Dozens of states have slashed spending on mental health care over the last four years, driven by the recession's toll on revenue and, in some cases, a new zeal to shrink government.

But that trend may be heading for a U-turn in 2013 after last year's shooting rampages by two mentally disturbed gunmen.

The reversal is especially jarring in statehouses dominated by conservative Republicans, who aggressively cut welfare programs but now find themselves caught in a crosscurrent of pressures involving gun control, public safety and health care for millions of disadvantaged Americans.

In many states, lawmakers have begun to recognize that their cuts "may have gone too deep," said Shelley Chandler, executive director of the Iowa Alliance of Community Providers. "People start talking when there's a crisis."

About 30 states have reduced mental health spending since 2008, when revenues were in steep decline, according to the National Alliance on Mental Illness. In a third of those states, the cuts surpassed 10 percent.

As a result, nine state-run psychiatric hospitals were closed and another 3,200 beds for mental health patients were eliminated, dramatically reducing treatment options for the poor and people in the criminal-justice system. Thousands of patients were turned onto the streets.

Making matters worse, the cuts came as unemployment was rising, causing more people to lose private insurance and forcing them to shift to public assistance.

The steepest drop by percentage was in South Carolina, where spending fell by nearly 40 percent over four years — an amount that Republican Gov. Nikki Haley has called "absolutely immoral."

Now Haley, who took office in 2011, has pledged to bolster a mental health system that dropped case workers, closed treatment centers and extended waiting lists. She also wants to expand remote access to psychiatrists through video conferencing.

Both Pennsylvania and Utah have put aside plans to scale back their mental health systems.

And Kansas, which cut mental health spending by 12 percent from 2008 to 2011, this month announced a new $10 million program aimed at identifying mental health dangers.

"I don't think we're well set as a state at all to be able to deal with these intensive cases" of mental illness, acknowledged Kansas Gov. Sam Brownback, usually an avid proponent of downsizing social programs.

The sudden pause reflects anxiety from last year's shootings in a Colorado movie theater and a Connecticut elementary school. Although little is known about the mental health of either gunman, the attacks have shaken state legislatures that, until recently, didn't intend to consider more social spending. In some cases, gun-rights advocates are seeking mental health reforms as an alternative to more gun laws.

Jon Thompson, spokesman for the Republican Governors Association, said many budget-cutting governors are having second thoughts, including whether to reform mental health policies "to further invest in the safety of their citizens."

South Carolina eliminated 600 full-time case workers and closed five treatment centers. That led to an increase in the number of people with mental illness in jail in Columbia — so much that it now exceeds the patient total at the city's public psychiatric hospital.

"We've been unable to maintain those preventative measures to keep people out of jail," said Bill Lindsey, director of South Carolina's National Association on Mental Illness.

During former Gov. Mark Sanford's term, the fiscal pressure was inescapable. The recession cut state revenue by more than $1 billion from 2008 to 2011.

"It wasn't really Sanford's fault," said former state Rep. Dan Cooper, Republican chairman of the House Ways and Means Committee. "There just wasn't enough money to go around."

Revenues have since recovered somewhat, and are projected to be at levels last seen in 2008.

In Kansas, under then-Gov. Kathleen Sebelius, a Democrat, state psychiatric hospitals began treating only the most dangerous cases. Caseloads at the Johnson County Mental Health Center near Kansas City rose from the recommended 15 per caseworker to more than 30 in 2010.

Tim DeWeese, the center's clinical director, said one of his patients who had finished college and gotten a job and an apartment became homeless after his doctor visits were cut off.

"It came crashing down all the way," DeWeese said.

Oklahoma also cut mental health programs in 2010 and 2011. But Republican Gov. Mary Fallin, a conservative elected in the GOP landslide of 2010 on a promise to cut spending, reversed course last year after grim warnings about the effect on public safety, and after several teen suicides in Oklahoma City.

"There just weren't enough resources," said Harry Tyler, director of the Mental Health Association of Central Oklahoma.

Fallin approved a 20 percent budget increase and has pledged to make mental health a priority again this year.

"You'll see more emphasis on being able to identify people that might have mental health challenges," she said.

Tyler said he would encourage Fallin to provide more money for screening teenagers who could endanger themselves or others.

New Jersey Gov. Chris Christie, another Republican, has promised to fully implement a new program under which people are required to take medication and attend therapy if a judge believes they pose a risk.

