Overview of Mental Health Services

Over the past three centuries, the complex patchwork of mental health services in the United States has become so fragmented that it is referred to as the de facto mental health system (Regier et al., 1993b). Its shape has been determined by many heterogeneous factors rather than by a single guiding set of organizing principles. The de facto system has been characterized as having distinct sectors, financing, duration of care, and settings (see Figure 2-4).

The four sectors of the system are the specialty mental health sector, the general medical/primary care sector, the human services sector, and the voluntary support network sector. Specialty mental health services include services provided by specialized mental health professionals (e.g., psychologists, psychiatric nurses, psychiatrists, and psychiatric social workers) and the specialized offices, facilities, and agencies in which they work. Specialty services were designed expressly for the provision of mental health services. The general medical/primary care sector consists of health care professionals (e.g., family physicians, nurse practitioners, internists, pediatricians, etc.) and the settings (i.e., offices, clinics, and hospitals) in which they work. These settings were designed for the full range of health care services, including, but not specialized for, the delivery of mental health services. The human services sector consists of social welfare, criminal justice, educational, religious, and charitable services. The voluntary support network refers to self-help groups and organizations. These are groups devoted to education, communication, and support, all of which extend beyond formal treatment.

Financing of the de facto system refers to the payer of services. The system is often described as being divided into a public (i.e., government) and a private sector. The term “public sector” refers both to services directly operated by government agencies (e.g., state and county mental hospitals) and to services financed with government resources (e.g., Medicaid, a Federal-state program for financing health care services for people who are poor and disabled, and Medicare, a Federal health insurance program primarily for older Americans and people who retired early due to disability). Publicly financed services may be provided by private organizations. The term “private sector” refers both to services directly operated by private agencies and to services financed with private resources (e.g., employer-provided insurance).

The duration of care is divided between services for the treatment of acute conditions and those devoted to the long-term care of chronic (i.e., severe and persistent) conditions, such as schizophrenia, bipolar disorder, and Alzheimer’s disease. The former, provided in psychiatric hospitals, psychiatric units in general hospitals, and in beds “scattered” in general hospital wards, includes brief treatment-oriented services. Long-term care includes residential care as well as some treatment services. Residential care is often referred to as “custodial,” when supervised living predominates over active treatment.

The settings for care and treatment include institutional, community-based, and home-based. The former refers to facilities, particularly public mental hospitals and nursing homes, which usually are seen by patients and families as large, regimented, and impersonal. They often are removed from the community by distance and frequency of contact with friends and family. In contrast, community-based services are close to where patients or clients live. Services are typically provided by community agencies and organizations. Home-based services include informal supports provided in an individual’s residence.

Chapter 6 examines the impact of recent changes in financing and organizing services on access and quality of care. Many of these issues also are addressed in Chapters 3 to 5, where they are discussed in the context of care and treatment at each stage of the life cycle. The following material provides general information on current patterns of use and focuses on the historical origins of mental health services.

Overall Patterns of Use

According to recent national surveys (Regier et al, 1993b; Kessler et al., 1996), a total of about 15 percent of the U.S. adult population use mental health services in any given year. Eleven percent receive their services from either the general medical care sector or the specialty mental health sector, in roughly equal proportions. In addition, about 5 percent receive care from the human services sector, and about 3 percent receive care from the voluntary support network. (The overlap across these latter two sectors accounts for these figures totaling more than 15 percent.)

Slightly more than half of the 15 percent of the adult population that use mental health services have a diagnosable mental or addictive disorder (8 percent), while the remaining portion has a mental health problem (7 percent). Bearing in mind that 28 percent of the population have a diagnosable mental or substance abuse disorder, only about one-third with a diagnosable mental disorder receives treatment in 1 year (Figure 2-5). In short, this translates to the majority of those with a diagnosable mental disorder not receiving treatment.

Similarly, about 21 percent of the child and adolescent population use mental health services annually. Nine percent receive care from the health care sector, almost exclusively from the specialty mental health sector. Seventeen percent of the child and adolescent population receive care from the human services sector, mostly in the school system, yet there is much overlap with the health sector (again accounting for the sum being more than 21 percent). The distribution of those who do and do not currently meet diagnostic criteria for a mental disorder is similar to that for adults (Figure 2-6).

