The organization of services for adults with severe mental disorders is the linchpin of effective treatment. Since many mental disorders are best treated by a constellation of medical and psychosocial services, it is not just the services in isolation, but the delivery system as a whole, that dictates the outcome of treatment (Goldman, 1998b). Access to a delivery system is critical for individuals with severe mental illness not only for treatment of symptoms but also to achieve a measure of community participation.
Among the fundamental elements of effective service delivery are integrated community-based services, continuity of providers and treatments, and culturally sensitive and high-quality, empowering services (Mowbray et al., 1997; Lehman & Steinwachs, 1998a). Effective service delivery also requires support from the social welfare system in the form of housing, job opportunities, welfare, and transportation (Goldman, 1998a), issues that are discussed in the final section of this chapter.
What models of service delivery are most effective? This section strives to answer this question by focusing on models of service delivery for individuals with severe and persistent mental disorders, including severe depression and bipolar disorder, as well as schizophrenia. Although adults with mental illness in midlife confront many service delivery issuesfor example, the problem of proper identification and treatment of depression in primary care settingsthose who are most disabled by mental disorders encounter special service delivery problems. The focus on the most disabled is warranted for three reasons: (1) Society has a special obligation to those who are most impaired and consequently are the least well off (Callahan, 1999; Goldman, 1999; Rosenheck, 1999); (2) the body of research on mental health services delivery for this population is extensive; and (3) existing service systems are seriously deficient.
The deficiency of existing service systems is best documented for individuals with schizophrenia. The majority of people with schizophrenia do not receive the treatment and support they need, according to a groundbreaking finding of PORT (Lehman & Steinwachs, 1998a). PORT, as noted earlier, developed a series of basic treatment recommendations after reviewing hundreds of outcome studies. It proceeded to determine whether these recommendations were being met by examining current patterns of care in two states in the United States.
Among those with severe mental disorders, any number of special populations might have been the focus for this section. These special populations have severe mental disorders and HIV/AIDS (Cournos & McKinnon, 1997); are involved in the criminal justice system (Abram & Teplin, 1991; CMHS, 1995; Lamb & Weinberger, 1998); or have somatic health problems (Berren et al., 1994; Felker et al., 1996; Brown, 1997). Although some of what follows may be relevant to the unique needs of each of these groups, the evidence base is less well developed.
The remainder of this section focuses on case management, assertive community treatment, psychosocial rehabilitation services, inpatient hospitalization and community alternatives for crisis care, and combined treatment for people with the dual diagnosis of substance abuse and severe mental illness.
The purpose of case management is to coordinate service delivery and to ensure continuity and integration of services. Case managers engage in a variety of activities, ranging from simple roles in locating services to more intensive roles in rehabilitation and clinical care. The less intensive models of case management seem to increase clients links to, and use of, other mental health services at relatively modest cost. More intensive models also appear to help clients to increase daily-task functioning, residential stability, and independence, and to reduce their hospitalizations (Borland et al., 1989; Mueser et al., 1998a). Overall, models that focus on specific outcomes are more effective than those with global, vaguely defined goals (Attkisson et al., 1992).
More programs are beginning to employ mental health consumers as case managers in their multidisciplinary staff. Results have been positive, but the programs are challenging to implement and require ongoing supervision as do all case management programs (Mowbray et al., 1996). In a controlled study, clients served by case management teams, along with consumers as peer-specialists, displayed greater gains in several areas of quality of life and greater reductions in major life problems, as compared with two comparison groups of clients served by case management teams without peer-specialists (Felton et al., 1995). One randomized clinical trial compared case management teams wholly staffed by consumers versus case management teams staffed by nonconsumers. The study (at 1-year and 2-year followup) found that clients improved equally well with consumer and nonconsumer case managers (Solomon & Draine, 1995). In this series of studies, the case management teams were part of an intensive program of services known as assertive community treatment.
