating across 
agencies, officials from a number of agencies noted that differences in 
their missions and goals may make it difficult to coordinate services 
for young adults with serious mental illness. For example, according to 
one SAMHSA official, mental health agencies are more focused on 
maintaining youth in the home or in a community-based setting, whereas 
juvenile justice agencies are more focused on protecting the community 
from youth offenders. Agency officials also cited differences in 
eligibility criteria across programs as a challenge for coordination, 
stating that age requirements for receiving benefits--often written in 
statute--vary across some programs. Despite these limitations, ongoing 
federal coordination efforts are beginning to address the needs of this 
population. 

The Federal Executive Steering Committee on Mental Health was formed in 
response to the 2003 President's New Freedom Commission on Mental 
Health, which made recommendations to the federal government to better 
coordinate services, such as employment supports and housing, for those 
with mental illness. The committee has taken steps to promote access to 
supported employment services for young adults with serious mental 
illness by reviewing existing federal programs and initiatives for 
youth transitioning to the workforce to better coordinate their 
efforts. To promote youth leadership and youth-guided policymaking 
related to mental health at the federal level, the committee, led by 
Labor's Office of Disability Employment Policy, also held a National 
Youth Summit in 2007. The President's New Freedom Commission 
recommended actions to address mental health stigma, and SAMHSA 
launched a campaign specifically targeted to young adults.[Footnote 71] 

The Shared Youth Vision Federal Collaborative Partnership was created 
to strengthen coordination among federal youth-serving agencies. It was 
formed in response to a report written by the White House Task Force on 
Disadvantaged Youth in 2003, which identified challenges related to 
coordination among youth-serving programs and prompted federal efforts 
to support capacity building and collaboration among those agencies. 
Many of the federal officials we spoke with indicated this initiative 
could have an impact on young adults, including those with serious 
mental illness. Sixteen states have received funding through this 
initiative to develop interagency collaboration as well as state and 
local partnerships to provide transition assistance to disadvantaged 
young adults, including those with serious mental illness. For example, 
the Oklahoma Youth Vision Project is working across eight state youth- 
serving agencies, Job Corps, as well as local school districts, group 
homes, and employers to help disadvantaged youth, particularly those 
aging out of foster care, aged 16 through 21, graduate from high school 
and become employed.[Footnote 72] In addition, this initiative sponsors 
technical assistance forums for participating federal agencies and runs 
a solutions desk that provides the 16 state grantees with a single 
point of access to federal resources such as training and technical 
assistance in implementing federal grants related to disadvantaged 
youth. 

The third coordination initiative, Federal Partners in Transition 
Workgroup, led by Labor's Office of Disability Employment Policy, began 
in June 2005 and focuses exclusively on disabled youth transitioning to 
adulthood, including young adults with serious mental illness. The 
Federal Partners in Transition Workgroup brings together federal agency 
staff who work on youth, transition, and disability issues. This group 
has concentrated on strengthening connections with employers and 
preparing youth with disabilities for the labor market. It also plans 
to hold a forum in 2008 to coordinate federally funded transition- 
focused technical assistance centers across agencies. 

Although none of these federal interagency coordination groups or 
existing programs focuses exclusively on young adults with serious 
mental illness, overall they are beginning to explore ways to 
coordinate and provide services to assist this group. 

Concluding Observations: 

State investments in programs to help young adults with serious mental 
illness become productive and independent are designed to address the 
challenges these individuals face. The state and local officials we 
spoke with appeared to be optimistic about the potential of efforts 
like theirs to make a difference for these young adults. The federal 
government has played a limited but important role in these efforts by 
funding demonstrations and research and providing technical assistance. 
Evaluations of these demonstration projects have shown some promising 
outcomes, and the number of practices grounded in evidence-based 
research continues to grow. While programs that assist transitional 
youth, youth with disabilities, and the mentally ill are situated in 
different departments, federal agencies are beginning to work together 
to coordinate these programs to better serve young adults with serious 
mental illness. The federal government's continuing efforts to 
disseminate information about promising state and local programs may 
sustain the momentum in this area by providing valuable lessons and 
encouragement to others interested in assisting young adults with 
serious mental illness. 

Response to Agency Comments: 

We provided a draft of this report to Education, DOJ, HHS, HUD, Labor, 
and SSA and draft sections concerning their states to agencies in 
Connecticut, Maryland, Massachusetts, and Mississippi. We received 
technical comments from all of the federal and state agencies, which we 
incorporated where appropriate, and general comments from HHS, which 
are included in appendix XIII. In its general comments, HHS indicated 
that the report was pertinent and timely. However, HHS stated that the 
report should have included a number of other important topics and 
should have focused on younger individuals as well as those aged 18 
through 26. While we agree that additional research could be 
beneficial, our report focused specifically on the objectives and 
population we agreed upon with our requesters. To better convey our 
scope, we revised the report title in response to HHS's suggestion. 

HHS also commented that our definition of serious mental illness was 
unclear. In particular, they took issue with our use of the NCS-R to 
estimate the number of young adults with serious mental illness. They 
believe that data from the NCS-R represent only a subset of those 
individuals who would be considered to have a serious mental illness 
under the definition used by SAMHSA to determine how states can use 
Community Mental Health Block grant (see 58 Fed. Reg. 29422 (May 20, 
1993), implementing Pub. L. 102-321). Specifically, they pointed out 
that the NCS-R does not include those in institutions and does not 
identify those with schizophrenia, or personality disorder. 
Additionally, HHS stated that the researchers and consumer 
organizations that we interviewed were weighted toward those with 
expertise in childhood mental illnesses and did not include experts in 
schizophrenia or adult mental health consumer organizations. HHS also 
stated that the report should have included a more extensive discussion 
of serious emotional disturbance and the degree to which states were 
providing services specifically for young adults with serious mental 
illness. 

Researchers and policy makers have long recognized that defining 
serious mental illness in order to estimate its prevalence or to 
determine eligibility for services presents a significant challenge. 
Our report generally uses a definition of serious mental illness that 
is based on SAMHSA's regulation implementing Pub. L. 102-321. We 
clarified the text to explain that in places throughout the report, we 
may use a slightly broader or narrower concept of serious mental 
illness as necessitated by available data as well as programmatic or 
administrative definitions. We used NCS-R data to estimate the 
prevalence of serious mental illness on the basis of recommendations 
from several researchers. In addition, the NCS-R was identified in a 
SAMHSA publication as a source of nationally representative data that 
measures the severity of mental disorders, which relates to SAMHSA's 
definition of serious mental illness.[Footnote 73] Our draft clearly 
acknowledges the limitations of the NCS-R by stating that our estimate 
is likely to be low. It also provides the number of individuals 18 
through 26 with serious mental illness who receive SSI and DI benefits 
due to mental illness. This number is likely to include young adults 
who may not have been included in the NCS-R, such as those living in an 
institution and many with schizophrenia or psychosis. To respond to 
HHS's comments, we have further highlighted our discussion of why 
limitations of the NCS-R result in an underestimate of the number of 
young adults with serious mental illness. With regard to the expertise 
of researchers and consumer organizations we interviewed, we chose the 
individuals and groups we did primarily because of their expertise in 
young adults with serious mental illness and, in many cases, because 
they were recommended to us by federal officials or researchers. While 
most also have an interest in a younger population, this group included 
organizations that have a strong interest in adult mental health 
issues, such as Mental Health America, several National Alliance of 
Mental Illness chapters, and Black Mental Health Alliance for Education 
and Consultation, Inc. In addition, we added information in response to 
HHS comments to better distinguish serious emotional disturbance from 
serious mental illness and information from other research on the 
degree to which state mental health agencies are implementing 
transition services. 

As agreed with your offices, unless you make arrangements to release 
its contents earlier, we will make no further distribution of this 
report until 30 days from the date of this letter. At that time, we 
will send copies of this report to Education, DOJ, HHS, HUD, Labor, and 
SSA. Copies will also be made available to others on request. This 
report is also available at no charge on GAO's Web site at [hyperlink, 
http://www.gao.gov]. 

Please contact us on (202) 512-7215 or (202) 512-7114 if you or your 
staff have any questions about this report. Contact points for our 
Office of Congressional Relations and Office of Public Affairs can be 
found on the last page of this report. Other major contributors to this 
report are listed in appendix XIV. 

Signed by: 

Cornelia M. Ashby: 
Director: 
Education, Workforce, and Income Security Issues: 

Signed by: 

Cynthia A. Bascetta: 
Director: 
Health Care Issues: 

[End of section] 

Appendix I: Scope and Methodology: 

To conduct our work, we relied on multiple methodologies, including 
data analyses, literature reviews, interviews, and site visits to four 
states. More specifically, to provide information on the number and 
demographic characteristics of young adults with serious mental 
illness, which we defined as individuals aged 18 through 26, we 
analyzed data from the federally funded National Comorbidity Survey- 
Replication, 2001-2003 (NCS-R), of the 2006 Current Population Survey, 
Annual Social and Economic Supplement (CPS), and two sources of data on 
individuals receiving disability benefits from the Social Security 
Administration (SSA): the 2006 Ticket Research File (TRF) and the 
National Beneficiary Survey, 2004 (NBS). We also reviewed published 
research on the extent of mental illness among the homeless and those 
involved with the criminal justice or foster care systems. To identify 
the challenges faced by young adults with serious mental illness, we 
reviewed published research and interviewed federal, state, and local 
officials; mental health practitioners; experts; and advocacy groups. 
To describe the programs and strategies that selected states are using 
to assist these youth, we visited four states that had implemented 
programs specifically focused on this population--Connecticut, 
Maryland, Massachusetts, and Mississippi--and met with officials from 
key state agencies and private organizations involved in service 
delivery. To determine how federal agencies are supporting states and 
coordinating federal programs to help young adults with serious mental 
illness, we interviewed key federal officials from agencies within the 
U.S. Department of Education (Education), Department of Health and 
Human Services (HHS), Department of Housing and Urban Development 
(HUD), Department of Justice (DOJ), Department of Labor (Labor), and 
SSA. We also reviewed documents pertaining to the activities and 
accomplishments of interagency coordination groups, as well as funding 
and eligibility information on federal programs relevant to young 
adults with serious mental illness. We conducted our work from June 
2007 through June 2008 in accordance with generally accepted government 
auditing standards. 

Data Analyses: 

To provide information on the number and demographic characteristics of 
young adults aged 18 through 26 with serious mental illness, we relied 
on data from the NCS-R, the CPS, the TRF, and the NBS. We considered 
using data from another survey, the National Survey on Drug Use and 
Health conducted by the Substance Abuse and Mental Health Services 
Administration (SAMHSA). Until 2004, SAMHSA reported rates of serious 
mental illness based on this survey but has since determined that the 
survey does not employ a sufficiently reliable measure of serious 
mental illness and therefore no longer uses it for this purpose. 

The National Comorbidity Survey Replication: 

The NCS-R is a nationally representative survey of English-speaking 
household and campus group housing residents aged 18 and over living in 
the contiguous United States. Funded primarily by the National 
Institute of Mental Health, with supplemental funding from the National 
Institute on Drug Abuse and the Substance Abuse and Mental Health 
Services Administration (SAMHSA), the NCS-R served as the U.S. 
participation in the World Health Organization's World Mental Health 
Survey Initiative. The household sample was selected using a multistage 
clustered area probability sampling technique, and students living in 
campus-housing were selected from the household sample. Between 
February 2001 and April 2003, 7,693 individuals were interviewed, 
yielding a response rate of 71 percent. During the interviews, 
respondents were assessed for the presence of mental disorders within 
the previous year, using the Composite International Diagnostic 
Interview, a lay-administered survey that generates diagnoses based on 
the American Psychiatric Association's Diagnostic and Statistical 
Manual of Mental Disorders--Fourth Edition (DSM-IV) and the 
International Classification of Diseases--10. 

