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This Web site is a component of the SAMHSA Health Information Network. |
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Section 4: Key Elements of the National Statistical PictureChapter 14. Highlights of Organized Mental Health Services in 1998 and Major National and State TrendsRonald W. Manderscheid, Ph.D.;* Joanne E. Atay, M.A.;* María del R. Hernández-Cartagena;* Pamela Y. Edmond;* Alisa Male, M.A.; †Albert C. E. Parker, Ph.D.; † and Hongwei Zhang, M.A.† *Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; †Synectics for Management Decisions, Inc. During the 28 years leading up to 1998, significant changes occurred in the number, capacity, structure, and operation of organizations providing mental health services in the United States. This chapter describes some of the changes that have occurred nationally in the delivery system, analyzes some of the policy implications of these changes for future planning purposes, and presents some comparative data by State. The source of the organizational data presented in this chapter is the periodic Survey of Mental Health Organizations and General Hospital Mental Health Services (SMHO; Appendix A), conducted by the Survey and Analysis Branch, Division of State and Community Systems Development, Center for Mental Health Services (CMHS). The Survey is a complete enumeration of all specialty mental health organizations and separate psychiatric services of non-Federal general hospitals, together with a sample survey, that collects descriptive information on the number and types of services, capacity (i. e., number of beds), volume of services (i. e., numbers of episodes, additions, and resident patients), staffing, expenditures, and sources of revenue. The types of mental health organizations covered include State and county mental hospitals, private psychiatric hospitals, non-Federal general hospitals with separate psychiatric services, Department of Veterans Affairs (VA) medical centers, residential treatment centers for emotionally disturbed children (RTCs), and "all other mental health organizations," which include multiservice mental health organizations, free-standing psychiatric outpatient clinics, and partial care psychiatric organizations. Definitions of these organization types are given in Appendix A. This chapter examines four organizational foci of the specialty mental health care sector:
Availability of Services The total number of mental health organizations in the United States1 increased between 1970 and 1998 from 3,005 to 5,722 (Table 1). Almost all of this increase occurred as a result of gains in the number of private psychiatric hospitals, separate psychiatric services of non-Federal general hospitals, RTCs, and "all other organizations," since the number of State and county mental hospitals (hereafter referred to as State mental hospitals) and freestanding outpatient clinics (included in the rubric "all other mental health organizations") decreased, and the number of VA medical centers with psychiatric services remained relatively unchanged. Although private psychiatric hospitals in 1998 still numbered more than twice that of 1970, this was a substantial decline from their 1992 peak. Along with the overall increase in mental health organizations, the number of organizations providing services in various treatment settings also increased. For example, between 1970 and 1994, the number providing 24-hour service more than doubled from 1,734 to 3,827.2 This number declined only slightly between 1994 and 1998, to 3,729. The number providing less than 24-hour services also rose consistently between 1970 and 1998, from 2,156 to 4,387.3 Number of Psychiatric Beds While the number of mental health organizations providing 24-hour services (hospital inpatient and residential treatment) more than doubled in the United States over the 28-year period, the number of psychiatric beds provided by these organizations decreased by half, from 524,878 in 1970 to 261,903 in 1998 (Table 2). The corresponding bed rates per 100,000 civilian population dropped proportionately more in the same period from 264 to 97. Beds in State mental hospitals accounted for most of this precipitous drop, with their number representing only 24 percent of all psychiatric beds in 1998, compared to almost 80 percent in 1970 (Figure 1). Trends in bed rates for specific organization types, shown in Figure 2, indicate that the rates for private psychiatric hospitals and non-Federal general hospital psychiatric inpatient services increased substantially between 1970 and 1990, with the greatest growth occurring between 1980 and 1990; since 1990, bed rates have been stable for non-Federal general hospitals, but have declined for private psychiatric hospitals, although the latter remain above the rates for 1980 and earlier. The rates for RTCs were nearly flat throughout the 1970–98 period, while the rate for State mental hospitals and VA psychiatric organizations decreased substantially. The greatest increase, from less than 1 to 24, occurred in the "all other organizations" category, which includes the multiservice organizations. It should be noted that in each of the years shown, the number of "scatter" beds in non-Federal general hospitals has been excluded. Scatter beds are those that are commingled with medical-surgical beds in non-Federal general hospitals as distinguished from those that are in the separate psychiatric services of these hospitals. Volume of Services The number of 24-hour hospital and