ERIC ED469203: Mental Health, United States, 2000.

360 Pages·2001·6.3 MB·English

by  ERIC

DOCUMENT RESUME
CG 031 967
ED 469 203
Manderscheid, Ronald W., Ed.; Henderson, Marilyn J., Ed.
AUTHOR
Mental Health, United States, 2000.
TITLE
Substance Abuse and Mental Health Services Administration
INSTITUTION
(DHHS/PHS), Rockville, MD. Center for Mental Health Services.
SMA-01-3537
REPORT NO
ISBN-0-16-049883-X
ISBN
2001-00-00
PUB DATE
359p.
NOTE
U.S. Government Printing Office, Superintendent of Documents,
AVAILABLE FROM
Mail Stop: SSOP, Washington, DC 20402-0001. Tel: 202 -512-
1800; Fax: [phone]; Web site: bookstore.gpo.gov.
Descriptive (141)
Reports
PUB TYPE
EDRS Price MFO1 /PC15 Plus Postage.
EDRS PRICE
*Change Strategies; *Delivery Systems; *Information
DESCRIPTORS
Dissemination; *Mental Health; Mental Health Programs;
Program Effectiveness; *Trend Analysis
*Knowledge Bases
IDENTIFIERS
ABSTRACT
In recent years, the mental health community has made great
strides in understanding more about the delivery of mental health services,
improving efficiency and quality in services, and also about how to build
strengths and resilience in the face of life's stresses. This volume adds to
the knowledge base so that the important task of system change and expansion
of service availability can proceed. Through a knowledge exchange process,
this volume seeks to highlight the challenges in the field of mental health
(1) "Where is Mental
and respond with useful information. Chapters include:
Health Likely to Be a Century Hence?" (Ronald W. Manderscheid, Marilyn J.
(2) "Mental Health Policy in 20th-Century America" (Gerald N.
Henderson);
(3) "Decision Support 2000+: A New Information System for Mental
Grob);
Health" (Marilyn J. Henderson, Sarah L. Minden; Ronald W. Manderscheid);
(4)
"Information Needs: A Consumer and Family Perspective" (Laura Van Tosh);
(5)
"Psychiatric Epidemiology: Recent Advances and Future Directions" (Ronald C.
Kessler, Elizabeth J. Costello, Kathleen Ries Merikangas, T. Bedirhan Ustun);
(6) "Status of National Accountability Efforts at the Millennium" (Ronald W.
(7) "Mental Health
Manderscheid, Marilyn J. Henderson, David Y. Brown);
Policy at the Millennium: Challenges and Opportunities" (David Mechanic);
(8)
"The Mental Health Economy and Mental Health Economics" (Richard G. Frank,
(9) "The Promise and Reality of Managed Behavioral Care" (E.
Thomas McGuire);
(10) "Co-occurring Addictive and Mental Disorders" (Fred C.
Clarke Ross);
(11) "Adult Mental Health Services in the 21st Century" (Mark S.
Osher);
Salzer, Michael Blank, Aileen Rothbard, Trevor Hadley);
(12)
"Pharmacoepidemiology of Methylphenidate and Other Medications for the
(13) "Refugee Mental Health: Issues
Treatment of ADHD" (Julie Magno Zito);
for the New Millenium" (James Jaranson, Susan Forbes Martin, Solvig Ekblad);
(14) "Highlights of Organized mental Health Services in 1998 and Major
National and State Trends" (Ronald W. Manderscheid, And Others);
(15)
"Persons Treated in Specialty Mental Health Care Programs, United States,
(16) "State Mental Health Agency
1997" (Laura J. Milazzo-Sayre, And Others);
Controlled Expenditures and Revenues for Mental Health Services, FY 1981 to
(17) "The 16-State Indicator Pilot
FY 1997" (Ted Lutterman, Michael Hogan);
Grant Project: Selected Performance Indicators and Implications for Policy-
(18) "The Availability of
and Decisionmaking" (Olinda Gonzalez, And Others);
Reproductions supplied by EDRS are the best that can be made
from the original document.
