ANNUAL REVIEWS
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RECENT DEVELOPMENTS IN MENTAL HEALTH: PERSPECTIVES AND SERVICES David Mechanic Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey 08903
KEY WORDS:
deinstitutionalization, community mental health care, schizophrenia, mental health policy, mental illness
Observers of the history of mental health policy note recurrent cycles reflect ing changing perceptions of treatment opportunities and altered willingness to invest public resources. These historical trends are a product of social ideologies, changing public opinion, fiscal conditions, new technologies, and changes in political dialogue. In the
30 years following World War II, major
changes in concepts of mental health and provision of mental health services have been apparent, but the US is again ambivalent. Whether this period is simply one of readjustment in a long-range trend or a major discontinuity and realignment of priorities relevant to community-based systems of mental health care remains unclear. I take as my point of departure developments in the past ten years; however, to put these in perspective, a brief review of long-term mental health trends is helpful.
POST-WORLD WAR II MENTAL HEALTH POLICY
A confluence of social, economic, and technological influences transformed mental health services in the post-World War II period. These already have been reviewed in detail (8,
23, 26), but we need some general observations to
put current public policy in its proper context. Experience in the selective
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service system and in the management of psychiatric casualties during war time impressed policymakers with the magnitude of mental health needs. They saw the requirement for broad approaches that could be responsive without enlarging already overcrowded public hospital systems, which were a burden to the states. Drawing on evolving social conceptions about the nature of mental illness and society, advocates built support for a widely accepted ideology about preventive community intervention and the social manage ment of mental illness. In the 1950s, the introduction of neuroleptic drugs in large mental hospitals helped control the most bizarre manifestations of psychotic illness. The drugs also gave administrators, families, and communities confidence to experiment with new hospital and community arrangements. These arrangements were facilitated further by a strong critique of mental hospitalization and its noxious effects on the coping capacities and social adaptations of patients. Though the ideological conditions were ripe for deinstitutionalization, hospitals found great difficulty in appropriately resettling patients in the community and supporting their subsistence. Deinstitutionalization became more feasible with the broad expansion of social programs in the middle 1960s, which enhanced housing opportunities, medical care, and disability subsistence (22, 23). Large-scale reduction of the number of public mental hospital beds only became possible with these developments, and the rate of deinstitutionaliza tion between 1966 and 1980 was almost five times that of the previous decade (9, 26). In the society at large, the rapid expansion of health insurance (particularly the growth of insured mental health benefits), the commitment of the federal government to support community mental health centers, and the growing acceptance of mental health care among the general public transformed the scope and configuration of the mental health care system. Between 1955 and 1983, the number of mental illness episodes treated in organized mental health settings increased from 1.7 to 7 million. The voluntary general hospital became the central site for acute inpatient psychiatric care. And, the number of public mental hospital beds decreased to 115,000. The locus of care shifted dramatically from inpatient to ambulatory settings, and the mentally ill and demented elderly were relocated to nursing homes that expanded in the mid-1960s, stimulated by Medicare and Medicaid. During the Kennedy and Johnson presidencies, the initiatives for mental health policy shifted to the federal government. The trend away from traditional, involuntary hospitaliza tion and toward community care was reinforced by vigorous legal advocacy that made it more difficult to use state police powers to treat the mentally ill. The momentum that developed in building a community mental health system parallel to and independent of the state programs progressed rapidly into the 1970s, when fiscal constraints and the hostility of the Nixon Adminis-
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tration slowed the momentum of the emerging infrastructure. It also became clear that the new community mental health centers (CMHCs) had attracted many new clients, and the boundaries of mental health care were expanded. However, the CMHCs had substantially neglected the most disadvantaged and seriously mentally ill. During the Carter Administration, the establishment of a Presidential Com mission on mental health and the interests of Rosalyn Carter set the stage for a reexamination of mental health policy and strong advocacy for a range of interested constituencies. The Commission's efforts, however, underscored the conflicting conceptions of mental health and system priorities and the competing viewpoints about the role of government, constituency groups, and mental health services, such as treatment, rehabilitation, or prevention activi ties (6). Moreover, the reality of fiscal constraint was becoming abundantly clear. Not prepared to adjudicate these conflicts, the Commission recom mended something for everyone, with no clear priorities, and served primarily as a platform for mental health advocacy. The tougher task came in passing comprehensive legislation. After much contentiousness and compromise, Congress passed the Mental Health Sys tems Act of 1980, resolving few of the real conceptual difficulties. This legislation supported enhancement of community mental health and pro gramming for the chronically mentally ill. It also supported a variety of other groups (children, the elderly) and functions (prevention, advocacy). Despite its defects, the legislation represented a new federal commitment. Parallel to these efforts, the Department of Health and Human Services put together a useful strategy for identifying and coordinating federal resources and pro grams to design a comprehensive service system for the most critically and chronically ill (36). With the Reagan Administration, and the introduction of a "new federal ism" philosophy, the mental health systems legislation was never imple mented. It was superseded by a program to distribute mental health services funds to states in block grants at reduced expenditure levels. Initiative for mental health policy was returned to the states, and the National Institute of Mental Health (NIMH), stripped of its service and policy functions, became substantially a research funding institute. The Reagan Administration's efforts to reduce the role of federal govern ment and to cut health and welfare programs affected the fate of the seriously mentally ill far more than the reductions in categorical mental health funding and the failure to implement the Systems Act. In the 1980s, the social and welfare programs that made deinstitutionalization possible were substantially reduced (e.g. housing and Social Security Disability Insurance/Supplemental Security Income) or failed to keep pace with the growth of the poverty population (Medicaid). Many chronically ill, who in earlier times would have
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been hospitalized, were in the community. They had neither adequate subsis tence and life supports nor an adequate infrastructure of essential community mental health services. Many persons with serious mental illness became part of the homeless population (13); however, the major cause was the erosion of the safety net, not deinstitutionalization policies. In the total context of efforts to restrain government expenditures and health care costs, reduce the federal deficit, and resist increased taxes, the chronically mentally ill occupied a low position in the nation's priorities. The problems associated with welfare reductions would have been acute in any case, but they are substantially exacerbated by the changing demography of the American population. As the baby boom generations have reached young adulthood, the period of life in which schizophrenia has its highest incidence, the aggregate numbers of seriously mentally ill persons in the community have increased substantially. Similarly, the oldest-old population, the age segment at highest risk of dementia and incapacity, is growing more rapidly than any other subgroup, which places large burdens on long-term care assistance. In the absence of a coherent long-term care policy, Medicaid is by default the nation's long-term care program, and the elderly in nursing homes account for almost half of total Medicaid expenditures. The growing burden of disability, combined with the government's unwillingness to tackle these issues in fear of the potential cost, contributes to the chaos characteriz ing these policy areas. The problems of severe mental illness are compounded by the increasingly prevalent pattern of drug and alcohol abuse, which presents a challenge for conventional mental health services. Patients with dual diagnoses are an increasing proportion of the psychiatric caseload; however, these patients are particularly difficult, and many facilities and programs refuse to treat them. At a broader level, drug abuse and the AIDS epidemic are overloading already strained crisis facilities in some of the nation's largest cities. One serious consequence of these trends is the growing gap between private and public mental health services. The more affluent employed population has attained increased mental health insurance coverage, provided fully or partial ly by employers (2). This expansion in recent decades has encouraged the growth of private psychiatric hospitals and clinics and fee-far-service per sonnel from a variety of professional groups. Similarly, the availability of insurance has motivated nonprofit hospitals to develop specialized psychiatric units and expand their mental health services. In contrast, constrained public budgets, the enlargement of the uninsured population to 35-40 million per sons, and the decreased willingness of the nongovernmental sector to provide indigent care have put extraordinary pressures on public institutions (21). Long-term, chronically ill patients typically become indigent and reliant on the public sector; however, this sector is underfinanced, fragmented, dis organized, and incapable of responding to the magnitude of need.
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As the states have come to play a larger role in financing CMHCs, these centers now more commonly treat the seriously ill and long-term chronic patients. But, as these centers face budgetary difficulties, they substitute other, lower paid professionals for psychiatrists and use the latter in more restrictive roles, such as approving medication. The numbers of psychiatrists
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employed in CMHCs has diminished, and psychiatric responsibility for patient care has eroded substantially in many localities
(5). It is ironic that
even as the community centers have begun to deal with the more seriously disabled, in cases often involving complicated medical co-morbidity, they have had to cut back on the professional staff and other resources needed to treat those very patients.