residential treatment additions increased steadily between 1969 and 1998, from 1,282,698 to 2,313,594, with a corresponding increase in the addition rate from 644 per 100, 000 civilian population in 1969 to 875 in 1994, with a slight decrease to 860 in 1998 (Table 3). In 1969, nearly three-quarters of the 24-hour hospital patients were about evenly divided between State mental hospitals and the psychiatric services of non-Federal general hospitals. A constant and precipitous decline in the number of additions and the addition rate to State mental hospitals during the 1969–98 period, accompanied by substantial increases in these measures for the 24-hour services at non-Federal general hospitals and private psychiatric hospitals, especially after 1979, shifted the volume of patient additions to these latter two organization types. By 1998, non-Federal general hospital inpatient psychiatric services accounted for nearly 50 percent and private psychiatric hospitals about 21 percent of all inpatient additions, while the proportion of State mental hospital inpatient additions dropped to 9 percent (Figure 3). Among the other mental health organizations, RTCs showed a more or less steady gain in additions between 1969 and 1990, dipped in 1992, and then recovered to exceed the 1990 level in 1994–98. Since 1979, VA inpatient additions as a proportion of all additions have been decreasing, from 12 percent to 6 percent in 1998. Additions to Less Than 24-Hour Care Services In the 1969–98 period, the number of less than 24-hour service additions to mental health organizations in the United States more than tripled, from 1,202,098 to 3, 967,019, and the corresponding addition rate per 100, 000 civilian population more than doubled from 604 to 1,475 (Table 4). Much of this increase occurred during the 1970's, when the number and rate of outpatient additions increased substantially in the freestanding psychiatric outpatient clinics and in the "all other organization" grouping encompassing federally funded CMHCs and other multiservice mental health organizations (Figure 4). Since 1980, the overall increase in additions to less than 24-hour services has moderated, and, in fact, a slight decrease is noted between 1990 and 1992, generated mainly by a substantial decrease in outpatient additions to non-Federal general hospital psychiatric services. The number of additions to these facilities resumed its increase in 1994. "All other organizations" now includes the free-standing outpatient and partial care clinics, as well as the multiservice organizations. In 1998, there were 2.8 million outpatient additions in this category. The less than 24-hour additions in the non-Federal general hospital psychiatric services ranked second, with more than 600,000 additions. Private psychiatric hospitals, RTCs, and the VA medical centers combined comprised over half a million additions. Additions in State mental hospitals numbered 42,000. All categories of organizations showed increases since 1994 in the number of additions except RTCs and State and county hospitals, but the latter declined by less than 100. Patients in 24-Hour Hospital and Residential Services The number of 24-hour hospital and residential patients generally decreased from 1969 to 1998, with increases since the previous survey in 1986 and 1994 (Table 5). The 1994 increase was due entirely to the inclusion of residential supportive patients that had been excluded in previous years. Thus, the 1994–98 decline continued a trend that had begun after 1986. In 1969, there had been 471,451 patients, but by 1992 the number had declined to 214,714. The number in 1998 was only 215,798. The rate per 100,000 civilian population decreased from 237 in 1969 to 80 in 1998. Much of the decrease occurred before 1979 when substantial reductions occurred in the number of resident patients in State mental hospitals and in VA medical center psychiatric inpatient services. The total resident patient count has continued to decline as decreases in the State mental hospital, VA medical center, and private psychiatric hospital resident patient populations (the last peaked in 1990 and have declined irregularly since) have not been offset by the increases seen by non-Federal general hospital psychiatric services, RTCs, and other organizations. In 1969, State mental hospitals accounted for the largest percentage of residents of psychiatric organizations, over three-fourths. Their percentage of residents declined steadily but they continued to treat more residential patients than any other type of treatment facility until 1998. In 1998, there were more residential patients in "all other organizations," with State and county hospitals and "all other organizations" each serving about a quarter of all patients. Patient Care Episodes Patient care episodes, unlike the other volume measures shown, provide an estimate of the number of persons under care throughout the year. They are defined as the number of persons receiving services at the beginning of the year in the 24-hour hospital and residential treatment and less than 24-hour care services of mental health organizations plus the number of additions to these services throughout the year. They are a duplicated count in that persons can be admitted to more than one type of service or can be admitted to the same service more than once during the year. Patient care episodes have been tracked by the National Institute of Mental Health and CMHS since 1955. From then until 1998, the locus of mental health care in the United States shifted from