Mike Hammond, executive director of Kansas' Association of Community Mental Health Centers, said his state's governor is looking for new ideas on mental health care.

"I think he's realized what's happening in our system," Hammond said.

To be sure, Republicans have not given up on keeping state government lean and taxes low. And some party members question how much mental health spending will be approved.

"I'm not telling you she gets the money," former South Carolina GOP Chairman Katon Dawson said of Haley.

Ty Masterson, Republican chairman of the Kansas Senate's Ways and Means Committee, acknowledged the same conflict: "There's obviously tension there."

Related stories:

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Shootings traumatize a nation

Asperger's not to blame in shooting

Don't miss the latest health news on NBCNews.com

In just 10 years the number of children diagnosed with attention deficit/hyperactivity disorder, or ADHD, rose dramatically, a  large new study suggests.

Overall, about 5 percent of nearly 843,000 kids ages 5 to 11 were diagnosed between 2001 and 2010 with the condition that can cause impulsive behavior and trouble concentrating. But during that time, rates of new ADHD diagnoses skyrocketed 24 percent – jumping from 2.5 percent in 2001 to 3.1 percent in 2010.

That’s according to a comprehensive review of medical records for children who were covered by the Kaiser Permanente Southern California health plan.  Rates rose most among minority kids during the study period, climbing nearly 70 percent overall in black children, and 60 percent among Hispanic youngsters, according the study published in JAMA Pediatrics. Among black girls, ADHD rates jumped 90 percent.

Rates remained highest in white children, climbing from 4.7 percent to 5.6 percent during the study period.

The biggest factor driving this increase may be the heightened awareness of ADHD among parents, teachers, and pediatricians, says the study’s lead author Dr. Darios Getahun, a scientist with Kaiser Permanente. For kids who need help, that’s a good thing, Getahun says.

“The earlier a diagnosis is made, the earlier we can initiate treatment which leads to a better outcome for the child,” he says.

Unlike previous studies in which researchers relied on reports from parents and teachers to say whether a child had ADHD, the new study tracked kids who were diagnosed according to ADHD medical codes entered by child and adolescent psychiatrists, developmental and behavioral pediatricians, child psychologists and neurologists.

ADHD is one of the most commonly diagnosed childhood disorders. Experts estimate that anywhere from 4 percent to 12 percent of school-age children are affected, many of whom continue to suffer from the disorder into adulthood.

Rates of diagnosis in the new study were greater in families with higher incomes, with nearly three-quarters of kids with ADHD coming from families that earned more than $50,000 a year.

“Higher rates of ADHD observed in affluent, white families likely represent an effort by these highly educated parents to seek help for their children who may not be fulfilling their expectations for schoolwork,” Getahun and his co-workers write.

Boys still outnumber girls 3 to 1 in ADHD diagnoses, but the gap appears to be closing among black girls.

“The increasing rate of ADHD among girls is an interesting finding and could represent an effort by parents to get more help for their daughters,” the authors say.

There was no change in the rate among Asian kids, but Getahun suspects this may have something to do with culture. Asians, as a rule, have been less likely to use mental health services and are more likely to discontinue therapy despite having equal access to care, Getahun says.

A child development specialist unaffiliated with the new study says he suspects that increased awareness of ADHD may have contributed to the increasing rate of diagnosis.

“Heightened professional awareness in general and improved efforts to detect ADHD exert an influence, but we cannot tell the magnitude of that,” says Alan Kazdin, the John M. Musser Professor of Psychology and Child Psychiatry at Yale University.

With all the coverage of the condition in the media, parents and teachers now have a better sense of what signs to look for, Kazdin says.

“Heightened awareness in the media, by parents and by teachers, too, may play a role. A child who in previous years just was said not to be able to control himself might now be more finely described.”

Related stories: 

• Childhood ADHD may limit adult achievements
• ADHD overdiagnosed in youngest kids in class
• Number of women on ADHD meds soars

By many accounts, Adam Lanza didn’t fit in. Family friends and neighbors describe a young man who went far beyond shy in avoiding people, who had few or no friends, and who dressed unlike most of peers, buttoning up his shirt to the top and carrying a briefcase to high school instead of a backpack.

Several people, including Ellen Adriani, a friend of his mother, Nancy Lanza, have now said he had Asperger’s, a type of autism, although there’s been no official medical confirmation of this.

