Section 3: Status of Mental Health Services at the Millennium

Chapter 11. Adult Mental Health Services in the 21st Century

Mark S. Salzer, Ph.D., Michael Blank, Ph.D., Aileen Rothbard, Ph.D., and Trevor Hadley, Ph.D.

Center for Mental Health Policy and Services Research, University of Pennsylvania

The observation that adult mental health services have changed dramatically over the past three centuries, even over the past few decades, is trite. Yet, historical context is critical for understanding and appreciating the current state of the field. Reflections on the history of publicly funded mental health services provide good grounding for a current review. These examples are partly based on Grob's (1994) excellent recitation of the history of care in America for those with mental illnesses. (See also Chapter 2 in the present publication.) Not surprisingly, a large section of the book documents the history of institutional care.

In colonial times, the care of those with mental illness was provided almost solely by the family, sometimes with financial assistance provided by the local community, according to Grob's review. Changes in the economic and social structure, as well as the rise of "moral treatment" as a service philosophy, spurred the establishment of "retreats" and asylums beginning in the early 19th century. Institutional care went through numerous transformations over the years, but remained the predominant form of treatment for persons with serious mental disorders for almost two centuries. While well-meaning in theory, institutional treatment became little more than a place to warehouse people with serious mental illnesses. By the mid-1900's, the picture of institutional settings offered by Albert Deutsch in his book "The Shame of the States" was grisly: "As I passed through some of Byberry's wards, I was reminded of the pictures of the Nazi concentration camps… I entered a building swarming with naked humans herded like cattle and treat-ed with less concern, pervaded by a fetid odor so heavy, so nauseating, that the stench seemed to have almost a physical existence of its own" (Deutsch, 1946, pp. 41–42).

Treatment options other than institutional care were minimal during this period. Freud's influence in the early 20th century and the development of psychoanalytic theory led to the emergence of psychotherapy delivered in office settings as an acceptable form of treatment. However, this form of treatment was most often available only to those who could afford to pay privately and most often focused on persons with neuroses. Nonetheless, psychoanalytic/psychodynamic psychotherapy practices in the mid-20th century were called into serious question (Eysenck, 1952). Biological treatment, especially the use of psychosurgery and electroshock, had gained a foothold as well. The 1950's were noteworthy for the initial use of phenothiazines in the treatment of psychoses that opened the eyes of many to the potential benefits of psychopharmacological approaches. However, these traditional neuroleptics, some of which are still in use today, are associated with numerous side effects that can and do diminish the quality of life for those with mental disorders.

With this historical backdrop, it is clear that advances in the delivery of mental health services have been made, especially over the past few decades. Many of these advances in treatments and services are enthusiastically documented in the first Surgeon General's report on mental health (U.S. Department of Health and Human Services, 1999). In this chapter, we provide an overview of important developments that have occurred more recently in the delivery of adult mental health services. Our review begins with a discussion of service planning, itself a vital improvement in service delivery, including influences on service planning decisions, such as psychiatric epidemiology and data-driven decision-making. This is followed by an assessment of recent changes in financing and organization of services, including parity legislation, managed care, and systems interventions. We then comment on specific intervention philosophies and approaches, including innovations in the development of community long-term care supports and psychopharmacological and psychosocial interventions. We conclude with a summary that offers a general comment on where the field has come from and where further development is needed, and a caution about overexuberant optimism regarding where the field currently stands despite obvious advances.

Service Planning

The organized planning of mental health services dates back to the first Federal efforts to develop a community mental health center system. The earliest of the Federal community mental health acts, which led to the construction of community mental centers, required States to provide plans of how they would create catchment areas and then structured services for all catchment areas in order to qualify for the grants (Beigel, 1982). Throughout the history of community mental health center funding, States were required to complete a variety of planning mechanisms, many of which included public comment, and to include appropriate providers and later consumers and family members in the planning process. This basic model was adopted by many States in their community mental health legislation in the 1960's and early 1970's. Very substantial numbers of States in one manner or another, either at county or catchment area level, required governmental or quasi-governmental entities to create plans. Those plans became the basis for the funding of community mental health services and, in some cases, the basis for performance indicators and the measurement of the adequacy of the delivery system (Estes & Wood, 1984). The core assumptions in this planning process are to deliver care at the most local level possible, organize a continuum of care, and include an extensive public process. This planning process is unique among other health and human services systems in the United States. The nature of other health and human services systems, even those that are largely governmental, tend not to be as participatory or as publicly planned and organized as mental health services (Hadley & Culhane, 1993).

