Advocates for the mentally ill say the USA has made fitful progress in the year since the shootings at Sandy Hook Elementary School turned the country's attention to failures in the mental health system.
Thirty-six states and the District of Columbia increased funding for mental health after the shootings in Newtown, Conn., partly due to the improving economy, according to a new report from the National Alliance on Mental Illness, or NAMI.
Lawmakers in nearly a dozen states also passed or strengthened laws that could allow more people to receive court-ordered treatment for symptoms of severe mental illness, according to the Treatment Advocacy Center.
And the White House -- which in June hosted a National Conference on Mental Health -- on Tuesday promised $100 million to increase access and quality of mental health services. President Obama put improving access to mental health services at the center of his response to Newtown, along with limiting access to the kinds of weapons used in the attack.
"Unfortunately, it often takes a tragedy to tip the balance," said Doris Fuller, executive director of the Treatment Advocacy Center, in a statement. "Some of the bills that passed in 2013 have been under consideration in one form or another for years. What changed with Sandy Hook was that the public demand and official will for them to pass grew."
An investigation of the Newtown shootings, released last month by Connecticut, concluded that the shooter, Adam Lanza, "had significant mental health issues that affected his ability to live a normal life and to interact with others." Lanza shot and killed 20 schoolchildren and six educators at Sandy Hook nearly one year ago, on Dec. 14, 2012, along with his mother and himself.
Since then, Texas boosted mental health funding by $259 million, the biggest increase in state history, according to the NAMI report. Texas also passed a law requiring teachers and students to undergo training in how to recognize and respond to symptoms of suicide or mental illness.
According to the White House, half of the $100 million will come through the new health care law to help community centers provide more mental health services. The other $50 million, via the Department of Agriculture, will help finance rural mental health facilities.
Yet even these improvements don't come close to making up for years of neglect and deep budget cuts to mental health, said Ron Manderscheid, executive director of the National Association of County Behavioral Health & Developmental Disability Directors.
States made $4.35 billion in budget cuts from fiscal year 2009 to 2012, according to the NAMI report. The number of public psychiatric beds has fallen 90% since the 1950s, according to the Treatment Advocacy Center.
"In most communities, there isn't the capacity to care for people who need care," Manderscheid said.
Thomas Insel, director of the National Institute for Mental Health, said he hopes the country remains committed to helping these patients and their families, even as time passes.
"This is a long-term problem that will require making mental health care a priority," Insel said.
Patient advocates disagree about whether the stigma of mental illness has improved.
The violence in Newtown, and in attacks such as the September shooting at the Washington Navy Yard, have led some people to assume that all people with mental illness are violent, Manderscheid said. In general, he said, people with a mental illness are no more violent than others.
In an appearance on Meet the Press after the Washington Navy Yard shooting in September, a National Rife Association official said that the way to prevent future atrocities is to lock up more mentally ill people in psychiatric hospitals. "If we leave these homicidal maniacs on the street ... they're going to kill," said Wayne LaPierre, the NRA's executive vice president. "They need to be committed."
But others say that the Newtown tragedy has led to more open discussions of mental health -- some of them led by the White House,
"There is a change in the way that this illness is discussed," said Mark Covall, president and CEO of the National Association of Psychiatric Health Systems. "It used to be seen as 'these people are violent and we don't want to deal with it.' Now, these folks are increasingly being viewed as our neighbors, our family members, and there is more of a sense that it can happen to anyone."
Congressional efforts to improve mental health – which were attached as an amendment to gun control legislation – have been "in limbo" ever since the gun control bill failed, Manderscheid said. Covall said he holds out hopes for new mental health legislation from Rep. Tim Murphy, R-Pa., who has said he plans to introduce a bill soon.
Although the roll-out of the Affordable Care Act has been bumpy, the law has the potential to help millions of previously uninsured Americans get mental health services, the NAMI report finds. Also as part of the Affordable Care Act, 25 states and the District of Columbia have opted to expand Medicaid, which pays for 27% of all mental health services.
And last month, the Department of Health and Human Services issued final rules on implementing a 2008 law guaranteeing that insurance plans provide equal coverage for mental and physical health.
Yet those in the mental health field say serious challenges remain. With millions more Americans eligible for mental health services, NAMI predicts the country could face "an acute shortage of mental health workers."