DIRECTIONS IN MENTAL HEALTH SERVICES RESEARCH With impressive developments in molecular biology, the neurosciences, and imaging technology, psychiatry has moved toward a more biological and medical emphasis. Although these fields hold great promise, efforts must proceed in a balanced way to provide high quality management for those currently ill while seeking more powerful technologies for the future. The history of mental health care attests to how endorsement of organic view points and the professionalization of psychiatry, when it had little specific to offer in any immediate terms, undermined constructive and humane efforts for patient management and rehabilitation (7). Hopefully, we will retain a broad perspective in the management of illness concomitant with the pursuit of increased biological understanding. As psychiatry has moved away from psychoanalytic formulations, which treat diagnosis as a subsidiary task, it has focused attention on more careful classification and differential diagnosis, which contribute to clearer com munication and more specific treatments. The DSM-III, despite lacking a theoretical basis and depending on an arbitrary system of classification, has improved the overall clarity and uniformity of psychiatric practice and re search design. The diagnostic awareness required in using DSM-llI will continue to bring improved research and practice. Like many tools, however, it can be abused when insurers, attorneys, and others treat its arbitrary classifications as realities. There has been an impressive movement in psychiatry away from simple unicausal theories to complex conceptions of multiple causality at all levels of research. As Kety puts it in a discussion of brain processes, " ... we now regard the synapses of the brain as constituting a great orchestra which creates its changing moods by an interplay between the strings, woodwinds, and brasses rather than by a sequence of solo voices" (15). Virtually everyone now regards the etiology of schizophrenia as unknown, a consequence of
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complex but inadequately understood interactions between genetic predisposi tion, brain processes, and psychosocial events. Much of the dogma of earlier periods that interfered with necessary inquiry has been replaced by sophisti cated conceptions of etiology and course, which demonstrate awareness of our limited knowledge. Longitudinal studies of schizophrenia, completed in different countries, have demonstrated that the perception of the condition as one with a course of continuing deterioration and a pessimistic future is exaggerated (10). Long term studies demonstrate a variety of outcomes with many patients either having a single episode or returning to a reasonable level of function after several episodes. Shepherd (32), for example, in one five-year follow-up, classifies patients into four groups: one episode with no impairment (13%); several episodes with little or no impairment (30%); impairment following the first episode associated with occasional exacerbations of symptoms or failure to return to normality (10%); and impairment increasing with each episode (47%). Other studies show improvements in function after as many as 30 to 40 years of illness and disability (1). It is not clear why clinicians have commonly perceived schizophrenia as a hopeless condition. One hypothesis is that they are influenced less by the epidemiological picture than by the subset of schizophrenic patients who are treatment failures. These patients return to clinical care repeatedly over the years and show successive increments of deterioration. They are the basis for the exaggerated pessimism that forms much of professional opinion. Some clinicians dismiss the recurrent observations on the more favorable course of the condition by maintaining that patients who have a single episode are not schizophrenic. In some centers, a diagnosis is not made until there are repeated episodes, which results in a classification system that makes an unfavorable prognosis a criterion for diagnosis. The sampling and classifica tion issues are central to understanding prognosis, but a World Health Organ ization (WHO) collaborative study (39) suggests that the results of recent longitudinal studies cannot be explained simply on this basis. In the late 1960s, the WHO, using a standardized diagnostic approach, carried out a collaborative study of 1202 schizophrenia patients in nine countries (39). One of the remarkable findings was a less favorable prognosis in developed as compared with developing nations. Some observers explained these differences in terms of family and social networks, labeling processes, and processes of inclusion and exclusion of the disabled; others were more skeptical and argued that patients from varying nations were not comparable. Thus, in a second study (30), efforts were made to obtain representative samples of new schizophrenic patients in ten countries. Sartorius et al moni tored defined populations over a two-year period to identify first contact with a helping agency because of psychotic symptoms, and they carefully identi-
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fied patients in different cultures by the same criteria. Subsequent analysis showed that the symptom profiles of schizophrenic patients in varying sam ples were similar. Again, the investigators found that the two-year pattern of schizophrenia was more favorable in developing countries. In such countries, 56% of schizophrenic patients had a mild course over the two-year period, whereas only 39% in the developed nations had comparable outcomes. The reasons for this remain highly speculative. For those involved with community care for chronic schizophrenic patients, these results are not particularly surprising. Many of the disabilities associated with long-term illness can be contained by good community management. In a recent review, Kiesler & Sibulkin (16) identify 14 experimental studies, most with random assignment, that compare community care with hospital treatment. They find such alternatives to be more effective than hospitaliza tion across a wide range of patient populations and treatment strategies. Perhaps best known of these alternatives is Stein & Test's "Training in Community Living" model, which combines aggressive psychiatric commu nity care with case-management and psychosocial skills training (34). In the 1970s, this model was demonstrated to be highly effective in Dane County, Wisconsin, the location of the major state university. Although replicated either totally or partially in a variety of communities, skepticism persisted as to whether the Dane County model could be translated to larger, more complex urban communities. In 1979-1981, the model was replicated in a randomized experimental trial in Sydney, Australia, with comparably good results (28). Particularly significant was that the approach was highly successful and favored by patients and their families over hospital care, despite the patients being maintained with a much lower level of staff intensity than in Dane County. The optimal and most cost-effective level of staffing for such programs is still uncertain. It is likely to depend on the array of community resources already in place, the mix of patients, and the com plexity of the community. Many of the newly developed community care programs have been pragmatic and oriented to patients' basic needs for medical and psychiatric care, subsistence and housing, basic living skills, and social support. Much more emphasis is given to working with other patient caretakers, by teaching them about mental illness and helping them cope with its uncertainties and burdens. From a theoretical perspective, the work on expressed emotion in families has helped focus some of the most impressive community care trials and has provided a more useful basis for working with families than un structured therapies have had in the past (18). Given the success of some community programs, why have they not diffused more widely over the past decade? The structure of financing and the lack of incentives are most commonly cited and are certainly of importance.