inpatient to ambulatory services, as measured by the number of patient care episodes. Of the 1.7 million episodes in 1955, 77 percent were in 24-hour hospital services and 23 percent in less than 24-hour services; by 1971, there were 4.2 million episodes, of which 42 percent were in 24-hour hospital service and 58 percent in less than 24-hour hospital services; by 1998, of the nearly 11 million episodes, 24 percent were in 24-hour hospital services and 76 percent were in less than 24-hour hospital services, almost exactly the reverse of the 1955 distribution (Table 6 and Figure 5). Along with the shift of patient care episodes from 24-hour hospital and residential treatment care to less than 24-hour services, a shift also occurred across organization types within these two services (Redick et al. 1994b). State mental hospitals accounted for 63 percent of 24-hour hospital and residential treatment episodes in 1955, compared to only 10 percent in 1998. By contrast, in 1998, psychiatric services for 24-hour hospital and residential treatment patients of non-Federal general hospitals and private psychiatric hospitals accounted for 47 and 20 percent, respectively. Compared to 1998, in 1955 a larger proportion of less than 24-hour care episodes was provided by State mental hospitals (9 percent in 1955, 1 percent in 1998) and VA medical centers (11 percent in 1955, 5 percent in 1998), while those of all other organization types combined were higher in 1955 than in 1998 (80 percent in 1955, 77 percent in 1998). See Figure 6 and Figure 7. Staffing of Mental Health Organizations The complete enumeration component of the survey that collected data on mental health organizations in 1998 was more limited in its subject coverage than previous inventories. The questionnaire did not ask about staffing or finances, which were covered in a subsequent sample survey. Therefore, the following section is based on data only through 1994 and has not been changed since the publication of Mental Health, United States, 1998. Detailed staffing data for 1998 will be provided in a subsequent report. Concomitant with increases in the number of mental health organizations and patients served by these organizations, the number of FTE staff employed by these organizations increased steadily between 1972 and 1994, from 375,984 to 577,669 (Table 7). Almost all of this increase was attributed to patient care staff, which increased from 241,265 to 370,635, and to professional staff, which increased from 100,886 to 225,250 during this period. In 1972, professional patient care staff comprised about 27 percent of all FTE staff compared to 39 percent of all FTE staff in 1994 (Figure 8). Among the professional patient care staff disciplines, the largest gains over the 20-year period were noted for psychiatrists, psychologists, social workers, registered nurses, and other mental health professionals. In 1994, each of these professions declined except for registered nurses (Table 7). By contrast, the number of other mental health workers (less than B. A.) employed in mental health organizations showed a variable pattern of increases and decreases between 1972 and 1994, with a larger number reported in 1994 (145,385) than in 1972 (140, 379). The number of FTE administrative, clerical, and maintenance staff showed a larger gain over the 1972–94 period, increasing from 134,719 to 207,034 (Table 7). As a percentage of all FTE staff, other mental health workers dropped from slightly over 37 percent in 1972 to 25 percent in 1994. The administrative and support staff declined from 36 percent in 1972 to 26 percent in 1990 and then rose to 36 percent again in 1994 (Table 7). The mental health organization types that showed the largest proportional increases in number between 1972 and 1994, namely, private psychiatric hospitals, non-Federal general hospitals with separate psychiatric services, RTCs, and "all other mental health organizations," accounted for all of the increases in total FTE staff among mental health organizations during this period (Tables 7a–f)(see below). Table 7a Financing of Services As with staffing, the complete enumeration component of the 1998 Survey collected no data on the financing of mental health services. Accordingly, this section is unchanged since the 1998 edition of Mental Health, United States, and the tables and text cover financing only up to 1994. Detailed data on resources and expenditures for 1998 will be covered in a subsequent report. Expenditures Total expenditures by mental health organizations in the United States, as measured in current dollars, increased tenfold between 1969 and 1994, from $3.3 billion to $33.1 billion. However, when adjustments were made for inflation, that is, expenditures were expressed in constant dollars (1969 = 100), the total expenditures rose from $3.3 billion in 1969 to slightly more than $5 billion in 1994, which was about the same number and percentage as in 1992 (Figure 9, Tables 8a, b). Thus, only $1.7 billion or 5 percent of the $33.1 billion increase in current dollar expenditures between 1969 and 1994 represented an increase in purchasing power, while 95 percent of the increase was due to inflation. All of the specific organization types registered increases in current dollar expenditures between 1969 and 1992, but State mental hospitals and VA medical centers showed declines from 1992 to 1994 (Figure 10). When measured in constant dollars, only State mental hospitals and VA medical centers showed no gains (Figure 11). As a result, the proportionate share of total