Data Influences on Services Planning: Psychiatric Epidemiology and Service System Data

Service planning has been advanced by efforts to document the scope of mental illness in the general population. The information culled from psychiatric epidemiology studies is critical for policymaking and service planning, both nationally and locally. An appreciation of the historical antecedents to current psychiatric epidemiological efforts is useful (for a more complete review, see Robins, 1990). The Midtown Manhattan study began in 1954 and was the first systematic assessment of the prevalence of mental illness in a U.S. community. In addition to providing estimates of the extent of illness, the study's intent was also to show that psychosocial and sociocultural factors influenced illness occurrence. The results of the Midtown Manhattan study were widely cited and caused a reexamination of the validity of methods used in psychiatric epidemiology. There are some major difficulties in estimating prevalence rates— a continuing problem in mental health services research. First, many previous studies had been inconsistent in identifying whether a case was coded as positive for psychopathology for lifetime prevalence of a disorder, or whether the disorder was manifest at the time data were gathered. Second, some studies used psychiatric hospitalization rates as an indicator, despite the fact that variability in incidence and prevalence rates was certainly confounded by the availability of inpatient beds and the proximity of inpatient facilities. It is also likely that underreporting of serious mental illness occurs more frequently in rural than in urban areas.

In the early 1970's, persons with serious and persistent mental illness became more widely recognized in the mental health literature as an underserved population. The early studies, taken together, did not provide compelling evidence regarding the absolute prevalence rate of mental illness. The Epidemiologic Catchment Area (ECA) study was a major accomplishment in providing a more systematic assessment of the occurrence of mental illness (Robins & Regier, 1991). The results of the ECA suggested that about 22 percent of the population were affected by mental illness during a 1-year period, and that, of those, about 7 percent were continuously affected for longer than 1 year. Of the latter, about 3 percent met diagnostic criteria for severe mental disorders. These findings were landmarks in mental health services research because they both broadened the scope of the problem of mental illness and refined estimates regarding resources necessary to meet demand for mental health services.

The National Comorbidity Survey (NCS) similarly revolutionized our understanding of mental illness and the need for mental health services (Kessler, McGonagle, Zhao, et al., 1994). This study demonstrated that lifetime prevalence for any mental disorder based on self-report approaches 50 percent, effectively establishing that being affected by mental illness is normative. Perhaps more important, the NCS established rates of comorbid disorder demonstrating that the probability of co-occurrence increased dramatically with each additional occurrence of a mental illness. The NCS was also the first psychiatric epidemiologic study to use a national probability sampling frame, which dramatically improved the external validity of estimates. The aforementioned epidemiological studies have been used to document inadequacies in funding for mental health services and are important in planning where precious service (and research) resources are spent.

Efforts to measure quality-of-care and continuous quality improvement represents another exciting data-driven trend in mental health service planning. The Institute of Medicine offers one definition of health care quality: "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional practice" (Lohr, 1990). There has been a great deal of recent activity geared toward the measurement of quality of mental health services (Bickman & Salzer, 1997). Perhaps the best known and most visible of these efforts is the Mental Health Statistics Improvement Program sponsored by the Center for Mental Health Services. Other efforts include those mounted by the National Committee for Quality Assurance (1997), and the American Managed Behavioral Healthcare Association and the American College of Mental Health Administrators (ACMHA, 1997). These efforts are driven by a growing consensus among providers, consumers, insurers, and policy-makers that these data are needed to improve accessibility, acceptability, and accountability for dollars spent (Druss, Rosenheck, & Stolar, 1999).

Little consensus exists as to the specific elements of a minimum data set to monitor system performance, but most attempts consist of service system structure, service delivery process, and some indication of outcomes (Salzer, Nixon, Schut, Karver, & Bickman, 1997). These efforts can be conceptualized as focusing on two distinct areas of mental health systems: performance indicators (e. g., Kamis-Gould, 1987; Windle, 1986) and cost-effectiveness (e. g., Frank, 1981). A number of analytic strategies for dealing with multiple indicators of system inputs and outputs have been utilized including structural equation modeling, data envelopment analysis (Schinnar, Kamis-Gould, Delucia, & Rothbard, 1990), and the balanced scorecard (Santiago, 1999). Ultimately the goal of these data-monitoring systems is continuous quality improvement or more specifically, total quality management (Forquer & Muse, 1996).

Integrated mental health care information systems are in their infancy, and it is too soon to know how they will impact system performance or influence service planning. One reason for this is that there is relatively little funding for these efforts, and, perhaps more important, little standardization to make comparisons between providers and within providers over time. Cleary and Edgman-Levitan (1997) emphasized the importance of incorporating consumers' perspectives into measurement of health outcomes. Lack of consensus about indicators between consumers, providers, and third-party insurers may be the single biggest obstacle to implementation of a performance and outcomes measurement system in mental health.