To estimate the prevalence of serious mental illness in young adults, 
we obtained the NCS-R public use data file, as well as a supplemental 
file containing an indicator of the severity--serious, moderate, or 
mild--for each respondent diagnosed with a mental illness. This 
severity indicator was developed separately by the principal 
investigator of the NCS-R and is not included in the public use file. 
Using these two files, we isolated the 1,589 respondents who were aged 
18 through 26 and identified the subset with serious mental illness 
[Footnote 74] as well as the subset with moderate, mild, or no mental 
illness. We applied weighting variables to our estimates in order to 
project these results to the general population of young adults in the 
United States.[Footnote 75] Following this methodology, we obtained a 
prevalence estimate of serious mental illness among young adults in 
U.S. households of 6.5 percent. 

To estimate the total number of young adults with serious mental 
illness in 2006, we obtained population estimates from the 2006 CPS. We 
applied the 6.5 percent prevalence estimate to the total civilian, 
noninstitutionalized population estimate for young adults aged 18 
through 26--37 million. Because NCS-R data pertain to individuals 
surveyed between February 2001 and April 2003, our 2006 estimates are 
based on the assumption that rates of serious mental illness were 
relatively stable among the young adult population from that survey 
period through 2006.[Footnote 76] This is supported by research that 
shows that the prevalence of serious mental illness among adults in the 
United States did not change significantly between 1990 and 2003. 

We also compared the demographic characteristics of the cohort of young 
adults aged 18 through 26 with serious mental illness to the cohort of 
young adults with mild or moderate mental illness and the cohort of 
those with no mental illness.[Footnote 77] We applied weighting 
variables to project our results to the general population of young 
adults in the United States, and all estimates are presented using a 95 
percent confidence interval, within plus or minus 12 percentage points, 
unless otherwise noted.[Footnote 78] All tests of statistical 
significance were conducted at the 5 percent significance level for our 
analyses. 

Ticket Research File: 

The TRF is a longitudinal database that combines administrative data 
from multiple SSA databases for all Supplemental Security Income (SSI) 
and Disability Insurance (DI) beneficiaries between age 18 and 
retirement age from 1996 through 2006. SSA provided us with an extract 
file containing data on the subset of 764,384 individuals aged 18 
through 26 in 2006. We identified 186,101 individuals whose primary 
disability was listed as a serious mental illness at any point in 2006 
by including those whose impairment fell under any of the following 
categories: major affective disorders, schizophrenia and psychoses, 
anxiety and neurotic disorders, and certain other mental disorders. 
[Footnote 79] We then analyzed several characteristics of those 
individuals, including race, gender, primary and secondary disability, 
and benefit type, using information in the database.[Footnote 80] 

National Beneficiary Survey: 

Sponsored by SSA's Office of Disability and Income Security, the NBS is 
a nationally representative survey of SSI and DI beneficiaries and 
Ticket to Work participants between the ages of 18 and 64. The sample 
was selected using a multistage clustered sampling technique, and 6,520 
individuals were interviewed between February and October 2004, for a 
weighted response rate of 77.5 percent. We used the same methodology 
for identifying the cohort of young adults with serious mental illness 
that we used for the TRF, based on each respondent's primary disabling 
condition. In total, the subsample contained 1,436 respondents aged 18 
through 26 and 356 that were found to have a serious mental illness 
listed as their primary disability. We applied weighting variables to 
each estimate in order to project our results to the general population 
of young adults receiving disability benefits because of a serious 
mental illness, and all estimates are presented using a 95 percent 
confidence interval, within plus or minus 7 percentage points. Finally, 
we identified demographic data in the NBS that could be directly 
compared to demographic data in the NCS-R. 

Data Reliability: 

We determined that data from the NCS-R, CPS, TRF, and NBS were 
sufficiently reliable for our purposes. In order to assess the 
reliability of the NCS-R, CPS, and NBS, we reviewed documentation 
pertaining to the sampling methodologies, survey instruments, and the 
structure of the data files. In order to assess the reliability of TRF 
data, we reviewed documentation on the construction of the file and the 
data reliability tests conducted by SSA's contractor--Mathematica 
Policy Research, Inc. 

Literature Review: 

To provide information on the number of young adults with serious 
mental illness who are in certain vulnerable populations--specifically, 
those who are homeless or involved in the justice or foster care 
systems--we conducted a literature review that included published peer- 
reviewed research articles identified through databases such as 
ProQuest, Dissertations, Ovid, PsycINFO, PsycFirst, MEDLINE, ECO/ 
WorldCat, Social Science Abstracts, and GAO publications. We used 
various search terms, such as young adult, mental illness, homeless, 
incarcerated, and foster care, in searching these databases, and we 
selected original research published since 1990. We were unable to 
identify any original research since 1990 that provided national 
estimates of the rates of serious mental illness in young adults in the 
three vulnerable populations. We did identify research on rates of 
mental illness in these vulnerable populations. We reviewed these 
studies' findings for methodological rigor and determined that they 
were sufficiently reliable for the purposes of this study. 

To learn more about the major challenges faced by young adults with 
serious mental illness and their families, as well as their demographic 
characteristics, we conducted a literature review using the same 
databases identified above. We used various search terms, such as young 
adult, mental illness, challenges, support needs, service needs, 
family, and caregivers, and selected original research published since 
1995. We also collected other literature cited in these studies as well 
as literature recommended to us during our interviews. We then 
conducted a more intensive review of the 18 studies identified through 
these methods. For each selected study, we reviewed the study's 
findings for methodological rigor and determined that it was 
sufficiently reliable for the purposes of this study. 

Interviews with Researchers and Mental Health Organizations: 

To gather information related to all four objectives, we also conducted 
interviews with academic researchers and other experts on mental health 
issues, including some who represented mental health organizations. We 
identified interviewees through our literature review and through 
recommendations from federal agency officials and other mental health 
experts. In addition, we identified mental health-related organizations 
in the states we visited as part of our site visits. For this study we 
interviewed: 

Hewitt B. Clark, Ph.D., University of South Florida; 
Maryann Davis, Ph. D., University of Massachusetts; 
Mary Molewyk Doornbos, Ph.D., R.N., Calvin College; 
Donna Folkemer, National Conference of State Legislatures; 
Vicki Hines-Martin, Ph.D., R.N., C.S., University of Louisville; 
Ronald C. Kessler, Ph.D., Harvard Medical School, Harvard University; 
Chris Koyanagi, Judge David L. Bazelon Center for Mental Health Law; 
Linda Rose, R.N., Ph.D., The Johns Hopkins University School of 
Nursing; 
Ann Vander Stoep, Ph.D., University of Washington; 
Mary Wagner Ph.D., SRI International. 

We also interviewed representatives from the following advocacy groups: 
Black Mental Health Alliance for Education and Consultation, Inc.; 
Maryland Coalition of Families for Children's Mental Health; 
Mississippi Families as Allies for Children's Mental Health, Inc.; 
Family Advocates for Children and Behavioral Health, Connecticut; 
National Federation of Families for Children's Mental Health; 
Generations United; National Alliance on Mental Illness, headquarters 
and chapters in Connecticut, Massachusetts, and Maryland; Mental Health 
America; National Family Caregivers Association; National Council on 
Independent Living; and Self Reliance, Inc., Center for Independent 
Living. 

Site Visits: 

To describe the programs and strategies that selected states are using 
to assist young adults with serious mental illness, we visited four 
states that had implemented programs specifically focused on this 
population--Connecticut, Maryland, Massachusetts, and Mississippi. To 
identify these states, we reviewed published research and interviewed 
federal and state officials, mental health researchers, and advocacy 
groups to learn of states that were viewed as offering progressive 
statewide or state-organized programs that focus specifically on young 
adults with serious mental illness. Programs in these states should not 
be considered representative of how states assist young adults with 
serious mental illness nationally; rather, they serve as examples of 
states that are providing such assistance. We considered other states 
identified by research or by the officials, researchers, and advocacy 
groups, but these states generally had small, local programs available 
to serve young adults with serious mental illness, not statewide or 
state-organized programs. Before we made the site visits, we reviewed 
available literature on the four states' mental health systems and 
programs, including state mental health planning documents and federal 
grants pertaining to this population. 

During the site visits, we met with officials from state mental health 
agencies, as well as other key state agencies and private sector 
organizations involved in providing, coordinating, or advocating for 
services for this population. During some of these meetings, we spoke 
with young adult consumers of state mental health services. Given that 
state mental health agencies are responsible for administering and 
coordinating services across the state for individuals with serious 
mental illness, we relied on each state mental health agency to serve 
as the lead agency in arranging visits with local mental health 
organizations, other state agencies, and private organizations. 

While state programs that assist young adults with serious mental 
illness varied in the specific age ranges they targeted, for purposes 
of this report we focused on the key programs that state mental health 
agency officials identified, which generally served individuals aged 16 
through 25. In addition, we reviewed written information on state 
policies and programs provided by state officials we interviewed. 

[End of section] 

Appendix II: Federal Programs Identified by Bazelon as Helping Young 
Adults with a Serious Mental Illness (SMI): 

Department: Corporation for National and Community Service; 
Program: Engaging Persons with Disabilities in National and Community 
Services Grants. 

Department: DOJ; 
Program: Drug-Free Communities Support Program Grants. 

Department: DOJ; 
Program: Juvenile Justice and Delinquency Prevention State Formula 
Grant. 

Department: DOJ; 
Program: Title V Community Prevention Grants Program. 

Department: DOD; 
Program: National Guard Youth ChalleNGe Program. 

Department: Education; 
Program: Elementary and Secondary School Counseling Program. 

Department: Education; 
Program: Federal Direct Student Loan and Family Education Loan 
Programs. 

Department: Education; 
Program: Grants for the Integration of Schools and Mental Health 
Systems. 

Department: Education; 
Program: Federal Perkins Loan Program. 

Department: Education; 
Program: Federal Supplemental Educational Opportunity Grants. 

Department: Education; 
Program: Federal Work-Study Program. 

Department: Education; 
Program: IDEA, Part B. 

Department: Education; 
Program: Independent Living Centers. 

Department: Education; 
Program: Pell Grants. 

Department: Education; 
Program: Safe and Drug Free Schools. 

Department: Education; 
Program: Transition Initiative. 

Department: Education; 
Program: Vocational and Adult Education State Basic Grants. 

Department: Education; 
Program: Vocational Rehabilitation: Supported Employment State Grants. 

Department: Education; 
Program: Vocational Rehabilitation, Title I Formula Grants. 

Department: HHS; 
Program: Adolescent Family Life Demonstration. 

Department: HHS; 
Program: Child Care Block Grant. 

Department: HHS; 
Program: Community Mental Health Services Block Grant. 

Department: HHS; 
Program: Community Services Block Grant. 

Department: HHS; 
Program: Comprehensive Community Mental Health Services for Children 
and Their Families. 

Department: HHS; 
Program: Educational and Training Vouchers Program for Youths Aging out 
of Foster Care. 

Department: HHS; 
Program: Health Care for the Homeless. 

Department: HHS; 
Program: Healthy and Ready to Work Initiative. 

Department: HHS; 
Program: John H. Chafee Foster Care Independence Program. 

Department: HHS; 
Program: Maternal & Child Health Block Grant. 

Department: HHS; 
Program: Medicaid. 

Department: HHS; 
Program: Partnerships for Youth in Transition. 

Department: HHS; 
Program: Projects for Assistance in Transition from Homelessness - 
PATH. 

Department: HHS; 
Program: Runaway and Homeless Youth Act Programs. 

Department: HHS; 
Program: State Adolescent Substance Abuse Treatment Coordination. 