expenditures changed significantly between 1969 and 1994 for some of the organization types. For example, State mental hospitals and VA medical centers comprised only 24 and 4 percent of total expenditures, respectively, in 1994 compared to 55 and 14 percent, respectively, in 1969; while private psychiatric hospitals, separate psychiatric services of non-Federal general hospitals and "all other organizations" (combined with CMHCs, multiservice, and ambulatory services) comprised 20, 16, and 29 percent, respectively, in 1994 (Figure 12), compared to 7, 9, and 7 percent, respectively, in 1969. Trends in per capita expenditures, that is, the amount of expenditures per person in the civilian population of the United States, followed patterns similar to those noted above for the absolute expenditures among the various types of mental health organizations between 1969 and 1994. All of the organization types showed increases of varying degrees in current dollar per capita expenditures during this period except for the State mental hospitals and the VA medical center psychiatric services. The rest of the increases were a result of the inflationary trend. However, when expressed in constant dollars, per capita expenditures decreased for all of the organizations except for the private psychiatric hospitals and the "all other mental health organizations." These two categories, however, increased at a considerably smaller rate than current dollar per capita expenditures. Revenues by Source In 1994, revenues of mental health organizations in the United States totaled $36 billion, an increase of $5.3 billion over 1992. Of the 1994 total revenues, 30 percent came from State mental health agencies and other State government funds, 18 percent from client fees, 39 percent from Federal Government sources (including Medicare and Medicaid), 8 percent from local governments, 1.4 percent from contracts, and 4 percent from all other sources (Figure 13). The distribution of revenues by source for 1994 was similar to 1992 in that the higher percentage of funds came from Federal and State government funding. Funding from other sources was proportionately the same as in 1992. Among the different organization types, the major revenue sources showed variation in 1994. As would be expected, State mental hospitals obtained most of their funding (71 percent) from State mental health agencies and other State government sources, and virtually all funding for VA medical centers came from the Federal Government. Slightly over 44 percent of all funding for private psychiatric hospitals was obtained from client fees, with another 40 percent being shared by Medicare and Medicaid. State and local governments and Medicaid were the major contributors of funds for RTCs and "all other mental health organizations," which include multiservice and ambulatory services (Table 9). Policy Implications This chapter provides data that allow for the analysis and planning of mental health service delivery. 4 By providing time-series data, it is possible to map the trends and evolution of mental health treatment. In addition, recent data, particularly4 those collected in 1992 and 1994, provide insight into the large-scale transformations in health care service in the 1990's. Analysts of health policy are faced with new challenges following the reform of Federal health care and social service programs, and mental health policy is no exception to change and reform in social services. Number of Beds The substantial increase in the number of private psychiatric hospitals and non-Federal general hospital psychiatric inpatient and residential services during the 1980's has generated mergers, consolidations, downsizings, and closings of some of these hospitals. During the 1990's the number of general hospitals with inpatient psychiatric services has fluctuated slightly but not markedly increased, and the number of inpatient beds has been even more stable. The number of private psychiatric hospitals declined somewhat from 1992 to 1994 and more sharply between 1994 and 1998, and the number of beds followed the same pattern. The effects of this trend are evident in the 1998 data for State and county mental hospitals. These facilities show a continued decline in their year-end resident patients and number of inpatient and residential beds, as many State governments struggle to reduce their budgets by eliminating costly hospital and residential programs, stressing community care, and preventing admission to psychiatric beds when possible. This is becoming even more critical as responsibilities continue to shift to States. The shift to nonresidential care is shown by the stability from 1994 to 1998 in additions to less than 24-hour care at State and county hospitals (decrease of 0.1 percent) compared to a substantial drop in additions to inpatient and residential care (decrease of 14 percent). Another factor in the decline in the number of psychiatric inpatient and residential beds may be the increased use of managed care and other cost-saving mechanisms, including the substitution of less costly care in less than 24-hour services for inpatient and residential care to further reduce the length of hospital stays, thereby reducing the cost of employee care to businesses and insurance companies. Indications are that the number of psychiatric beds may continue to decline in the foreseeable future (Redick et al. 1994a). Patient Care Episodes Policy implications evident from the trend data on patient care episodes involve such issues as (1) the future role of