Philosophical Factors in Service Planning: Community Support Program and Consumerism

The philosophy underlying national and local service planning is guided by principles developed as part of the Community Support Program (CSP) and by the rising influence of consumers. Both highlight quality-of-life issues in the lives of persons with mental illness. CSP, which originated under the auspices of the National Institute of Mental Health (NIMH), recognized that persons with severe and persistent mental illness (SPMI) include individuals who have a disorder that seriously impairs their personal relationships, living arrangements, education, or employment for an extended period. CSP provided for the needs of persons who have undergone psychiatric treatment more intensive than outpatient care more than once in a lifetime (e. g., emergency services, alternate home care, partial hospitalization, or inpatient hospitalization), or experienced a single episode of continuous-structure supportive residential care or hospitalization for at least 2 months. In addition, a CSP client was expected to meet at least two of the following criteria on a continuing or intermittent basis for at least 2 years: (1) unemployed, employed in a sheltered work setting, or has marginal or limited skills and poor work history; (2) requires public financial assistance for community maintenance and unable to procure this assistance without help; (3) shows severe inability to establish or maintain a personal social support system; (4) requires help in basic living skills; and (5) exhibits inappropriate social behavior which requires intervention by the mental health or judicial system (NIMH, 1980).

Community care of consumers is predicated on the assumption that the community will provide social and tangible support to ensure the continued optimal functioning of the consumer. The ideal of community placement presumes the immersion of the consumer into the social structure of the family and community, connecting the consumer to supports that enable the consumer to thrive in the community. Mental health, human service, welfare, and medical service organizations constitute the potential sources of formal support for the consumer residing in a community. The role of formal organization is to ensure the availability of housing, economic support, and psychiatric and medical treatment to sustain the consumer. Ideally, case management enables the consumer and the primary group to access the formal service system by facilitating contact between a variety of service systems and the consumer (Fox, Blank, Kane, & Hargrove, 1994).

Kanter (1989) characterized participation in all aspects of the consumer's community life as the unifying principle of case management. Other principles include (1) continuity of care; (2) use of the case management relationship; (3) titrating support and structure; (4) flexibility; and (5) facilitating the consumer's resourcefulness. Kanter emphasized the case manager's responsibility for linking with family and social networks of clients in order to enhance and develop consumer resourcefulness. Several investigators have reported that the extent of consumers' support networks and the frequency of the case manager's contact with family, neighbors, and friends of consumers were related to decreased case manager/client contacts, decreased hospitalization, and increased community stability (Harris & Bergman, 1988; Schoenfeld, Halevy-Martini, & Hemley-Van de Velden, 1985).

Meeting the comprehensive needs of consumers with long-term mental illnesses in community settings requires provision and coordination of a variety of mental health and social services (Turner & TenHoor, 1978) as well as effective interactions between these resources and the families and significant others associated with the consumer (Intagliata, 1982). The organizational ability of local units to effectively mobilize and coordinate relationships among various service systems determines effective service delivery to consumers. There are both theoretical and pragmatic questions about how formal care systems and primary groups cooperate to solve mutual problems without interfering with each other.

The consumer movement has experienced unprecedented growth over the past decade and has had an important impact on the service planning philosophy. The consumer movement, like any movement, is not monolithic. There are many organizations concerned about mental health policy and practices that have varied experiences and interests, from those who are directly impacted by mental health services (i. e., service recipients), to family and friends. Views on issues understandably differ at times, sometimes dramatically. Most important, this vast movement has found a "voice" and is increasingly being understood as a long-ignored constituency, arguably the most important constituency, in mental health policy, practice, and research debates.

Consumer organizations and representatives are major collaborators in the development of national and local policymaking and are called to provide testimony in front of congressional committees on important topics such as seclusion and restraint. Consumer organizations have also had major influence in the development and proliferation of interventions.For example, the National Alliance for the Mentally Ill (NAMI) has taken up the cause for the expansion of jail diversion and Assertive Community Treatment interventions across the country, albeit not without opposition from other consumer groups. Program developments, especially consumer-operated and -delivered services (e. g., self-help/mutual-help groups, drop-in centers, peer-delivered services) also benefit from the efforts of the consumer movement. Finally, consumers are influencing the aforementioned efforts in the assessment of quality of mental health care.

Financing and Service System Integration

Over the past 40 years there have been dramatic changes in the financing and organization of the mental health system from a relatively simple single-facility system to a current system characterized by a multiplicity of providers which exist in a highly complex and often fragmented environment (Grob, 1991; Hadley, Schinnar, & Rothbard, 1991; Rothbard, Hadley, Schinnar, Morgan, & Whitehill, 1989; Schlesinger, 1986). Since financing models often drive the organization of care, it is important to attempt to understand how the changes in the organization of the service system have been shaped by the changes in the financing of the system. Since 1950, the mental health system has been through what can be described as five major phases of financing mental health services (Hadley, Schinnar, & Rothbard, 1991).

