No genuine system of mental health care exists in the United States. This country's diagnosis and treatment of mental health problems are fragmented across a variety of providers and payers – and they are all too often unaffordable. If you think about it, the list of complications is almost endless:  Our mental health system is a non-system – and a dysfunctional non-system at that.  The evidence is everywhere that things have been getting worse – more and more Americans with mental illness are stranded in emergency rooms, for example, and simply for want of hospital beds. And that is in no small part because nobody has tried, in more than 50 years, to design a comprehensive mental health system for all Americans.  It's time to try again.  The last major rethinking of the system's flaws began, in 1955, with an act of Congress that resulted in the appointment of something called the Joint Commission on Mental Illness and Health. The commission's report, Action for Mental Health, offered a vision of community-based mental health treatment: a new clinic would be created for every 50,000 persons – for prevention and early intervention services. People who once had to wait for their symptoms to become bad enough to go to the hospital before anything could be done? They would receive prompt care in their own communities and return quickly to life as usual – back at work, living with their families, seeing their friends.  Soon came the downsizing of large state hospitals and, in 1963, the passage of the Community Mental Health Act. That legislation envisioned the creation of a network of mental health centers spanning the country, so that every citizen would have a single point of access. A person experiencing early symptoms of mental disorder could receive emergency, inpatient, partial hospitalization and outpatient care – all in the same place – while her family was educated about her disorder and how best they could help.  Unfortunately, fewer than half of the centers were ever built, and adequate support for their operation was never provided. As federal funding ceased, many of the existing centers shifted away from caring for the most seriously ill ... to serving paying customers. The promise of an effective community-based system of care remains unfulfilled.  Yet we are, half a century later, in a different world for which a different vision may be required – a vision of comprehensive care aimed at helping people with mental illness continue to be functioning members of society. But the essential notion of having an integrated system of healthcare – a system that recognizes the spectrum of needs associated with mental disorders, from family therapy to medication to supported housing – is too important to relinquish.  President Obama can kick-start planning for a genuine system of mental health care, by establishing a presidential commission to suggest realistic, re-inventive steps forward.  It could be a landmark moment, right now, today.  Here's what it might take:  In the 21st century, with our instantaneous electronic communications, it may be less important to house these kinds of services in a single site – but it's no less important to insure that they are all available.  A half-century of patchwork efforts to improve one or another aspect of the mental health system has resulted in abject failure. Unless we take a comprehensive approach, and mend the safety net that protects us all, we will fail again.  Paul S Appelbaum is the Dollard Professor of Psychiatry, Medicine and Law at Columbia University, and a former president of the American Psychiatric Association.
Paul S Appelbaum: A checklist of real, tangible ideas for President Obama to kick-start an integrated healthcare system that works. We've tried it before, and it is long past time to try again. (Yes, there will have to be a website.)