State mental hospitals, (2) the balance between community-based and State mental hospital services, (3) the balance between hospital and residential and ambulatory services, and (4) the contracting by State mental health agencies for the provision of services through the private sector. As the number of hospital and residential epi-sodes in State mental hospitals has continued to decline, policymakers are confronted with momentous decisions regarding these organizations. Of particular importance is the question of whether these facilities should be expanded, or, conversely, closed. At one extreme, some argue that these hospitals have contracted in size to such an extent that persons with severe mental illness are being denied admission, and therefore, further downsizing is unwise. By contrast, others argue that all persons, regardless of the severity of their mental illness, can be cared for in the community and that the State mental hospitals should be phased out entirely. Confounding the options of the policymakers are economic pressures brought by communities and labor unions to keep the State mental hospitals open and to increase their size. State mental health agencies favor the expansion of community-based services at the expense of State mental hospital services. In addition, Federal legislation promotes community-based services to the exclusion of State mental hospital services in the distribution of community mental health service block grant funds to the States. Furthermore, between 1955 and 1994, aftercare services shifted from the State mental hospitals to community-based facilities. Despite these facts, State mental hospitals still consumed almost half of total expenditures by State mental health agencies in 1994. In light of this situation, one of the major issues facing the mental health community today is how to strike a balance between the services of community-based mental health agencies and those provided by State mental hospitals. The proper balance of hospital and residential and ambulatory services needs to be examined for treatment efficacy, as well as for cost-benefit. Although the percentage of less than 24-hour care is now much greater than it was between 1955 and 1971, the proportion has remained almost the same since 1975. Decisions will have to be made about the role of ambulatory versus hospital and residential services and, in particular, about whether or not ambulatory services should be increased at the expense of hospital and residential services. Staffing Accompanying the increase in the number of mental health organizations and their caseloads during the 1970– 94 period has been an increase in the number of FTE staff employed by these organizations. Most of this increase (62 percent of the total increase) occurred among the professional patient care staff, notably in the number of psychiatrists, psychologists, social workers, registered nurses, and other mental health professionals, in contrast to paraprofessional mental health workers (licensed practical nurses, aides, and orderlies) and support staff (administrative, clerical, and maintenance staff). The number of professional staff increased by 123 percent, compared to 54 percent for support staff and 4 percent for paraprofessional staff. This can be attributed in large part to the expansion of community-based mental health care services during this period, which has led to a greater emphasis on short-term hospital and residential as well as less than 24-hour care and partial care services, with the primary goal of keeping clients functioning in their own communities. A feature of the contemporary evolution of health care service has been the replacement of higher cost professionals, particularly physicians, with other staff in less expensive labor categories, such as registered nurses and other mental health care workers. While the overall number of FTE staff in all mental health organizations increased in the 24 years between 1972 and 1994, the number of physicians serving these mental health institutions experienced a gradual decrease, especially since the beginning of the 1990's, and by 1994 the number of psychiatrists had fallen from its 1992 peak. While the 1970's and 1980's saw increases in all labor categories, recent data suggest that growth in higher paying labor categories is flat, and in some categories, a noticeable decline is occurring. As the trends in the number and rates per population associated with hospital and residential care (e. g., decreases in resident patients and psychiatric beds) appear to be leveling off, and policies regarding the effectiveness of long-term hospital and residential care versus short-term hospital and residential and ambulatory care come under review, assessment must be given to the future human resource needs of mental health organizations, particularly as to whether the supply of paraprofessional and professional mental health care workers needs to be augmented or selectively reduced. Consideration also needs to be given to the substitutability of staff disciplines in certain situations. Managed Care In 1994, 40 percent of all mental health organizations were a part of one or more managed care networks. Of the specific organization types, private psychiatric hospitals and non-Federal general hospitals with separate psychiatric services were the largest percentage of managed care participants, 62 and 63 percent, respectively. The next largest percentages were all others (32 percent) and RTCs (18 percent), and the least likely managed care participants