“Nancy was always concerned about Adam because of his Asperger’s and the typical behavior that goes along with that,” Adriani told NBC News.

If Adam Lanza did have Asperger’s syndrome or another form of autism, he committed the unfathomable murders of 20 children, six school staff and his own mother despite the condition, not because of it, experts agree.

The kind of carefully planned, violent attack like the killings in Newtown, Conn., on Friday would be out of character for someone with Asperger’s, said autism expert Travis Thompson, Ph.D., of the Special Education Program at the University of Minnesota.

“I have known a lot of people with Asperger’s and I have never known one who is violent. They are very anxious,” Thompson said. “They have a lot of problems with anxiety and they have problems with relationships with other people too but that doesn’t translate into violence. When they are little kids, they have tantrums because they don’t know what to do and they feel adults don’t understand them. When they become older they develop mechanisms and since they are usually very verbal they can ask questions.”

Parents of kids with Asperger’s worry about the discrimination that could come from all the speculation.

“I think a lot of parents who are dealing with this already are awash with anxiety and uncertainty, and when someone sits in front of the camera and says people like my son are dangerous because of an association with a condition, it’s scary,” says Ron Fournier, editorial director at National Journal, who has written several recent high-profile commentaries about his son with Asperger’s.

Julie Steck, a child and pediatric psychologist in private practice in Indianapolis, said people with a developmental disorder like autism are more likely to have a range of other physical and mental disorders.

That’s in part because of the genetics, in part because of the stress of coping with the disorder itself, she said.

Family friend Adriani said Adam Lanza also had an unusual condition where he didn’t feel physical pain. “If he were to cut himself or even if he fell down or if he injured himself he wouldn’t necessarily know how severe it was because usually the pain is, oh something’s wrong.  So if he cut himself he wouldn’t even necessarily know it,” she said.

Richard Novia, who was Lanza’s tech club adviser at Newtown High School, backed that detail in an interview with the Associated Press. "If that boy would've burned himself, he would not have known it or felt it physically," Novia said.

It's not clear to experts if that is tied to Asperger's. "Individuals with Asperger’s often have poorly modulated responses to pain—they may over-react to something which seems minor to others but totally block out or not respond to something we would see as painful," says Steck. "However, I am not familiar with there being a correlation with not feeling or being able to respond to pain at all."

Russell Hanoman, another friend of Nancy Lanza, described Adam as being obviously uncomfortable around other people.

“I remember when I first met him, he deliberately stood maybe six feet away from me and took three exaggerated steps toward me, stuck out his hand, shook it, put it back, and three exaggerated steps back,” Hanoman told NBC News.

Thompson also said it is unlikely a person with Asperger’s would have plotted something like Friday’s shootings over a long period of time without telling someone about it.

“I am not saying a person with Asperger’s would not do something like this,” he said. “It is possible a person with Asperger’s could have done something like this but so might someone who was depressed or someone with schizophrenia.” Or someone with no diagnosed mental illness at all.

Descriptions of Lanza’s painfully awkward ways have fueled speculation that he might have been lashing out after a childhood of having been bullied.

But there’s no evidence that Lanza was bullied, and Thompson doesn’t see the connection between any possible bullying and the murders. “Why would he go in and kill a bunch of little children?” Thompson asked.

One thing psychologists do agree on – mental health is still not adequately diagnosed or treated in the United States, and especially not among young people.“We need to destigmatize it so that people seek treatment for their children and for themselves. I think obviously that funding is a huge issue,” said Steck, the Indianapolis child and pediatric psychologist. “It is very under recognized and under financed and many of the programs out there are not delivered in a very effective manner.”

Connecticut Gov. Dan Malloy agrees.

“Mental illness has long been relegated to a different discussion, as has physical health,” Malloy said at a Hartford, Conn., news conference Monday about the shootings. “It is not a distinction that I think serves our country. We need to begin in earnest the process of removing that distinction.”

NBC News’ Michael Isikoff contributed to this report.

In his speech at the memorial service for the Newtown victims, President Barack Obama included mental health in calling for a national response to the massacre, a conversation that so far has focused on gun control. "I will use whatever power this office holds to engage my fellow citizens -- from law enforcement to mental health professionals to parents and educators -- in an effort aimed at preventing more tragedies like this," the president said.

On Monday, White House spokesman Jay Carney pointed to the federal health reform law as evidence that the administration has already started to tackle the issue. Mental health issues are "clearly a factor that needs to be addressed in some of these cases of horrific violence," Carney said. "Obamacare, if you will, has ensured that mental health services are a part of the services" provided under the health law.