Throughout the 1950's, the mental health system was relatively simple with most funding coming from States and the Federal government to operate State psychiatric hospitals and Veterans Administration hospitals. The first major change in this system began in the early 1960's with the advent of Community Mental Health Center Grants funded by the Federal government (ADAMHA, 1981). Funds flowed through grants from NIMH to a new set of local provider agencies termed "community mental health centers" whose very existence was often dependent on the grant (Beigel, 1982). In the 1970's, the beginning of the fee-for-service (FFS) Federal and State health care finance systems, Medicaid, and Medicare created further complexity in the system. These programs simultaneously expanded the number of persons receiving service and supported the creation of new general hospital psychiatry services (McGuire & Fairbank, 1988). At around the same time a small but increasing number of private health insurers began to expand coverage for mental illness. This growth in the privately insured sector helped create the for-profit private psychiatric hospital system and the ever growing private practice of psychiatrists and other mental health professionals. In recent years the pressures to achieve "parity" of mental health benefits and the enormous growth of the care system have increasingly led to a wide variety of managed mental health care (Oss, 1994).

From Unmanaged Care Systems to Managed Care Organizations

In the past decade, privatization of mental health care delivery has resulted in the diminishing role of the "State" in administering publicly funded mental health care programs for persons with severe mental illness (SMI). Most States today are contracting out mental health services to nongovernmental, private sector managed behavioral care entities in order to contain costs and reduce fiscal risk. A managed care tracking project funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) documented that 97 managed care programs operating in 47 States include some form of mental health and drug abuse benefits. Most integrated programs (which include mental health and physical health) contract with private sector organizations, whereas carve-out arrangements for behavioral health are equally divided between private and governmental agencies. Almost all contracts place the managed care entity at financial risk through capitated arrangements whereas the providers are usually paid on an FFS basis (Babijian et al., 1992).

How persons with SMI will fare under managed care is a policy concern particularly when that care is managed by for-profit companies. Whether the cost reductions and administrative efficiencies associated with managed care in the private health sector can be realized in the public mental health sector is uncertain given that these persons have the most severe and longstanding psychiatric conditions, often overlaid with a variety of co-occurring medical and substance abuse problems, poverty, inadequate housing, and the lack of social supports. Due to the recurrent nature of their illnesses and the associated high volume of service use, persons with SMI may not fare as well under managed care programs that emphasize cost reductions, substitute high-intensity services for low-intensity services, and cost-shift or outright cost-avoid, whenever possible. Moreover, the variety of social rehabilitative needs that historically were attended to by State funding and by tacit use of insurance reimbursements may be ignored when the criteria of stringent medical necessity is applied. It has been argued that managed care arrangements under a for-profit organizational structure put persons with SMI at a disadvantage.

Studies of managed care programs in the private sector and in some public sector populations have been able to document substantial reductions in the costs of mental health treatment by reducing hospitalization and substituting less expensive and less intensive outpatient services for more costly approaches. Additionally, access to care is increased in that a larger number of enrollees in managed care plans receive mental health services compared to those in FFS plans; however, fewer receive extended treatment in managed care (Rothbard, 1999). Nevertheless, direct application of private sector models to public sector populations is likely to be unsuccessful for persons with SMI unless cost-containment goals are integrated with performance measures involving quality of care. Also, there needs to be community involvement and oversight through advising boards and consumer groups (Bartsch & Shern, 1990; Stuart & Weinrich, 1998).

However, there is reason for cautious optimism. Preliminary results of a SAMHSA multisite study on managed care for persons with SMI find little difference in satisfaction or clinical outcomes for adults with SMI in managed care versus FFS programs. Five sites have collected data using a common protocol, including common outcome measures. Additionally, the SAMHSA study offers a large amount of person-level administrative data that is equal to or greater than all that exists from individual studies that have been completed to date. Also, information on a variety of managed care programs used by persons with SMI will enable researchers to associate which mechanisms relate to access, utilization, cost, and outcomes of care.

Service System Integration

One promising organizational change is the increased attention paid to addressing service fragmentation, duplication, and restricted array of services available to address effectively the needs of adults with mental illness. Systems-level integration efforts have been aimed at five important areas outlined by Konrad (1996): information sharing and communication, cooperation and coordination, collaboration, consolidation, and integration (single authority, operates collectively, activities fully blended). Changes in these areas are hypothesized to increase the array of available services, increase access to these services, improve service-delivery patterns (e. g., fewer hospital services and more rehabilitation services), and increase service efficiency and effectiveness. One review (Salzer, Kamis-Gould, & Hadley, in press) indicates that the few system intervention demonstration projects that have been undertaken in the adult area, such as the Robert Wood Johnson Foundation Program on Chronic Mental Illness and the Access to Community Care and Effective Services and Supports (ACCESS) study, have produced changes in critical areas like access to services, the development of a continuum of services, decreased use of expensive inpatient services, enhanced service coordination and continuity of care, and consumer satisfaction. However, these interventions have not had a convincing impact on clinical outcomes. Interestingly, similar results are found for systems interventions in the children's area, such as the Fort Bragg Demonstration Project (Bickman et al., 1995) and Stark County Evaluation Project (Bickman, Noser, & Summerfelt, 1999; Bickman, Summerfelt, & Noser, 1997).