History of Mental Health Services

The history of mental health services in the United States has been chronicled by historian Gerald N. Grob in a series of landmark books from which this account is drawn (Grob, 1983, 1991, 1994). The origins of the mental health services system coincide with the colonial settlement of the United States. Individuals with mental illness were cared for at home until urbanization induced state governments to confront a problem that had been relegated largely to families. The states’ response was to build institutions, known first as asylums and later as mental hospitals. When the Pennsylvania Hospital opened in Philadelphia in the mid-18th century, it had provisions for individuals with mental illness housed in its basement. Also in the mid-18th century, colonial Virginia was the first state to build an asylum for mentally ill citizens, which it constructed in its capital at Williamsburg. If not cared for at home or in asylums, those with mental illness were likely to be found in jails, almshouses, work houses, and other institutions. By the time of the Revolutionary War, the beginnings were in place for each of the four sectors of the de facto mental health system.

The origins of treatment for mental illness in the general medical/primary care sector can be traced to the Pennsylvania Hospital. The origins of specialty mental health care can be traced to the Williamsburg asylum. Home care, the most common response to mental illness, probably became a part of the voluntary support network, whereas the human services sector was by far the most common organized or institutional response, by placing individuals in almshouses (homes for the poor) and work houses. The first form of treatment—known as “moral treatment”—was not given until the very end of the 18th century, after the Revolutionary War.

Figure 2-5a. Annual prevalence of mental/addictive disorders and services for adults

Figure 2-5b. Annual prevalence of mental/addictive disorders and services for adults

Figure 2-6a. Annual prevalence of mental/addictive disorders for children

Figure 2-6b. Annual prevalence of mental/addictive disorders for children

An era of “moral treatment” was introduced from Europe at the turn of the 19th century, representing the first of four reform movements in mental health services in the United States (Morrissey & Goldman, 1984; Goldman & Morrissey, 1985) (Table 2-10).

The first reformers, including Dorothea Dix and Horace Mann, imported the idea that mental illness could be treated by removing the individual to an asylum to receive a mix of somatic and psychosocial treatments in a controlled environment characterized by “moral” sensibilities. The term “moral” had a connotation different from that of today. It meant the return of the individual to reason by the application of psychologically oriented therapy¹⁹ (Grob, 1994). The “moral treatment” period was characterized by the building of private and public asylums. Almost every state had an asylum dedicated to the early treatment of mental illness to restore mental health and to keep patients from becoming chronically ill. Moral treatment accomplished the former objective, but it could not prevent chronicity.

Shortly after the Civil War, the failures of the promise of early treatment were recognized and asylums were built for untreatable, chronic patients. The quality of care deteriorated in public institutions, where overcrowding and underfunding ran rampant. A new reform movement, devoted to “mental hygiene,” began late in the 19th century. It combined the newly emerging concepts of public health (which at the time was referred to as “hygiene”), scientific medicine, and social progressivism. Although the states built the public asylums, local government was expected to pay for each episode of care. To avoid the expense, many communities continued to use local almshouses and jails. Asylums could not maintain their budgets, care deteriorated, and newspaper exposés revealed inhuman conditions both in asylums and local welfare institutions. State Care Acts were passed between 1894 and World War I. These acts centralized financial responsibility for the care of individuals with mental illness in every state government. Local government took the opportunity to send everyone with a mental illness, including dependent older citizens, to the state asylums. Dementia was redefined as a mental illness, although only some of the older residents were demented. For the past century the states have carried this responsibility at very low cost, in spite of the magnitude of the task.

The reformers of the “mental hygiene” period, who formed the National Committee on Mental Hygiene (now the National Mental Health Association [NMHA]), called for an expansion of the new science, particularly of neuropathology, in asylums, which were renamed mental hospitals. They also called for “psychopathic hospitals and clinics” to bring the new science to patients in smaller institutions associated with medical schools. They opened several psychiatric units in general hospitals to move mental health care into the mainstream of health care. The mental hygienists believed in the principles of early treatment and expected to prevent chronic mental illness. To support this effort, they advocated for outpatient treatment to identify early cases of mental disorder and to follow discharged inpatients.

Treatments were not effective. Early treatment was no more successful in preventing patients from becoming chronically ill in the early 20th century than it was in the early years of the previous century. At best, the hospitals provided humane custodial care; at worst, they neglected or abused the patients. Length of stay did begin to decline for newly admitted inpatients, but older, long-stay patients filled public asylums. The financial problems and overcrowding deepened during the Depression and during World War II.