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"Training in Community Living" has prospered in part because mental health financing in Wisconsin allows local programs to use savings from reduced hospital admissions to support their base. The state system of financing allows dollars to "follow the patient" and gives local program personnel the opportu nity to balance community care against hospital care (33). That most counties in Wisconsin, despite its financing system and unique history of county mental health services, lack the programs so highly regarded in Dane County suggests that financing incentives are only a part of a more complex constella tion. If providing counties with the funds and authority for decision-making is so crucial, why is the California system in such major disarray? In 1985, Wisconsin expended less per capita on its mental health agencies than the US average and only ranked in the middle among states (27); yet it seems to have maintained a reasonably high standard of care. Financing provides the framework, but the success of community care also depends on professional leadership, interagency communication and coopera tion, and a supportive community environment. There are no substantial professional rewards for community care efforts, and managing the care of schizophrenic patients brings neither high income nor prestige among one's colleagues. In addition, there is great potential for blame when patients get into trouble. For many professionals, resistance and inertia is a comfortable stance. Few professional schools, whether of psychology, social work, or nursing, specifically train students to work with. the chronically ill; thus, special burdens are placed on innovative programs for on-the-job training. An advan tage of the longevity of the Dane County program is its accessibility to mental health professional students who learn to feel comfortable with this model of care. Over time, the effective institutionalization of community care depends on its effective integration with professional training and recruitment. THE CHANGING LEGAL CONTEXT OF MENTAL HEALTH CARE
Since the late 1960s public interest lawyers socialized in the civil rights movement directed their energies to the mental health arena, particularly to civil commitment procedures. Efforts were also made on many other fronts, such as "right to treatment" and "right to refuse treatment." Mental health lawyers had great expectations about the potentials of legal reform. In retro spect, despite significant gains in extending mental patients' rights and pro tections, the hope that litigation could fundamentally shape the system of community services seems naive. By directing attention to particular de ficiencies, legal advocates could induce service improvement, but often at the cost of neglecting other problems or discharging patients from the protection of service systems. The strategy behind much of the litigation was premised
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on the use of coercive powers by the state; thus, the remedies did not apply to those in noncoercive settings. More recently, legal efforts have been made in some jurisdictions to require government to provide an acceptable minimum of care, but the degree to which courts can direct state allocation of funds among competing priorities remains unclear. Despite the attention given to civil commitment, great dissatisfaction and divisiveness remain. To many mental health professionals, the law has gone too far in protecting the freedoms of persons at high risk who are incapable of making reasonable judgments about their needs. Others, however, resist any erosion of hard-won liberty interests. There is great heat but not much useful dialogue between these two groups. Although much acrimony is focused on commitment procedures, the key issue is the integrity and responsiveness of community care services. Many states are now experimenting with outpatient commitment, a less restrictive intervention than traditional civil commitment. Such commitments provide a mechanism to deal with the persistent failure to maintain essential drug treatment and the subsequent relapse within a less restrictive approach than coercive hospitalization. Studies in North Carolina indicate that the success of outpatient commitment depends on the responsiveness of the community mental health services system and the willingness to cooperate with the courts (12). When the services system and the courts work together, outpatient commitment appears to manage many troublesome problems. There is dis illusionment and frustration with commitment statutes. It is increasingly difficult to provide treatment to uncooperative and psychotic patients who are not imminently dangerous. These problems and the increasing demands for more extensive involuntary hospitalization make exploration of such mech anisms as outpatient commitment particularly prudent (3). THE RESEARCH ARENA
While research in mental health focuses on biology and the neurosciences, the desperate need for deeper knowledge of population, organizational, and behavioral factors and the functioning of mental health services systems continues. Research in the brain sciences is more dramatic, but we have made some significant gains in these other research areas, as well. In the past ten years, we have learned a great deal about the successful application of methods of behavior control and ways to manage illness to reduce disability. We have also seen advances in epidemiology and health services research, as the following examples illustrate. Fifteen years ago, psychiatric epidemiology was in the doldrums. A large gap existed between psychiatric conditions as measured in community epidemiological studies and clinical psychiatric practice. With the develop-
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ment of the Diagnostic Interview Survey (DIS) based on DSM-I1I criteria, the gap was substantially closed, and the Epidemiological Catchment Area Pro gram gave new vitality to epidemiological questions (4). Although many questions remain about the validity and applicability of the DIS to clinical efforts, it is a flexible instrument, allowing a wide range of investigatory approaches, that helps explore a broad range of substantive and methodolog ical concerns. With the encouragement of the NIMH, mental health services research has also advanced with increasing sophistication in organization and financing (35a). Some of the experimental work on models of care for the severely ill and on expressed emotion have already been noted, but such work as the RAND Health Insurance Experiment (HIE) also merits special attention. This controlled trial randomized 6970 respondents into insurance plans with vary ing coinsurance requirements, including one setting at Group Health In surance in Seattle, a health maintenance organization (HMO) (29). This experiment has been a fund of information for health services research in general. It has also substantially contributed to our understanding of how insurance and health care organization affect the provision of mental health services. A few findings will be illustrative. Cost-sharing has important effects on the use of general ambulatory care, but even larger effects on mental health services. In the HIE there was a fourfold variation between extreme coinsurance groups. Those with 50% coinsurance and no limits on cost-sharing spent two fifths as much as those who were not required to share costs (14). Coinsurance primarily affected the number of episodes of treatment, but once a person entered care the duration and intensity varied less. The experiment made it possible to study how patients randomized to prepaid care used services differently than those in plans with no coinsurance, an equivalent group in terms of out-of-pocket expenditure risk. Prepaid enrollees actually used more mental health services, but they were provided much less intensively. Patients with prepaid insurance were more likely to receive services from a general medical provider, and overall mental health expenditures were only one third that of the comparable group with no coinsurance. When prepaid enrollees saw a mental health provider, they had only one third the number of mental health visits as patients in the general fee-for-service sector. The HMO relied more on social workers than on psychiatrists or psychologists and less on individual than on group or family therapies (19, 20). Most patients who receive formal care for psychiatric disorders are man aged exclusively by general physicians, typically within the context of overall medical care (31). The most severely and persistently mentally ill eventually enter specialty care, but a large proportion of patients with all diagnoses do
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not. These patients commonly receive no treatment at all (17). Affective disorders are most prevalent, but at least half are probably not recognized in general medical practice (37). Such conditions, however, are extremely distressing and disabling. The Medical Outcomes Study, involving more than 11 ,000 patients in varying outpatient settings, found that patients with a diagnosis of clinical depression, or depressive symptoms short of a clinical diagnosis, were equally or more disabled than patients with such major chronic conditions as gastrointestinal problems, diabetes, back problems, and angina. Only the patients with advanced coronary artery disease were more disabled. Depressed patients had the worst social and role functioning and had more days in bed than any group except the coronary artery disease group (38). THE IMPORTANCE OF MENTAL HEALTH ADVOCACY
Mental health care has been transformed substantially in recent decades, and the availability and acceptability of services have grown. But with constraints on public funding, the gap has widened between insured persons and the uninsured or underinsured groups, which include the majority of long-term patients with persistent disabilities. In some sense, those who were traditional clients of public institutions may be worse off than ever before. They lost the refuge of the mental hospital, but are also excluded from the richness of community service options that have been developed for the insured. The process of defining health needs is largely political, a product of interest group activity. The ability to draw attention to need, and evoke sympathy for patients and their families, depends substantially on the mobilization and skill of advocacy groups. Traditionally, mental health advocacy has been weak for a variety of reasons. With mental health almost exclusively a public responsibility of the individual states, it has been difficult to form a strong national constituency. Moreover, the severely mentally ill have neither the personal resources nor the credibility to compete successfully with other disease constituencies. Their families often avoid public identifica tion because of stigma, which limits vigorous public participation. Although powerful advocates occasionally came forward, as in the case of Dorothea Dix, Clifford Beers, and Mike Gorman, and later those associated with the growing mental health professions and the establishment of the NIMH, there has never been the kind of sustained advocacy characteristic of other health lobbies. Mental health advocacy has also been crippled by bitter contentiousness. Advocates are highly fragmented and encourage competing and conflicting agendas: the severely mentally ill versus mental health education and pre vention; children versus adults; mental illness versus developmental dis-