Clinical effectiveness is arguably a result of the potency of the services that are delivered. One explanation for why systems integration efforts might not impact clinical effectiveness is that delivered services are not sufficiently improved by increased integration (Goldman, Morrissey, & Ridgely, 1994; Ridgely, Morrissey, Paulson, Goldman, & Calloway, 1998; Salzer & Bickman, 1997). It is noteworthy that, to date, no system integration demonstrations have focused on ensuring that delivered services are more effective. For example, financial incentives for using evidence-based practices or performance-based contracting may lead to the use of more effective services. Such interventions are more likely to succeed in bringing about better clinical outcomes.

Changes in the Organizational Structure of the Mental Health System
From Institutional to Community Care Organizations

The closing or "downsizing" of State and county psychiatric hospitals has had profound implications for the long-term care of persons with SMI throughout the United States. Over the past 30 years, the process of deinstitutionalization has reduced the number of public psychiatric hospitals and the resident patient population. The number of State psychiatric hospitals in the United States has gone from 277 in 1970 to 231 in 1996. Patient census has gone from 186 residents per 100,000 population in 1969 to 33 residents per 100,000 in 1992 (CMHS, 1996). The decline is primarily related to downsizing rather than closing since only 46 State hospitals have actually shut their doors (NASMHPD, 1996).

As State hospitals have downsized, the share of State mental health dollars going to community care has increased to almost 50 percent (NASMHPD, 1996). This flow of dollars to community-based care has dramatically changed the site of care delivery from State institutions to local communities, where multiple providers, mostly not-for-profit out-patient programs, are responsible for bundling care around individual client needs. Case-management teams organized at the local county level under the auspices of the public mental health authorities generally are responsible for the coordination of these services.

During the first decade of deinstitutionalization, the major concern of mental health consumers, families, and psychiatric providers was related to the public sector's abandonment of persons with SMI and the safety net that supported them. Studies on the "discharge" population done during the 1970's and 1980's found community programs to be equally or slightly more effective than conventional long-term hospitalization. However, most of these findings came from experimental studies where particular interventions had been mounted for a subset of the discharged population (Braun et al., 1981; Hargreaves & Shumway, 1989) rather than with deinstitutionalization as it was actually carried out. Later studies continued to find that patients preferred life in the community rather than an institution (Barry & Crosby, 1996; Dickey, Gudeman, Hellman, Donatelle, & Grinspoon, 1981; Okin, Borus, Baer, & Jones, 1995; Okin & Pearsall, 1993; Solomon, 1992), but again, these findings were predominately based on interventions with special populations as opposed to those individuals who received no targeted follow-up services. In contrast to these special populations, a longitudinal study of formerly institutionalized patients in Vermont with no special service intervention showed that more than half of the population also achieved considerable improvement after their hospital discharge (Harding, Brooks, Ashikaga, Strauss, & Breier, 1987). Except for a small group of patients with specialized problems (Furlong, 1996), the vast majority of long-stay patients appear to be capable of maintaining or improving their level of functioning while receiving treatment in a community system.

The process of deinstitutionalization has moved into its second generation, with patients discharged during this second wave more disabled than prior cohorts. Many have special behavioral problems that make them difficult to place and maintain in community settings. However, as the majority of State mental health agency dollars are now being allocated to outpatient and residential services, and other public funding sources, predominately Medicaid, are paying for short-stay acute care psychiatric episodes in community hospitals, the ability to maintain most persons with SMI in community settings has dramatically improved.

Empirical evidence based on several studies suggests that the long-stay discharge population shows an improved satisfaction with life following discharge, with little deterioration in level of functioning. In addition, costs generally have been the same or less for discharged patients living in the community. Increased homelessness and criminal justice involvement have not been substantiated by the data for the discharged population. The desire to create a cost-effective service system that provides care in the least restrictive setting while promoting quality of life for individuals with SMI is shared by all communities. The relevant question, at this juncture, is what mix and level of service(s) should replace the former "State" hospital system, not whether long-stay psychiatric institutions should be eliminated.

Development of Community Long-Term Care Supports and Hospital Diversion

Deinstitutionalization also has spurred the development of long-term community support interventions to enhance community tenure. For example, there have been innovations in addressing the needs of persons in acute crisis. These include the development of day treatment and residential programs for those in acute crisis that have been found to produce slightly better clinical outcomes, decreased costs, and potentially less psychological trauma compared with hospitalization (e. g., Fenton, Mosher, Herrell, & Blyler, 1998; Sledge et al., 1996). Community-based acute psychiatric crisis treatment centers in homelike settings are another unique development (Warner, 1995). The basic element of this approach is to create a positive and calming therapeutic environment in which the person in distress does not feel coerced by staff or the environment.