Mental Health Services to Young People in Juvenile Justice Facilities: A
National Survey" (Ingrid Goldstrom, Fan Jaiquan, Marilyn Henderson, Alisa
(19) "Estimates of Mental and. Emotional
Male, Ronald W. Manderscheid);
Problems, Functional Impairments, and Associated Disability Outsomes for the
U.S. Child Population in Households" (Lisa J. Colpe); and (20) "Mental Health
Practitioners and Trainees" (Joyce West, And Others). (Contains over 500
references, 64 tables, and 4 appendixes.)
(GCP)
Reproductions supplied by EDRS are the best that can be made
from the original document.
Mental Health,
United States,
2000
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U.S. DEPARTMENT OF EDUCATION
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Office of Educational Research and Improvement
EDUCATIONAL RESOURCES INFORMATION
CENTER (ERIC)
This document has been reproduced as
received from the person or organization
originating it.
Minor changes have been made to
improve reproduction quality
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Points of view or opinions stated in this
document do not necessarily represent
official OERI position or policy
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U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
www.samhsa.gov
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'BEST COPY AVAILABLE
I
Mental Health,
United States,
2000
Edited by
Ronald W. Manderscheid, Ph.D.
and
Marilyn J. Henderson, M.P.A.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
5600 Fishers Lane
Rockville, Maryland 20857
For sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov
Phone: [phone]
Fax: [phone]
Mail: Stop SSOP, Washington, DC 20402-0001
ISBN 0-16-050952-1
ACKNOWLEDGMENTS
This volume could not have been compiled without the essential assistance of the local mental health
providers and the State mental health agencies that contributed data on program operations. Compilation of
these data was greatly facilitated by the National Association of State Mental Health Program Directors,
the American Hospital Association, the National Association of Psychiatric Healthcare Systems, and the
National Center on Health Statistics. In addition, the managed behavioral health
care industry and the
health maintenance organization industry provided important information.
Particular recognition is due to EEI Communications, Inc., for its editorial support. All other support and
,
assistance are gratefully acknowledged.
Disclaimer
The content of this publication does not necessarily reflect the views
or policies of SAMHSA or HHS.
Public Domain Notice
All material appearing in this report is in the public domain and may be reproduced
or copied without
permission from the Substance Abuse and Mental Health Services Administration. Citation of the
source is
appreciated. However, this publication may not be reproduced or distributed for a fee without the specific,
written authorization of the Office of Communications, SAMHSA, U.S. Department of Health and Human
Services.
Electronic Access and Copies of Publication
This publication can be accessed electronically through the following Internet World Wide Web connection:
http://www.samhsa.gov, For additional free copies of this document, please call the National Mental Health
Services Knowledge Exchange Network, 1-800-789-2647.
Recommended Citation
Center for Mental Health Services. Mental Health, United States,
2000. Manderscheid, R.W., and Henderson, M.J., eds. DHHS Pub No.
(SMA) 01-3537. Washington, DC: Supt. of Docs., U.S. Govt. Print.
Off., 2001.
Originating Office
Survey and Analysis Branch, Division of State and Community Systems, Center for Mental Health Services,
Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD 20857
DHHS Publication No. (SMA) 01-3537
Printed 2001
ISBN 0 -16- 049883 -X
Foreword
of which the Center for Mental Health Services is a
It is with great pleasure that we bring you' this
part, works to accomplish these goals in partnership
United States, 2000' Our
edition of Mental Health,
with many other organizations and groups. We do
nation has made great strides in recent years in
so through a variety of grants and contracts, but
understanding the working of the brain in health
very importantly, through a knowledge exchange
and in illness. We also are making great strides in
process through which we learn of the challenges in
understanding more about the delivery of mental
the field and respond with useful information.
health services, improving efficiency and quality in
Mental Health, United States, 2000 is a continuing
services, and also about how we can build strengths
series addressing these information needs. We hope
and resilience in the face of life's stresses.
find many uses for the information
you will
Our efforts, however, are far from complete. Many
provided.
individuals find the services they need to be
inaccessible, through distance, cost, or coverage
Joseph H. Autry, III, M.D.
limitations. Others are able to access services, but
Acting Administrator
the services may not be fully evidence based, of the
Substance Abuse and Mental Health
highest quality, and respectful of culture, race and
Services Administration
ethnicity of the recipient.