Enthusiasm for early interventions, developed by military mental health services during World War II, brought a new sense of optimism about treatment by the middle of the 20th century. Again, early treatment of mental disorders was championed and a new concept was born, “community mental health.” The NMHA figured prominently in this reform, along with the Group for the Advancement of Psychiatry. Borrowing some ideas from the mental hygienists and capitalizing on the advent of new drugs for treating psychosis and depression, community mental health reformers argued that they could bring mental health services to the public in their communities. They suggested that long-term institutional care in mental hospitals had been neglectful, ineffective, even harmful. The joint policies of “community care” and “deinstitutionalization” led to dramatic declines in the length of hospital stay and the discharge of many patients from custodial care in hospitals.

Table 2-10. Historical reform movements in mental health treatment in the United States

Sources: Morrissey & Goldman, 1984; Goldman & Morrissey, 1985.

Concomitantly, these policies led to the expansion of outpatient services in the community, particularly in federally funded community mental health centers. Federal legislation beginning in the mid-1960s fueled this expansion through grants to centers and then through the inclusion of some (albeit limited) mental health benefits in Medicare and Medicaid. The latter was particularly important, because it stimulated the transfer of many long-term inpatients from public mental hospitals to nursing homes, encouraged the opening of psychiatric units in general hospitals, and ultimately paid for many rehabilitation services for individuals with severe and persistent mental disorders.

The dual policies of community care and deinstitutionalization, however, were implemented without evidence of effectiveness of treatments and without a social welfare system attuned to the needs of hundreds of thousands of individuals with disabling mental illness. Housing, support services, community treatment approaches, vocational opportunities, and income supports for those unable to work were not universally available in the community. Neither was there a truly welcoming spirit of community support for “returning” mental patients. Many discharged mental patients found themselves in welfare and criminal justice institutions, as had their predecessors in earlier eras; some became homeless or lived in regimented residential (e.g., board and care) settings in the community.

The special needs of individuals with severe and persistent mental illness were not being met (General Accounting Office, 1977; Turner & TenHoor, 1978). Early treatment did not prevent disability, although new approaches to treatment would eventually reduce morbidity and improve quality of life. A fourth reform era (1975–present), called the “community support” movement, grew directly out of the “community mental health movement.” This new reform movement called for an end to viewing and responding to chronic mental disorder only as the object of neglect, by favoring acute treatment and prevention. Reformers advocated for developing “community support systems,” with an expanded vision of care and treatment as encompassing the social welfare needs of individuals with disabling mental illness. The emphasis favored the view that individuals could once again become citizens of their community, if given support and access to mainstream resources such as housing and vocational opportunities (Goldman, 1998). At first, mental health treatments were de-emphasized in favor of social supports, but newer medications, such as SSRIs and novel antipsychotic drugs, and more effective psychosocial interventions, such as assertive community treatment for schizophrenia (Chapter 4), facilitated the objectives of community support and recovery in the community.

The voluntary support network expanded with an emphasis on “recovery,” a concept introduced by service users, or consumers, who began to take an active role in their own care and support and in making policy. From their inception in the late 1970s, family organizations, such as the National Alliance for the Mentally Ill and the Federation of Families, advocated for services for individuals who are most impaired. As discussed later in this chapter, consumers, who also call themselves “survivors,” have formed their own networks for support and advocacy and work with other advocacy groups such as the National Mental Health Association and the Bazelon Center for Mental Health Law.

The de facto mental health system is complex because it has metamorphosed over time under the influence of a wide array of factors, including reform movements and their ideologies, financial incentives based on who would pay for what kind of services, and advances in care and treatment technology. Each factor has been important in its own way. The hybrid system that emerged serves many diverse functions. Unfortunately for those individuals with the most complex needs, and who often have the fewest financial resources, the system is fragmented and difficult to use to meet those needs effectively. Efforts at integrating the service system and tailoring it to those with the greatest needs are discussed, by age group, in subsequent chapters of the report. Many problems remain, including the lack of health insurance by 16 percent of the U.S. population, underinsurance for mental disorders even among those who have health insurance, access barriers to members of many racial and ethnic groups, discrimination, and the stigma about mental illness, which is one of the factors that impedes help-seeking behavior.

¹⁹ According to a student of the originator of moral treatment, Philippe Pinel, “moral treatment is the application of the faculty of intelligence and of the emotions in the treatment of mental alienation” (Grob, 1994).