Department: HHS; 
Program: S-CHIP. 

Department: HHS; 
Program: Social Services Block Grant. 

Department: HHS; 
Program: Substance Abuse Prevention and Treatment Block Grant. 

Department: HHS; 
Program: Temporary Assistance for Needy Families. 

Department: HHS; 
Program: Title IV-B and Promoting Safe and Stable Families. 

Department: HHS; 
Program: Title IV-E - Payments for Children in Foster Care. 

Department: HHS; 
Program: Youth Transition Into the Workplace Grant. 

Department: HHS/Education/DOJ; 
Program: Safe Schools and Healthy Students Initiative. 

Department: HUD; 
Program: Community Development Block Grant. 

Department: HUD; 
Program: HOME Investment Partnership. 

Department: HUD; 
Program: Public Housing. 

Department: HUD; 
Program: Section 8 Housing Choice Vouchers. 

Department: HUD; 
Program: Shelter-Plus-Care. 

Department: Labor; 
Program: Job Corps. 

Department: Labor; 
Program: One-Stop Career Centers. 

Department: Labor; 
Program: Workforce Investment Act Youth Formula Grants. 

Department: Labor; 
Program: YouthBuild. 

Department: SSA; 
Program: SSI Disability Benefits. 

Department: SSA; 
Program: SSI Youth Transition Demonstration. 

Department: SSA; 
Program: Ticket-To-Work and Work Incentives Improvement. 

Department: USDA; 
Program: Special Supplemental Nutrition for Women, Infants and Children 
(WIC). 

Department: USDA; 
Program: Food Stamps. 

Department: USDA; 
Program: American Conservation and Youth Service Corps. 

Source: Moving On: Analysis of Federal Programs Funding Services to 
Assist Transition-Age Youth with Serious Mental Health Conditions. 
Judge David L. Bazelon Center for Mental Health Law. 2005. 

[End of table] 

[End of section] 

Appendix III: Evidence-Based Practices Promoted by SAMHSA: 

Evidence-Based Practice: Assertive Community Treatment; 
Description: Helps people stay out of the hospital and develop skills 
for living in the community, through treatment customized to individual 
needs delivered by a team of practitioners, available 24 hours a day. 

Evidence-Based Practice: Co-Occurring Disorders: Integrated Dual 
Disorders Treatment; 
Description: Integrated treatment for mental illness and substance 
abuse addiction for people who have these co-occurring disorders. 

Evidence-Based Practice: Family Psychoeducation; 
Description: Involves a partnership among consumers, families, and 
practitioners to learn ways to manage mental illness and reduce tension 
and stress within the family. 

Evidence-Based Practice: Illness Management and Recovery; 
Description: Emphasizes helping people set and pursue personal goals 
and implement action strategies in their everyday lives. 

Evidence-Based Practice: Supported Employment; 
Description: A well-defined approach to help people with mental illness 
find and keep competitive employment within their communities, through 
employment services that are integrated with mental health treatment. 

Source: SAMHSA. 

Note: On its website, SAMHSA provides toolkits for these five evidence- 
based practices. SAMHSA is also promoting and implementing research on 
evidence-based practices in a number of other areas, such as supportive 
housing and supported education, and plans on providing toolkits or 
other informational materials for these as well. 

[End of table] 

[End of section] 

Appendix IV: Demographic Characteristics of Young Adults Aged 18-26, by 
Severity of Mental Illness, 2001-2003: 

Demographic characteristic: Sex: Male; 
Serious mental illness: 45% (34-56); 
Moderate or mild mental illness: 43% (38-49); 
No mental illness: 53% (49-58). 

Demographic characteristic: Sex: Female; 
Serious mental illness: 55% (44-67); 
Moderate or mild mental illness: 57% (51-62); 
No mental illness: 47% (42-51). 

Demographic characteristic: Race: Caucasian; 
Serious mental illness: 59% (47-72); 
Moderate or mild mental illness: 68% (61-75); 
No mental illness: 64% (59-70). 

Demographic characteristic: Race: African-American; 
Serious mental illness: 19% (11-27); 
Moderate or mild mental illness: 11% (6-15); 
No mental illness: 12% (8-16). 

Demographic characteristic: Race: Hispanic; 
Serious mental illness: 17% (10-24); 
Moderate or mild mental illness: 16% (11-21); 
No mental illness: 19% (15-23). 

Demographic characteristic: Race: Other; 
Serious mental illness: 5% (1-8); 
Moderate or mild mental illness: 5% (2-9); 
No mental illness: 5% (3-7). 

Demographic characteristic: Region: Northeast; 
Serious mental illness: 20% (11-28); 
Moderate or mild mental illness: 16% (11-21); 
No mental illness: 19% (12-27). 

Demographic characteristic: Region: Midwest; 
Serious mental illness: 26% (17-36); 
Moderate or mild mental illness: 20% (15-26); 
No mental illness: 21% (17-26). 

Demographic characteristic: Region: South; 
Serious mental illness: 34% (25-43); 
Moderate or mild mental illness: 35% (26-44); 
No mental illness: 33% (26-41). 

Demographic characteristic: Region: West; 
Serious mental illness: 20% (8-32); 
Moderate or mild mental illness: 29% (16-41); 
No mental illness: 26% (15-37). 

Demographic characteristic: Marital status: Married; 
Serious mental illness: 20% (13-28); 
Moderate or mild mental illness: 25.5% (21-30); 
No mental illness: 20% (16-23). 

Demographic characteristic: Marital status: Not married; 
Serious mental illness: 80% (72-87); 
Moderate or mild mental illness: 74.5% (70-79); 
No mental illness: 80% (77-84). 

Demographic characteristic: Children: No children; 
Serious mental illness: 71% (57-84); 
Moderate or mild mental illness: 75% (69-81); 
No mental illness: 81% (76-85). 

Demographic characteristic: Children: One child or more; 
Serious mental illness: 29% (16-43); 
Moderate or mild mental illness: 25% (19-31); 
No mental illness: 19% (15-24). 

Demographic characteristic: Employment status: Employed; 
Serious mental illness: 63% (52-75); 
Moderate or mild mental illness: 68% (62-73); 
No mental illness: 71% (67-75). 

Demographic characteristic: Employment status: Unemployed or student; 
Serious mental illness: 37% (25-48); 
Moderate or mild mental illness: 32% (27-38); 
No mental illness: 29% (25-33). 

Demographic characteristic: Education: 0-11 years; 
Serious mental illness: 36% (24-47); 
Moderate or mild mental illness: 19% (15-23); 
No mental illness: 17% (14-21). 

Demographic characteristic: Education: 12 years; 
Serious mental illness: 32% (24-40); 
Moderate or mild mental illness: 35% (28-42); 
No mental illness: 31% (25-38). 

Demographic characteristic: Education: More than 12 years; 
Serious mental illness: 32% (24-41); 
Moderate or mild mental illness: 46% (39-54); 
No mental illness: 51% (44-59). 

Demographic characteristic: Health insurance: Insured; 
Serious mental illness: 71% (61-81); 
Moderate or mild mental illness: 73% (38-78); 
No mental illness: 75% (70-80). 

Demographic characteristic: Health insurance: Uninsured; 
Serious mental illness: 29% (19-39); 
Moderate or mild mental illness: 27% (22-32); 
No mental illness: 25% (20-30). 

Source: GAO analysis of the National Co-morbidity Survey Replication, 
2001-2003. 

Note: Numbers in parentheses are confidence intervals at the 95% level. 

[End of table] 

[End of section] 

Appendix V: Demographic Characteristics of Young Adults 18-26 Who 
Received SSA Disability Benefits Because of a SMI: 

Results from the Ticket Research File, 2006: 

Demographic characteristic: Sex: Male; 
Among those with serious mental illness: 60%. 

Demographic characteristic: Sex: Female; 
Among those with serious mental illness: 40%. 

Demographic characteristic: Race: Caucasian; 
Among those with serious mental illness: 53%. 

Demographic characteristic: Race: African-American; 
Among those with serious mental illness: 29%. 

Demographic characteristic: Race: Hispanic; 
Among those with serious mental illness: 12%. 

Demographic characteristic: Race: Other or missing data; 
Among those with serious mental illness: 6%. 

Demographic characteristic: Benefit type: SSI payment; 
Among those with serious mental illness: 67%. 

Demographic characteristic: Benefit type: DI payment; 
Among those with serious mental illness: 9%. 

Demographic characteristic: Benefit type: Both; 
Among those with serious mental illness: 24%. 

Results from the National Beneficiary Survey, 2004: 

Demographic characteristic: Marital status: Married; 
Among those with serious mental illness: 10% (6-13). 

Demographic characteristic: Marital status: Not married; 
Among those with serious mental illness: 90% (87-94). 

Demographic characteristic: Employment status: Employed; 
Among those with serious mental illness: 15% (10-19). 

Demographic characteristic: Employment status: Not employed; 
Among those with serious mental illness: 85% (81-90). 

Demographic characteristic: Ever worked: Yes; 
Among those with serious mental illness: 59% (53-66). 

Demographic characteristic: Ever worked: No; 
Among those with serious mental illness: 41% (34-47). 

Demographic characteristic: Education: 0-11 years; 
Among those with serious mental illness: 48% (41-55). 

Demographic characteristic: Education: 12 years; 
Among those with serious mental illness: 42% (36-48). 

Demographic characteristic: Education: More than 12 years; 
Among those with serious mental illness: 10% (7-13). 

Demographic characteristic: Health insurance: Insured; 
Among those with serious mental illness: 93% (89-96). 

Demographic characteristic:Health insurance: Uninsured; 
Among those with serious mental illness: 7% (4-11). 

Source: GAO analysis of SSA's Ticket Research File, 2006, and National 
Beneficiary Survey, 2004. 

Notes: This analysis does not include those who receive disability 
benefits because of abnormalities in cognition or intellectual 
functioning, such as mental retardation or autism. Numbers in 
parentheses are confidence intervals at the 95% level. Confidence 
intervals do not apply to statistics derived from the Ticket Research 
File, as they are true population values rather than estimates. 

[End of table] 

[End of section] 

Appendix VI: Selected Programs States Can Use to Target or Provide 
Comprehensive Services for Young Adults with SMI: 

Program: Justice and Mental Health Collaboration Program; 
Department: DOJ; 
Description: The Justice and Mental Health Collaboration Program was 
created to increase public safety by facilitating collaboration among 
the criminal justice, juvenile justice, and mental health and substance 
abuse treatment systems to increase access to services for offenders 
with mental illness. 

Program: Disability Program Navigator Initiative; 
Department: Labor; 
Description: Jointly funded by SSA and Labor, the Disability Program 
Navigator Initiative funds program liaisons who seek to coordinate all 
federally funded services to assist disabled individuals with 
employment training and employment placement at One-Stop centers which 
were established under the Workforce Investment Act of 1998. 

Program: Individuals with Disabilities Education Act Grants; 
Department: Education; 
Description: The Individuals with Disabilities Education Act authorizes 
formula grants to states and discretionary grants to institutions of 
higher education and other non-profit organizations to support 
research, demonstrations, technical assistance and dissemination, 
technology and personnel development, and parent-training and 
information centers. 

Program: Vocational Rehabilitation Grants to States; 
Department: Education; 
Description: Under Title I of the Rehabilitation Act, these grants 
provide federal funds to help cover the costs of providing vocational 
rehabilitation services which include assessment, counseling, 
vocational and other training, and job placement necessary for an 
individual with a disability to achieve an employment outcome. 

Program: Rehabilitation Services Demonstration and Training Programs; 
Department: Education; 
Description: Activities under this program include carrying out special 
demonstrations for expanding and improving the provision of 
rehabilitation and other services including: technical assistance, 
special studies and evaluations, demonstrations of service delivery, 
transition services, supportive employment, services to underserved 
populations and/or unserved or underserved areas, among other services. 