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abilities; civil liberties versus tougher commitment laws; community care versus revitalizing public hospitals; social work versus psychology; psycholo gy versus psychiatry; biological psychiatry versus social psychiatry; drugs versus psychotherapy, and so on. Many of the controversies are important and relate to core issues of care, but the internal bickering among consumers and professionals has diminished effective advocacy. As a consequence, the sector has great difficulty setting priorities as evidenced by the products of the Carter Presidential Commission, the controversies over the Mental Health Systems Act, and the failures to understand the importance of mental health categorical issues relative to larger health policy issues that affect the mentally ill. Mental health advocates have too frequently misdirected their main efforts. They confuse symbolic issues with the health policy initiatives that shape the mental health sector. More forceful advocacy, which holds real promise for elevating mental health interests, has recently emerged. The establishment and rapid growth of the National Alliance for the Mentally III has mobilized a large and potentially effective lobby at the local, state, and federal levels (11). The challenge facing the Alliance, which incorporates conflicting viewpoints, is to develop its data acquisition, policy strategies, and political skills and more astutely bring competing perspectives together. Through the Alliance and other groups, former mental patients and their families now come forward publicly to address relevant issues. Such participation by visible and influential figures is increasingly common. Increased influence could come by orchestrating these efforts relative to the media and the policy formulation process. Efforts are also now being made to develop coalitions among competing mental health interests. A visible coalition has not emerged at the national level, but local advocacy groups representing consumers, professional groups, and mental health organizations are beginning to appreciate the value of a united front. An agenda that satisfies diverse organizations is not easy to build, but it is essential if the sector is to have equal access to the policy process. CONCLUSION Compared with previous decades, the past decade has been characterized by less rhetoric. We have seen greater appreciation of the tough realities of providing effective community care to seriously mentally ill persons. We understand better the complexities of finance and organization of service arrangements and their interconnections with housing, welfare, and medical and legal arrangements. Research technologies have advanced significantly, which promises major potential for the future. The nation has a vast pool of mental health professionals and facilities that can form the basis of a highly
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effective mental health care system. Mental health advocacy is also more sophisticated and active than ever before. Despite these gains, all is not well in mental health services. The promises of deinstitutionalization are largely unfulfilled, and the neglected condition of many seriously mentally ill persons in the community has contributed to a bitter backlash. The public sector and public welfare, on which many of these patients depend, have suffered significant erosion, and public sector delivery systems are in considerable disarray. Problems are exacerbated by the in creased population of seriously mentally ill, a consequence of the changing demography of the American population. Moreover, the federal deficit and the pressures on public budgets make it particularly difficult to attract signifi cant new public monies for services. Although public mental health services are significantly underfunded, present resources are substantial. These resources could be used more effec tively by correcting the fragmentation, duplication, and disorganization of the services system and establishing clear priorities focused on the seriously and persistently mentally ill (13a, 35). Building an integrated system requires new financing and organizational strategies, such as continuous team case management arrangements, the development of strong local mental health authorities, and mental health HMOs organized around capitation arrange ments (24-26). The crisis in mental health care is substantially affected by the lack of insurance and the erosion of welfare for the most seriously and persistently mentally ill, and many of these patients cannot get the necessary services. They are homeless, in part, because of the dearth of housing programs in the 1980s and the loss of low income housing stock. Any long-term solution will be a product of health and welfare policy and some reasonable response to the large un- or underinsured population. It is a sad commentary that a nation that spends more than a half trillion dollars on health each year and has such rich resources of manpower and facilities cannot do better for its most needy and disadvantaged citizens. Literature Cited 1. Bleuler, M. 1978. The Schizophrenic Disorders: Long·Term Patient and Family Studies. Trans!. S. M. Clemens. New Haven: Yale Univ. Press 2. Brady, J., Sharfstein, S. S., Muszynski, I. L. Jr. 1986. Trends in private in surance coverage for mental illness. Am. 1. Psychiatry 143:1276--79 3. Brooks, A. D. 1987. Outpatient com mitment for the chronic mentally ill: Law and policy. See Ref. 23a, pp. 11728
4. Eaton, W. W., Kessler, L. G., eds. 1985. Epidemiologic Field Methods in Psychiatry: The NIMH Epidemiologic Catchment Area Program. Orlando, Fla: Academic 5. Faulkner, L. R., Bloom, J. D., Bray, J. D . , Maricle, R. 1986. Medical services in community mental health programs. Hasp. Community Psychiatry 37:104547 6. Foley, H. A., Sharfstein, S. 1983. Mad ness and Government: Who Cares for
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the Mentally Ill? Washington, DC: Am. Psychiatr. Press 7. Grob, G. N. 1966. The State and the Mentally Ill: A History of Worcester State Hospital in Massachusetts. 18301920. Chapel Hill: Univ. North Carolina Press 8. Grob, G. N. 1987. Mental health policy in IX>st World War II America. See Ref. 23a, pp. IS-32 9. Gronfein, W. 1985. Incentives and in tentions in mental health policy: A com parison of the medicaid and community mental health programs. J. Health Soc. Behav. 26:192-206 10. Harding, C. M. , Zubin, J. , Strauss, J. S. 1987. Chronicity in schizophrenia: Fact, partial facts or artifact? Hosp. Communi ty Psychiatry 38:477-86 II. Hatfield, A. , ed. 1987. Families of the Mentally Ill: Meeting the Ch alle nges. New Dir. Ment. Health Servo No. 34. San Francisco: Jossey-Bass 12. Hiday, V., Scheid-Cook, T. 1986. The North Carolina experience with out patient commitment: a critical apprais al. Presented at Int. Congr. Law Psychi atry, Montreal 13. Inst. Medicine. 1988. Homelessness. Health and Human Needs. Washington, DC: Natl. Acad. Press 13a. Johnson, A. B. 1990. Out of Bedlam: The Truth About Deinstitutionalization. New York: Basic Books 14. Keeler, E. B., Wells, K. B. , Manning, W. G., Rumpel, J. D., Hanley, J. M. 1986. The Demand/or Episodes of Men tal Health Services (R-3432-NIMH). Santa Monica, Calif: RAND Corp. IS. Kety, S. 1986. The interface between neuroscience and psychiatry. In Psychi atry and Its Related Disciplines. ed. R. Rosenberg, F. Schulsinger, E. Strom gren, p. 23. Cophenhagen: World Psy chiatr. Assoc. 16. Kiesler, C. A., Sibulkin, A. E. 1987. Mental Hospitalization: Myths and Facts About a National Crisis. Newbury Park, Calif: Sage 17. Leaf, P. J. , Livingston, M. M., Tis chler, G. L., Weissman, M. M. , Holzer, C. E. , Myers, J. K. 1985. Contact with health professionals for the treatment of psychiatric and emotional problems. Med. Care 23:1302-37 18. Leff, J. , Vaughn, C. 1985. Expressed Emotion in Families. New York: Guil ford 19. Manning, W. G. , Wells, K. B. 1986. Preliminary results of a controlled trial of the effect of a prepaid group practice on the outpatient use of mental health services. J. Hum. Resour. 21:293-320
20. Manning, W. G. , Wells, K. B. , Ben jamin, B. 1986. Use oj Outpatient Men tal Health Care: Trial oj a Prepaid Group Practice Versus Fee-For-Service (R-3277-NIMH). Santa Monica, Calif: RAND Corp. 21. Mechanic, D. 1986. From Advocacy to Allocation: The Evolving American Health Care System. New York: Free Press 22. Mechanic, D. 1987. Correcting mis conceptions in mental health policy: Strategies for improved care of the seriously mentally ill. Milbank Fund Q. 6S:203-30 23. Mechanic, D. 1989. Mental Health and Social Policy. Englewood Cliffs, NJ: Prentice-Hall. 3rd ed. 23a. Mechanic, D., ed. 1987. Improving Mental Health Services: What the Social Sciences Can Tell Us. New DiL Ment. Health Servo No. 36 (Winter): 117-28. San Francisco: Jossey-Bass 24. Mechanic, D. , Aiken, L. 1987. Improv ing the care of patients with chronic mental illness. N. Eng!. J. Med. 317:1634-38 25. Mechanic, D. , Aiken, L., eds. 1989. Paying for Services: Promises and Pit falls of Capitation. New Directions Ser. 43. San Francisco: Jossey-Bass 26. Mechanic, D. , Rochefort, D. A. 1990. Deinstitutionalization: An appraisal of reform. Annu. Rev. Sociol. 16:30127 27. Natl. Inst. Mental Health. 1987. Mental Health, United States. 1987, ed. R. W. Manderscheid, S. A. Barrett. DHHS Pub!. No. (ADM) 87-1518. Washing ton, DC: GPO 28. New South Wales, Dep. Health. 1983. Psychiatric Hospital Versus Community Treatment: A Controlled Study. (HSR 83-046), Sydney, Australia 29. Newhouse, J. 1974. A design for a health insurance experiment. Inquiry II:S-27 30. Sartorius, N. , Jablensky, A. , Korten, A., Eroberg, A , Anker, M. , et al. 1986. Early manifestations and first contact incidence of schizophrenia in different cultures. Psychol. Med. 16: 909--28 31. Shapiro, S., Skinner, E. A., Kramer, M. , Steinwachs, D. M. , Regier, D. A. 1985. Measuring need for mental health services in a general population. Med. Care 23: 1033-43 32. Shepherd, M. 1987. Formulation of new research strategies on schizophrenia. In Search/or the Causes of Schizophrenia. ed. H. Hafner, W. F. Gattaz, W. Janzar ik, pp. 29--38. Berlin: Springer-Verlag .
DEVELOPMENTS IN MENTAL HEALTH 33. Stein, L. I., Ganser, L. J. 1983. Wis consin system for funding mental health services. In New Directions for Mental Health Services: Unified Mental Health System, ed. J. Talbott, pp. 25-32. San Francisco: Jossey-Bass 34. S tein L. I., Test M. A., eds. 1985. The Training in Community Living Model: A Decade of Experience. New Dir. Ment. Health Servo No. 26. San Francisco: Jossey-Bass 35. Torrey, E. F. 1988. Nowhere to Go: The Tragic Odyssey of the Homeless Mental ly Ill. New York: Harper & Row 35a. Taube, C. A., Mechanic, D., Hohmann, A. A., eds. 1989. The Future of Mental Health Services Research. DHHS Publ. No. (ADM) 89-1600. Washington, DC: US Print. Off.
