Tom Daschle's confirmation hearings gestured awareness that mental illness and substance use disorders should be incorporated in any reform movement: community programs for early intervention and prevention, protecting people with disabilities, spreading the obligations of wellness throughout the community and federal agencies, and making science and evidence the basis of decisions instead of politics and ideology. It all sounds good.

Daschle wants to make health hot.

When it comes to using flashlight on mental illnesses, a quick and dirty Lexis search suggests no fewer than 2,000 stories a month during 2008 about topics as diverse as soldiers not getting treatment in a timely fashion; patients at risk in state hospitals in Georgia, North Carolina and Delaware; jails neglecting the mentally ill in Virginia. In April the Association of Health Care Journalists awarded three of its competitive prizes to stories about mental illness. In July, and entire issue of the American Prospect discussed the politics of mental illness; NPR advertised for a mental health beat and The New Yorker profiled a vet with PTSD. News doesn't get more mainstream.

Neither Daschle's appropriate models, nor news, can alone repair the highway to health. Can a new administration and the 111th Congress do it? What else needs tending? A few thoughts. . .

Last year
•2008 finally saw passage of insurance parity. It was tucked into the 11th-hour $700 billion bail out package, and came just before the retirements of Sen. Pete Domenici and Rep. Jim Ramstad. This Herculean effort included plus Sen. Edward Kennedy and Rep. Patrick Kennedy, father and son.

The impact of this long sought measure might have included more people before the economy soured and so many lost their jobs and access to employer-based insurance coverage. It's a reminder that the fight is not over for those left out. Workers in companies larger than 50 could also benefit by an end to legal insurance discrimination. The cost of untreated bi-polar disorder alone approaches nearly $15 billion.

•Michelle's Law guarantees a year of insurance for college students forced to withdraw during an academic year because of medical conditions.

•Reauthorization of behavioral health courts helping mentally ill offenders is another Domenici accomplishment.

Alarm bells
Accomplishments such as the above should not dull awareness that indicators point to an increase in psychiatric hospitalizations. While we await the implementation of Daschle's paradigm shift to health and community resources, recent indicators point to an increase in hospitalizations for psychiatric treatments. Along with the emergence of for-profit companies managing psychiatric services to benefit Wall Street, an unintended consequence of passing parity insurance could could accelerate this new trend.

Count the dollars and sense
Almost all states face deficits. Many are turning to cut services and programs
Some will try to make up the difference by raiding programs for mental health.

•Eyes are on California where Gov. Schwartzeneger will likely square off against Pro-Tem Speaker Senator Darrell Steinberg over using money from Prop 63 to close a $40-billion deficit. Prop 63 was the result of a 2004 voter referendum to tax millionaires to create new sources for mental health services. Steinberg is one of the nation's few politicians whose elections have been based on promises of mental health reform. And he wrote Prop 63. Schwartzenegger has already tried to cut mental health programs.

•New York can make some pretty myopic decisions, such as closing drug treatment programs for those leaving prison. So, too, a program to prevent relapse, denying help to 2,700 people. Makes no sense. On the other hand, Gov. Paterson proposes extending the insurance umbrella to young people in their 20s, a group that is often left out but is also high risk for early on-set.

Make outsourcing accountable
The example from North Carolina, which failed miserably, should be avoided. To reform mental health systems, they sank more than $400 million into start-up agencies draining public resources. Meanwhile they made a mockery of community-based programs. Georgia is about to transfer the state system to private hands. We need to watch what happens when government abandons oversight of human services. Remember Medicare Advantage?

Finish business
•SCHIP: A new president and congress are likely to soon pass the States Children's Health Insurance Program. California's Rep. Henry Waxman called this a down-payment on national health insurance.

•Physician Payments Sunshine Act: Dubious conflicts of interest and ethical practices are shaking confidence in the medical profession. Introduced by Sen. Charles Grassley and the Senate Finance Committee, the Physician Payments Sunshine Act asks for transparency in transactions between doctors, pharmaceutical companies and the research they conduct and report. While drug companies have courted physicians throughout medical specialties, psychiatrists have been hard hit for notable lapses and conflicts of interest. In December, Emory University informed NIH of its new arrangement with Dr. Charles Nemeroff, former chairman of psychiatry, whose lapses contributed to the public and professional outrage. Psychiatrist Dr. Dan Carlat has been on the scene from the beginning. It's great to seeinfluential psychiatrists outraged, and the vigilant American Medical Student Association leading reform.

•Although Jan. 1 was the turn around date for ending pharma gifts to doctors, many suspect it is more of a band-aid than a tourniquet. It would be a surprise if enactment of a new standard in the pharmaceutical industry did the trick.

The list could continue. . .and will. What do you think merits the watch of MIWatch?