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The Mental Health
Care System

Diana M. Tisnado, PhD

Associate Professor, Health Science

California State University Fullerton

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Introduction (1)

  • Includes psychological, emotional, and social well-being
  • Positive mental health and wellness involve being able to

Cope with stresses of life

Work/fulfill roles productively

Make meaningful contributions to family, community

Fulfill one’s potential

  • Influenced by many factors including biology, environmental exposures, and life experiences

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Introduction (2)

  • Mental health problems include conditions in which thinking, mood, or behavior may be affected.
  • Over 44 million American adults (about 18%) have a mental health condition; about 1 in 25 has a serious illness such as schizophrenia, bipolar disorder, or major depression (2016 data).
  • Over half of mental health conditions first show signs in children and adolescents < age 14; 75% in those < age 24.

Prevalence statistics for “Any Mental Illness” (serious or mild) in 2016, from National Institute of Mental Health (NIMH), retrieved from https://www.nimh.nih.gov/health/statistics/mental-illness.shtml

Any Disorder Among Children, Retrieved from http://www.nimh.nih.gov/health/statistics/prevalence/any-disorder-among-children.shtml

https://www.nami.org/NAMI/media/NAMI-Media/Infographics/GeneralMHFacts.pdf

Substance Abuse and Mental Health Services Administration, Results from the 2014 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-50, HHS Publication No. (SMA) 15-4927. Rockville, MD: Substance Abuse and Mental Health Services Administration. (2015). Retrieved October 27, 2015 from http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf

https://www.nimh.nih.gov/health/statistics/global/global-leading-categories-of-diseases-disorders.shtml

https://www.nimh.nih.gov/health/statistics/disability/us-leading-categories-of-diseases-disorders.shtml

Metrics: Disability-Adjusted Life Year (DALY), Quantifying the Burden of Disease from mortality and morbidity, World Health Organization Definition

One DALY can be thought of as one lost year of "healthy" life. The sum of these DALYs across the population, or the burden of disease, can be thought of as a measurement of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability. 

DALYs for a disease or health condition are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition or its consequences. (http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/)

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Historical Views of Mental Illness

  • Historically myths around mental illness have persisted, e.g.:
  • Mental health problems result from spiritual failing (or in some cultures, special spiritual gifts)
  • Mental health problems result from character or moral failings, and can be overcome by personal strength of will or effort
  • Mental health problems are hopeless and not preventable or treatable

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History of Mental Health Care Delivery

  • In centuries past, the mentally ill were often thought to be possessed, or in need of religion.
  • Negative attitudes and stigma persisted in the US through the 1800s.
  • Individuals were often confined (ostensibly for their protection and the protection of others) in degrading and unhealthy conditions. Little in the way of treatment was available.
  • Mid-1800’s: Dorothea Dix campaigned against such inhumane conditions and lobbied for creation of government-funded state psychiatric hospitals.

Retrieved from https://www.pbs.org/wgbh/americanexperience/features/nash-treatments-mental-illness/

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Transition from Institution to Community-based Care Delivery (1)

  • At the time, this model of institutionalization was seen as the best way to provide access to care to patients while easing family burden.
  • However, institutions were underfunded, understaffed, and reports of poor living conditions and human rights abuses became widespread.
  • In the 1950’s, anti-psychotic medications became available, and movements began in many countries to transition from “asylum-based” care to community-based care models.

https://www.pbs.org/wgbh/americanexperience/features/nash-treatments-mental-illness/

Women and Madness: Chesler, P. (2005). Women and madness. New York, NY, : Palgrave Macmillan.

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Transition from Institution to Community-based Care Delivery (2)

  • 1963 Community Mental Health Centers Act: enacted strict standards so that only individuals “who posed an imminent danger to themselves or someone else” could be committed involuntarily to state psychiatric hospitals.
  • Community-based mental health care developed to include a range of treatment options, e.g., community mental health centers, residential homes, community-based psychiatric teams.
  • Numbers institutionalized fell to ¼ of 1950’s levels, but with mixed results.

For general information on de-institutionalization movement: https://www.pbs.org/wgbh/pages/frontline/shows/asylums/special/excerpt.html, excerpted from Out of the Shadows: Confronting America's Mental Illness Crisis by E. Fuller Torrey, M.D. (New York: John Wiley & Sons, 1997)

Martinez-Leal, R., Salvador-Carulla, L., Linehan, C., Walsh, P., Weber, G., Van Hove, G., Maatta, T., Azema, B., Haveman, M., Buono, S., Germanavicius, A., van Schrojenstein LAntman-de Valk, H., Tossebro, J., Carmen-Cara, A., Berger, D. M., Perry, J., Kerr, M.  (2011). The impact of living arrangements and deinstitutionalisation in the health status of persons with intellectual disability in Europe. J Intellect Disabil Res, 55(9): 858-872.;

Knapp, M., Beecham, J., McDaid, D., Matosevic, T., Smith, M. (2011). The economic consequences of deinstitutionalisation of mental health services: lessons from a systematic review of European experience. Health and Social Care in the Community, 19(2): 113-125.;

Novella, E.J. (2010). Mental health care and the politics of inclusion: a social systems account of psychiatric deinstitutionalization. Theor Med Bioeth, 31: 411-427.