were State mental hospitals and VA medical centers, at 4 percent each. Expenditures With the advent of health care reform, much interest has developed in the role of inflation in the increase of expenditures by mental health organizations. Since both the number of private psychiatric hospitals and the expenditures they incurred increased dramatically between 1969 and 1994, these hospitals showed gains in absolute dollar amounts and in dollar amounts per capita (except for 1990), even if the expenditures are expressed in constant dollars. Although in 1994, non-Federal general hospitals with psychiatric services and the residential treatment centers for emotionally disturbed children showed increases in expenditures and per capita as measured in current dollars, these hospitals showed a decrease if measured in constant dollars. Yet their 24-hour care population continued to increase. Only private psychiatric hospitals and "all other mental health organizations" show increased expenditures in both current and constant dollars and in per capita in 1994. Mental Health Services Data by State In conjunction with the preparation of national data for this chapter, CMHS tabulated the 1998 Survey data by State. In recent years, these State data have become increasingly important for managers of State mental health agencies, enabling them to compare their program statistics with those of other States and with national totals. In addition, State legislators, budget officers, and planners of mental health services frequently ask program administrators to furnish comparable statistical information from other States. Although State populations, programs, services, and funding patterns differ somewhat, State mental health program directors have usually identified enough similarities between their State and one or several others to make statistical comparisons. Among the most important factors in selecting other States for comparison is the need for States to have similarly organized services as well as somewhat similar populations. Geographical proximity may also be a relevant factor. Tables 10, 10a, and 10b show the number of facilities in each State in each of the six facility types. Table 10 shows the number of facilities offering any services. Table 10a displays the number providing 24-hour hospital inpatient and residential care; Table 10b lists the number in each State providing outpatient care. All three tables compare the number of facilities in 1998 with the numbers in 1992 and 1994. Figure 14, Figure 15, and Figure 16 show three key variables by State: inpatient and residential treatment beds, inpatient and residential treatment additions, and outpatient additions. All three maps display rates per 100,000 civilian population on July 1, 1998. Psychiatric inpatient and residential treatment beds (Figure 14) are least common in the western States and most common in the east, especially the northeast. South Dakota has an unusually high rate of inpatient and residential beds for a western State, and South Carolina stands out among the eastern States for a low bed rate. Mississippi is also surrounded by States with markedly lower bed rates. Inpatient additions (Figure 15) display a similar regional pattern, being less frequent in the western States than in the eastern, although the area of lowest addition rates is farther west, mostly west of the Great Plains. A band of high admission rates extends from Kentucky westward through Missouri to Kansas and Oklahoma, and many of the adjacent States also have relatively high addition rates. In the east, New Jersey rather than South Carolina has the lowest rate. Outpatient additions (Figure 16) have a third pattern. There are three clusters of States with relatively high outpatient admission rates: New England; the Ohio Valley States of Ohio, Indiana, and Kentucky; and the northern Plains States and adjacent Wyoming, and even extending to Minnesota, Iowa, and Kansas. Low outpatient admission rates are found in most of the States bordering Arkansas, which itself has a relatively high rate; in Idaho, Nevada, Utah, and Colorado; and in an arc of States from New York to Georgia, or even as far as Texas, with the exception of Alabama. Data for 1994, which are similar to those presented in the figures, are available in Mental Health United States, 1998. Moreover, comparative State data for 1983, 1986, and 1988 can be found in Mental Health, United States, 1992; for 1986, 1988, and 1990 in Mental Health, United States, 1994; and for 1986, 1990, and 1992 in Mental Health, United States, 1996. References Redick, R. W., Witkin, M. J., Atay, J. E., & Manderscheid, R. W. (1994a). Mental Health Statistical Note No. 213. Availability of psychiatric beds, United States: Selected years, 1970– 1990. Rockville, MD: Center for Mental Health Services. Redick, R. W., Witkin, M. J., Atay, J. E., & Manderscheid, R. W. (1994b). Mental Health Statistical Note No. 210. The evolution and expansion of mental health care in the United States between 1955 and 1990. Rockville, MD: Center for Mental Health Services. Witkin, M. J., Atay, J. E., & Manderscheid, R. W. (1994). Mental Health Statistical Note No. 212. The effect of inflation on expenditures by mental health organizations between 1969 and 1990. Rockville, MD: Center for Mental Health Services. 1 Throughout this chapter, including the tables, "United States" includes the 50 States and the District of Columbia. SMHO also covers facilities in Puerto Rico and the territories. |
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