AN INTRODUCTION TO PUBLIC MENTAL HEALTH

DATE TOPIC FACULTY

Jul 4 HOLIDAY

Jul 11 OVERVIEW: History and Principles Schmidt

Jul 18 OVERVIEW: Challenges and Policy Issues Alden

Jul 25 The Public Mental Health System in Utah/

Clubhouse Model of Psychosocial Rehab Bachman/Winn et al

Aug 1 The impact of family members and other advocacy groups Baker/Cottrell/Nelson

Aug 8 Managed Care/ Valley Mental Health Dangerfield

Aug 15 Site Visit to Utah State Hospital ** Spencer/Chilton

Aug 22 Site Visit to a Mental Health Center ** Alden, Schmidt

Aug 29 Case Presentation/The Future: discussion Schmidt/Alden/Wander

** PLEASE NOTE: Meet at UNI promptly at 8:45AM and expect to return at 4:00PM!

PUBLIC MENTAL HEALTH CHALLENGES AND POLICY ISSUES

Meredith Alden, Ph.D., M.D.

2001

Serious and persistent mental illness (SPMI)

People with SPMI have been the primary target population for public mental health. People with SPMI have major mental illness such as schizophrenia or major affective disorder that may cause functional impairment in social and/or vocational performance.

The demographics of people with SPMI have changed as the population as a whole has changed. The “graying of America” is reflected in the increased average age of state hospital residents. Also the “baby boom” generation includes a large number of people in their 40’s and 50’s who developed major mental illness 20-30 years ago and still need considerable social, vocational, housing and medical support. Also, these people often now have children of their own. Little has been done to research prevention and support needs for this new generation, which has both biological and environmental risks for mental illness.

Younger people with SPMI tend to have stormier courses with more bizarre, active symptomatology whereas in older individuals the so-called “negative” symptoms predominate. Newly diagnosed patients need intensive education about their illness and should get aggressive psychosocial habilitation to support their developmental challenges to achieve personal goals and become productive members of society. Unfortunately, the economics of mental health care do not favor such an intensive, proactive approach at the onset of serious mental illness. Instead, our system spends more money on more restrictive care after chronicity and functional impairment are a well-established pattern.

The new generation of “atypical” antipsychotic medication has promise to change significantly the course of major mental illness. Greater efficacy and less objectionable side-effect profiles can improve adherence to recommended treatment and therefore reduce relapse and the risk of deterioration in functioning over time. Policy makers who build the public mental health system of care must therefore consider that the characteristics and needs of the target population may change over time.

Housing issues

Deinstitutionalization, permitted by the discovery of antipsychotics in the 1950’s, was hailed by many as a revolutionary success story. Unfortunately, many people did not comprehend that the state hospitals had fulfilled essential functions beyond treatment for people with serious mental illness. The need for asylum – “a place where one is safe and secure” – was lost in the condemnation of deplorable institutions. Many people with mental illness were turned out into mainstream society lacking basic survival skills. Community support, while a laudable concept, was only that in the 1950’s. Communities lacked systems of support to provide for their new neighbors with mental illness.

As a result, many former state hospital patients lived lives fraught with poverty and victimization. In an effort to help them, some were “transinstitutionalized” to nursing homes. In recent years, community mental health providers have developed more housing options for people with SPMI. In progressive communities (e.g. Salt Lake City), a range of housing alternatives includes supported “independent” living, group home, intermediate care facilities, and adult foster care. But despite such aggressive community placement efforts, there will probably always be a need for some ‘asylum’placements. There is an ongoing debate about how many are needed per 100,000 general population – a rough estimate is 2 –3 per 100,000, which would translate to about 50 people in Utah.