Residential services also have emerged. Because comprehensive data for supported housing and residential services for adults with mental illness do not exist, most of what is known stems from the individual States. Provision of supported housing for persons with serious and persistent mental illness has moved into the mainstream of the service array of most public mental health systems (Mize & Abbott, 1996). These programs have developed largely on an ad hoc basis as a result of gaps in services which deinstitutionalization exposed. Elderly persons with mental illness moved into nursing homes, which were historically separate from specialty mental health systems. The use of single room occupancy (SRO) hotels peaked and then ebbed as it was increasingly recognized that the squalor so often associated with SRO hotels contributed to relapse and victimization of persons with mental illness. In many States, homes for adults, both licensed and unlicensed, evolved as a cottage industry in response to increased demand for living alternatives for the disabled population (Downs & Fox, 1993). The realization that supported housing and residential services was an ongoing and previously unmet need was slowly recognized (Ridgeway & Zipple, 1990).

The Program of Assertive Community Treat-ment (PACT) has been demonstrated to be an effective strategy for serving the severely mentally ill population (Bond, Miller, Krumwied, & Ward, 1988; Stein & Test, 1980, 1985). Model programs consist of multidisciplinary teams that provide continuous care to a limited number of persons with SMI (approximately 1:10 staff/client ratio). Variations of PACT have been implemented in primarily urban and semi-urban settings. Such programs promote the maintenance of clients in the least restrictive environments and actively engage the client's social network. Decreases in number of hospitalizations, length of stay, and emergency room use have been reported. Improved medication compliance, community housing maintenance, and clients' satisfaction with services have been documented. Cost savings are predominately associated with decreased hospitalization and length of stay (Dincin et al., 1993).

Rural applications of this program have been conducted with apparent success (Husted, Wentler, & Bursell, 1994; Santos et al., 1993). However, these initial studies were quasi-experimental and PACT programs have not generally been implemented in rural areas (Mechanic, 1990). Assertive community treatment programs have the potential to significantly improve the care of the rural persons with SMI. However, those factors that presently impede the provision of mental health services in rural areas also are inherent in delivering PACT programs.

Provision of a PACT program enhanced with an advanced practice psychiatric nurse and consumer provider may be a viable method of reducing disability in a setting where few treatment options exist. A program that targets the specific risk factors for relapse and physical illness would be expected to be particularly effective. Inclusion of stabilized consumers as peer supporters in the program may optimize the program's effectiveness by providing opportunities for role modeling and providing aspects of social support that are not available from formal care providers (Kane, Blank, & Hundley, 1999).

Adult Mental Health Services: Successes and Challenges

More and more efficacious clinical services have been developed over the past few decades. Particularly astounding are the advances in the development of new psychopharmacological approaches in treating a broad-range of mental illnesses. These advances are spurred by basic research that have followed technological innovations such as functional magnetic resonance imaging. Knowledge about brain physiology from basic research is being actively translated by pharmaceutical companies into new pharmacological compounds. Selective serotonin re-uptake inhibitors, such as fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft), have all been found to be effective in the treatment of depression and produce fewer side effects than the older monoamine oxidase inhibitor drugs. These same compounds also have been found to be efficacious in the treatment of obsessive-compulsive disorder and panic disorder. Similar advances have been made in the treatment of schizophrenia-spectrum disorders, including the development of so-called atypical antipsychotics. Atypical antipsychotics, such as clozapine (Clozaril), olanzapine (Zyprexa), and risperidone (Risperdal), are defined by their ability to decrease psychotic symptomatology with minimal extrapyramidal symptoms (Meltzer, 1995). More-over, there is substantial evidence that clozapine offers benefits to persons who have not previously responded to other antipsychotic medications (e. g., Kane, Honigfeld, Singer, Meltzer, & Clozaril Collaborative Study Group, 1988; Rosenheck et al., 1997).

Impressive advances in psychosocial interventions have also been made. Cognitive-behavioral psychotherapy has been found to have long-lasting effects in the treatment of affective and anxiety disorders (Barlow & Lehman, 1996; Robinson, Berman, & Neimeyer, 1990). Cognitive-behavioral therapy also is being found to be beneficial in the treatment of cognitive distortions associated with psychosis (Garety, Fowler, & Kuipers, 2000). Finally, timely advances, especially in the current managed costs environment, have also been made in the development of brief psychotherapies (Garfield, 1998).

Traditional intervention approaches have focused on reducing symptoms and increasing functioning. Consumer advocacy in the mental health movement has led researchers and service providers to focus on what consumers want to achieve as a result of mental health services. This has resulted in a reorientation away from symptoms and functioning as the sine qua non of treatment to the valuing of quality of life, recovery, hope, empowerment, and other related outcomes. Focusing on the latter outcomes represents a shift in views of serious and persistent mental illness from a focus on progressive deterioration, especially in schizophrenia, to recovery and rehabilitation.