Program: Mental Health Transformation State Incentive Grant; 
Department: HHS; 
Description: This SAMHSA grant focuses on a state's infrastructure in 
order to reduce fragmentation of services across systems. 

Program: Real Choice Systems Change Grants for Community Living; 
Department: HHS; Description: These CMS grants are specifically 
intended to help states build the infrastructure that will result in 
improvements in integrated community-based services. 

Program: Comprehensive Mental Health for Children and Families; 
Department: HHS; 
Description: This grant program was created by SAMHSA to provide 
community-based systems of care for children and adolescents with a 
serious emotional disturbance and their families. 

Program: Medicaid Buy-In; 
Department: HHS; 
Description: The CMS Medicaid buy-in program allows states to expand 
Medicaid coverage to workers with disabilities whose income and assets 
would ordinarily make them ineligible for Medicaid. 

Program: Medicaid Rehabilitation Option; 
Department: HHS; 
Description: The CMS Medicaid rehabilitation option provides a more 
flexible benefit and can be provided in other locations in the 
community, including in the person's home or other living arrangement. 
Rehabilitation services may extend beyond the clinical treatment of a 
person's mental illness to include helping the person to acquire the 
skills that are essential for everyday functioning. 

Program: Money Follows the Person; 
Department: HHS; 
Description: This grant creates a system of flexible financing for long-
term services and supports that enable available funds to move with the 
individual to the most appropriate and preferred setting as the 
individual's needs and preferences change. Populations targeted for 
transition include individuals of all ages with disabilities including 
mental illness. 

Source: GAO Analysis. 

[End of table] 

[End of section] 

Appendix VII: Overview of Programs for Young Adults with SMI in Four 
States: 

This appendix provides an overview of the key programs that target 
services for young adults with serious mental illness in the four 
states we visited--Connecticut, Maryland, Massachusetts, and 
Mississippi. 

Connecticut's Department of Mental Health and Addiction Services 
administers the Young Adult Services program. Since 1998 in 
coordination with the Department of Children and Families and several 
other state agencies,[Footnote 81] this program has provided mental 
health treatment, supported employment, vocational or educational 
support, life skills training, and supportive housing, with the 
particular array and level of care varying slightly by location. 
[Footnote 82] Connecticut offers different levels of care, ranging from 
basic case management services and employment and educational support 
to highly structured group homes or supervised housing programs with 
intensive case management, or Assertive Community Treatment 
programs.[Footnote 83] In addition, some programs are gender specific. 
Sixteen of the 21 local mental health authorities offer the Young Adult 
Services program. State officials indicated that they launched the 
program due to a federal lawsuit, which resulted in legislative funding 
for as special group of young adults who were diagnosed with pervasive 
developmental disorders and exhibited high risk sexual behavior issues. 
The program evolved to encompass a broader cohort of young adults with 
severe behavioral health issues and high risk behavior who, without any 
services, would have ended up in jail or homeless. Because many of 
these young adults spent most of their lives in institutional settings, 
such as psychiatric rehabilitative treatment centers, they had not 
developed interpersonal skills to effectively live in the community. In 
state fiscal year 2007, 716 individuals were served in the Young Adult 
Services program or about 27 percent of the 2,615 young adults with 
serious mental illness receiving any mental health services from the 
state mental health agency. 

Maryland's Mental Hygiene Administration, within the Maryland 
Department of Health and Mental Hygiene, administers the Transition-Age 
Youth Initiative, which consists of various programs that provide 
mental health treatment, supported employment, life skills training, 
residential services, and, in some cases, supportive housing in the 
community. Eleven of the state's 20 mental health agencies offer 
services through this initiative, although the type and number of 
services offered vary by region. Some of these programs provide a 
greater array of services, including various types of mental health 
treatment services with supported employment, residential, and 
supportive housing, while others provide more limited case management 
services. Maryland mental health agency officials stated that program 
variety was beneficial, because a particular program design will work 
well for some young adults but not others. State officials told us that 
Maryland's Transition-Age Youth programs originated in the late 1990s 
when the Governor launched an initiative to expand services for young 
adults with disabilities who were transitioning from the children's 
system. As part of the initiative, funds were made available to the 
various agencies that serve these youth, including the Mental Hygiene 
Administration. With the money, mental health agency officials decided 
to fund a variety of types of small programs around the state, with the 
goal of evaluating them to identify promising programs that could be 
expanded. A Maryland mental health official said that funds were used 
to leverage and maximize other types of funds in order to create new 
services. While these Transition-Age Youth programs continue, a 
comprehensive evaluation has not been done. In fiscal year 2007, 8,753 
young adults aged 18 through 24 received services from the Department 
of Mental Health and Hygiene, of which 415 received case management and 
287 received supported employment services. In total, the state funded 
the Transition-Age Youth Initiative, which has capacity to treat about 
250 individuals per year. Age criteria for individual programs differs, 
with one program serving individuals as young as 13 and another 
covering individuals as old as 25. 

Massachusetts's Department of Mental Health established the Transition 
Age-Youth Initiative in 2005 to assist young adults with serious mental 
illness, including those transitioning from the children's mental 
health system to the adult system, as well as those aging out of foster 
care or the juvenile justice systems. This initiative provides an array 
of age-appropriate services to individuals aged 16 through 25 that 
address their needs in the areas of mental health treatment, vocational 
rehabilitation, employment, housing, peer support, and family 
psychoeducation. As part of this effort, as of January 2008, the 
Massachusetts Department of Mental Health had trained both child and 
adult case managers, as well as 36 Transition Age Youth case managers 
on the special needs of transition-age youth to better prepare them to 
assist young adults with serious mental illness in accessing services 
from the adult mental health system, according to a state mental health 
official. Transition-Age Youth services are available in all six 
Massachusetts Mental Health Service Delivery Areas, but the array of 
services differs by location. State officials cited several factors 
that influenced the development of the Transition-Age Youth Initiative. 
One factor was a concern about an area office that reported a decrease 
in the number of young adults requesting services after transitioning 
out of the children's mental health system. After researching the 
situation, the state found that the adult mental health program had not 
been providing the types of transition services that this age group 
needed and found appealing. Another factor was the issuance of the 
President's New Freedom Commission on Mental Health report and various 
other publications on transition-age youth by mental health 
researchers.[Footnote 84] In 2007, about 2,600 individuals were 
enrolled in the Transition-Age Youth Initiative, according to a state 
mental health official. 

In contrast with other states, Mississippi does not have a centralized 
and statewide program for young adults with serious mental illness but 
has several small-scale initiatives for this population. One of its key 
initiatives is the Transition Outreach Program, which provides mental 
health, supported employment, and life skills training to adolescents 
and young adults in two locations--Hattiesburg and Jackson. This 
program assists young adults in developing healthy relationships that 
can motivate them to change their behavior. This program developed 
because of the gap in services for the transition-age youth with 
serious mental illness. According to the officials, eventually young 
people would return to the mental health system, resurfacing at a 
mental health facility and in crisis. By June 2007, the Transitional 
Outreach Program had served more than 150 individuals. Another key 
initiative is the "Multidisciplinary Assessment and Planning Teams," 
which consist of officials from various state agencies and advocates 
that meet to review cases that include youth ages 14 to 21 
transitioning from the child to adult mental health systems, as well as 
other youth considered to be high-risk. Established in 1996, these 
teams also coordinate the delivery of multiple services including 
mental health, education, vocational rehabilitation, health care, and 
juvenile justice services. As of November 2007 the teams were operating 
in 33 of 82 counties. 

[End of section] 

Appendix VIII: Comments from the Department of Health and Human 
Services: 

Department Of Health & Human Services: 
Office Of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

June 11, 2008: 

Ms. Cornelia M. Ashby, Director: 
Education, Workforce, and Income Security Issues: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Ashby: 

Enclosed are the Department's comments on the U.S. Government 
Accountability Office's (GAO) draft report entitled: "Young Adults with 
Serious Mental Illness: Some States and Federal Agencies are Taking 
Steps to Address Their Challenges" (GAO 08-678). 

The Department appreciates the opportunity to comment on this draft 
report before its publication. 

Signed by: 

Jennifer D. Luong: 

For: 
Vincent J. Ventimiglia, Jr. 
Assistant Secretary for Legislation: 

Attachment: 

General Comments Of The Department Of Health And Human Services (HHS) 
On The Government Accountability Office's (GAO) Draft Report Entitled: 
Young Adults With Serious Mental Illness: Some States And Federal 
Agencies Are Taking Steps To Address Their Challenges (GAO-O8-678): 

HHS appreciates the opportunity to review this GAO report. This is a 
very pertinent and timely report, persons with some mental illnesses 
are diagnosed when they are children and transitioning to adulthood and 
aging out of certain systems can be a challenge for many. 

The title may be more appropriately listed as "Young Adults with 
Serious Mental Illness and Challenges in the Transition to Adulthood." 
The current title seems to imply that the report will focus on all 
types of challenges, the most pertinent of which can include their 
actual symptoms, impairments, and the costs to the social support 
system. 

Role of Families: 

The GAO has redefined the issues/questions and, therefore, has not 
answered two of the objectives "(1) determine what is known about how 
many seriously mentally ill or seriously emotionally disturbed young 
adults are supported by their parents or grandparents and what are the 
key federal programs to assist them, and (2) determine if there are 
ways to reduce program overlap so that savings can be used to extend 
eligibility beyond age 18. " There is almost no mention of families or 
the role that families can play in supporting young adults, an issue 
that is particularly important in the discussion of housing. For 
example, the data from the Clark County Washington Partnerships for 
Youth Transition (PYT) Grant showed that 60% of the youth were living 
at home with family members. 

Program Overlap: 

Also GAO does not discuss ways to reduce program overlap which is 
critically important because funding defines policy and practice. If 
redundancies were to be identified that could be applied to this 
population, this report would provide an important contribution. One of 
the issues GAO highlights in the report is the narrower adult 
eligibility criteria for mental health services, and how that can 
eliminate receipt of needed services by individuals who have 
significant support needs but don't meet the stringent criteria. In a 
report sponsored by SAMHSA, Davis & Hunt (2005) state that adult mental 
health administrators identified lack of funding as one of the greatest 
barriers to improving services for young adults in their systems. Thus, 
the effort to identify such potential funds is critically important. 

Definition of Mental Illness: 

Also, the GAO needs to better define mental illness in this report. The 
GAO has not described the issue of Serious Emotional Disturbance (SEA) 
vs. Serious Mental Illness (SMI), and has shifted to using ONLY the 
terminology of SMI. Furthermore, SMI is not well defined. The report 
describes the SAMHSA definition but doesn't use it in the analysis. 
Instead the report uses what is termed to be the DSM-IV's definition of 
mental illness. But DSM-IV doesn't define the term mental illness; it 
defines mental disorder which includes ALL disorders in the DSM-IV. The 
report then discounts cognitive disorders but not substance use 
disorders (both should not be included in any definition of mental 
illness). The report uses the NCS-R data to come up with a count, 
acknowledges that it didn't include homeless, institutionalized or 
incarcerated individuals, but doesn't mention that it didn't assess all 
diagnoses that could be considered either a mental illness by their 
definition or by SAMHSA's definition (the GAO excludes personality 
disorders because the NCS-R didn't assess it). 

We suggest you list the definition as indicated by Public Law 102-321 
or consider using a term other than "serious" and defining exactly 
which disorders are classified using the new terminology. We are 
uncertain why substance use disorders would not fall into the category 
"serious mental illness." 