People with serious mental illness who have entered the community mental health system may have housing options that are funded and managed by that system. But people who have these problems and have not accessed community mental health care are at risk for homelessness or housing in the correctional system. In the past decade, our country has seen a tremendous increase in the number of homeless individuals and families. Estimates are that about 30% of homeless people also suffer from mental illness. A number of federal programs have offered grants to communities to develop housing for indigent persons, but unfortunately these programs include no money for mental health services. Thus, there is little economic incentive for community mental health centers to participate in accessing these federal grants: doing so would amount to case-finding without accompanying funding to provide services. An exception to this funding pattern is the PATH (Projects for Assistance in Transition from Homelessness) federal program that provides grants to states to provide mental health services to homeless persons.

Many homeless people with mental illness eventually receive temporary or long term housing and sustenance from the criminal justice system. This results from a combination of factors. First, society has limited tolerance of the severely disordered behavior of people with mental illness. Second, legal restrictions on involuntary hospitalization results in diversion for some people to jails instead of hospitals. Third, people with mental illness often commit minor offenses such as vagrancy and petty theft, which are motivated by their dire straits of poverty and homelessness. Fourth, they often lack the financial and social resources to defend themselves against jail terms imposed for such minor charges.

Continuity of care

During the course of serious mental illness, an individual is likely to need a variety of treatments and treatment settings, depending on the amount of protection and support that is needed during the phase of the illness. During times of increased stress and increased symptomatology including the possibility of dangerousness to self or others, a patient may need the structure and enhanced protection of a hospital. During better times, he or she may be able to live and work in the community with support from family and friends, mental health care providers. In between these most and least restrictive, intensive settings, there is a continuum of care that includes halfway houses supervised apartment living, day treatment, crisis intervention and others. These alternatives help avoid hospitalization. The disadvantages of hospitalization are legion and include loss of freedom, fostering of acculturation to illness instead of recovery, stigmatization, and expense.

But, as noted above, hospitals provide a lot more than psychiatric treatment. Medical care, respite for the family, a tolerant social network, food, clothing and shelter are basic needs that hospitals provide and that must be duplicated in the community if people are to live successfully outside of the hospital. Community mental health centers have taken over responsibility for a lot of these services, but some are still managed through other agencies. For example, food stamps and non-psychiatric medical care are overseen by different government agencies. This division of responsibilities has led to categorization, or fragmentation of services. Different agencies have different rules, different criteria for assessing eligibility. They tend to work independently, with little attempt to coordinate their efforts. Turf issues abound. The agencies may work at cross purposes because of differing conceptions of their missions. This is confusing even for people without mental illness. These problems have led to recognition of the importance of case management. Case managers are specially trained in negotiating the bureaucratic intricacies of financial, health care, housing and other entitlements. They also often provide extensive emotional support. They are dedicated care providers who often invest an extensive amount of time for each person they assist.

Psychosocial rehabilitation

An important principle of rehabilitation of mentally ill people is that disability is not dependent on severity of symptoms. Even people who are actively hallucinating and delusional may be able to work productively and meet their other social responsibilities if they are provided the necessary education and support. However, as noted above, there has not been the necessary support for psychosocial rehabilitation programs. Utah has embraced the clubhouse model of psychosocial rehabilitation. We have ten clubhouses in the state (more per capita than any other state in the nation) as well as a training base. Alliance House in Salt Lake City is one of only five training sites in the U.S. and the only one in the West. The Utah Division of Mental Health has adopted the International Center for Clubhouse Development standards as the quality standard for the state.

Problems in advocacy

Because of the nature of mental illness, consumers of mental health services often don’t articulate and assert their needs. A counterpoint to this is that people without (active symptoms of) mental illness often want people with mental illness segregated from the mainstream, “out of mind, out of sight.” And despite good intentions, public mental health administrators often respond to the economic consumer (taxpayers, insurance and Medicaid payers, and community leaders) rather than the people who are most in need of changes in public mental health policy.

Family members, or “secondary consumers”, have taken an active advocacy role in the past twenty years. The National Alliance for the Mentally Ill in Utah (NAMI Utah) was formed in the early 1980’s and has had representatives on the state planning task force for compliance with federal Public Law 99-660, the state Board of Mental Health and in other policy influencing positions.