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36. US DHHS. 1980. Toward a National Plan for the Chronically Mentally Ill, Report to the Secretary-J980. Pub\. No. ADM 81-1077. Rockville, Md: DHHS 37. Wells, K. B. 1985. Depression as a tra cer condition for the national study of medical care outcomes: Background re view. 3293-RWJ-HJK RAND Corp. Santa Monica, Calif: RAND Corp. 38. Wells, K. B., Stewart, A., Hays, R. D., Burnam, M. A., Rogers, W., et al. 1989. The functioning and well -being of depressed patients: Results from the medical outcomes study. J. Am. Med. Assoc. 262:914-19 39. WHO. 1979. Schizophrenia: An In ternational Follow-up Study. Geneva, NY: Wiley
Further
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Copyright
© 1991 by
Annual Reviews 1nc. All rights reserved
RECENT DEVELOPMENTS IN MENTAL HEALTH: PERSPECTIVES AND SERVICES David Mechanic Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey 08903
KEY WORDS:
deinstitutionalization, community mental health care, schizophrenia, mental health policy, mental illness
Observers of the history of mental health policy note recurrent cycles reflect ing changing perceptions of treatment opportunities and altered willingness to invest public resources. These historical trends are a product of social ideologies, changing public opinion, fiscal conditions, new technologies, and changes in political dialogue. In the
30 years following World War II, major
changes in concepts of mental health and provision of mental health services have been apparent, but the US is again ambivalent. Whether this period is simply one of readjustment in a long-range trend or a major discontinuity and realignment of priorities relevant to community-based systems of mental health care remains unclear. I take as my point of departure developments in the past ten years; however, to put these in perspective, a brief review of long-term mental health trends is helpful.
POST-WORLD WAR II MENTAL HEALTH POLICY
A confluence of social, economic, and technological influences transformed mental health services in the post-World War II period. These already have been reviewed in detail (8,
23, 26), but we need some general observations to
put current public policy in its proper context. Experience in the selective
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service system and in the management of psychiatric casualties during war time impressed policymakers with the magnitude of mental health needs. They saw the requirement for broad approaches that could be responsive without enlarging already overcrowded public hospital systems, which were a burden to the states. Drawing on evolving social conceptions about the nature of mental illness and society, advocates built support for a widely accepted ideology about preventive community intervention and the social manage ment of mental illness. In the 1950s, the introduction of neuroleptic drugs in large mental hospitals helped control the most bizarre manifestations of psychotic illness. The drugs also gave administrators, families, and communities confidence to experiment with new hospital and community arrangements. These arrangements were facilitated further by a strong critique of mental hospitalization and its noxious effects on the coping capacities and social adaptations of patients. Though the ideological conditions were ripe for deinstitutionalization, hospitals found great difficulty in appropriately resettling patients in the community and supporting their subsistence. Deinstitutionalization became more feasible with the broad expansion of social programs in the middle 1960s, which enhanced housing opportunities, medical care, and disability subsistence (22, 23). Large-scale reduction of the number of public mental hospital beds only became possible with these developments, and the rate of deinstitutionaliza tion between 1966 and 1980 was almost five times that of the previous decade (9, 26). In the society at large, the rapid expansion of health insurance (particularly the growth of insured mental health benefits), the commitment of the federal government to support community mental health centers, and the growing acceptance of mental health care among the general public transformed the scope and configuration of the mental health care system. Between 1955 and 1983, the number of mental illness episodes treated in organized mental health settings increased from 1.7 to 7 million. The voluntary general hospital became the central site for acute inpatient psychiatric care. And, the number of public mental hospital beds decreased to 115,000. The locus of care shifted dramatically from inpatient to ambulatory settings, and the mentally ill and demented elderly were relocated to nursing homes that expanded in the mid-1960s, stimulated by Medicare and Medicaid. During the Kennedy and Johnson presidencies, the initiatives for mental health policy shifted to the federal government. The trend away from traditional, involuntary hospitaliza tion and toward community care was reinforced by vigorous legal advocacy that made it more difficult to use state police powers to treat the mentally ill. The momentum that developed in building a community mental health system parallel to and independent of the state programs progressed rapidly into the 1970s, when fiscal constraints and the hostility of the Nixon Adminis-
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tration slowed the momentum of the emerging infrastructure. It also became clear that the new community mental health centers (CMHCs) had attracted many new clients, and the boundaries of mental health care were expanded. However, the CMHCs had substantially neglected the most disadvantaged and seriously mentally ill. During the Carter Administration, the establishment of a Presidential Com mission on mental health and the interests of Rosalyn Carter set the stage for a reexamination of mental health policy and strong advocacy for a range of interested constituencies. The Commission's efforts, however, underscored the conflicting conceptions of mental health and system priorities and the competing viewpoints about the role of government, constituency groups, and mental health services, such as treatment, rehabilitation, or prevention activi ties (6). Moreover, the reality of fiscal constraint was becoming abundantly clear. Not prepared to adjudicate these conflicts, the Commission recom mended something for everyone, with no clear priorities, and served primarily as a platform for mental health advocacy. The tougher task came in passing comprehensive legislation. After much contentiousness and compromise, Congress passed the Mental Health Sys tems Act of 1980, resolving few of the real conceptual difficulties. This legislation supported enhancement of community mental health and pro gramming for the chronically mentally ill. It also supported a variety of other groups (children, the elderly) and functions (prevention, advocacy). Despite its defects, the legislation represented a new federal commitment. Parallel to these efforts, the Department of Health and Human Services put together a useful strategy for identifying and coordinating federal resources and pro grams to design a comprehensive service system for the most critically and chronically ill (36). With the Reagan Administration, and the introduction of a "new federal ism" philosophy, the mental health systems legislation was never imple mented. It was superseded by a program to distribute mental health services funds to states in block grants at reduced expenditure levels. Initiative for mental health policy was returned to the states, and the National Institute of Mental Health (NIMH), stripped of its service and policy functions, became substantially a research funding institute. The Reagan Administration's efforts to reduce the role of federal govern ment and to cut health and welfare programs affected the fate of the seriously mentally ill far more than the reductions in categorical mental health funding and the failure to implement the Systems Act. In the 1980s, the social and welfare programs that made deinstitutionalization possible were substantially reduced (e.g. housing and Social Security Disability Insurance/Supplemental Security Income) or failed to keep pace with the growth of the poverty population (Medicaid). Many chronically ill, who in earlier times would have
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been hospitalized, were in the community. They had neither adequate subsis tence and life supports nor an adequate infrastructure of essential community mental health services. Many persons with serious mental illness became part of the homeless population (13); however, the major cause was the erosion of the safety net, not deinstitutionalization policies. In the total context of efforts to restrain government expenditures and health care costs, reduce the federal deficit, and resist increased taxes, the chronically mentally ill occupied a low position in the nation's priorities. The problems associated with welfare reductions would have been acute in any case, but they are substantially exacerbated by the changing demography of the American population. As the baby boom generations have reached young adulthood, the period of life in which schizophrenia has its highest incidence, the aggregate numbers of seriously mentally ill persons in the community have increased substantially. Similarly, the oldest-old population, the age segment at highest risk of dementia and incapacity, is growing more rapidly than any other subgroup, which places large burdens on long-term care assistance. In the absence of a coherent long-term care policy, Medicaid is by default the nation's long-term care program, and the elderly in nursing homes account for almost half of total Medicaid expenditures. The growing burden of disability, combined with the government's unwillingness to tackle these issues in fear of the potential cost, contributes to the chaos characteriz ing these policy areas. The problems of severe mental illness are compounded by the increasingly prevalent pattern of drug and alcohol abuse, which presents a challenge for conventional mental health services. Patients with dual diagnoses are an increasing proportion of the psychiatric caseload; however, these patients are particularly difficult, and many facilities and programs refuse to treat them. At a broader level, drug abuse and the AIDS epidemic are overloading already strained crisis facilities in some of the nation's largest cities. One serious consequence of these trends is the growing gap between private and public mental health services. The more affluent employed population has attained increased mental health insurance coverage, provided fully or partial ly by employers (2). This expansion in recent decades has encouraged the growth of private psychiatric hospitals and clinics and fee-far-service per sonnel from a variety of professional groups. Similarly, the availability of insurance has motivated nonprofit hospitals to develop specialized psychiatric units and expand their mental health services. In contrast, constrained public budgets, the enlargement of the uninsured population to 35-40 million per sons, and the decreased willingness of the nongovernmental sector to provide indigent care have put extraordinary pressures on public institutions (21). Long-term, chronically ill patients typically become indigent and reliant on the public sector; however, this sector is underfinanced, fragmented, dis organized, and incapable of responding to the magnitude of need.
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As the states have come to play a larger role in financing CMHCs, these centers now more commonly treat the seriously ill and long-term chronic patients. But, as these centers face budgetary difficulties, they substitute other, lower paid professionals for psychiatrists and use the latter in more restrictive roles, such as approving medication. The numbers of psychiatrists
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employed in CMHCs has diminished, and psychiatric responsibility for patient care has eroded substantially in many localities
(5). It is ironic that
even as the community centers have begun to deal with the more seriously disabled, in cases often involving complicated medical co-morbidity, they have had to cut back on the professional staff and other resources needed to treat those very patients.