Insurance coverage for mental health treatment has long been spotty. More than a quarter of U.S. adults have a diagnosable mental health problem in any given year, but fewer than half receive treatment. While the Affordable Care Act, along with the Mental Health Parity Act of 2008, go a long way toward assuring coverage for most Americans, some gaps persist. There are questions, for example, about just what counts as equivalent treatment under the parity law, and whether it's being fully enforced. 

Here are some answers to frequently asked questions about mental health coverage:

Didn't the Mental Health Parity Act already guarantee coverage for Americans with insurance?

The Mental Health Parity and Addiction Equity Act, signed into law in 2008, made a big dent in the problem of mental health coverage.

Under that law, employers with more than 50 workers that include mental health services in their insurance plans were barred from covering them at a lower level than other medical conditions. That means that the plans could not provide fewer inpatient hospital days or require higher out-of-pocket costs, more cost sharing or separate deductibles for mental health conditions.

An estimated 140 million Americans were expected to benefit from the changes. But Paul Samuels, director and president of the Legal Action Center, says that some people still aren't receiving equal coverage, and the law is not always enforced. "That's a problem we're really concerned about," he says.

And while the law guaranteed parity for employees of companies that chose to offer mental health coverage, the law didn't require employers to offer such coverage. Even so, in 2012, 85 percent of employers offered some form of mental health benefits, according to the Society for Human Resource Management.

Mental health coverage under small business and individual market plans was not included in the Parity Act. In short, whether you have mental health coverage in an employer-sponsored insurance plan depends on where you work.

What if I don't have mental health coverage in my employer’s insurance plan? Will the ACA change that?

Employers with 50 or more workers can continue to not offer the benefits. But small group and individual plans will be required to offer the coverage in 2014 through online exchanges created under the law.

I'm planning to buy an insurance plan through one of the new exchanges. What kind of mental health coverage will I have?

All plans sold in the exchanges will be required to provide coverage for mental health and substance abuse as one of 10 essential benefit categories. That coverage must also comply with the parity laws already required for large employers. The exchanges will be open to individuals and small businesses.

The same rules will apply to small group and individual plans purchased outside of the exchange.

This means that beginning in 2014, if you, or your small employer, are purchasing any new insurance plan, coverage will include mental health benefits on par with any other medical condition. It’s not clear what exactly will be covered – for example, group home and residential treatment outside of a hospital.

I'll be covered under the Medicaid expansion authorized by the law. What kind of mental health coverage will I get?

If you earn less than 138 percent of the federal poverty level (about $32,809 for a family of four), you may be newly eligible for Medicaid coverage in 2014. Like people who purchase coverage through the exchange, new Medicaid beneficiaries will receive mental health benefits on par with other medical or surgical needs.

That coverage is less robust than the current traditional Medicaid coverage offered by states, says Jennifer Mathis, deputy legal director at the Bazelon Center for Mental Health Law. That's because most states offer mental health benefits for Medicaid recipients that are more generous than the coverage offered by commercial insurance plans. But the new Medicaid benefits will be modeled on and measured against private insurance purchased by small businesses now.

Mathis says, however, that it will likely be difficult for states to maintain two parallel Medicaid programs, one for current beneficiaries and a second for the newly eligible. She hopes that most will choose to offer all Medicaid recipients the more robust benefits instead.

What else in the ACA may improve mental health treatment?

The ACA has several other provisions that will affect mental health coverage and treatment.

The Prevention and Public Health Fund created by the law, for example, includes $35 million to integrate primary care and mental health care, $10 million to train and recruit mental health professionals, and an additional $53 million in mental health screening, surveillance and suicide prevention funds.

The ACA also requires that plans offer depression screening for adults without a copayment, co-insurance or a deductible.

What problems might arise?

While the ACA "provides enormous potential and opportunity to make sure than many millions more Americans obtain the services they need," says Samuels, "that will only happen if the implementation of those reforms is effective." Samuels worries that the rules from HHS will not be clear or strong enough to make the parity laws meaningful. He also worries about getting everyone who is eligible for coverage enrolled, particularly those with severe mental health disorders who be may homeless or living on the fringes of society.

In addition, governors in several Republican states have said that they will not expand Medicaid, leeway they were given by the Supreme Court's health law decision in June. That could leave many Americans without any form of insurance coverage, including mental health benefits.