The importance of family work as an integral part of care for persons with serious mental illness cannot be overemphasized. Extensive clinical research supports the value of psycho-educational approaches with family members in order to involve them as allies in treatment and decrease the stress of serious mental illness on those who personally struggle with mental illness, as well as those who support them. The out-of-date concept of “schizophrenogenic mothers” did a great injustice to families and is hopefully a thing of the past. Models such as McFarland’s multiple family group therapy (MFG) show promise in utilizing the strengths of families without contributing to blame. Because family members fear a return to blaming, advocacy efforts emphasize the biological interventions and the model to deliver them (P/ACT). The Journey of Hope is a family education course taught by UAMI family volunteers who have completed a special intensive training.

Primary consumers of mental health services are also making themselves heard. Nationally and here in Utah, the consumer movement is changing individual and community perceptions of people with serious mental illness. Depending on the area of the country, there tends to be more (East coast) or less (Midwest) backlash sentiment against mental health providers (especially psychiatrists). Some consumer groups have a primary anti-psychiatry agenda and reject established mental health services as being unnecessary or even harmful. Others, including the consumer groups in Utah, espouse principles of collaboration between consumers and providers with the main goal of empowerment of consumers. The Consumer Affairs Specialist program is a federally funded program administered by the state Division of Mental Health, which provides for a state level consumer advocate based in the Division as well as local consumers in the mental health centers. These consumer advocates are involved in program development, advocacy for enhanced service delivery, settlement of grievances, and support for mental health funding and positive mental health legislation. The mental health consumer movement is arguably the most revolutionary development in public mental health since the discovery of antipsychotic medication. Empowerment of consumers means that they become active participants in treatment planning and rehabilitation rather than the passive recipients of substandard or even abusive treatments that were all too commonplace in the past.

Rural community mental health

Rural populations need psychiatric services but often have poor access. Treatment modalities may be limited by a small staff. Residential and hospital facilities may be particularly scarce. Excessive distances may limit aggregation of patients for day treatment or clubhouse programs. Young adult persons with serious mental illness are often highly visible in rural sites and they may resist using services that further identify them as mental patients.

Mental health professionals usually have to be service generalists and they often suffer from professional isolation. They may lack peer support and opportunities for professional and personal growth. Workloads may be excessive and financial rewards minimal.

Despite these challenges, rural mental health has some advantages. There is often a stronger sense of community responsibility for mentally ill residents. It is easier to know and nurture the relationships with the key players who orchestrate social services in a small community. For example, being responsive to and on a first-name basis with the local sheriff can often help resolve conflict between law enforcement and a mentally ill offender much more expeditiously and inexpensively than can be done in the city.

Mental health needs of children and youth

38% of Utah’s population is under the age of 18. About 10% of children and youth are seriously emotionally disturbed (SED), which means about 60,000 SED children in this state. Only a few thousand are treated by the public mental health system.

In Utah and nationwide, services for SED children and youth have lagged behind those for adults. Public mental health has a history of committing services to chronically mentally ill adults but has only recently begun to dedicate resources to children and youth. A full continuum of care is lacking, and until recently, children were treated only in hospitals or outpatient clinics. A full range of services would include in home services, after school and day treatment, therapeutic foster care, respite care, crisis intervention, and non-hospital residential treatment. However, financing such a comprehensive system of care would cost about $60 million in this state alone. The Utah legislature has appropriated only about $3 million to expand children’s mental health services.

However, the Utah Division of Mental Health is the recipient of a multimillion dollar federal grant to develop wraparound systems of care for children in rural and frontier areas of the state. This is called the Utah Frontiers Project and is the most geographically ambitious federally funded children’s mental health grant. Major challenges of the grant include identifying fiscal and in-kind state matching funds and building permanent sustainability into the project so that it can continue after the federal funding lapses.