* Public Law 102-321 defines serious mental illness as the presence of 
any Diagnostic and Statistical Manual of Mental Disorders (DSM) mental 
disorder, substance use disorder, or developmental disorder that leads 

to "substantial interference" with "one or more major life activities." 
The diagnostic component of this definition was operationalized in the 
NCS with CIDI diagnoses of 3 broad classes of 12-month DSM-III-R 
disorders: mood disorders (major depression, dysthymia, bipolar 
disorder), anxiety disorders (panic disorder, generalized anxiety 
disorder, phobias, posttraumatic stress disorder), and nonaffective 
psychoses (schizophrenia, schizophreniform disorder, schizoaffective 
disorder, delusional disorder, brief psychotic disorder, and psychotic 
disorder not otherwise specified). 

Classification of the Population: 

Throughout the document, the GAO should specify whether the 
program/policy/research finding directly addresses this population or 
if only indirectly (e.g. all adults with SMI or all transition age 
youth with disabilities) so that it is clear to the reader what exactly 
that program/policy/research has to offer. The GAO should include some 
discussion about the issue of children being classified as having a SED 
and adults, at age 18 and older, being classified as having a SMI, and 
what that means. The report specifies it in the IDEA discussion, but 
not for mental health agency discussion (but use some studies of youths 
with SED). When the report uses more narrow/broad definitions, GAO 
should mention that the term used in childhood in mental health and 
education is "emotional disturbance", just to clarify that 
documents/programs/language that involves ED is related to this issue. 

Estimates of Assistance or Support: 

In addition, the GAO was asked to provide "existing estimates of the 
number who do not receive the assistance or support they need." This is 
the crux of what is missing in this report. There is no estimate of 
unmet need and, therefore, no explanation of why there is unmet need. 
The report should address the fact that there is evidence (between 
their poor outcomes and the journal article Davis and Sondheimer 
published in 2006) that states do little in their adult mental health 
system to address the needs of this population, and why that is the 
case. Data in both that report and in a paper by Davis, Geller & Hunt, 
2006, show that at least half of states adult mental health agencies 
were offering no programs tailored to this age group (as of 2003). In 
addition it is a difficult task for states to cobble together Federal 
programs that could address the needs of this population, and that 
those funds are currently used to address the needs of some other 
vulnerable group - so it means taking that away from that group in 
order to address the needs of this group - this is difficult for states 
to do without some encouragement and perhaps some incentives. Also the 
report to CMHS by Davis (Pioneering Transition Programs) highlights 
evidence that typical states struggle with how to address the needs of 
this population (and why) as well as the factors that administrators 
listed as problematic in addressing their needs. 

The GAO report should state that young adults are at the middle and end 
of a process of becoming an adult that starts before young adulthood in 
adolescence. Systems have organized themselves into child and adult and 
that has created a problem for young adults; they sometimes get dropped 
out and they often find programs that are not tailored to their needs 
because adult services are typically focused on full adulthood, not 
young adulthood. The GAO could clarify that some of the issues which 
arise from the transition age youth (TAY) literature (such as 
eligibility issues). Some of the issues raised in states regarding the 
young adult population directly stem from the recognition that some of 
the challenges start before adulthood. Some of the issues faced by 
young adults are defined by that immediately preceding period of life - 
as alluded to when describing eligibility and "transitional youth". GAO 
should acknowledge that improving services for transition age youth 
will, by definition, improve services for young adults and that several 
of the programs GAO reviewed are aimed at the transition period. Those 
typically are focused on individuals who were involved in systems or 
had illness as adolescents, and may not recognize newly ill young 
adults. 

Tic Report Back to Original Concerns: 

Since the report offers concluding observations, the report should tie 
the findings back to the original concerns - that this population isn't 
finishing school (which should get them back to the transition issues), 
they aren't adequately employed, and they are arrested much more 
frequently. The report should acknowledge other research that has found 
other outcomes that is not adequately addressed with the NCS-R. When 
the GAO uses those findings to address outcomes it should be noted that 
those in the worst circumstances (e.g. those that adult MH should 
serve) would not have been picked up in the NCS-R. 

Schizophrenia and Child-Serving Systems: 

The disjunction between the stated intent of the report and the 
findings presented, however, highlight the large gap that exists 
between child- and adult-serving systems of care in terms of 
populations served. Although the report mentions in several places that 
the service eligibility criteria for adults are narrower than those for 
children, nothing is said of the lack of experience and expertise in 
providing care for individuals with schizophrenia within child-serving 
systems. 

Analyses of Social Security disability data presented in the report 
reveal that schizophrenia is among the most prevalent diagnoses (33%) 
among adults with disabling mental illnesses. In contrast, 
schizophrenia is rare (4.7%) among those served by children's programs 
(Greenbaum et al., 1996). The discrepancy does not result from a 
difference in eligibility criteria but, rather, from the difference in 
the typical age of onset of the disorder. 

Because schizophrenia typically emerges in the late teens or early 
adulthood, it is rarely seen in child-serving systems. Because the 
expertise in the treatment of schizophrenia primarily resides within 
adult-serving systems, young people with the disorder most often begin 
their course of treatment within the adult system, bypassing children's 
systems altogether. As the report correctly points out, although the 
adult system may have the best expertise for treating schizophrenia, it 
is not specifically designed to deal with young people and may hold 
little appeal to those seeking care. 

Recognition of the difference in diagnoses served by the two systems is 
critical for ensuring that proposed solutions will adequately address 
the goals of transitional services. In the introductory sections of the 
report, GAO specifically mentions how difficult transition can be for 
young adults with schizophrenia. Yet, the methodology for reviewing 
programs that serve youth in transition is heavily weighted toward 
youth who were previously served by children's systems rather than 
those with newly emerging and debilitating illnesses in young 
adulthood. Indeed, the National Comorbidity Survey-Replication used to 
determine estimates of mental illness for this age group does not even 
include schizophrenia among diagnoses examined. The researchers and 
mental health organizations interviewed were heavily weighted to those 
with expertise in childhood illnesses and included neither experts in 
schizophrenia nor adult mental health primary consumer organizations. 

[End of section] 

Appendix IX: GAO Contacts and Staff Acknowledgments: 

GAO Contacts: 

Cornelia M. Ashby (202) 512-7215 or [email protected]:
Cynthia A. Bascetta (202) 512-7114 or [email protected]: 

Staff Acknowledgments: 

In addition to the contacts named above, Clarita A. Mrena and Sheila K. 
Avruch, Assistant Directors; Irene Barnett, Kimberly Siegal, and Yorick 
Uzes, Analysts-in-Charge; Rachel Beers; Laura Brogan; Leigh Ann Nally; 
and Carmen Rivera-Lowitt, made major contributions to this report. 
Martha Kelly, Jean McSween, Suzanne Worth and Paul Gold provided 
assistance with design and analysis; Susan Bernstein advised on report 
preparation; and Roger Thomas provided legal advice. 

[End of section] 

Selected Bibliography: 

Bazelon Center for Mental Health Law. Moving On: Analysis of Federal 
Programs Funding Services to Assist Transition-Age Youth with Serious 
Mental Health Conditions. Washington, D.C.: 2005. 

Burt, M., and others. Helping America's Homeless: Emergency Shelter or 
Affordable Housing? Washington, D.C.: Urban Institute Press, 2001. 

Casey Family Programs. Improving Family Foster Care: Findings from the 
Northwest Foster Care Alumni Study. Seattle: 2005. 

Clark, H. B., and others. "Partnerships for Youth Transition (PYT): 
Overview of Community Initiatives and Preliminary Findings on 
Transition to Adulthood for Youth and Young Adults with Mental Health 
Challenges," 329-32. In The 20th Annual Research Conference 
Proceedings: A System of Care for Children's Mental Health: Expanding 
the Research Base, edited by C. Newman and others. Tampa: University of 
South Florida, Louis de la Parte Florida Mental Health Institute, 
Research and Training Center for Children's Mental Health, 2008. 

Clark, H. B., and others. "Services for Youth in Transition to 
Adulthood in Systems of Care." In The System of Care Handbook: 
Transforming Mental Health Services for Children, Youth, and Families, 
edited by B. A. Stroul and G. M. Blau. Baltimore: Paul H. Brookes, 
forthcoming. 

Clark, H. B., and others. "Transition into Community Roles for Young 
People with Emotional or Behavioral Disorders: Collaborative Systems 
and Programs Outcomes." Chapter 11 in Transition of Secondary Students 
with Emotional or Behavioral Disorders: Current Approaches for Positive 
Outcomes, Arlington, Va.: The Divisions of the Council for Exceptional 
Children, 2004. 

Consumer Quality Initiatives. Voices of Youth in Transition: The 
Experience of Aging Out of the Adolescent Public Mental Health Service 
System in Massachusetts: Policy Implications and Recommendations. 
Dorchester, Mass.: Dec. 11, 2002. 

Davis, M., and others. "Longitudinal Patterns of Offending During the 
Transition to Adulthood in Youth from the Mental Health System." The 
Journal of Behavioral Health Services and Research 31, no. 4 (2004): 
351-66. 

Davis, M., J. Geller, and B. Hunt. "Within-State Availability of 
Transition-to-Adulthood Services for Youths with Serious Mental Health 
Conditions." Psychiatric Services 57, no. 11 (2006): 1594-99. 

Davis, Maryann. "Improving Youth Transitions Systems and Measuring 
Change." Paper, National Partnerships for Youth in Transition Forum, 
Center for Mental Health Services, Massachusetts, August, 2005. 

Davis, Maryann. Pioneering Transition Programs: The Establishment of 
Programs That Span the Ages Served by Child and Adult Mental Health. 
Rockville, Md.: Substance Abuse and Mental Health Services 
Administration, Center for Mental Health Services, 2007. 

Davis, Maryann, and Nancy Koroloff. "The Great Divide: How Mental 
Health Policy Fails Young Adults" Research in Community and Mental 
Health 14 (2006): 53-74. 

Davis, Maryann, and Diane L. Sondheimer. "State Child Mental Health 
Efforts to Support Youth in Transition to Adulthood." Journal of 
Behavioral Health Services and Research 32, no. 1 (2005): 27-42. 

Davis, Maryann, and Ann Vander Stoep. The Transition to Adulthood among 
Adolescents Who Have Serious Emotional Disturbance. Prepared for The 
Delmar, New York, National Resource Center on Homelessness and Mental 
Illness Policy Research Associates. Rockville, Md.: Center for Mental 
Health Services, Substance Abuse and Mental Health Services 
Administration, April 1996. 

Deschenes, N., H. B. Clark, and J. Herrygers. "Evaluating Fidelity of 
Community Programs for Transition-Age Youth," 137-39. In The 21st 
Annual Research Conference Proceedings: A System of Care for Children's 
Mental Health: Expanding the Research Base, edited by C. Newman and 
others. Tampa: University of South Florida. Louis de la Parte Florida 
Mental Health Institute, Research and Training Center for Children's 
Mental Health, 2008. 

Doornbos, Mary Molewyk. "The 24-7-52 Job: Family Caregiving for Young 
Adults with Serious and Persistent Mental Illness." Journal of Family 
Nursing 7, no. 4 (2001): 328-44: 

Doornbos, Mary Molewyk. "Family Caregivers and the Mental Health Care 
System: Reality and Dreams." Archives of Psychiatric Nursing 16, no. 1 
(2002): 39-46. 

Greenbaum, P. E., and others. "National Adolescent and Child Treatment 
Study (NACTS): Outcomes for Children with Serious Emotional and 
Behavioral Disturbance." Journal of Emotional and Behavioral Disorders 
4, no. 3 (1996): 130-46. 

Haber, M. G., and others. "Predicting Improvement of Transitioning 
Young People in the Partnerships for Youth Transition Initiative: 
Findings from a Multi-Site Demonstration." Journal of Behavioral Health 
Services and Research, forthcoming. 

