The history of mental health services in the United States is one of good intentions followed by poor execution; of promises to deliver better services for less cost; and of periodic revolutionary change with neither the evidence to support the new programs or the financial investment to see if the new approach could be effective if carried out adequately. While it can be argued that community mental health services date back to the beginnings of American history, until the mid-1950s, public mental health in the United States was largely institutionally based and entirely state supported. Early in U.S. history, local communities either served the mentally ill with family-centered care or expelled individuals who came from elsewhere. However, with the massive population growth of the United States in the nineteenth century, mentally ill individuals came to be concentrated, and for the most part poorly served, in local jails, prisons, poorhouses, and almshouses. Appalled by these circumstances, Dorothea Dix, a teacher, undertook a crusade to create mental hospitals in the United States modeled after the York Retreat in England. These family-like asylums would provide "moral treatment," which was believed to be curative at the time. Dix's attempt to get the federal government to take responsibility for the mentally ill in America was ultimately thwarted by a veto from President Franklin Pierce. Dix then turned to the states and was remarkably effective in getting all states to establish hospitals for state-of-the-art treatment of the mentally ill. A federal role in supporting mental health services would wait another one hundred years until the development of Medicaid, Medicare, and Supplemental Security Income.
While state hospitals started out with great promise, in many places they had deteriorated by the mid-1950s into little more than human warehouses. In post-World War II America, a new crusade began to replace state hospitals with community-based care. The experience of World War II psychiatrists with care at the front lines, the exposure of the dismal conditions of state hospitals by conscientious objectors and journalists, the development of antipsychotic medications with the discovery of the effectiveness of chlorpromazine, and the states' interests in shifting costs for caring for the mentally ill to the federal government all contributed to what, after the fact, came to be known as deinstitutionalization.
The community mental health era in the United States was launched with the 1963 passage of the Community Mental Health Centers Act, signed into law in by President John F. Kennedy. This law provided federal funding, which ultimately led to the establishment of more than 750 community mental health centers (CMHC) throughout the United States. However, the CMHCs tended to care for people with mental health problems (i.e., problems in living) much more than for those people with serious mental illness who were historically cared for by the states.
DEFINITION OF COMMUNITY MENTAL HEALTH SERVICES
Mental illness, as described in the 1999 Surgeon General's Report on Mental Health, "is the term used to define all diagnosable mental disorders. Mental disorders are health conditions characterized by alterations in thinking, mood or behavior (or some combination thereof) associated with distress and/or impaired functioning" (p. 5). While many service systems do not consider alcohol and other drug-related disorders (e.g., alcohol dependence) to be mental disorders, and many service systems do not include the dementias and what historically have been called organic mental disorders as disorders subject to treatment in the "mental health system," the surgeon general includes these disorders, which are clearly diagnosed within the framework of the Diagnostic and Statistical Manual (DSMIV) of the American Psychiatric Association. Mental health problems, signs, or symptoms that do not meet the intensity or duration to meet criteria for a mental disorder can also warrant active intervention, according to the surgeon general.
Mental health services are diverse and variable, depending on the sector where the services are being provided and the profession and training of the person providing the services. While in the past there tended to be strong divisions between a "medical model" and a "rehabilitation model" for service provision, most providers now accept an integrated bio-psycho-social (some add a spiritual component as well) model. The notion of recovery, in which the individual with the disorder self-determines how best to cope with and overcome the limitations of the disorder, is gaining ascendancy as well. Other key principles in community mental health are continuity of care and the need to assertively bring services to those reluctant or unable to seek them on their own. These principles have led to the development of multidisciplinary teams, case management services, and assertive community treatment teams.
ORGANIZATION
As the Surgeon General's Report indicates, treatment for mental illness and mental health problems is scattered and loosely coordinated into what can best be considered a de facto mental health system. The report indicates that there are actually four major components of this de facto system from which mental health services can be received: the specialty mental health sector, consisting of psychiatrists, psychologists, psychiatric nurses, and social workers trained to treat persons with mental disorders; the general medical/primary care sector, consisting of general health care professionals (nonpsychiatric physicians and nurse practitioners); the human services sector, consisting of nonmedical social services, school-based counseling, vocational rehabilitation, residential rehabilitation, criminal justice–based services, and religious professional counseling; and the volunteer support network sector, with self-help and other groups such as Alcoholics Anonymous, peer counseling, and support services. According to the surgeon general, about ten percent of the adult population in the United States use mental health services in the health sector in any one year, about evenly divided between the general health and mental health specialty sectors. About five percent receive services from social service sector agencies, schools, religious, or self-help groups.
The organization of specialized mental health services has included a private system and a public system. The private system was comprised of psychiatric hospitals, both free-standing and units located within acute care hospitals, and psychiatrists, psychologists, social workers, and counselors practicing individually or in groups. The public system was made up primarily of state-or county-operated or not-for-profit organizations. The private system served persons with employer-provided health insurance coverage or those who could afford to pay for the services themselves. The public system served persons who were considered medically indigent.
The public and private systems have become more and more defined by reimbursement than by setting or organization. State and local funding provide the majority of financial support for mental health services, with the federal government assuming a growing role. Federal funding includes the Community Mental Health Block Grant, Medicaid (approximately 60 percent federal and 40 percent state or local), plus other specialized funding programs.
Over time, the distinction between private and public clients has become blurred, as it has become increasingly difficult to distinguish public mental health services from those delivered by the private system. The surgeon general suggests that public system services refer both to services directly provided by government agencies (e.g., state or county hospitals) and to those services supported by government resources. Thus, any service supported by Medicaid would be considered a public system service. Such services are increasingly provided by private sector agencies or practitioners. The growth of managed care in the private system has produced interest on the part of states to experiment with managed care models for the public system. As managed care practices evolved within the private sector, limiting scope, duration, and frequency of services, and subsequently limiting or reducing payment, private providers have become more interested in populations and reimbursement sources historically served by the public system (e.g., clients with Medicaid).