It is important to recognize that mental health interventions are more effective the earlier they start; yet most treatment programs are geared to adolescents who have developed a pattern of problem behavior as a result of longstanding emotional disturbance. Also children have important developmental tasks and family connections that must be considered as an integral part of any treatment. Community-based, least restrictive care should be emphasized. Stigmatization and alienation are potential negative outcomes of psychiatric hospitalization that would seem to be especially powerful influences on children, and yet these have not been systematically studied.

Another important consideration for mental health care for young people is how to develop services that are acceptable and effective for youth transitioning into adulthood,. The average age of young adults who move permanently out of their parents’ home in the United States is 26. Yet we emancipate young people from state custody when they turn 18, often with no or minimal ongoing social supports. Furthermore, young people do not typically identify mental health care as a high priority, being more interested in finding a job, housing, social contacts and other concerns that are appropriate to the developmental phase of young adults. SED youth transitioning are a different mental health population than are young adults experiencing the first onset of serious mental illness in their late teens or early 20’s. SED transitioning youth need skill development and support to help the transition into the adult world, and they also need continuing attention to the chronic behavioral and emotional disorders that have challenged them often since early childhood.

Economic challenges and health care reform

Historically there has been better funding for acute, intensive, restrictive and expensive (e.g. hospital) care than for community-based care. Insurance payers and Medicaid cover hospital and outpatient treatment but tend to not pay for the continuum in between. Better education of insurers is needed to persuade them to support the alternatives. Also advocacy is needed to support insurance parity of mental illness. Many “cafeteria plan” health insurances tend to discourage mental health coverage.

Another approach to developing new services as well as keeping costs down is capitated, rather than fee-for-service funding. This system allows for creative development of continuum of care treatment because the provider gets the same fee for each eligible person and thus has a financial incentive to research and use more cost-effective interventions.

An additional complicating factor in the funding of public mental health in this state and in many others is that CMHC’s must find funding for community-based services, but they give up this responsibility if the patient is transferred to state hospital care. In that event, the state assumes the cost of care as long as the patient remains in the state hospital. This situation is a disincentive for CMHC’s to move patients out of the state hospital, and as a result, there has been pressure to increase the number of beds at the state hospital as well as chronic debate over state hospital “bed allocation” to the various CMHC’s. This problem has been partially addressed by allocating beds to greater control of the CMHC’s so that they can budget their resources better.

The United States, and Utah in particular, have seen a proliferation of privately owned hospital chains that have tried to cash in on the “big business” of mental health. The relatively low overhead costs for freestanding mental hospitals (facilities that don’t require expensive operating suites, medical technology, etc.) was attractive to health care entrepreneurs. However, what evolved was a tension between those business enterprises and the third party payers who were asked to fund them. (Often this tension existed within one large corporation -–e.g., Intermountain Health Care, which on the one hand markets and attempts to expand mental health services but on the other hand, tries to keep costs down in its in-house provider organization.) Competition developed between private mental hospitals, and the result of this lack of cooperation and collaboration was an over development of the most restrictive, most expensive end of the continuum of mental health care rather than a filling in of the gaps in the continuum of care. The hospital competitive market has now largely stabilized, and the latest development on the mental health scene is market competition between managed behavioral health care companies. These entities attempt to control costs by limiting their provider pools and steering patients into levels and quantities of service, which are less expensive but also hopefully of good quality. We are beginning to see more emphasis on outpatient and transitional services.

The national health care reform effort has now largely devolved to the state level. Mental health advocates in Utah have formed a consortium to advocate for better mental health insurance coverage. A parity law was passed during the 2000 legislative session. While advocates are rightfully proud of this victory after three years of failed attempts, nevertheless the new law is largely a symbolic victory. Advocates for mental health coverage inclusion in health care reform should help policy makers to understand the following important issues:

1. Neglect of mental health care creates enormous costs in physical health care needs.

2. The needs of individuals challenged by serious mental illness extend far beyond “basic benefits” and include housing, vocational needs, social support, and others. CMHC’s have provided many of these services. Private providers have not heretofore had experience or incentives to assist. Private insurance needs to broaden its basic benefits to include those wraparound support services. Otherwise we will continue to have a dual system of mental health care – private mental health care paid for by insurance premiums of the well off, and public mental health care paid by taxpayers.