This volume adds to the knowledge base so that the
Bernard S. Arons, M.D.
important task of system change and expansion of
service availability can proceed. The Substance
Director
Center for Mental Health Services
Abuse and Mental Health Services Administration,
Executive Summary
until near mid-century, when the appropriateness of
The preparation of Mental Health,
United
institutional care was questioned, and the early out-
States, 2000 presented interesting challenges: How
lines of community care were becoming evident.
could we encapsulate the current status of mental
Changes in care concepts, the introduction of medi-
health services for present and future readers? Of
cations, changes in financing at the Federal level,
equal importance, how could we describe the cur-
and the development of community mental health
rent development of mental health statistics? To
centers all contributed to the process of deinstitu-
resolve these issues, we construct Section 1 with an
tionalization, which Grob analyzes in detail. Some
editorial on likely future directions and a chapter on
of the key issues raised by this process gave rise to
where the field has been over the past 100 years.
that
new forms of integrated community-based care
These pieces set the essential context for Section 2,
have shown some success, yet there are still large
statistics;
on the current status of mental health
numbers of homeless and unemployed persons with
and Section 3, on the current status of mental
mental illness, as well as individuals with mental
health services. Each of these sections is new to
illness in the criminal justice system who have not
Mental Health, United States, 2000. Section 4, as in
been effectively reached by this new care system.
all previous editions, updates the national statisti-
Much remains to be done as we enter the 21st cen-
cal picture for mental health. The paragraphs below
tury.
provide an executive summary for each of these four
sections.
Section 2:
Section 1:
Status of Mental Health Statistics
Looking Ahead and Reflecting
at the Millennium
Upon the Past
In Chapter 3, Henderson, Minden, and Mander-
scheid present the key outlines of a new develop-
In an editorial prospective presented in Chap-
system
health
information
mental
mental
ter 1, Manderscheid and Henderson examine where
framework for the 21st century. This work is based
the mental health system is likely to be a century
the
on the belief that improving information for
hence. Four scenarios are constructed to examine
entire field is at the heart of improving the quality
changes in the roles persons with mental illness
of mental health care. Currently, the mental health
will have in the future and how these changes will
field has critical needs for improved information as
interact with simultaneous changes in the treat-
a part of major efforts to improve the quality
of
ment of mental illness. The four scenarios predict
care.
that human rights will be established as fundamen-
tal in our health care system; consumers and family
CMHS is working to meet those needs. Decision
Support 2000+ is being designed to meet these
members will seek and be given more responsibility
for health and health care; technology will become a
needs through support for better decisionmaking,
primary vehicle for delivering health care; and
accountability, recording of data, simplified report-
genetic treatments for biologically based disorders
ing at all levels, and continuous quality improve-
will become routine. Readers are encouraged to
ment. Based in the public health model, Decision
help construct the future, not just wait for it to
Support 2000+ will incorporate data standards for
epidemiology and needs assessment; insurance
unfold.
enrollment; encounter, practice guideline, human
In Chapter 2, Grob describes the evolution of
information
resource, organizational, and financial
the U.S. mental health care system from the end of
about services; and key quality measures needed in
the 19th century to the end of the 20th. Early in this
the new managed care environment: outcomes,
period, local responsibility diminished in favor of
report cards, and performance indicators. Cur-
State government and the burgeoning State mental
rently, a requirements analysis is available for
hospital system. This pattern continued unabated
6
Executive Summary
comment at the Web site www.mhsip.org, and mini-
tive and clinical epidemiology However,
new work
mum data sets are being completed for each of the
is emerging on modifiable risk factors and
preven-
domains of measurement. Decision Support 2000+
tive interventions; psychiatric epidemiologists need
has been made possible through developmental
more involvement in these endeavors. Areas of psy-
work undertaken by the Survey and Analysis
chiatric epidemiology that show particular promise
Branch Division of State and Community Systems
for the future include application of developmental
Development, Center for Mental Health Services
principles to child and adolescent disorders and to
(CMHS) and the Mental Health Statistics Improve-
comorbidity; genetic epidemiology; and work
on bar-
ment Program (MHSIP) community.