DIRECTIONS IN MENTAL HEALTH SERVICES RESEARCH With impressive developments in molecular biology, the neurosciences, and imaging technology, psychiatry has moved toward a more biological and medical emphasis. Although these fields hold great promise, efforts must proceed in a balanced way to provide high quality management for those currently ill while seeking more powerful technologies for the future. The history of mental health care attests to how endorsement of organic view points and the professionalization of psychiatry, when it had little specific to offer in any immediate terms, undermined constructive and humane efforts for patient management and rehabilitation (7). Hopefully, we will retain a broad perspective in the management of illness concomitant with the pursuit of increased biological understanding. As psychiatry has moved away from psychoanalytic formulations, which treat diagnosis as a subsidiary task, it has focused attention on more careful classification and differential diagnosis, which contribute to clearer com munication and more specific treatments. The DSM-III, despite lacking a theoretical basis and depending on an arbitrary system of classification, has improved the overall clarity and uniformity of psychiatric practice and re search design. The diagnostic awareness required in using DSM-llI will continue to bring improved research and practice. Like many tools, however, it can be abused when insurers, attorneys, and others treat its arbitrary classifications as realities. There has been an impressive movement in psychiatry away from simple unicausal theories to complex conceptions of multiple causality at all levels of research. As Kety puts it in a discussion of brain processes, " ... we now regard the synapses of the brain as constituting a great orchestra which creates its changing moods by an interplay between the strings, woodwinds, and brasses rather than by a sequence of solo voices" (15). Virtually everyone now regards the etiology of schizophrenia as unknown, a consequence of
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complex but inadequately understood interactions between genetic predisposi tion, brain processes, and psychosocial events. Much of the dogma of earlier periods that interfered with necessary inquiry has been replaced by sophisti cated conceptions of etiology and course, which demonstrate awareness of our limited knowledge. Longitudinal studies of schizophrenia, completed in different countries, have demonstrated that the perception of the condition as one with a course of continuing deterioration and a pessimistic future is exaggerated (10). Long term studies demonstrate a variety of outcomes with many patients either having a single episode or returning to a reasonable level of function after several episodes. Shepherd (32), for example, in one five-year follow-up, classifies patients into four groups: one episode with no impairment (13%); several episodes with little or no impairment (30%); impairment following the first episode associated with occasional exacerbations of symptoms or failure to return to normality (10%); and impairment increasing with each episode (47%). Other studies show improvements in function after as many as 30 to 40 years of illness and disability (1). It is not clear why clinicians have commonly perceived schizophrenia as a hopeless condition. One hypothesis is that they are influenced less by the epidemiological picture than by the subset of schizophrenic patients who are treatment failures. These patients return to clinical care repeatedly over the years and show successive increments of deterioration. They are the basis for the exaggerated pessimism that forms much of professional opinion. Some clinicians dismiss the recurrent observations on the more favorable course of the condition by maintaining that patients who have a single episode are not schizophrenic. In some centers, a diagnosis is not made until there are repeated episodes, which results in a classification system that makes an unfavorable prognosis a criterion for diagnosis. The sampling and classifica tion issues are central to understanding prognosis, but a World Health Organ ization (WHO) collaborative study (39) suggests that the results of recent longitudinal studies cannot be explained simply on this basis. In the late 1960s, the WHO, using a standardized diagnostic approach, carried out a collaborative study of 1202 schizophrenia patients in nine countries (39). One of the remarkable findings was a less favorable prognosis in developed as compared with developing nations. Some observers explained these differences in terms of family and social networks, labeling processes, and processes of inclusion and exclusion of the disabled; others were more skeptical and argued that patients from varying nations were not comparable. Thus, in a second study (30), efforts were made to obtain representative samples of new schizophrenic patients in ten countries. Sartorius et al moni tored defined populations over a two-year period to identify first contact with a helping agency because of psychotic symptoms, and they carefully identi-
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fied patients in different cultures by the same criteria. Subsequent analysis showed that the symptom profiles of schizophrenic patients in varying sam ples were similar. Again, the investigators found that the two-year pattern of schizophrenia was more favorable in developing countries. In such countries, 56% of schizophrenic patients had a mild course over the two-year period, whereas only 39% in the developed nations had comparable outcomes. The reasons for this remain highly speculative. For those involved with community care for chronic schizophrenic patients, these results are not particularly surprising. Many of the disabilities associated with long-term illness can be contained by good community management. In a recent review, Kiesler & Sibulkin (16) identify 14 experimental studies, most with random assignment, that compare community care with hospital treatment. They find such alternatives to be more effective than hospitaliza tion across a wide range of patient populations and treatment strategies. Perhaps best known of these alternatives is Stein & Test's "Training in Community Living" model, which combines aggressive psychiatric commu nity care with case-management and psychosocial skills training (34). In the 1970s, this model was demonstrated to be highly effective in Dane County, Wisconsin, the location of the major state university. Although replicated either totally or partially in a variety of communities, skepticism persisted as to whether the Dane County model could be translated to larger, more complex urban communities. In 1979-1981, the model was replicated in a randomized experimental trial in Sydney, Australia, with comparably good results (28). Particularly significant was that the approach was highly successful and favored by patients and their families over hospital care, despite the patients being maintained with a much lower level of staff intensity than in Dane County. The optimal and most cost-effective level of staffing for such programs is still uncertain. It is likely to depend on the array of community resources already in place, the mix of patients, and the com plexity of the community. Many of the newly developed community care programs have been pragmatic and oriented to patients' basic needs for medical and psychiatric care, subsistence and housing, basic living skills, and social support. Much more emphasis is given to working with other patient caretakers, by teaching them about mental illness and helping them cope with its uncertainties and burdens. From a theoretical perspective, the work on expressed emotion in families has helped focus some of the most impressive community care trials and has provided a more useful basis for working with families than un structured therapies have had in the past (18). Given the success of some community programs, why have they not diffused more widely over the past decade? The structure of financing and the lack of incentives are most commonly cited and are certainly of importance.