3. Federal and matching state Medicaid funds have become a major source for care of persons with serious mental illness. If Medicaid is “reformed” to the point of major cuts, and if as expected, federal entitlements are removed from individuals and block granted to the states, there will likely be a major loss of federal funding for people with serious mental illness. Since it is doubtful that the federal government will “carve out” the SPMI population for special support, financial responsibility for these citizens is likely to revert to states and counties. State health care reform efforts must take this into account.

Outcome research

Those who are asked to fund mental health services deserve to know what they are getting for their money. Insurance payers are demanding accountability as are legislators. Also consumers and family members want to know that treatment is state-of-the-art effective.

Relevant outcome measures vary depending on who is the audience. Legislators and policy makers tend to be most interested in social and vocational functioning, cost-effectiveness and decreased criminality. Family and consumer advocates are more interested in decreased symptomatology and family burden and improved quality of life. Providers want to know if treatment goals have been met and if consumers are satisfied with services.

To be optimally valid and reliable, parties who are independent of the providers should analyze outcome data. However, in the past, community mental health centers have been protective of data because of fear of loss of funding or inappropriate use of the data. The community mental health centers and Division of Mental Health, with support from other state agencies, are now cooperating on a system-wide collection of data on treatment processes and outcomes that provides some standardized, meaningful measures of the public mental health system’s effectiveness. This outcome project provides data regarding quality, access and cost. In addition, the Division of Mental Health’s monitoring process links to this quantitative data set by providing in-depth, case-specific qualitative data.

Evidence-based preferred practices in community mental health

An extensive review of the literature by a team of researchers at Dartmouth, funded by the federal Substance Abuse and Mental Health Services Administration, has determined that there are six practices in community mental health that are proven effective. These are: 1) Programs for Assertive Community Treatment (P/ACT), 2) family psycho-education, 3) supported employment, 4) skills development (in managing aspects of mental illness), 5) integrated treatment for persons with co-occurring mental illness and substance use disorders, and 6) medication algorithms.

Utah has no P/ACT teams that meet strict program criteria.

There are Journey of Hope courses taught around the state as previously mentioned in the section on advocacy; however, this particular model of family psycho-education has not been rigorously studied for efficacy.

Supported employment occurs mainly through clubhouse programs, but collaboration between mental health agencies and the Department of Workforce Services is limited.

Skills for managing mental illness are presented as part of mental health programming in some areas of the state, notably Adult Day Treatment at Valley Mental Health and through the Bridges program, which is a consumer-taught course designed similarly to Journey of Hope, and which is co-sponsored by the Division of Mental Health and NAMI Utah.

Integrated treatment for persons with co-occurring disorders is provided through the CAMI (Chemically Addicted Mentally Ill) program at Valley Mental Health but has not been embraced statewide. Barriers include funding divisions between substance abuse and mental health agencies, lack of cross training of providers, and differences in philosophies.

The Texas Medication Algorithms Project has promise for bringing the public mental health system into consistency with regard to prescribing practices; however, it has not as yet been adopted.

Legal issues

Nationally civil commitment laws are gradually reforming to more protective and “right-to-treatment” principles. There is still a strong force of civil libertarians, however, who see themselves as champions of the individual “liberties” of mentally ill persons and will argue against commitment of all but the most imminently dangerous patients. In Utah, the Disability Law Center has been the most active group advocating for “liberty interests.” It is important to educate lawyers and other non-mental health professionals that effective treatment often cannot be provided without psychotropic medication. Furthermore, persons with serious mental illness often lack insight into their need for care and therefore adequate treatment sometimes requires the legal authority of civil commitment. The object is not to confine but rather to treat and then return the patient to a least restrictive, most productive living situation. In this way, civil commitment seeks to restore meaningful personal liberty by alleviating illness.