Assertive community treatment is an intensive approach to the treatment of people with serious mental illnesses that relies on provision of a comprehensive array of services in the community. The model originated in the late 1970s with the Program of Assertive Community Treatment in Madison, Wisconsin (Stein & Test, 1980). Fueled by deinstitutionalization and the vital need for community-based services, a multidisciplinary team serving psychiatric inpatients adapted its role to patients in the community. For this reason, assertive community treatment often is likened to a hospital without walls.
The hallmark of assertive community treatment is an interdisciplinary team of usually 10 to 12 professionals, including case managers, a psychiatrist, several nurses and social workers, vocational specialists, and more recently includes substance abuse treatment specialists and peer specialists. Assertive community treatment also possesses these features: coverage 24 hours, 7 days per week; comprehensive treatment planning; ongoing responsibility; staff continuity; and small caseloads, most commonly with 1 staff member for every 10 clients (Scott & Dixon, 1995b). Because of the intensity of services, assertive community treatment is most cost-effective when targeted to individuals with the greatest service need, particularly those with a history of multiple hospitalizations (Scott & Dixon, 1995b; Lehman & Steinwachs et al., 1998a).
Randomized controlled trials have demonstrated that assertive community treatment and similar models of intensive case management substantially reduce inpatient service use, promote continuity of outpatient care, and increase community tenure and residence stability for people with serious mental illnesses (Stein & Test, 1980; Bond et al., 1995; Lehman, 1998; Mueser et al., 1998a). Among the beneficiaries are homeless individuals and those with substance abuse problems and mental disorders. Evidence of effectiveness is weaker for other outcomes (e.g., social integration, employment) and for amelioration of substance abuse problems associated with schizophrenia, particularly when combined treatment is not offered (Mueser et al., 1998b). Assertive community treatment models are generally popular with clients (Stein & Test, 1980) and family members (Flynn, 1998). There also are some preliminary results suggesting that employing peer (i.e., consumer) or family outreach workers on the multidisciplinary assertive community treatment teams increases positive outcomes (Dixon et al., 1997, 1998) and creates more positive attitudes among team members toward people with mental illnesses.
As noted above, there are a range of multicomponent programs called psychosocial rehabilitation services that are distinct from the single component skills training interventions described in the section on interventions for schizophrenia. These psychosocial rehabilitation programs combine pharmacologic treatment, independent living and social skills training, psychological support to clients and their families, housing, vocational rehabilitation, social support and network enhancement, and access to leisure activities (WHO, 1997). Randomized clinical trials have shown that psychosocial rehabilitation recipients experience fewer and shorter hospitalizations than comparison groups in traditional outpatient treatment (Dincin & Witheridge, 1982; Bell & Ryan, 1984). In addition, recipients are more likely to be employed (Bond & Dincin, 1986). Cook & Jonikas (1996) review the outcomes of a wide range of psychosocial rehabilitation programs, including Fairweather lodges (Fairweather et al., 1969) and psychosocial clubhouses (Dincin, 1975), some of which were demonstrated as effective 20 and 30 years ago but have not been widely implemented.
The role of psychiatric hospitalization has changed greatly over recent decades, stemming from the recognition of poor and occasionally abusive conditions, excessive patient dependency, and patients loss of connection to the community (Wing, 1962; Gruenberg, 1974). More recent evolution in hospitalization traces to changes in the financing of care and the introduction of new medications (Appleby et al., 1993; Bezold et al., 1996). Community-based alternatives for crisis care services began to flourish in lieu of hospitalization (Fenton et al., 1998; Mosher, 1999).
The new priorities of psychiatric hospitalization focus on ameliorating the risk of danger to self or others in those circumstances in which dangerous behavior is associated with mental disorder, and the rapid return of patients to the community (Sederer & Dickey, 1995). Inpatient units are seen as short-term intensive settings to contain and resolve crises that cannot be resolved in the community. For this reason, inpatients are commonly suicidal, homicidal, or decompensating (experiencing the rapid return of severe symptoms) to the degree that they cannot care for themselves or respond to community-based services. Inpatient services therefore emphasize safety measures, crisis intervention, acute medication and reevaluation of ongoing medications, and (re)establishing the clients links to other supports and services (Sederer & Dickey, 1997).