riers to help seeking. Likely future challenges
include linking multiple risk factors with multiple
Van Tosh brings the consumer and family
per-
integrating
outcomes;
spective to information in Chapter 4. She asserts
psychiatric
epidemiology
that the mental health field needs
with prevention science and social policy analysis;
an excellent
initiating more work on secondary prevention; and
information system; a principal application of this
information system will be to provide essential
understanding the determinants of help-seeking
behavior.
information to consumers and family members.
Information needs of consumers and families
range
Chapter 6 authors Manderscheid, Henderson,
from types and costs of services to accreditation
sta-
and Brown offer a status report
on national
tus and utilization review procedures. Van Tosh also
accountability efforts in mental health. Quality
identifies key benefits of Decision Support 2000+ for
accountability can refer to practices, outcomes, plan
consumers and families: reduced fragmentation and
performance, or system performance. Criteria to
increased accountability for services; promotion of
judge quality tools in each of these
areas include
visionary policy development; and reinforcement of
simplicity, communality, and appropriateness. Clin-
the link between service delivery and quality of
ical practice guidelines are being developed, but not
care. The challenges to implementing Decision Sup
-.
in a consistent way; system practice guidelines
are
port 2000+ will include guaranteeing informed
con-
in their infancy. The Practice Guideline Coalition
sent, promoting consumer and family
access to
seeks to reduce the variability in clinical practice
medical records, expanding service choice, and
guidelines and related measures; both will receive
ensuring accurate data interpretation and report-
increased attention in the future. Outcome
mea-
ing.
sures can help identify effective practices and pro-
In Chapter 5, Kessler, Costello, Merikangas,
vide a vehicle for future reimbursement. Field work
and Ustin provide a status report
is under way to develop outcome
on psychiatric epi-
measures for both
demiology at the beginning of 21st century. Descrip-
children and adults.
tive psychiatric epidemiology is at a less developed
An important development is person-centered
stage for children and adolescents than for adults
outcomes and related consumer surveys. In the
near
because of developmental changes that children
term, calibration work among instruments will be
a
undergo and the question of who should report for
high priority. Report cards have emerged in the past
them. For adults, the major surveys carried out
over
5 years to provide an overview of plan performance.
the past quarter-century have produced reliable
The MHSIP Consumer-Oriented Report Card is
cur-
information on prevalence, age of onset, disability,
rently being tested by 40 States. In the future,
and treatment. Recently, some have questioned the
report cards will describe not only plan perfor-
diagnostic criteria leading to the high prevalence
mance, but contributions to the community as well.
shown in these surveys. The techniques developed
The development of performance indicators has
par-
in these adult surveys have been applied to clinical
alleled that of report cards. The CMHS is working
epidemiological surveys as well. Surveys of elderly
with both States and the private sector to develop
persons represent a new frontier. Challenges that
performance indicator systems. This work shows
need to be faced in the future include underreport-
considerable promise. Overall, the tension will
con-
ing and production of estimates for small geographi-
tinue between the need for common accountability
cal areas.
tools and the uniqueness demanded at
a time when
Analytical and experimental psychiatric epide-
mental health services are considered to be
a com-
miology are much less developed than
are descrip-
modity.
7
vi
Executive Summary
decrease in the relative role of government as a
Section 3:
the emergence of
payer for mental health care and
Status of Mental Health Services
private markets between 1965 and 1985. The latter
at the Millennium
of
factor is partially attributable to the emergence
Medicare and Medicaid payment systems, the
for
growth and increasing range of mental health pro-
In Chapter 7, Mechanic sets the framework
fessionals, the evolution of improved treatments,
the section by examining the challenges and oppor-
mil-
tunities mental health policy confronts at the
and the rapid growth of managed behavioral health
What has been learned
lennium. He notes that the past 50 years have
care over the past decade.