Access to treatment will likely also remain a serious stumbling block. States have cut $4.35 billion in public mental health spending from 2009  to 2012, a trend that is likely to continue over the next several years, according to the National Association of State Mental Health Program Directors. At the same time, the system has seen nearly a 10 percent increase in usage.

As many as 30 million people are expected to gain insurance coverage beginning in 2014. Of those, the U.S. Substance Abuse and Mental Health Services Administration estimates that 6 to 10 million will have untreated mental illnesses or addiction, adding additional demands to a system that is already overwhelmed. Patients may experience long wait times to see a psychiatrist, for example, and may require additional investments to expand the mental health workforce.

"I think there will be initial period where you may see folks with mental health coverage waiting longer than they'd like to get care," says Joel Miller, senior director of policy and health care reform at the state mental health program directors group.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Las Vegas Review-Journal

At least 15 truckloads of items were hauled from Kenneth Epstein's home on Oct. 5, the Las Vegas Review-Journal reported.

Reality TV has brought national attention to hoarding, and now a recent change in the influential psychiatric diagnosis guide may actually bring help for millions of Americans suffering from the isolating condition.

Hoarding – a psychological condition that can result in homes crammed floor to ceiling with papers, junk mail, books, clothing and other “valuables”-- has been associated with obsessive-compulsive behavior, although experts have long held that the two disorders aren’t necessarily connected.

In the revised, fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), "hoarding disorder" becomes a separate diagnosis, characterized by a "persistent difficulty discarding or parting with possessions, regardless of their actual value."

The revised diagnosis should “result in more people having access to treatment," says Randy Frost, a professor of psychology at Smith College who specializes in hoarding issues. "Right now, there are very few clinicians who know how to treat it. Once it shows up in DSM, there will be much more pressure on clinicians to train in how to treat this problem."

Hoarding isn’t just a messy garage or packed closet. According to the APA, it's defined by its harmful effects -- emotional, physical, social, financial and even legal -- both on the hoarder and the hoarder's family members.

Hoarding is “a disorder that involves the living areas of the home being so cluttered they can't be used for their intended purpose,” says Frost, co-author of Stuff: Compulsive Hoarding and the Meaning of Things.

Set to publish in May, the DSM is a guide doctors use to diagnose mental disorders. DSM codes are also used for insurance reimbursements and certain research grants.

Rachel Kramer Bussel, a 37-year-old writer and editor from Brooklyn, says she's long had hoarding tendencies, although she only recently came clean about them in an essay on Salon.com, a difficult step considering the stigma surrounding the disorder.

"I think people's only reference point is reality TV," says Bussel, who hasn't sought treatment but has worked with a personal organizer. "They think all hoarders are literally crazy cat ladies or people who don't function in the rest of society."

Las Vegas Review-Journal

Rachel Kramer Bussel carries two large bag stuffed with belongings that give her comfort.

Bussel hoards books, clothing and other items at home; she also carries around at least two large bags stuffed with belongings she says give her "comfort". She says she hopes the new classification will help others become more accepting of the often-misunderstood disorder.

The most common reaction to a hoarding confession is, "'Just get rid of everything. Get a dumpster and throw it all out and then you won't be a hoarder,'" Bussel says.

In fact, recent research finds abnormal brain activity in people with hoarding disorder.

There’s no hard evidence that hoarding is increasing, although certain societal factors -- such as the abundance of junk mail, our materialistic mindset, and an aging population (getting older increases the chance that a person will experience trauma or loss that contributes to hoarding) -- may translate into more hoarders, says David Kutz, an Albuquerque clinical psychologist specializing in hoarding and OCD.

At least 4 million people in the U.S. would meet full criteria for hoarding, according to Kutz. Other data suggests between 2.5 to 6 percent of the U.S. adult population, or up to a 15 million people, may have hoarding disorder, says Frost, who conducted the first-ever study of hoarding in the U.S. in 1993. “That’s a whopping number," Frost says.

Many hoarders don't recognize the problem. About “90 percent are sent by family members or a city counsel or the local sheriff,” says Kutz, who has appeared on A&E’s “Hoarders” three times.

While experts and hoarders alike say they believe the new DSM classification will help hoarders get better treatment, Frost stresses there is no "magic pill."