Lamb, H.R.L., Weinberger, L.E. (2005). The shift of psychiatric inpatient care from hospitals to jails and prisons. J Am Acad Psychiatry Law, 33: 529-34.

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Mental Health Care Approaches

  • Psychotherapy: many approaches based on differing theories, but generally involve counseling in a structured individual or group situation with a therapist. One approach is cognitive behavioral therapy (CBT) which seeks to change maladaptive patterns of thinking and behavior.
  • Pharmacotherapy: Psychiatric medications alter brain chemistry.
  • Assertive Community Treatment (ACT): seeks to provide comprehensive, individualized treatment based in the community.

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Access to Mental Health Care

  • Treatments can be expensive: high costs limit access to care for low and middle income.
  • Health insurance coverage for mental health care is often limited, so even those with health insurance often face unaffordable care.
  • Non-financial: stigma, lack of education.
  • Workforce shortages are also a problem, particularly shortages of professionals trained to care for children and adolescents.

Saxena, S., Thornicroft, G., Knapp, M., Whiteford, H. (2007). Resources for mental health: scarcity, inequity, and inefficiency. Lancet, 370: 878-89.

Kessler, R.C., Berglund, P.A., Bruce, M.L., Koch, J.R., Laska, E.M., Leaf, P.J., Manderscheid, R.W., Rosenheck, R.A., Walters, E.E., Wang, P.S. (2001). The prevalence and correlates of untreated serious mental illness. HSR: Health Services Research, 36(6): 987-1007.

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Historical Health Insurance Issues

  • Severely limited numbers of days, numbers of visits, or total dollar amounts that were covered
  • High co-pays or co-insurance for mental health care provider fees and for medications
  • Limited availability of providers in managed care networks, meaning potentially long waits and lack of choice of provider.
  • Medicaid has become largest payer for mental health-related services including substance abuse, & including outpatient, home health, and inpatient care

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In Pursuit of “Parity” in Access to Mental Health Care

  • To improve access to mental health care, Congress passed the “Mental Health Parity and Addiction Equity Act” in 2008.

Stated that if a health plan offered mental health coverage, such coverage had to be comparable to coverage for medical and surgical care.

  • However, studies continue to find disparities between access to mental health vs medical care.

More out-of-network care, indicating shortages of professionals in network, and higher out of pocket costs

  • Health insurers often reimburse mental health care providers less than primary care providers

Sarah Goodell, “Mental Health Parity, " Health Affairs Health Policy Brief, April 3, 2014.DOI: 10.1377/hpb20140403.871424

Retrieved from https://www.healthaffairs.org/do/10.1377/hpb20140403.871424/full/

Sarah Goodell, “Enforcing Mental Health Parity, " Health Affairs Health Policy Brief, November 9, 2015.DOI: 10.1377/hpb20151109.624272

Retrieved from https://www.healthaffairs.org/do/10.1377/hpb20151109.624272/full/

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Workforce Issues

  • Congress has called lack of mental health professionals “a workforce crisis.”
  • SAMHSA 2013 Report cited 55% of counties report no practicing mental health professionals and 77% of counties report serious unmet needs.
  • Key professions include psychiatrist (MD + 4 year residency); clinical psychologist (PhD); masters-level professional counselor or marriage and family counselor (masters degree + 2 years experience); and substance abuse counselor (training varies, but masters degree + certification desirable)

For more on types of mental health professionals, see mentalhealthamerica.net,

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Initiatives of SAMHSA, HRSA, to Improve Mental Healthcare (1)

  • Efforts have been made to direct more mental health care to the primary care setting, which increases access but may not provide all patients with appropriate level of specialization
  • Partnership with military to improve culture of awareness and treatment without stigma
  • Training public health, community health workers, and peers in programs such as SBIRT: Screening, Brief Intervention, and Referral to Treatment, to catch substance use problems early and refer to treatment before severe consequences occur

Federal collaborations: see more at https://www.samhsa.gov/samhsaNewsLetter/Volume_22_Number_4/building_the_behavioral_health_workforce/

Integrating primary and mental health care: See more at https://www.samhsa.gov/integrated-health-solutions. SBIRT: see more at https://www.integration.samhsa.gov/clinical-practice/sbirt

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Initiatives of SAMHSA, HRSA, to Improve Mental Healthcare (2)

  • Fellowships and other partnerships with institutions of higher education, medical schools, and residencies, to increase interest in careers treating mental health and substance use conditions

https://www.samhsa.gov/samhsaNewsLetter/Volume_22_Number_4/building_the_behavioral_health_workforce/

For more on workforce expansion grants, see: https://www.samhsa.gov/newsroom/press-announcements/201706211200

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Ongoing Issues and Needs

  • Reduce stigma
  • Improve awareness and recognition
  • Improve scientific evidence base for improving treatments, including culturally tailored treatments
  • Train more professionals, especially those specializing in children and adolescents
  • Reduce barriers to entering treatment, including structural and financial barriers
  • Support family and caregiver needs

Derived from Executive Summary: A Report of the Surgeon General on Mental Health, released 1999, retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1308561/pdf/pubhealthrep00023-0091.pdf

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