authors list four fac-
witnessed extraordinary improvements in mental
over this 50-year period? The
health insurance coverage and care. At the 20th
volume
tors: financial incentives do influence the
in
and quality of care; markets can fail, resulting
century's end, managed care is further accelerating
differential copayments; managed care can control
the transformation of the field. Within this context,
spending without limiting insurance coverage; out-
Mechanic reviews the gains and unanticipated con-
substan-
policy in six areas: dein-
come returns from mental health care are
sequences of mental health
tial and improving. In this context, Frank and
stitutionalization, improved treatment technologies,
mental health parity, the legal context and criminal
McGuire conclude that mental health economics
justice services, managed behavioral health care,
will have a major role in policy formulation as we
and the growth of consumer and family involve-
enter the 21st century.
most
ment. Deinstitutionalization has been the
and
In Chapter 9, Ross examines the promise
enduring change of the past 50 years, but service
the reality of managed behavioral health care. Man-
networks have yet to be built in many communities,
aged care has changed the landscape of modern
and many persons with mental illness have been
mental health care. The most recent statistics avail-
research,
sustained
Through
criminalized.
able show that almost 177 million Americans have
improved treatment technologies have emerged,
their behavioral health care benefits managed by
including better drug therapies and better psycho-
health care organi-
one of the managed behavioral
social management approaches, but much remains
zations, and an additional 19 million are in a health
is being
to be learned about mental illness. Progress
maintenance organization (HMO). Yet, at least
made in adopting parity for mental health insur-
behav-
eight major issues are confronting managed
does not exist on the
ance coverage, yet agreement
ioral health care: ability to control cost; substitution
covered. The Ameri-
scope of the population to be
of types of mental health services; adequacy of ser-
and the Olmstead
cans with Disabilities Act
vices; seamless systems of care; medical necessity
Supreme Court decision have promoted community
necessity; public
vs. clinical necessity vs. human
living for persons with mental illness, but new
accountability; consumer, family, and enrollee par-
restrictions, such as outpatient commitment, have
ticipation; and forms of delivery. Clearly, managed
behavioral health care has
grown apace. Managed
behavioral health care can control costs. Cost con-
improved the focus on quality of care and outcome,
trol is accomplished through substitution of ambu-
service
yet the carveouts have prevented needed
latory for inpatient services and the use of medical
integration. The consumer and family movements,
necessity criteria. Thus, a question arises as to
particularly the National Alliance for the Mentally
whether sufficient resources are being expended for
Ill, have grown exponentially in the past 20 years,
the care of persons with severe mental illnesses.
but full integration of consumer and family initia-
Good systems of care must have clear boundaries
future
Clearly,
its
in
infancy.
remains
tives
and responsibilities among components, or the com-
advances will be contingent upon learning more
ponents must be integrated; neither situation pre-
about mental illness and evolving appropriate pol-
its
in
is
Public accountability
vails currently.
icy to consolidate the new knowledge and to learn
infancy, particularly around outcome and consumer-
from past mistakes.
of
oriented measures, and the comparative effects
Frank and McGuire review the transformations
the different models of managed care are only dimly
of the mental health economy and mental health
understood. Consumer, family, and enrollee partici-
economics over the past 50 years in Chapter 8. Cen-
pation is rare in key aspects of services. Ross con-
tral to their review is the notion that we have
cludes that managed care has overpromised what it
moved from a predominantly planned mental
can deliver.
health economy in the 1950's to a predominantly
Chapter 10 author Osher presents the latest
market economy at present. Frank and McGuire
information on the prevalence and treatment of
attribute this change to several factors, including a
Executive Summary
co-occurring mental and addictive disorders.