"We don't know yet whether there are medications that might be useful for this," he says. "But that's one of the things that will happen now that it's in the DSM. There will be an interest in researching this."

Until then, hoarders can get help overcoming their urge to acquire and save through cognitive behavior therapy and/or peer support groups, a form of treatment that greatly helped Lee Shuer, a 37-year-old mental health worker from Northampton, Mass.

"My mindset has completely changed," says Shuer, who began facilitating hoarding peer support groups after his hoarding habit went into "remission.” "I'm at the point where I can go to places where I used to acquire things - tag sales and thrift shops - and not buy anything. I can come across things that used to make my heart race but they don't turn me on any more. The thrill for excess is gone."

 For more on hoarding:

OCFoundation.org's Hoarding Center

 Childrenofhoarders.com

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Ed Zurga / AP file

Kansas City Chiefs inside linebacker Jovan Belcher, shown in a September game, two months before the 25-year-old killed his girlfriend and committed suicide.

Four months after the NFL sought to curb domestic violence in its ranks by launching a crisis hotline, a bolstered mental-health program and fresh encouragement for troubled players to seek help, that fortified safety net could not prevent the murder-suicide Saturday involving Jovan Belcher. The Kansas City Chiefs linebacker, 25, shot his girlfriend Kasandra Perkins, 22, at their home, then drove to Arrowhead Stadium and killed himself in front of two coaches and the team's general manager.

After the high-profile suicide of retired NFL superstar Junior Seau, 43, last May — two years after Seau drove his car off a cliff following his assault on a girlfriend — NFL commissioner Roger Goodell installed the 24-hour hotline for players and a reinforced mental-health initiative on July 26. That same week, following a spate of NFL-related domestic attacks — at least six other family violence cases in the NFL have been reported since 2010 — Goodell met with the player’s union to discuss possible solutions. 

Yet even as the league was taking steps to help mentally troubled players and their families, the Kansas City Chiefs were aware of Belcher's problems, Kansas City police spokeswoman Sgt. Marisa Barnes told NBC News.

And Police Sgt. Richard Sharp told the Kansas City Star that team officials "were bending over backwards" to help the couple.

The Belcher murder-suicide is the type of nightmarish incident the league has been working harder to prevent, said Robert Gulliver, the NFL’s executive vice president of human resources/chief diversity officer. 

“One of the biggest things that we are trying to do here (in the NFL) is to change the culture, where people realize that it’s OK to seek out help for mental health issues,” Gulliver told NBC News. “We were very deliberate in ... making the point that mental health is part of total wellness, that it’s OK to seek out help for mental health issues because that’s part of your overall well-being."

In addition to help from the team's counselors, Belcher and his girlfriend Perkins, who was mother of his 3-month-old daughter and shared his home, would have had access to the hotline and the league's mental health program. 

At the end of July, the NFL emailed information on its new crisis line and on the league's available mental-health help to the home of every NFL player, Aiello said, adding: "The information is sent with the idea that the player's wife also sees it. If a player's girlfriend sees it, it would be the same thing."

What's more, all 32 NFL teams employ a player development director to help encourage use of the programs, Aiello said.

In addition, the NFL Players Association — the labor union for players — staffs its own 24-hour, toll-free hotline for players to use "if they need any support whatsoever," said George Atallah, NFLPA spokesman. "If a player has an alcohol-addiction problem (for example), he calls in and we route that call to a facility near them, and (facility members) then come pick him up and give him the assistance he needs. That goes for any depression issues and mental health issues." The NFLPA also offers counseling services to players, and it employs a group of retired players "to get a pulse of what’s going on in the locker rooms, handle situations confidentially, and provide support when necessary."

As part of what the NFL calls its “new comprehensive health program” — formally dubbed NFL Total Wellness — Goodell and the league worked with former U.S. Surgeon General David Satcher last summer to strengthen its mental health tools and assistance. The new program encourages players and their families to seek support for behavioral issues, provides health and safety information and offers confidential, free advice via telephone and the Internet. That aid is available to all players and “all members of the NFL family” who find themselves “in times of need,” the NFL says. The same experts who operate the "NFL Life Line" run a similar emergency system for members of the U.S. military.

However, even with best intentions, the NFL remains essentially an elite club in which players have long been trained to hide physical pain — if not injuries — to keep their jobs. That environment could keep players from truly opening up about possible symptoms of depression, anxiety or other mental-health woes.