Hines-Martin, V., and others. "Barriers to Mental Health Care Access in 
an African American Population." Issues in Mental Health Nursing 24 
(2003): 237-56. 

Hines-Martin, Vicki P. "Environmental Context of Caregiving for 
Severely Mentally Ill Adults: An African American Experience." Issues 
in Mental Health Nursing 19 (1998): 433-51. 

Horwitz, Allan V. and Susan C. Reinhard. "Ethnic Differences in 
Caregiving Duties and Burdens among Parents and Siblings of Persons 
with Severe Mental Illnesses." Journal of Health and Social Behavior 
36, no. 2 (1995): 138-50. 

James, D. and L. Glaze. Mental Health Problems of Prison and Jail 
Inmates. Special report prepared by the Bureau of Justice Statistics, 
U.S. Department of Justice. Washington, D.C.: 2006. 

Johnson, Eric D. "Differences among Families Coping with Serious Mental 
Illness: A Qualitative Analysis." American Journal of Orthopsychiatry 
70, no. 1 (2000): 126-34. 

Karpur, A. H. B. Clark, P. Caproni, and H. Sterner. "Transition to 
Adult Roles for Students with Emotional/Behavioral Disturbances: A 
Follow-Up Study of Student Exiters from Steps-to-Success." Career 
Development for Exceptional Individuals 28, no. 1 (2005): 36-46. 

Kaye, Steve. Employment and Social Participation among People with 
Mental Health Disabilities. San Francisco: National Disability 
Statistics and Policy Forum, 2002. 

Kessler, R., and others. "The Prevalence and Correlates of Serious 
Mental Illness (SMI) in the National Comorbidity Survey Replication 
(NCS-R)." In Mental Health, United States, 2004, edited by R. W. 
Manderscheid and J. T. Berry. DHHS Publication (SMA)-06-4195. 
Rockville, Md.: Substance Abuse and Mental Health Services 
Administration, 2006. 

Kessler, R., and others. "Prevalence, Severity, and Comorbidity of 12- 
Month DSM-IV Disorders in the National Comorbidity Survey Replication." 
Archives of General Psychiatry 62 (2005): 617-27. 

Kessler, R., and others. "Prevalence and Treatment of Mental Disorders, 
1990 to 2003." The New England Journal of Medicine 352, no. 24 (2005): 
2515-23. 

Mays, Gloria D. and Carole L. Lund. "Male Caregivers of Mentally Ill 
Relatives." Perspectives in Psychiatric Care 35, no. 2 (1999): 19-28. 

National Collaborative on Workforce and Disability for Youth, Institute 
for Educational Leadership. Tunnels & Cliffs: A Guide for Workforce 
Development Practitioners and Policymakers Serving Youth with Mental 
Health Needs. Number E-9-4-1-0070. Washington, D.C.: March 2007. 

New Freedom Commission on Mental Health. Achieving the Promise: 
Transforming Mental Health Care in America: Final Report. DHHS 
Publication SMA-03-3832. Rockville, Md.: 2003. 

Pilowsky, Daniel J. and Li-Tzy Wu. "Psychiatric Symptoms and Substance 
Use Disorders in a Nationally Representative Sample of American 
Adolescents Involved with Foster Care." Journal of Adolescent Health 38 
(2006): 351-58. 

Rose, L., R. K. Mallinson and L. D. Gerson. "Mastery, Burden, and Areas 
of Concern among Family Caregivers of Mentally Ill Persons." Archives 
of Psychiatric Nursing 20, no. 1 (2006): 41-51. 

Rose, Linda. "Caring for Caregivers: Perceptions of Social Support." 
Journal of Psychosocial Nursing and Mental Health Services 35, no. 2 
(1997): 17-24. 

Shufelt, Jennie L. and Joseph J. Cocozza. Youth with Mental Health 
Disorders in the Juvenile Justice System: Results from a Multi-State 
Prevalence Study. Delmar, N.Y.: National Center for Mental Health and 
Juvenile Justice, 2006. 

Smiley, Amy, and Alysia Pascaris. A Chance for Change: Supporting Youth 
in Transition in New York City: A Report on the Findings of the 2006- 
2007 Youth Initiative Work Group. New York: Coalition of Behavioral 
Health Agencies, 2007. 

Styron, T. H., and others. "Troubled Youth in Transition: An Evaluation 
of Connecticut's Special Services for Individuals Aging Out of 
Adolescent Mental Health Programs." Children and Youth Services Review 
28, no. 9 (2006): 1088-101. 

Unger, J., and others. "Homeless Youths and Young Adults in Los 
Angeles: Prevalence of Mental Health Problems and the Relationship 
between Mental Health and Substance Abuse Disorders." American Journal 
of Community Psychology 25 (1997): 371-94. 

Vander Stoep, Ann. "Through the Cracks: Transition to Adulthood for 
Severely Psychiatrically Impaired Youth," 357-68. In The 4th Annual 
Research Conference Proceedings, A System of Care for Children's Mental 
Health: Expanding the Research Base, edited by A. Algarin and R. 
Friedman. Tampa: University of South Florida, Florida Mental Health 
Institute, Research and Training Center for Children's Mental Health, 
1992. 

Wagner, Mary M. "Outcomes for Youths with Serious Emotional Disturbance 
in Secondary School and Early Adulthood." The Future of Children 5, no. 
2 (1995): 90-112. 

Wagner, Mary and Maryann Davis. "How Are We Preparing Students with 
Emotional Disturbances for the Transition to Young Adulthood? Findings 
from the National Longitudinal Transition Study--2." Journal of 
Emotional and Behavioral Disorders 14, no. 2 (2006): 86-98. 

[End of section] 

Related GAO Products: 

GAO, Disconnected Youth: Federal Action Could Address Some of the 
Challenges Faced by Local Programs That Reconnect Youth to Education 
and Employment, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-
313] (Washington, D.C.: Feb. 28, 2008): 

GAO, Residential Treatment Programs: Concerns Regarding Abuse and Death 
in Certain Programs for Troubled Youth, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-08-146T] (Washington, D.C.: Oct. 
10, 2007): 

GAO, School Mental Health: Role of the Substance Abuse and Mental 
Health Services Administration and Factors Affecting Service Provision, 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-19R] (Washington, 
D.C.: Oct. 05, 2007): 

GAO, Child Welfare: HHS Actions Would Help States Prepare Youth in the 
Foster Care System for Independent Living, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-07-1097T] (Washington, D.C.: Jul. 
12, 2007): 

GAO, African American Children in Foster Care: Additional HHS 
Assistance Needed to Help States Reduce the Proportion in Care, 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-816] (Washington, 
D.C.: Jul. 11, 2007): 

GAO, Child Welfare: Additional Federal Action Could Help States Address 
Challenges in Providing Services to Children and Families, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-07-850T] (Washington, D.C.: May. 
15, 2007): 

GAO, Child Welfare: Improving Social Service Program, Training, and 
Technical Assistance Information Would Help Address Long-standing 
Service-Level and Workforce Challenges, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-07-75] (Washington, D.C.: Oct. 
06, 2006): 

GAO, D.C. Child and Family Services Agency: Performance Has Improved, 
but Exploring Health Care Options and Providing Specialized Training 
May Further Enhance Performance, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-06-1093] (Washington, D.C.: Sep. 28, 2006): 

GAO, Summary of a GAO Conference: Helping California Youths with 
Disabilities Transition to Work or Postsecondary Education, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-06-759SP] (Washington, D.C.: Jun. 
20, 2006): 

GAO, Child Welfare: Federal Oversight of State IV-B Activities Could 
Inform Action Needed to Improve Services to Families and Statutory 
Compliance, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-787T] 
(Washington, D.C.: May. 23, 2006): 

GAO, Children's Health Insurance: Recent HHS-OIG Reviews Inform the 
Congress on Improper Enrollment and Reductions in Low-Income, Uninsured 
Children, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-457R] 
(Washington, D.C.: Mar. 09, 2006): 

GAO, District of Columbia: Federal Funds for Foster Care Improvements 
Used to Implement New Programs, but Challenges Remain, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-05-787] (Washington, D.C.: Jul. 
22, 2005): 

GAO, Medicaid Financing: States' Use of Contingency-Fee Consultants to 
Maximize Federal Reimbursements Highlights Need for Improved Federal 
Oversight, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-748], 
(Washington, D.C.: June 28, 2005). 

GAO, Child Welfare: Better Data and Evaluations Could Improve Processes 
and Programs for Adopting Children with Special Needs, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-05-292] (Washington, D.C.: Jun. 
13, 2005): 

GAO, Medicaid Managed Care: Access and Quality Requirements Specific to 
Low-Income and Other Special Needs Enrollees, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-05-44R] (Washington, D.C.: Dec. 
08, 2004): 

GAO, Foster Youth: HHS Actions Could Improve Coordination of Services 
and Monitoring of States' Independent Living Programs, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-05-25] (Washington, D.C.: Nov. 
18, 2004): 

GAO, D.C. Child And Family Services Agency: More Focus Needed on Human 
Capital Management Issues for Caseworkers and Foster Parent Recruitment 
and Retention, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-
1017] (Washington, D.C.: Sep. 24, 2004): 

GAO, Substance Abuse and Mental Health Services Administration: 
Planning for Program Changes and Future Workforce Needs is Incomplete, 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-683] (Washington, 
D.C.: June 4, 2004): 

GAO, Child Welfare: Improved Federal Oversight Could Assist States in 
Overcoming Key Challenges, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-04-418T] (Washington, D.C.: Jan. 28, 2004): 

GAO, Child Welfare: Enhanced Federal Oversight of Title IV-B Could 
Provide States Additional Information to Improve Services, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-03-956] (Washington, D.C.: Sep. 
12, 2003): 

GAO, Child Welfare: Most States Are Developing Statewide Information 
Systems, but the Reliability of Child Welfare Data Could Be Improved, 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-03-809] (Washington, 
D.C.: Jul. 31, 2003): 

GAO, Child Welfare and Juvenile Justice: Several Factors Influence the 
Placement of Children Solely to Obtain Mental Health Services, 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-03-865T] (Washington, 
D.C.: Jul. 17, 2003): 

GAO, Child Welfare and Juvenile Justice: Federal Agencies Could Play a 
Stronger Role in Helping States Reduce the Number of Children Placed 
Solely to Obtain Mental Health Services, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-03-397] (Washington, D.C.: Apr. 
21, 2003): 

GAO, Medicaid and SCHIP: States Use Varying Approaches to Monitor 
Children's Access to Care, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-03-222 (Washington, D.C.: Jan. 14, 2003): 

[End of section] 

Footnotes: 

[1] For purposes of this report, the term "mental illness" excludes 
mental disorders that constitute abnormalities in cognition or 
intellectual functioning, such as mental retardation, autism, or 
Alzheimer's disease. 

[2] All NCS-R and NBS estimates of the number and demographic 
characteristics of young adults with serious mental illness are 
presented with a 95 percent confidence interval. Unless otherwise 
noted, the sampling error is within plus or minus 12 percentage points 
for NCS-R estimates and within plus or minus 7 percentage points for 
NBS estimates. 

[3] These states are not considered representative of all states in the 
manner and extent to which they assist young adults with serious mental 
illness. 

[4] In this report, transition-aged youth programs generally refer to 
programs that include individuals aged 16 through 25, although programs 
vary with some serving a broader age range. 

[5] Mental disorders are diagnosed using criteria in the Diagnostic and 
Statistical Manual of Mental Disorders--Fourth Edition (DSM-IV). Each 
diagnosis, such as generalized anxiety disorder, major depressive 
disorder, or schizophrenia, is based on a specific set of symptoms 
reported over a given period of time. For example, major depressive 
disorder can be diagnosed if an individual reports experiencing five or 
more of seven specified symptoms, such as fatigue, feelings of 
worthlessness or excessive or inappropriate guilt, and a diminished 
ability to concentrate, over a minimum of 2 weeks. 