Mobile crisis services have developed in many urban areas to prevent hospitalization (Zealberg 1997), as have day hospital programs. With crisis services, a multidisciplinary team comes directly to the aid of the client in the community to provide immediate evaluation and services. This new conceptualization of inpatient care and crisis intervention services minimizes the use of hospital resources; however, well-coordinated teams, sufficient community programs, and ready linkages are not widely available, particularly in rural and frontier areas.
African Americans and Native Americans are overrepresented in psychiatric inpatient units in relation to their representation in the population (Snowden & Cheung, 1990; Snowden, in press). Overrepresentation is found in hospitals of all types except private psychiatric hospitals. The reasons for this disparity, while not completely understood, may reflect a mix of limited access to outpatient services and differences in cultural patterns of help-seeking behavior and overt discriminatory practices. Cost, disinclination to seek help, and lack of community support may contribute to patients delay in seeking treatment until symptoms are severe enough to warrant inpatient care. Clinician bias may also be at work. Cultural differences in treatment seeking and treatment utilization are discussed in greater detail in Chapter 2.
As many as half of people with serious mental illnesses develop alcohol or other drug abuse problems at some point in their lives (Mueser et al., 1990; Regier et al., 1993; Drake & Osher, 1997). Theories to explain comorbidity (also known as dual diagnosis) range from genetic to psychosocial, but empirical support for any one theory is inconclusive (Kosten & Ziedonis, 1997; Mueser et al., 1998b). In short, the cause of such widespread comorbidity is unknown.
Comorbidity worsens clinical course and outcomes for individuals with mental disorders. It is associated with symptom exacerbation, treatment noncompliance, more frequent hospitalization, greater depression and likelihood of suicide, incarceration, family friction, and high services, use, and cost (Bartels et al., 1995; Mueser et al., 1997a; Bellack & Gearon, 1998; Havassy & Arns, 1998). Furthermore, patients may be jeopardized by the consequences of substance abuse, namely, increased risk of violence, HIV infection, and alcohol-related disorders (IOM, 1995).
In light of the extent of mental disorder and substance abuse comorbidity, substance abuse treatment is a critical element of treatment for people with mental disorders. Likewise, treatment of symptoms and signs of mental disorders is a critical element of recovery from substance abuse. Yet decades of treating comorbidity through separate mental health and substance abuse service systems proved ineffective (Ridgely et al., 1990; Mueser et al., 1997a).
Research amassed over the past 10 years supports a shift to treatment that combines interventions directed simultaneously to both conditionsthat is, severe mental illness and substance abuseby the same group of providers (Kosten & Ziedonis, 1997; for an example, see Mowbray et al. 1995), but access to such treatment remains limited. Most successful models of combined treatment include case management, group interventions (such as persuasion groups and social skills training), and assertive outreach to bring people into treatment (Mueser et al., 1997a). They typically take into account the cognitive and motivational deficits that characterize serious mental illnesses (Bellack & Gearon, 1998), although many providers still need to be educated (Kirchner et al., 1998). Combined treatment is effective at engaging people with both diagnoses in outpatient services, maintaining continuity and consistency of care, reducing hospitalization, and decreasing substance abuse, while at the same time improving social functioning (Miner et al., 1997; Mueser et al., 1997a).
Although there is little evidence for any particular approach to combining treatments for comorbidity (Ley et al., 1999), recent research suggests that services incorporating behavioral (motivational) approaches to substance abuse treatment are superior to traditional 12-step approaches (e.g., Alcoholics Anonymous) with this population of clients (Drake et al., 1998). This may be because the more structured behavioral methods better accommodate the cognitive difficulties that accompany schizophrenia. Others, however, find self-help interventions tailored to dual-diagnosis clients quite useful (Vogel et al., 1998). Current research also is seeking to tailor combined treatment to the needs and preferences of specific patient subgroups, such as men, women (Alexander, 1996), people with addiction to multiple substances (as opposed to alcohol addiction alone), and people with histories of physical and psychological trauma (Mueser et al., 1997a).