Gulliver declined to say how many players have phoned the hotline and tapped into the league’s enhanced mental-health program via the web since its launch.

"We don’t publicize the actual usage or percentage numbers," Gulliver said.

As the program has become more widely known by players, however, Satcher said: "The usage of it is increasing."

Gulliver wouldn't comment whether Belcher, his family, friends or any Chiefs players called the crisis line ahead of the murder- suicide, or tried to contact the league’s new mental health services professionals about Belcher.

“That, too, is information that we do not publicize. There are lots of privacy laws that we make sure we uphold. The program is actually administered by the third-party provider so it’s not information that comes into the NFL office. We wanted this to be independent and completely confidential for the members for the NFL family," Gulliver said. 

He added: "Our hearts really hurt for the tragedy that has played out in Kansas City. And we absolutely want to make sure that we provide resources so that people realize there is another way that they can get the help that they need."

Seau’s suicide last May served as the ultimate spark for the new hotline and the league's extra mental-health measures.

“It really did prompt us to step back and say: What more could we be providing for our players and for the NFL family?” Gulliver said. 

But even with a beefed-up program available to players and their spouses, it's difficult to predict this kind of tragedy, Satcher said, adding: "I don’t know that anybody could." 

The American Foundation for Suicide Prevention lists warning signs that someone may be considering suicide due to depression:

• Relentlessly low mood; pessimism; hopelessness; desperation; anxiety or inner tension
• Withdrawal; sleep problems
• Increased alcohol and/or other drug use
• Recent impulsiveness and taking unnecessary risks; threatening suicide or expressing a strong wish to die
• Making a plan; giving away prized possessions
• Sudden or impulsive purchase of a firearm; obtaining other means of killing oneself such as poisons or medications
• Unexpected rage or anger.

Anyone can call the National Suicide Prevention Hotline at 1-800-273-8255.

During the planning meetings for the NFL’s revamped mental-health platform, Satcher said he and league leaders discussed the hot-button issue of chronic concussions sustained by NFL players — and the behavioral instability those injuries are known to carry.

“The brain is a delicate organ and, therefore, head-to-head contact can no longer be viewed as acceptable. The hits start early - in junior high and high school," said Satcher, head of the Satcher Health Leadership Institute at the Morehouse School of Medicine in Atlanta. 

Satcher called the NFL's around-the-clock telephone “lifeline” and the other added mental-health backstops “a major advance” for the league.

Since 2010, these high-profile domestic violence cases have involved NFL players:

• Chad Johnson was released by the Miami Dolphins during the team’s 2012 training camp after the receiver was arrested in early August for allegedly striking his wife in the head.
• Erik Walden, a Green Bay Packers linebacker, was jailed during Thanksgiving 2011, originally charged with a felony after he allegedly assaulted his girlfriend. Later, he received a deferred judgement and agreed to do community service work.
• Dez Bryant, a receiver for the Dallas Cowboys, was arrested in July after allegedly shoving his mother. He was charged with a misdemeanor.
• Seau, a linebacker who spent most of his career with the San Diego Chargers, allegedly assaulted his girlfriend in 2010, two years before he shot himself to death.
• Chris Cook, a cornerback for the Minnesota Vikings, was arrested in October 2011 for domestic violence after he allegedly choked his girlfriend. He was acquitted at trial.
• Brandon Marshall, a wide receiver for the Chicago Bears, has a history of domestic crimes dating back to 2004. In March, he was accused by a 24-year-old woman of punching her in the eye. Marshall’s attorney said Marshall’s wife was the woman injured and that Marshall was a victim in the assault.

The National Suicide Prevention Hotline number is 1-800-273-8255.

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• Details in Belcher murder-suicide emerge as families grieve
• Contact sports leave pattern of brain injuries, study finds

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WASHINGTON — Teva Pharmaceuticals is pulling its generic version of a popular antidepressant off the market after a federal analysis showed the pill does not work properly. 

The Food and Drug Administration called on Teva to withdraw Budeprion XL 300 after chemical testing showed the drug releases its key ingredient faster than the original drug Wellbutrin, made by GlaxoSmithKline.

The action contradicts the FDA's previous update on the issue in 2008, when regulators said the drugs are essentially the same. That review came after hundreds of patients complained that Teva's drug did not work or caused side effects like headaches, anxiety and insomnia.

The agency said it completed its own study of the two pills in August, which showed Budeprion does not release into the blood at the appropriate rate. 

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