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"Training in Community Living" has prospered in part because mental health financing in Wisconsin allows local programs to use savings from reduced hospital admissions to support their base. The state system of financing allows dollars to "follow the patient" and gives local program personnel the opportu nity to balance community care against hospital care (33). That most counties in Wisconsin, despite its financing system and unique history of county mental health services, lack the programs so highly regarded in Dane County suggests that financing incentives are only a part of a more complex constella tion. If providing counties with the funds and authority for decision-making is so crucial, why is the California system in such major disarray? In 1985, Wisconsin expended less per capita on its mental health agencies than the US average and only ranked in the middle among states (27); yet it seems to have maintained a reasonably high standard of care. Financing provides the framework, but the success of community care also depends on professional leadership, interagency communication and coopera tion, and a supportive community environment. There are no substantial professional rewards for community care efforts, and managing the care of schizophrenic patients brings neither high income nor prestige among one's colleagues. In addition, there is great potential for blame when patients get into trouble. For many professionals, resistance and inertia is a comfortable stance. Few professional schools, whether of psychology, social work, or nursing, specifically train students to work with. the chronically ill; thus, special burdens are placed on innovative programs for on-the-job training. An advan tage of the longevity of the Dane County program is its accessibility to mental health professional students who learn to feel comfortable with this model of care. Over time, the effective institutionalization of community care depends on its effective integration with professional training and recruitment. THE CHANGING LEGAL CONTEXT OF MENTAL HEALTH CARE
Since the late 1960s public interest lawyers socialized in the civil rights movement directed their energies to the mental health arena, particularly to civil commitment procedures. Efforts were also made on many other fronts, such as "right to treatment" and "right to refuse treatment." Mental health lawyers had great expectations about the potentials of legal reform. In retro spect, despite significant gains in extending mental patients' rights and pro tections, the hope that litigation could fundamentally shape the system of community services seems naive. By directing attention to particular de ficiencies, legal advocates could induce service improvement, but often at the cost of neglecting other problems or discharging patients from the protection of service systems. The strategy behind much of the litigation was premised
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on the use of coercive powers by the state; thus, the remedies did not apply to those in noncoercive settings. More recently, legal efforts have been made in some jurisdictions to require government to provide an acceptable minimum of care, but the degree to which courts can direct state allocation of funds among competing priorities remains unclear. Despite the attention given to civil commitment, great dissatisfaction and divisiveness remain. To many mental health professionals, the law has gone too far in protecting the freedoms of persons at high risk who are incapable of making reasonable judgments about their needs. Others, however, resist any erosion of hard-won liberty interests. There is great heat but not much useful dialogue between these two groups. Although much acrimony is focused on commitment procedures, the key issue is the integrity and responsiveness of community care services. Many states are now experimenting with outpatient commitment, a less restrictive intervention than traditional civil commitment. Such commitments provide a mechanism to deal with the persistent failure to maintain essential drug treatment and the subsequent relapse within a less restrictive approach than coercive hospitalization. Studies in North Carolina indicate that the success of outpatient commitment depends on the responsiveness of the community mental health services system and the willingness to cooperate with the courts (12). When the services system and the courts work together, outpatient commitment appears to manage many troublesome problems. There is dis illusionment and frustration with commitment statutes. It is increasingly difficult to provide treatment to uncooperative and psychotic patients who are not imminently dangerous. These problems and the increasing demands for more extensive involuntary hospitalization make exploration of such mech anisms as outpatient commitment particularly prudent (3). THE RESEARCH ARENA
While research in mental health focuses on biology and the neurosciences, the desperate need for deeper knowledge of population, organizational, and behavioral factors and the functioning of mental health services systems continues. Research in the brain sciences is more dramatic, but we have made some significant gains in these other research areas, as well. In the past ten years, we have learned a great deal about the successful application of methods of behavior control and ways to manage illness to reduce disability. We have also seen advances in epidemiology and health services research, as the following examples illustrate. Fifteen years ago, psychiatric epidemiology was in the doldrums. A large gap existed between psychiatric conditions as measured in community epidemiological studies and clinical psychiatric practice. With the develop-
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ment of the Diagnostic Interview Survey (DIS) based on DSM-I1I criteria, the gap was substantially closed, and the Epidemiological Catchment Area Pro gram gave new vitality to epidemiological questions (4). Although many questions remain about the validity and applicability of the DIS to clinical efforts, it is a flexible instrument, allowing a wide range of investigatory approaches, that helps explore a broad range of substantive and methodolog ical concerns. With the encouragement of the NIMH, mental health services research has also advanced with increasing sophistication in organization and financing (35a). Some of the experimental work on models of care for the severely ill and on expressed emotion have already been noted, but such work as the RAND Health Insurance Experiment (HIE) also merits special attention. This controlled trial randomized 6970 respondents into insurance plans with vary ing coinsurance requirements, including one setting at Group Health In surance in Seattle, a health maintenance organization (HMO) (29). This experiment has been a fund of information for health services research in general. It has also substantially contributed to our understanding of how insurance and health care organization affect the provision of mental health services. A few findings will be illustrative. Cost-sharing has important effects on the use of general ambulatory care, but even larger effects on mental health services. In the HIE there was a fourfold variation between extreme coinsurance groups. Those with 50% coinsurance and no limits on cost-sharing spent two fifths as much as those who were not required to share costs (14). Coinsurance primarily affected the number of episodes of treatment, but once a person entered care the duration and intensity varied less. The experiment made it possible to study how patients randomized to prepaid care used services differently than those in plans with no coinsurance, an equivalent group in terms of out-of-pocket expenditure risk. Prepaid enrollees actually used more mental health services, but they were provided much less intensively. Patients with prepaid insurance were more likely to receive services from a general medical provider, and overall mental health expenditures were only one third that of the comparable group with no coinsurance. When prepaid enrollees saw a mental health provider, they had only one third the number of mental health visits as patients in the general fee-for-service sector. The HMO relied more on social workers than on psychiatrists or psychologists and less on individual than on group or family therapies (19, 20). Most patients who receive formal care for psychiatric disorders are man aged exclusively by general physicians, typically within the context of overall medical care (31). The most severely and persistently mentally ill eventually enter specialty care, but a large proportion of patients with all diagnoses do
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not. These patients commonly receive no treatment at all (17). Affective disorders are most prevalent, but at least half are probably not recognized in general medical practice (37). Such conditions, however, are extremely distressing and disabling. The Medical Outcomes Study, involving more than 11 ,000 patients in varying outpatient settings, found that patients with a diagnosis of clinical depression, or depressive symptoms short of a clinical diagnosis, were equally or more disabled than patients with such major chronic conditions as gastrointestinal problems, diabetes, back problems, and angina. Only the patients with advanced coronary artery disease were more disabled. Depressed patients had the worst social and role functioning and had more days in bed than any group except the coronary artery disease group (38). THE IMPORTANCE OF MENTAL HEALTH ADVOCACY
Mental health care has been transformed substantially in recent decades, and the availability and acceptability of services have grown. But with constraints on public funding, the gap has widened between insured persons and the uninsured or underinsured groups, which include the majority of long-term patients with persistent disabilities. In some sense, those who were traditional clients of public institutions may be worse off than ever before. They lost the refuge of the mental hospital, but are also excluded from the richness of community service options that have been developed for the insured. The process of defining health needs is largely political, a product of interest group activity. The ability to draw attention to need, and evoke sympathy for patients and their families, depends substantially on the mobilization and skill of advocacy groups. Traditionally, mental health advocacy has been weak for a variety of reasons. With mental health almost exclusively a public responsibility of the individual states, it has been difficult to form a strong national constituency. Moreover, the severely mentally ill have neither the personal resources nor the credibility to compete successfully with other disease constituencies. Their families often avoid public identifica tion because of stigma, which limits vigorous public participation. Although powerful advocates occasionally came forward, as in the case of Dorothea Dix, Clifford Beers, and Mike Gorman, and later those associated with the growing mental health professions and the establishment of the NIMH, there has never been the kind of sustained advocacy characteristic of other health lobbies. Mental health advocacy has also been crippled by bitter contentiousness. Advocates are highly fragmented and encourage competing and conflicting agendas: the severely mentally ill versus mental health education and pre vention; children versus adults; mental illness versus developmental dis-