The civil commitment statute in Utah was changed during the 1992 legislative session to define treatment as including psychotropic medication when indicated. The due process protections which were also specified were deleted from law during the 1994 session so that institutions are now responsible for developing their own procedures for involuntarily medicating patients. Judicial interpretation, however, has required a medication hearing that is separate from the commitment process. As the initial commitment establishes that the person can be ordered into treatment, and is “unable to engage in rational decision-making”, many believe that this should be sufficient to justify medication orders.

The children’s commitment law was changed in 1996 to create a “due process” that is more family friendly and does not require a change in legal custody. However, the procedures involved are costly and onerous to the public mental health system and, furthermore, do not apply in the private sector hospitals and residential treatment centers, where most of the abuses have occurred.

Recent local tragedies involving mentally ill persons who shot and killed victims in irrational acts of violence have raised anew the issue of the adequacy of the commitment law in Utah. The mental health community appears to be at consensus that the Utah requirement that a person be at immediate risk of physical injury to self or others is too restrictive. The 2001 legislature has asked for a study to review the civil commitment statute and determine if the immediate risk requirement should be revised to “substantial risk in the reasonably foreseeable future” or other similar statutory language.

Involuntary procedures for individuals with organic brain syndromes are also in need of improvement. For example, obtaining emergency treatment for an elderly, demented person may require a petition of involuntary hospitalization. However, not all hospital facilities are licensed to provide involuntary care. The patient may have to be admitted to a locked psychiatric unit rather than one specializing in more appropriate geriatric care.

Right to care in a community setting (Olmstead) – Olmstead is a recent (1999) US Supreme Court decision that addresses the rights of disabled persons to receive services in the community rather than in more restrictive (for example, institutional) settings. It cites Title 23 of the Americans with Disabilities Act. Two people in an institution in Georgia sued the state over their right to receive community-based services. The federal appeals court decided in their favor and State of Georgia took the case to the Supreme Court. The ruling says that states have a duty to provide community-based care but only if the professionals on the case agree and if the client does not object. Also states have several other defenses: 1) they only need to make “reasonable” accommodations, 2) waiting lists are OK if there is a plan in place for eventual community placement, and 3) if the state has a comprehensive plan, plaintiffs can’t sue to try to “get to the top of the list”. There are differing opinions as to whether this decision will move public policy significantly faster. The federal Office for Civil Rights has taken oversight of compliance with the decision and by some accounts may be overbroad in its interpretation and consequent sanctions against states. This may encourage state funding of community-based care or it may result in backlash by states against perceived federalism.

Kansas v. Hendricks – This 1997 Supreme Court decision has called into question issues of appropriateness of civil commitment (to mental health facilities) of persons who have committed sex crimes. The decision came in the wake of prosecution of a serial sex crimes perpetrator, who confessed/stated that he would not be able to refrain from re-victimization if not confined. Some states (not yet Utah) have created special institutionally based mental health programs for sexual perpetrators. Policy questions include: 1) whether these offenders suffer from mental illness that is treatable, 2) if these programs will have positive outcomes for perpetrators and potential victims, 3) whether confinement in mental institutions will result in ‘transinsitutionalization’ of criminals into hospitals, thereby invading and diminishing limited mental health resources, 4) if including sex crimes in the lexicon of mental illnesses removes personal responsibility (as some perpetrators have reported) and, therefore, dedication to rehabilitation.

Welfare reform

Under federal welfare reform states must move people off of the welfare rolls more quickly. There is a lifetime benefits cap of at most 5 years. (In Utah it is 3 years.) This means that there is great pressure to help people gain job skills and provide them with necessary supports such as childcare. However, there is a 20% of total caseload exclusionary provision, which says that the state may have a plan to keep some persons on welfare indefinitely. It is important to strike a balance between protecting the welfare entitlements of persons who are incapacitated by their mental illnesses and at the same time respecting principles of recovery and the ability of many persons with serious mental illness to recover to the point where they can reach gainful employment. This may require special supports such as job coaching and other psychosocial rehab programs.