The
tial supports. Psychopharmacology has
advanced
current estimate of the annual prevalence of such
rapidly over the past decade, and psychosocial
inter-
disorders
is approximately 10 million
persons.
ventions have proven their effectiveness during
this
Although identification and characterization
of per-
period. Yet the adult services field still
confronts
sons with these disorders remains difficult, several
several major challenges, including the
difficulties
factors are known: Persons with co-occurring
disor-
associated with translating research findings
into
ders are much more likely to seek mental
health
effective practices and the lack of adherence
to prac-
and substance abuse services, and
persons with par-
tice guidelines known to be effective. The
authors
ticular mental disorders
are more likely to develop
conclude that cautious, but not undue, optimism
is
substance abuse disorders at
a later point. Achiev-
warranted.
ing good outcomes is difficult. Over the
past decade,
Chapter 12 author Zito presents results from
a
research and professional
consensus have con-
study of change in pharmacotherapy for the
treat-
verged on comprehensive, integrated
care as the
ment of attention deficit hyperactivity
disorder
preferred method of treatment. Care
must be based
(ADHD). From Medicaid records in two
States and
on the principles of acceptance, accessibility, inte-
the records of an HMO, the author
was able to show
gration, continuity, individualized treatment,
com-
large increases in the prescription of
stimulants
prehensiveness, quality, responsible implementa-
over a 10-year interval. Stimulant use increased
tion, and optimism and
recovery. New models are
more than 600 percent for those under age 20 in the
being developed to share responsibility for
this pop-
HMO; stimulant use among 5- to 14-year-olds
was
ulation among primary
care, mental health, and
twofold greater in the Medicaid setting
than in the
substance abuse providers depending
on severity
HMO. Differences were observed by
age, gender,
and the exact combination of disorders,
and to
race, and geographic locale. Increased medication
detail how integrated services
can be developed.
use appears to be related to a larger number of
Osher concludes that the failure to implement
com-
youths in treatment, longer times in
treatment, and
prehensive care for persons with co-occurring
disor-
concurrent use of stimulants and ancillary medica-
ders is a failure of clinical and
administrative
tions. Other related factors include less
stringent
leadership.
diagnostic
criteria;
increasing
identification
of
In Chapter 11, Salzer, Blank,
Rothbard, and
comorbidities, such as depression; and the
large role
Hadley provide an overview of the
of primary care practices in treating
status of adult
ADHD. Zito
mental health services at the beginning
concludes by calling for careful consideration
of the 21st
of the
century. They note that the changes in mental
appropriateness, safety, and long-term effectiveness
health services over the past three
decades rival
of current pharmacotherapy prescription practices.1
developments that have occurred
over the two cen-
In Chapter 13, Jaranson, Martin, and
Ekblad
turies since the Colonial period. The authors
then
provide a status report
on the epidemiology and
review four key factors that have influenced
the
mental health care of refugeespersons
who are
current status of adult mental health services:
ser-
outside the country of their nationality
because of
vice planning, financing and service
organization,
fear of being persecuted. In 1999, there
were an
development of community long-term
care supports,
estimated 13.5 million refugees worldwide,
down
and the rapid evolution of psychopharmacological
from almost 17 million at the beginning
of the
and psychosocial interventions. The
recent history
decade. The largest number
was in the Middle East
of service planning derives partly from
the history
(6 million), followed by Africa (3 million),
Europe
of modern mental health epidemiology,
as well as
and South Asia (1.7 million each), the
Americas
the growth of the Community Support Program
phi-
(750 thousand), and East Asia and the Pacific
(500
losophy and a consumer orientation
characterized
thousand). The decrease in number of refugees
is
by informal care, self-help, and
consumer and fam-
due to repatriation, as well
as an increased diffi-
ily networks. For the past decade,
financing has
culty in finding countries willing to
accept them.
been dominated by managed behavioral
health care,
U.S. policies and practices
on accepting refugees are
which has resulted in increased
cost controls and
reviewed from this point of view. Refugees
are at
rapid movement toward service
integration. Ser-
particular risk not only for developing mental
disor-
vices have moved from institutions to
communities,
ders, but also for failing to receive
treatment for
with several waves of deinstitutionalization.
Com-
their illnesses. Risk factors for
poor mental health
munity services have benefited from the
develop-
include marginalization and minority
status, socio-
ment of the Program of Assertive Community
economic disadvantage, poor physical health,
star-
Treatment, together with other long-term
residen-
vation and malnutrition, head trauma and
injuries,
viii
9