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abilities; civil liberties versus tougher commitment laws; community care versus revitalizing public hospitals; social work versus psychology; psycholo gy versus psychiatry; biological psychiatry versus social psychiatry; drugs versus psychotherapy, and so on. Many of the controversies are important and relate to core issues of care, but the internal bickering among consumers and professionals has diminished effective advocacy. As a consequence, the sector has great difficulty setting priorities as evidenced by the products of the Carter Presidential Commission, the controversies over the Mental Health Systems Act, and the failures to understand the importance of mental health categorical issues relative to larger health policy issues that affect the mentally ill. Mental health advocates have too frequently misdirected their main efforts. They confuse symbolic issues with the health policy initiatives that shape the mental health sector. More forceful advocacy, which holds real promise for elevating mental health interests, has recently emerged. The establishment and rapid growth of the National Alliance for the Mentally III has mobilized a large and potentially effective lobby at the local, state, and federal levels (11). The challenge facing the Alliance, which incorporates conflicting viewpoints, is to develop its data acquisition, policy strategies, and political skills and more astutely bring competing perspectives together. Through the Alliance and other groups, former mental patients and their families now come forward publicly to address relevant issues. Such participation by visible and influential figures is increasingly common. Increased influence could come by orchestrating these efforts relative to the media and the policy formulation process. Efforts are also now being made to develop coalitions among competing mental health interests. A visible coalition has not emerged at the national level, but local advocacy groups representing consumers, professional groups, and mental health organizations are beginning to appreciate the value of a united front. An agenda that satisfies diverse organizations is not easy to build, but it is essential if the sector is to have equal access to the policy process. CONCLUSION Compared with previous decades, the past decade has been characterized by less rhetoric. We have seen greater appreciation of the tough realities of providing effective community care to seriously mentally ill persons. We understand better the complexities of finance and organization of service arrangements and their interconnections with housing, welfare, and medical and legal arrangements. Research technologies have advanced significantly, which promises major potential for the future. The nation has a vast pool of mental health professionals and facilities that can form the basis of a highly
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effective mental health care system. Mental health advocacy is also more sophisticated and active than ever before. Despite these gains, all is not well in mental health services. The promises of deinstitutionalization are largely unfulfilled, and the neglected condition of many seriously mentally ill persons in the community has contributed to a bitter backlash. The public sector and public welfare, on which many of these patients depend, have suffered significant erosion, and public sector delivery systems are in considerable disarray. Problems are exacerbated by the in creased population of seriously mentally ill, a consequence of the changing demography of the American population. Moreover, the federal deficit and the pressures on public budgets make it particularly difficult to attract signifi cant new public monies for services. Although public mental health services are significantly underfunded, present resources are substantial. These resources could be used more effec tively by correcting the fragmentation, duplication, and disorganization of the services system and establishing clear priorities focused on the seriously and persistently mentally ill (13a, 35). Building an integrated system requires new financing and organizational strategies, such as continuous team case management arrangements, the development of strong local mental health authorities, and mental health HMOs organized around capitation arrange ments (24-26). The crisis in mental health care is substantially affected by the lack of insurance and the erosion of welfare for the most seriously and persistently mentally ill, and many of these patients cannot get the necessary services. They are homeless, in part, because of the dearth of housing programs in the 1980s and the loss of low income housing stock. Any long-term solution will be a product of health and welfare policy and some reasonable response to the large un- or underinsured population. It is a sad commentary that a nation that spends more than a half trillion dollars on health each year and has such rich resources of manpower and facilities cannot do better for its most needy and disadvantaged citizens. Literature Cited 1. Bleuler, M. 1978. The Schizophrenic Disorders: Long·Term Patient and Family Studies. Trans!. S. M. Clemens. New Haven: Yale Univ. Press 2. Brady, J., Sharfstein, S. S., Muszynski, I. L. Jr. 1986. Trends in private in surance coverage for mental illness. Am. 1. Psychiatry 143:1276--79 3. Brooks, A. D. 1987. Outpatient com mitment for the chronic mentally ill: Law and policy. See Ref. 23a, pp. 11728
4. Eaton, W. W., Kessler, L. G., eds. 1985. Epidemiologic Field Methods in Psychiatry: The NIMH Epidemiologic Catchment Area Program. Orlando, Fla: Academic 5. Faulkner, L. R., Bloom, J. D., Bray, J. D . , Maricle, R. 1986. Medical services in community mental health programs. Hasp. Community Psychiatry 37:104547 6. Foley, H. A., Sharfstein, S. 1983. Mad ness and Government: Who Cares for
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the Mentally Ill? Washington, DC: Am. Psychiatr. Press 7. Grob, G. N. 1966. The State and the Mentally Ill: A History of Worcester State Hospital in Massachusetts. 18301920. Chapel Hill: Univ. North Carolina Press 8. Grob, G. N. 1987. Mental health policy in IX>st World War II America. See Ref. 23a, pp. IS-32 9. Gronfein, W. 1985. Incentives and in tentions in mental health policy: A com parison of the medicaid and community mental health programs. J. Health Soc. Behav. 26:192-206 10. Harding, C. M. , Zubin, J. , Strauss, J. S. 1987. Chronicity in schizophrenia: Fact, partial facts or artifact? Hosp. Communi ty Psychiatry 38:477-86 II. Hatfield, A. , ed. 1987. Families of the Mentally Ill: Meeting the Ch alle nges. New Dir. Ment. Health Servo No. 34. San Francisco: Jossey-Bass 12. Hiday, V., Scheid-Cook, T. 1986. The North Carolina experience with out patient commitment: a critical apprais al. Presented at Int. Congr. Law Psychi atry, Montreal 13. Inst. Medicine. 1988. Homelessness. Health and Human Needs. Washington, DC: Natl. Acad. Press 13a. Johnson, A. B. 1990. Out of Bedlam: The Truth About Deinstitutionalization. New York: Basic Books 14. Keeler, E. B., Wells, K. B. , Manning, W. G., Rumpel, J. D., Hanley, J. M. 1986. The Demand/or Episodes of Men tal Health Services (R-3432-NIMH). Santa Monica, Calif: RAND Corp. IS. Kety, S. 1986. The interface between neuroscience and psychiatry. In Psychi atry and Its Related Disciplines. ed. R. Rosenberg, F. Schulsinger, E. Strom gren, p. 23. Cophenhagen: World Psy chiatr. Assoc. 16. Kiesler, C. A., Sibulkin, A. E. 1987. Mental Hospitalization: Myths and Facts About a National Crisis. Newbury Park, Calif: Sage 17. Leaf, P. J. , Livingston, M. M., Tis chler, G. L., Weissman, M. M. , Holzer, C. E. , Myers, J. K. 1985. Contact with health professionals for the treatment of psychiatric and emotional problems. Med. Care 23:1302-37 18. Leff, J. , Vaughn, C. 1985. Expressed Emotion in Families. New York: Guil ford 19. Manning, W. G. , Wells, K. B. 1986. Preliminary results of a controlled trial of the effect of a prepaid group practice on the outpatient use of mental health services. J. Hum. Resour. 21:293-320
20. Manning, W. G. , Wells, K. B. , Ben jamin, B. 1986. Use oj Outpatient Men tal Health Care: Trial oj a Prepaid Group Practice Versus Fee-For-Service (R-3277-NIMH). Santa Monica, Calif: RAND Corp. 21. Mechanic, D. 1986. From Advocacy to Allocation: The Evolving American Health Care System. New York: Free Press 22. Mechanic, D. 1987. Correcting mis conceptions in mental health policy: Strategies for improved care of the seriously mentally ill. Milbank Fund Q. 6S:203-30 23. Mechanic, D. 1989. Mental Health and Social Policy. Englewood Cliffs, NJ: Prentice-Hall. 3rd ed. 23a. Mechanic, D., ed. 1987. Improving Mental Health Services: What the Social Sciences Can Tell Us. New DiL Ment. Health Servo No. 36 (Winter): 117-28. San Francisco: Jossey-Bass 24. Mechanic, D. , Aiken, L. 1987. Improv ing the care of patients with chronic mental illness. N. Eng!. J. Med. 317:1634-38 25. Mechanic, D. , Aiken, L., eds. 1989. Paying for Services: Promises and Pit falls of Capitation. New Directions Ser. 43. San Francisco: Jossey-Bass 26. Mechanic, D. , Rochefort, D. A. 1990. Deinstitutionalization: An appraisal of reform. Annu. Rev. Sociol. 16:30127 27. Natl. Inst. Mental Health. 1987. Mental Health, United States. 1987, ed. R. W. Manderscheid, S. A. Barrett. DHHS Pub!. No. (ADM) 87-1518. Washing ton, DC: GPO 28. New South Wales, Dep. Health. 1983. Psychiatric Hospital Versus Community Treatment: A Controlled Study. (HSR 83-046), Sydney, Australia 29. Newhouse, J. 1974. A design for a health insurance experiment. Inquiry II:S-27 30. Sartorius, N. , Jablensky, A. , Korten, A., Eroberg, A , Anker, M. , et al. 1986. Early manifestations and first contact incidence of schizophrenia in different cultures. Psychol. Med. 16: 909--28 31. Shapiro, S., Skinner, E. A., Kramer, M. , Steinwachs, D. M. , Regier, D. A. 1985. Measuring need for mental health services in a general population. Med. Care 23: 1033-43 32. Shepherd, M. 1987. Formulation of new research strategies on schizophrenia. In Search/or the Causes of Schizophrenia. ed. H. Hafner, W. F. Gattaz, W. Janzar ik, pp. 29--38. Berlin: Springer-Verlag .
DEVELOPMENTS IN MENTAL HEALTH 33. Stein, L. I., Ganser, L. J. 1983. Wis consin system for funding mental health services. In New Directions for Mental Health Services: Unified Mental Health System, ed. J. Talbott, pp. 25-32. San Francisco: Jossey-Bass 34. S tein L. I., Test M. A., eds. 1985. The Training in Community Living Model: A Decade of Experience. New Dir. Ment. Health Servo No. 26. San Francisco: Jossey-Bass 35. Torrey, E. F. 1988. Nowhere to Go: The Tragic Odyssey of the Homeless Mental ly Ill. New York: Harper & Row 35a. Taube, C. A., Mechanic, D., Hohmann, A. A., eds. 1989. The Future of Mental Health Services Research. DHHS Publ. No. (ADM) 89-1600. Washington, DC: US Print. Off.
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36. US DHHS. 1980. Toward a National Plan for the Chronically Mentally Ill, Report to the Secretary-J980. Pub\. No. ADM 81-1077. Rockville, Md: DHHS 37. Wells, K. B. 1985. Depression as a tra cer condition for the national study of medical care outcomes: Background re view. 3293-RWJ-HJK RAND Corp. Santa Monica, Calif: RAND Corp. 38. Wells, K. B., Stewart, A., Hays, R. D., Burnam, M. A., Rogers, W., et al. 1989. The functioning and well -being of depressed patients: Results from the medical outcomes study. J. Am. Med. Assoc. 262:914-19 39. WHO. 1979. Schizophrenia: An In ternational Follow-up Study. Geneva, NY: Wiley