[6] Those with mental health issues in childhood may be considered to 
have a "serious emotional disturbance" defined as "persons from birth 
up to age 18, who currently or at any time during the past year, have 
had a diagnosable mental, behavioral, or emotional disorder of 
sufficient duration to meet diagnostic criteria specified within DSM- 
III-R, that resulted in functional impairment which substantially 
interferes with or limits the child's role or functioning in family, 
school, or community activities." 58 Fed. Reg. 29422 (May 20, 1993). 
The DSM-III-R predates the DSM-IV. 

[7] Kessler, R., P. Berglund, O. Demler, R. Jin, K. Merikangas, and E. 
Walters. "Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV 
Disorders in the National Comorbidity Survey Replication." Archives of 
General Psychiatry 62 (2005): 593-602. 

[8] Pub. L. No. 102-321, ï¿½ 201. Mental Health Block Grant funding is 
also targeted to children with a serious emotional disturbance. 

[9] 58 Fed. Reg. 29422 (May 20, 1993). This report generally uses the 
term "serious mental illness" based on SAMHSA's regulation. However, in 
places throughout this report, we may use a slightly broader or 
narrower conception of serious mental illness as necessitated by 
available data as well as programmatic or administrative definitions. 

[10] Individuals can also qualify if they can demonstrate that they 
have a physical impairment that is expected to result in death. 

[11] Individuals known as "disabled adult children" can also receive DI 
benefits if they are aged 18 or older, were disabled before age 22, and 
have at least one parent who also receives Social Security payments 
because of retirement or disability or who is deceased but worked long 
enough to be eligible to receive benefits. 

[12] In most states, individuals receiving SSI are also eligible for 
Medicaid. 

[13] The Medicaid rehabilitation option provides a more flexible 
benefit and can be provided in other locations in the community, 
including in the person's home or other living arrangement. 
Rehabilitation services may extend beyond the clinical treatment of a 
person's mental illness to include helping the person to acquire the 
skills that are essential for everyday functioning. For GAO work that 
addresses the rehabilitation option, see Medicaid Financing: States' 
Use of Contingency-Fee Consultants to Maximize Federal Reimbursements 
Highlights Need for Improved Federal Oversight, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-05-748] (Washington, D.C.: June 
28, 2005). 

[14] According to SAMHSA, these evidence-based practices have been 
tested on the adult population, which included some young adults aged 
18 through 30, but have not been systematically or empirically tested 
specifically on the young adult population. 

[15] For a GAO study related to SAMHSA's administration of mental 
health programs, see Substance Abuse and Mental Health Services 
Administration: Planning for Program Changes and Future Workforce Needs 
Is Incomplete, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-
683] (Washington, D.C.: June 4, 2004). 

[16] As defined by the Individuals with Disabilities Education Act, an 
emotional disturbance is a condition exhibiting certain characteristics 
over a long period of time and to a marked degree that adversely 
affects educational performance. The characteristics include an 
inability to learn that cannot be explained by intellectual, sensory, 
or health factors and inappropriate types of behavior or feelings under 
normal circumstances, among others. 

[17] The Foster Care Independence Act also authorizes $60 million for 
payments to states for postsecondary educational and training vouchers 
for youth likely to experience difficulty as they transition to 
adulthood after the age of 18. 

[18] See GAO, Child Welfare: HHS Actions Would Help States Prepare 
Youth in the Foster Care System for Independent Living, [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-07-1097T] (Washington, D.C.: July 
12, 2007). 

[19] The sampling error for this estimate is plus or minus 1.2 
percentage points. 

[20] While estimates of the size of these populations exist, they are 
for different years and are not all recent. The National Survey of 
Homeless Assistance Providers and Clients estimated that between 
124,000 and 236,000 individuals aged 20 through 24 were homeless in 
1996. According to Bureau of Justice Statistics officials, about 
222,000 young adults aged 18 through 24 were incarcerated in federal or 
state prison in 2004, and about 177,000 were in local jails in 2002. 
While the total number of institutionalized young adults is unknown, 
one study found that the average number of individuals who were 
institutionalized because of a mental illness on any day in 1992 was 
nearly 84,000. 

[21] Prevalence estimates may also be affected by the exclusion of non- 
English-speaking households from the survey. 

[22] Schizophrenia and nonaffective psychosis are characterized by an 
inability to distinguish between what is real and what is imaginary. 
Symptoms include delusions, hallucinations, extreme apathy, and social 
withdrawal. According to NCS-R researchers, household surveys may 
underestimate the prevalence of these disorders, because these 
individuals may be less likely than those with other types of serious 
mental illness to live at home or be less willing to participate in a 
survey. However, to the extent that they do live at home, researchers 
believe they are likely to be represented in the NCS-R estimates 
because many are diagnosed with multiple mental disorders. 

[23] The NCS-R provides separate prevalence estimates for bipolar I and 
bipolar II disorder. For the purposes of this analysis, we add the 
estimates together to derive the prevalence of bipolar disorder 
generally. 

[24] The NCS-R does not distinguish between primary and secondary 
diagnoses. 

[25] The sampling error for this estimate is plus or minus 13 
percentage points. Drug abuse, drug dependence, alcohol abuse, and 
alcohol dependence are all considered diagnosable mental illnesses in 
the DSM-IV. In general, substance abuse is defined as the continued use 
of a substance despite school-related or work-related or interpersonal 
problems. Dependence is characterized by an increasing need for the 
substance to achieve the desired effects as well as withdrawal symptoms 
when the substance is not used. 

[26] Steve Kaye. Employment and Social Participation among People with 
Mental Health Disabilities. (San Francisco: National Disability 
Statistics and Policy Forum, 2002). 

[27] The President's New Freedom Commission on Mental Health, Achieving 
the Promise: Transforming Mental Health Care in America: Final Report, 
DHHS Publication SMA-03-3832 (Rockville, Md.: 2003). 

[28] Individuals are not eligible to receive SSI or DI benefits for a 
drug or alcohol addiction that is material to the disability 
determination; however, some individuals with a substance-related 
disorder may be eligible because of another disability. 

[29] Those receiving SSI or DI are encouraged to participate in the 
Ticket to Work program, an employment program administered by SSA that 
provides rehabilitation opportunities and support for disabled 
individuals to return to work without automatically losing their cash 
benefits and health care coverage. 

[30] As a result, many people may need another adult's help when 
applying for or while receiving benefits. In fact, nearly 68 percent of 
SSI recipients with a serious mental illness in 2006 had a 
representative payee who received the payments on their behalf, and 
just over half of these payees were parents or other relatives. 

[31] Secondary diagnosis is defined as the most significant diagnosis 
in terms of severity following the primary diagnosis. 

[32] D. Pilowsky and L.T. Wu, "Psychiatric Symptoms and Substance Use 
Disorders in a Nationally Representative Sample of American Adolescents 
Involved with Foster Care," Journal of Adolescent Health 38 (2006): 351-
58. 

[33] See Casey Family Programs, Improving Family Foster Care: Findings 
from the Northwest Foster Care Alumni Study (Seattle, WA: 2005). 

[34] In this study, respondents were classified as having a mental 
health problem if they met one of several conditions--for example, if 
they reported that they had been receiving treatment or been 
hospitalized for mental or emotional problems or if they reported that 
a mental health condition was the single largest factor keeping them 
from getting out of homelessness. See M. Burt and others, Helping 
America's Homeless: Emergency Shelter or Affordable Housing? 
(Washington, D.C.: Urban Institute Press, 2001) 157. 

[35] J. Unger and others, "Homeless Youths and Young Adults in Los 
Angeles: Prevalence of Mental Health Problems and the Relationship 
between Mental Health and Substance Abuse Disorders," American Journal 
of Community Psychology 25 (1997): 371-94. 

[36] In this study, respondents were classified as having a mental 
health problem using two measures: a recent history or symptoms of a 
mental health problem within the past 12 months. A recent history 
included a clinical diagnosis or treatment by a mental health 
professional. Symptoms of a mental disorder were based on criteria 
specified in the DSM-IV. See James, Doris J. and Glaze, Lauren E. 
Mental Health Problems of Prison and Jail Inmates, a special report 
prepared by the Bureau of Justice Statistics, September 2006. 

[37] Mental health disorders were identified using the Diagnostic 
Interview Schedule for Children--Voice Version IV, a structured 
interview designed to measure over 30 psychiatric diagnoses common 
among adolescents. Severe mental illnesses were those that met criteria 
for certain severe disorders that required significant or immediate 
treatment or resulted in hospitalization. See Jennie L. Shufelt and 
Joseph J. Cocozza, Youth with Mental Health Disorders in the Juvenile 
Justice System: Results from a Multi-State Prevalence Study (Delmar, 
N.Y.: National Center for Mental Health and Juvenile Justice, 2006). 

[38] GAO, Disconnected Youth: Federal Action Could Address Some of the 
Challenges Faced by Local Programs That Reconnect Youth to Education 
and Employment, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-
313] (Washington, D.C.: Feb. 28, 2008). 

[39] Consumer Quality Initiatives, Voices of Youth in Transition Report 
the Experience of Aging Out of the Adolescent Public Mental Health 
Service System in Massachusetts: Policy Implications and Recommendation 
(Dorchester, Mass.: Dec. 11, 2002). 

[40] Several mental health advocates have noted that it may also be 
difficult for young adults to find culturally competent or 
linguistically appropriate mental health care. The Surgeon General 
noted in the 2001 report - Mental Health: Culture, Race, and Ethnicity 
- A Supplement to Mental Health: A Report of the Surgeon General - that 
racial and ethnic minorities have less access to mental health services 
and are less likely to receive needed care. 

[41] While vocational rehabilitation programs have been traditionally 
used by those with physical, more than half of all persons who exit 
these with an employment outcome have some type of mental impairment, 
broadly defined. Within that broad category, in FY 2006, persons with 
mental illness specifically comprised 31 percent of all vocational 
rehabilitation applicants and represented 23 percent of all consumers 
who exited with an employment outcome. 

[42] SAMHSA is beginning to develop a resource guide on supported 
education which is intended to help individuals with serious mental 
illness begin or return to postsecondary education. 

[43] SAMSHA, What a Difference a Friend Makes: Social Acceptance Is Key 
to Mental Health Recovery, National Mental Health Anti-Stigma Campaign, 
SMA 07-4257 (Washington, D.C.: March 2007) [hyperlink, 
http://mentalhealth.samhsa.gov/publications/allpubs/SMA07257/default.asp
]. 

[44] National Conference of State Legislatures, A Difficult Passage: 
Helping Youth with Mental Health Needs Transition into Adulthood, 
Michelle Herman, (September 2006). 

[45] Maryann Davis and Nancy Koroloff, "The Great Divide: How Mental 
Health Policy Fails Young Adults," Research in Community and Mental 
Health 14: 53-74. 

[46] However, SSA officials noted that adults may be deemed eligible 
for SSI or DI based on symptoms related to a disorder that qualified 
them as children, even if the disorder itself did not. 

[47] National Collaborative on Workforce and Disability for Youth, 
Institute for Educational Leadership. Tunnels and Cliffs: A Guide for 
Workforce Development Practitioners and Policymakers Serving Youth with 
Mental Health Needs, Office of Disability Employment Policy E-9-4-1-
0070 (Washington, D.C.: March 2007). 

[48] Judge David L. Bazelon Center for Mental Health Law, Moving On: 
Analysis of Federal Programs Funding Services to Assist Transition-Age 
Youth with Serious Mental Health Conditions (Washington, D.C.: 2005). 