SOURCES OF FUNDING
According to the Surgeon General's Report, the period of 1986 through 1996 experienced slower growth in spending for mental health treatment (over 7 percent per year) than general health care expenditures (over 8 percent per year). Medicare, Medicaid, and other federal program spending for mental health services grew more slowly than overall program spending during this same period. A number of reasons for the slower growth rate may be possible, including the influence of managed care cost containment methods on mental health treatment (improving efficiency while increasing the risk of imposing barriers to service access); policy changes at the federal and state level, limiting spending in state hospitals and emphasizing outpatient care delivered in community settings; and increasing service delivery in nonspecialty sectors, such as nursing homes and criminal justice settings (i.e., jails and prisons).
The significance of federal participation has made Medicaid policy, along with state mental health authorities, an increasingly important influence in the delivery of mental health care. Private health care insurance has historically been more limited in its coverage for mental illness than for general health care. Those private insurers that did not simply refuse to cover treatment for mental illness limited coverage for acute care services in particular and other services in general by placing annual and lifetime limits on care and by increasing deductibles and co-payments. The public sector's historical role as the provider of "catastrophic care" for the uninsured and the underinsured provided a means for the private sector to minimize its financial risk and focus on the care of less impaired persons, most of whom had health insurance coverage through their employers. As late as 1988, the model of "unmanaged fee-for-service" was used by the majority of private insurance companies as the payment mechanism. However, in the past decade this model was used by only 15 percent of companies, giving way to managed care arrangements and techniques fundamentally changing the way in which health care resources are allocated.
While managed care may be able to effectively reduce the cost of mental health services, great care must be taken to assure that efforts to contain costs do not have adverse effects. That is, incentives that are part of prepaid contracts can result in inadequate care for those suffering from a mental illness. Particularly at risk are persons with less severe mental health problems, who may be completely denied access to services, and the most seriously mentally ill, who may be undertreated. In addition, private HMOs, because of the limitations on scope, duration, and frequency of services inherent to managed care, routinely refer individuals to public sector agencies who are assessed as inappropriate for time-limited service or upon the exhaustion of benefits for a particular episode of care. This effectively results in cost shifting of substantial expenses to already challenged public budgets. In order to know whether or not access and quality of care can be improved or at least maintained with managed care, development or improvement of the capacity to assess functional improvements is necessary.
Parity in the coverage of mental health care would require all insurance companies to offer the same coverage for mental illness as for all other disorders. Parity legislation along with managed care may actually result in reduced costs; however, the ability to measure access and quality should be integral to any well-designed plan.
ADEQUACY OF MENTAL HEALTH SERVICES
The Surgeon General's Report disclosed that only about one-third of those with a diagnosable mental disorder receive treatment in a one-year period. This is believed to reflect both problems with access and availability of services as well as the problem of the stigma still associated with receiving mental health care. The availability of adequate mental health services throughout the United States is highly variable. Depending on how services are organized and funded, there is marked variation even within a given city, county, or state.
The state of mental health practice clearly lags behind the state of knowledge. A striking example of this is the treatment of schizophrenia, probably the prototype serious mental disorder. The Schizophrenia PORT study in 1998 describes several scientifically proven interventions effective in the treatment of schizophrenia. Yet, when actual practices are examined, few communities adequately provide any of the effective treatments. Even the use of antipsychotic medication was woefully inadequate in the systems studied.
As many states have downsized and closed state hospitals, there has been an infusion of funds from the institutions into community-based programs. However, even in states with a coherent and well-considered plan to shift funding to community sites, the transfer has not been dollar for dollar. In Ohio, for example, with a financing plan where dollars were to follow patients as hospitals were downsized, only approximately fifty cents of every dollar transferred from the hospitals actually made it to the communities.
The effect of inadequately funded and suboptimally delivered mental health services are the shames of deinstitutionalization: co-morbidity, homelessness, and criminalization. Increasing numbers of people with serious mental disorders struggle with substance abuse disorders. Despite estimates that half or more of seriously mentally ill patients have co-morbid substance abuse disorders, few systems of care provide integrated behavioral health treatment for both problems. Only integrated treatment has been shown to be effective.
It is estimated that 30 to 40 percent of the homeless have serious mental disorders (and many more have substance use disorders). A more recent phenomenon is the criminalization of the mentally ill. A report from the U.S. Department of Justice estimated that by mid-1998 there were 283,800 mentally ill offenders in the nation's jails and prisons, representing 16 percent of state prison inmates, 7 percent of federal inmates, and 16 percent of jail inmates. This represents more than four times the number of individuals in the nation's state hospitals. It has been frequently pointed out that the largest institution for the mentally ill in the United States is the Los Angeles County Jail. As this problem has been increasingly recognized by the criminal justice system, creative efforts have begun to move patients back from the criminal justice (punishment) system to the mental health (treatment) system. Diversion programs are being examined in a number of communities around the country. Pre-arrest diversion programs such as the Memphis Crisis Intervention Team facilitate interactions between police officers and the mental health system that make referral for treatment preferable to arrest, especially for nonviolent acts related to symptomatic mental illness. Post-arrest diversion, like the mental health court program started in Broward County, Florida, attempts to use the court therapeutically to persuade mentally ill individuals to accept treatment in lieu of criminal prosecution. While these and other programs show great promise, they are not likely to be successful unless the treatment system to which people are diverted is adequately funded and organized. This is the challenge facing the public mental health system in the new millennium.
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