Forensic issues

A new 100 bed forensic hospital was opened in 1999 on state hospital grounds. This facility is now fully staffed and is a great improvement over previous deteriorating and non-secure buildings. This hospital cares for persons who are being evaluated for competency to stand trial, those who need to have their competency restored before trial, and a few individuals who have been found guilty and mentally ill.

In recent years, the Department of Corrections has come under criticism for its treatment of mentally ill offenders. Use of a physical restraint chair for an inmate with schizophrenia resulted in the death of that inmate from a pulmonary embolus. Mental health and civil rights advocates have expressed concern about the quality of mental health care in the prison and lack of formal external oversight. A new mental health facility at the prison is providing specialized care for those inmates with mental illness who need to be segregated from the general prison population because of the severity of their illness. The Department of Corrections and the Division of Mental Health have increased their collaboration recently in an effort to develop treatment standards and staffing guidelines that are more consistent between the state hospital and the state prison.

Regulatory pressures

Many different agencies dictate standards to mental health care providers. These regulatory agencies include professional organizations, third party payers, state and federal government agencies, advocacy groups, and institutional organizations. All of them have rules and regulations that both limit the activities of providers and inundate them with paperwork. The regulatory agencies were of course developed to correct the abuses suffered by mentally ill consumers. However, in many cases enforcement of standards has resulted in loss of beneficial programs. For example, staffing ratio requirements in hospital settings have resulted in reallocation of special program dollars for staff salaries. Limitations on the work that patients can provide for upkeep of the physical plant have caused the loss of some vocational training opportunities. And of course, energy, time and money spent on meeting “paperwork” standards takes away from direct service to consumers.

Cultural competency

There is growing respect for the variety of cultural beliefs and attitudes that influence the course of mental illness. Utah is more ethnically and culturally homogenous than most other states. However, the large Native American population in southeastern Utah and the extensive Hispanic, African American, Asian and Pacific Islander populations on the Wasatch front are examples of groups with different cultural orientations to mental illness. Public mental health is challenged to recruit and train care providers who can communicate in both the language and culture of minority groups.

“Dual diagnosis”

Co-occurring mental illness and substance abuse

According to the National Co-Morbidity Study, up to 10 million persons in the United States have a mental disorder and substance-related disorder in any given year. 51% of those with a mental disorder have a co-occurring addictive disorder (47% of those with schizophrenia and 61%of those with bipolar disorder). Estimates ‘from the field’ suggest that 80% of persons with a ‘primary diagnosis’ of serious mental illness have a co-occurring substance abuse disorder; and at least 50% of people presenting with substance abuse/dependency have a diagnosable mental disorder. Current definitions of best practice emphasize that mental health and substance abuse treatment should be integrated and concurrent; yet providers are usually not equipped to do this. Funding and organizational divisions exist from the federal level through the state and local to the provider level. Training curricula are significantly different between substance abuse treatment and mental health/therapy programs. The differences arise from philosophical differences in worldview, training of professionals including assumptions about etiology, best treatment and individual responsibility.

Mentally ill/developmentally disabled persons

These people have been underestimated and under served chronically. Mental health treatment is generally considered an entitlement, yet public mental health programs have never been funded to serve more than those in the most extreme need of treatment. Furthermore, psychiatrists and therapists receive little training on the assessment and treatment of those with developmental disorders, and few programs have been developed to treat those with co-occurring conditions. Services to persons with disabilities, on the other hand, have not been defined as an entitlement, but rather an “add-on” service for the relatively few who qualify based on severity of need and time on the waiting list. These programs conversely often lack the expertise for psychiatric and therapeutic management of the psychiatric component of the developmental disability. These factors combined result in a large population that is not only unfunded, but for whom there is limited treatment technology or clinical expertise. These individuals often enter the system because they have committed crimes of impulse control such as sexual perpetration, or have become a public nuisance. Barriers to needed program development and coordination include lack of trained clinical staff, poor understanding about missions, operations and funding of the two major service systems (public mental health and Division of Services for People with Disabilities), and lack of necessary funding to build service capacity.