[49] With regard to states in general, research based on 2003 survey 
data from 41 states and the District of Columbia found that one half of 
state adult mental health systems offered some transition services, but 
few provided any kind of transition service at more than one site. See 
Davis, M., J. Geller, and B. Hunt. "Within-State Availability of 
Transition-to-Adulthood Services for Youths with Serious Mental Health 
Conditions" Psychiatric Services 57, no. 11 (2006): 1594-1599. 

[50] State officials noted that their programs are culturally competent 
because they take into account a participant's age, race, gender, and 
culture. 

[51] Connecticut's Department of Children and Families is responsible 
for providing children and adolescents' behavioral health services, 
juvenile justice and protection services. 

[52] Individuals receiving Assertive Community Treatment services have 
a variety of mental health impairments, such as difficulties with 
basic, everyday activities like keeping themselves safe, caring for 
their basic physical needs, or maintaining safe and adequate housing. 
They may also struggle with unemployment, substance abuse, 
homelessness, and involvement in the criminal justice system. 

[53] Assertive Community Treatment team members are cross-trained in 
each other's areas of expertise to the maximum extent feasible. The 
team, which typically works with a relatively small number of 
individuals, is available for support as long as the services are 
needed. 

[54] All 30 evidence-based programs can serve young adults, but six of 
these are separate programs specifically designed for young adults aged 
17 and above. 

[55] The supported education counselor works closely with the state 
adult and child mental health agencies and with youth formerly in 
foster care or juvenile justice who are transitioning out of the child 
mental health system. 

[56] In addition to mental health agency officials, the Task Force 
consists of officials from Mississippi's Department of Rehabilitation 
Services; Department of Human Services (foster care); Mississippi 
Families as Allies, a nonprofit advocacy organization for individuals 
with mental illnesses and their families; and senior program staff from 
the Transitional Outreach Program. This task force meets twice a year. 

[57] Maryland also uses a team approach in local jurisdictions to 
address transition issues of young adults receiving residential 
services. 

[58] Other health care services that can be provided under this option 
include other diagnostic, screening, preventive, and rehabilitation 
services and certain evidence-based practices such as Assertive 
Community Treatment. 

[59] Connecticut mental health officials told us that they have chosen 
not to use the rehabilitation option to cover services associated with 
the state's program for young adults with serious mental illness, but 
they use it to cover other mental health services. 

[60] Person-centered planning is an approach that emphasizes 
individualized services and consumer choice in treatment. 

[61] Some state mental health agencies provided grants to nonprofit 
agencies that administer their young adult program to help pay for 
services not covered by Medicaid. 

[62] The Housing Choice Voucher program is authorized by section 8 of 
the U.S. Housing Act of 1937, as amended (42 U.S.C. 1437f). Regulations 
are found in 24 C.F.R. Part 982. HUD's Office of Public and Indian 
Housing oversees the administration of the program. 

[63] Local public housing agencies administer the Section 8 Housing 
Choice Voucher program on HUD's behalf and provide eligible households 
with a subsidy to seek and rent suitable housing in the private market. 
These vouchers can be used in group homes for persons with serious 
mental illness. 

[64] One-Stop Centers provide employment training and placement to any 
individual seeking work. 

[65] The TIP System model is driven by seven guidelines or principles 
that include but are not limited to engaging young people through 
relationship development and person-centered planning, providing 
developmentally appropriate services and supports, and teaching life- 
skills. The model can be used as part of case management or in a team 
format, such as Assertive Community Treatment. The TIP system is based 
on research that includes outcomes. According to its author, the TIP 
model is an "evidence-supported practice" based on the findings from 
numerous outcomes studies. However, it has not been evaluated against a 
control group using random clinical assignment. For details regarding 
the TIP model, see [hyperlink, http://tip.fmhi.usf.edu] and Clark, H. 
B. Transition to Independence Process System Development and Operations 
Manual University of South Florida (Florida) 2004. 

[66] In 2002, two executive orders highlighted issues concerning 
fragmentation across mental health and youth-serving programs. These 
executive orders created the President's New Freedom Commission on 
Mental Health and the White House Task Force on Disadvantaged Youth. 

[67] The grant also funded services for youth with serious emotional 
disturbances. 

[68] It should be noted that this evaluation lacked a control group 
and, according to the researchers, improvements identified might be 
explained by factors other than the program, such as attrition and 
maturation effects, despite efforts to account for such factors in 
their analyses. Also, the results are limited to the 193 program 
participants for whom data were available and should be not generalized 
to all program participants. M.G. Haber and others, "Predicting 
Improvement of Transitioning Young People in the Partnerships for Youth 
Transition Initiative: Findings from a Multi-Site Demonstration," 
Journal of Behavioral Health Services and Research, forthcoming. 

[69] National Collaborative on Workforce & Disability for Youth, 
Institute for Educational Leadership, Tunnels & Cliffs: A Guide for 
Workforce Development Practitioners and Policymakers Serving Youth with 
Mental Health Needs, Office of Disability Employment Policy Number #E- 
9-4-1-0070 (Washington, D.C.: March 2007). 

[70] SAMHSA has also developed as part of the Partnerships for Youth in 
Transition demonstration, an age-appropriate outcome measurement tool 
as well as a program fidelity instrument to assess how well programs 
are implemented. According to HHS, the existence of such standardized 
tools is a critical precursor to conducting randomized trails of the 
model. 

[71] SAMHSA launched "What a Difference a Friend Makes," as part of the 
Mental Health Campaign for Mental Health Recovery, which is designed to 
encourage, educate, and inspire people between 18 and 25 to support 
their friends who are experiencing mental health problems. 

[72] Job Corps, administered by Labor, is an education and job training 
program for at-risk youth age 16 through 24. 

[73] Kessler, R., W. T. Chiu, L. Colpe, O. Demler, K. Merikangas, E. 
Walters, and P. Wang. "The Prevalence and Correlates of Serious Mental 
Illness (SMI) in the National Comorbidity Survey Replication (NCS-R)." 
In Mental Health, United States, 2004, ed. R.W. Manderscheid and Berry, 
J.T. DHHS Pub No. (SMA)-06-4195. Rockville, Maryland: Substance Abuse 
and Mental Health Services Administration, 2006. 

[74] Respondents were determined to have a serious mental illness if 
they met any of the following criteria within the previous 12 months: 
made a serious suicide attempt; experienced a work disability or other 
substantial limitation because of a mental or substance disorder; or 
were diagnosed with bipolar I or II disorder, nonaffective psychosis, 
substance dependence with serious role impairment, impulse control 
disorder with repeated serious violence, or any disorder that resulted 
in 30 or more days functioning out of role in the year. 

[75] We used weights specific to part 2 of the NCS-R for estimates of 
severity. 

[76] According to the CPS, the population of 18-26--year-olds increased 
by about 7 percent from 2001 to 2006, from approximately 34.6 million 
to 37 million. 

[77] The survey was administered in two parts. Part 1 contained a core 
diagnostic assessment while part 2 contained questions pertaining to 
specific behaviors, risk factors, and severity of mental illness. All 
respondents who met lifetime criteria for a mental illness in part 1 
participated in part 2, as well as a probability subsample of those 
with no mental illness. 

[78] Because the NCS-R employed a probability procedure based on random 
selections, the selected sample was only one of a large number of 
samples that might have been drawn. Since each sample could have 
provided different estimates, we express our confidence in the 
precision of the particular sample's results as a 95 percent confidence 
interval (e.g., plus or minus 12 percentage points). This is the 
interval that would contain the actual population value for 95 percent 
of the samples that could have been drawn. As a result, we are 95 
percent confident that each of the confidence intervals in this report 
will include the true values in the study population. 

[79] Mathematica Policy Research, Inc. developed these groupings as 
part of its evaluation of the Ticket to Work Program. Because we define 
"mental illness" to exclude mental disorders that constitute 
abnormalities in cognition or intellectual functioning, we excluded 
individuals whose primary disabling condition was listed as mental 
retardation, autistic disorder, other pervasive development disorders, 
organic mental disorders (chronic brain syndrome), or somatoform 
disorders. We also excluded eating and tic disorders and substance 
abuse disorders. 

[80] In determining primary and secondary disabilities, we excluded SSI 
recipients who began receiving benefits as children and had not yet 
been redetermined by SSA under adult eligibility criteria. According to 
our analysis, this applied to about 32 percent of the total SSI 
population aged 18-26. DI recipients are not subject to the 
redetermination process. 

[81] Other state agencies that collaborated in the development of this 
program are the Office of Policy and Management and the Department of 
Mental Retardation. 

[82] The levels of care are based on the young adults' clinical needs 
and are generally geared to help them develop increasing levels of 
independence and success in the community. Young adults receiving 
mental health services can access various levels of care during their 
recovery, depending on their clinical needs. 

[83] Basic case management services consist of office-based and 
outreach visits on a monthly, biweekly, or weekly basis. The highly 
structured programs include: the specialized apartment program, 
designed for those that require staff in the apartment for nearly all 
day; group homes, which are congregate residential programs where 
individuals develop life skill, and specialized residential services 
programs with staff and supervision usually 24 hours a day seven days a 
week. A Connecticut mental health official told us that Connecticut 
primarily uses intensive case management, which is similar to the 
Assertive Community Treatment model, but does not meet all the criteria 
for Assertive Community Treatment, including having a psychiatrist 
available 24 hours a day seven days a week. 

[84] See Davis, Maryann and Ann Vander Stoep. The Transition to 
Adulthood Among Adolescents Who Have Serious Emotional Disturbance, 
prepared for The National Resource Center on Homelessness and Mental 
Illness Policy Research Associates, Inc. Delmar, New York: under 
contract to the Center for Mental Health Services, Substance Abuse and 
Mental Health Services Administration, April 1996; and Davis, Maryann. 
"Improving Youth Transitions Systems and Measuring Change." 
Presentation at the National Partnerships for Youth in Transition 
Forum, Center for Mental Health Services, Massachusetts: August 2005. 

[End of section] 

GAO's Mission: 

The Government Accountability Office, the audit, evaluation and 
investigative arm of Congress, exists to support Congress in meeting 
its constitutional responsibilities and to help improve the performance 
and accountability of the federal government for the American people. 
GAO examines the use of public funds; evaluates federal programs and 
policies; and provides analyses, recommendations, and other assistance 
to help Congress make informed oversight, policy, and funding 
decisions. GAO's commitment to good government is reflected in its core 
values of accountability, integrity, and reliability. 

Obtaining Copies of GAO Reports and Testimony: 

The fastest and easiest way to obtain copies of GAO documents at no 
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each 
weekday, GAO posts newly released reports, testimony, and 
correspondence on its Web site. To have GAO e-mail you a list of newly 
posted products every afternoon, go to [hyperlink, http://www.gao.gov] 
and select "E-mail Updates." 

Order by Mail or Phone: 

The first copy of each printed report is free. Additional copies are $2 
each. A check or money order should be made out to the Superintendent 
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 
more copies mailed to a single address are discounted 25 percent. 
Orders should be sent to: 

U.S. Government Accountability Office: 
441 G Street NW, Room LM: 
Washington, D.C. 20548: 

To order by Phone: 
Voice: (202) 512-6000: 
TDD: (202) 512-2537: 
Fax: (202) 512-6061: 

To Report Fraud, Waste, and Abuse in Federal Programs: 

Contact: 

Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]: 
E-mail: [email protected]: 
Automated answering system: (800) 424-5454 or (202) 512-7470: 

Congressional Relations: 

Ralph Dawn, Managing Director, [email protected]: 
(202) 512-4400: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7125: 
Washington, D.C. 20548: 

Public Affairs: 

Chuck Young, Managing Director, [email protected]: 
(202) 512-4800: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7149: 
Washington, D.C. 20548: 

*** End of document. ***