Psychosocial rehabilitation services have flourished as a result of new consumer-centeredness. Cognitive remediation in schizophrenia represents a very promising, yet still developing set of interventions aimed at overcoming cognitive deficits associated with this illness, such as impairment in attention, concentration, and cognitive flexibility (Bellack, Gold, & Buchanan, 1999). Employment is now an expectation for persons with serious and persistent mental illness. Early research in this area suggests that persons with mental illnesses have greater work histories than has been previously assumed (Baron & Salzer, 2000). There have been impressive developments in research, theory, and practice in vocational rehabilitation (see Cook & Razzano, 2000). One example of progress in this area includes the development and research on the Individual Placement and Support model that has been found to dramatically increase competitive employment among persons with an SMI (Drake, Becker, Clark, & Mueser, 1999).

Psychosocial rehabilitation services delivered by consumers also represent a major advance in service delivery. Consumer-delivered services enhance the sensitivity of services to consumer needs as well as build trust and rapport, especially when consumers are in more traditional professional roles such as case managers (Solomon & Draine, 1995), crisis services (Lyons, Cook, Ruth, & Karver, 1996), and vocational and employment coaches (Mowbray et al., 1994). Consumer-delivered services also include peer support programs, drop-in centers, and self-help groups that are oftentimes fully controlled and operated by consumers. Consumer-providers may offer increased sensitivity to the needs of service recipients that may enhance trust and rapport. As Mowbray and Moxley (1997, pp. 506–507) explain, "Consumers know firsthand about illness, disability, and handicaps and how to cope and how to 'spring back.' Making this knowledge accessible to other consumers may encourage recovery. Consumer service provision brings consumers together in novel ways of support. These ways can liberate the tacit knowledge that consumers often keep to themselves. The 'externalization' of recovery knowledge may be one of the most important outcomes produced by consumer service provision." There is some evidence (Davidson et al., 1999; Mowbray, Moxley, Jasper, & Howell, 1997) that the unique philosophy and approach of consumer-delivered services enhance outcomes in those domains not usually addressed by traditional mental health services, such as quality of life, recovery, and empowerment, and also draw in persons who might normally avoid traditional services as well as those who simultaneously or sequentially utilize professional services.

Another important development in service delivery is the promulgation of practice guidelines and evidence-based practices reflecting the recognition that the mental health field has developed efficacious treatments. The Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research) developed one of the first practice guidelines for the treatment of adult depression (AHCPR, 1993). The clinical psychology division (Division 12: Sanderson & Woody, 1995) of the American Psychological Association established a task force aimed at producing empirically validated treatments and has documented a list of empirically validated interventions (Chambless et al., 1998; Woody & Sanderson, 1998). Other examples of the trend toward evidence-based mental health practice include the many guidelines that have come out for the treatment of schizophrenia and psychosis (American Psychiatric Association, 1997; Veterans Health Administration, 1998), and the Schizophrenia Patient Outcomes Research Team's (PORT) recommendations (Lehman, Steinwachs, & Co-Investigators, 1998a).

Treatment Barriers: Limiting Effectiveness

Efficacy-research studies provide the basis for much of our knowledge about the benefits of mental health treatments. These studies examine the extent to which a specific treatment improves outcomes under conditions in which considerable control is exerted over who receives services as well as the circumstances in which the services are delivered. Randomized clinical trials represent the classic efficacy-research approach. Patients are recruited who are homogeneous in terms of diagnosis, age, gender, and socioeconomic status, among other characteristics. Service providers are uniformly trained in the treatment modality under study and are monitored in order to ensure strict adherence to the treatment protocol. Efficacy studies examine how helpful clinical interventions can be for various problems under ideal conditions. In contrast, effectiveness research attempts to identify whether efficacious treatments improve outcomes in usual care settings involving a relatively heterogeneous sample of persons in terms of presence or absence of co-occurring conditions, illness duration, participation in treatment (e. g., motivation, keeping appointments, treatment adherence), and other client factors that might impact outcomes. Service providers also tend not to have special training in providing the specific treatment. Research efforts include experimental and quasi-experimental designs depending on local circumstances and research questions (see Hoagwood, Hibbs, Brent, & Jensen, 1995; Weisz, Donenberg, Han, & Kauneckis, 1995; and Wells, 1999 for discussions of efficacy and effectiveness research). To date, the evidence for treatment effectiveness is not impressive. For example, one review found only nine scientifically valid studies that examined the effectiveness of community-based psychotherapy services for children (Weisz & Weiss, 1993). The average effect size for these nine studies was nearly zero. "Bridging the gap between science and practice" has become the mantra in the delivery of behavioral health care services (Lamb, Greenlick, & McCarty, 1998; NIMH, 1999).