Axis II conditions

When severe enough, Axis II conditions qualify under state definitions of serious and persistent mental illness. Persons with diagnoses of personality disorders represent a significant portion of those being treated in the public mental heath system, and they may require intensive services and a disproportionate share of staff time. Yet within the mental health system there is sometimes resentment that these individuals, who may be high users of service and often generate intense affect among treatment staff, are not suffering from “true” mental illness. Outside the Utah treatment system, federal grant opportunities and knowledge development efforts often overlook or specifically exclude this population. Advocacy organizations, notably the National Alliance for the Mentally Ill, are focussing on the “biological conditions” and emphasizing that mental illness is not the fault of the families. They are resistant to address equally the personality disorders when many of those with these diagnoses have trauma and abuse histories.

A notable exception is that borderline personality disorder has been embraced by NAMI as a high priority for research and treatment. Additionally, the Utah Division of Mental Health is the recipient of a federal grant to bring the public mental health system to consensus over adoption of Dialectical Behavior Therapy as the treatment of choice for borderline personality disorder. The grant provides funds for training of mental health professionals in this therapeutic model.

Medical records confidentiality

The Health Insurance Portability Act of 1996 required Congress to pass legislation to address medical records privacy. Up to now there has been no federal law addressing medical records – this has been left to the states. However, with electronic record-keeping, a mobile national population, and managed care pressure to have access to medical data in order to contain costs, there is increasing concern about privacy. Federal bills that have been proposed typically do not adequately address the especially sensitive nature of mental health records and do not address the special considerations for persons who are civilly committed (that is, that public agencies are responsible to care for committed persons and need to be able to share information in order to coordinate care.)

Seclusion and restraint

In October of 1998, the Hartford Courant ran a series of investigative reports detailing specific cases of deaths in inpatient psychiatric units resulting from the use of restraints or “therapeutic holds.” The reports revealed that a least 142 persons have died in the past decade, many of them children and youth in private hospitals or residential facilities. The outcry from advocacy organizations, such as NAMI, and attention from national organizations (e.g., the Medical Directors Division of the National Association of State Mental Health Program Directors, JCAHO, Healthcare Financing Administration) has furthered the debate, and is resulting in specific efforts to reduce and eliminate the use of seclusion/restraint. Within the debate is the growing awareness, strengthened by testimonials from consumers, that the practice of secluding or mechanically restraining psychiatric patients revivifies past trauma/abuse.

In Utah a panel commissioned by the Division of Mental Health is developing preferred practices for the prevention, proper application, assessment and quality improvement of seclusion/restraint practices.

Recovery philosophy versus medical model

Since the deinstitutionalization movement of the 60’s and 70’s, a new philosophy towards mental illness has been developing, led by the consumer movement, known as recovery. The philosophy of recovery is analogous to the third stage of grief reactions: understanding, acceptance and action. The philosophy differs from the medical model in some important ways: 1) Treatment, programs and mental health professionals cannot “cure” the illness, their role is to facilitate recovery, which is what the person with the disability does, 2) The person can recover even if the illness cannot be removed, 3) The person focuses on new meaning and purpose in life rather than symptom reduction, 4) Rather than a clinical entity, recovery is a universal human experience with a course that is unique to each individual.

Human services needs

Public mental health has had a reputation in the past for being understaffed and ‘second rate.’ However, people with serious mental illness are often best served in the public mental health system. There are many rewards for psychiatrists in the public sector. These include being part of a multi-disciplinary team in clinical decision making, clinical research, teaching and scholarship, and influencing public mental health policy.

Purpose and Scope