A number of factors account for the gap. The Medical Outcomes Study found that depression was both underidentified and undertreated in primary and specialty health care settings (Wells, Sturm, Sherbourne, & Meredith, 1996). Another study found that persons with major depression were treated with inadequate medication dosages in specialty mental health care settings, based on best practices for treatment developed from efficacy research (Oquendo, Malone, Ellis, Sackheim, & Mann, 1999). Investigators also have compared the treatment received by a random sample of 719 persons with schizophrenia against the PORT treatment recommendations (Lehman, Steinwachs, & Co-Investigators, 1998b). Overall, they found that current usual treatment care practices for schizophrenia do not meet current best practices based on efficacy research. These studies indicate that best practices based on efficacy studies are not fully implemented in usual care settings.

One explanation for these results is that practitioners in usual care settings are not being reached by current dissemination strategies, mostly research publications, and therefore are not using current best practices. The adoption of treatment innovations also is hindered by a number of factors unique to mental health organizations (Glaser & Backer, 1979): (1) Medical model orientation emphasizes hierarchical decisionmaking processes that inhibit broad involvement in decisionmaking; (2) Emotional reactions to change are not usually discussed in civil service agencies; (3) Organizations are open to numerous outside influences (e. g., legislature, funders, State and local mental health offices) who may veto adoption of innovations or whose views may be seriously considered when confronted with adoption; and (4) Varied interests and motivations inhibit the development of reward structures to nurture adoption. Clinicians also express a number of concerns about adopting innovations, especially based on practice guidelines (Addis, Wade, & Hatgis, 1999), including impact on therapeutic relationships, restriction of clinical innovation, and weariness about the feasibility of the guidelines for use in clinical practices.

Poor treatment adherence, including failure to keep clinical appointments, not taking medications as prescribed, and dropping out of treatment altogether, is another major factor undermining clinical effectiveness. It is clear from the literature that treatment adherence is a problem with treatment for all health conditions, especially chronic conditions (Cramer & Rosenheck, 1998). The mean level of compliance with antipsychotics is found to be 58 percent of the recommended amount of medication and 65 percent with antidepressants (Cramer & Rosenheck, 1998). Medication costs further undermine treatment effectiveness. Medication costs to consumers is a significant barrier in treatment adherence. Medication costs also undermine prescription of newer, more effective, yet costlier medications that are not on prescription formularies. Arguments for including these newer medications include the potential for cost-savings from decreased hospitalizations and crisis service use because of increased effectiveness. However, it may be the case that cost savings may be realized only for those who have been previously treatment-resistant and frequently use expensive services and not for those with limited hospitalizations (Rosenheck, Massari, & Frisman, 1993).

Summary

In this chapter we have attempted to review some of the major current advances that have taken place in the delivery of adult mental health services as the field moves into the 21st century. As this review illustrates, there is a great deal to be optimistic about. Current optimism is now fueled by these service developments, such as new medications for a wide range of mental disorders, evidence-based practice guidelines, expansion of case management services to address the needs of persons with SMI, emphasis on rehabilitation and recovery, data-based service planning, and efforts to improve service systems.

Attention is also being focused on other important areas in order to enhance the effectiveness of mental health services. For example, there is now a recognition that most mental health treatment occurs in primary care rather than specialty care settings. Efforts are under way to improve identification and treatment of mental health needs in primary care. Racial disparities in mental health service delivery have drawn attention to creating culturally sensitive services. The efforts of NAMI and other advocacy groups has helped identify stigma as a major impediment to quality of life and recovery of persons with SMI (Wahl, 1999). Innovative steps have been taken to address stigma through the use of theoretically derived interventions (Corrigan & Penn, 1999). Another exciting theoretical development is that prevention, once linked almost exclusively to work with children and adolescents, is now viewed as moving into a third generation that links prevention and treatment across the life span (National Advisory Mental Health Council Work-group on Mental Disorders Prevention Research, 1998). This focus includes the application of prevention concepts in thwarting relapse, disability, and comorbidity among adults with serious and persistent mental illness.

However, optimism about today's advances may quickly turn to disappointment, as we saw initially with deinstitutionalization. For example, while the development and attempted implementation of evidence-based practices appear to be an advancement, previous evidence-based practices are now met with indignation. Braslow (1999) reviewed evidence-based somatic practices in the first half of the 20th century in the treatment of mental illness. He points out that these treatments, including hydrotherapy, sterilization, and lobotomies, were viewed as state-of-the-art based on current knowledge and scientific practices. Braslow encourages a dose of humility go along with any inclination to congratulate ourselves on perceived scientific and clinical progress. One important lesson from history, therefore, is that advancement in the delivery of adult mental health services requires that we adopt a stance of cautious optimism during such times as these.

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