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Section 4: Key Elements of the National Statistical Picture

Chapter 15. Persons Treated in Specialty Mental Health Care Programs, United States, 1997

Laura J. Milazzo-Sayre;* Marilyn J. Henderson, M.P.A.;* Ronald W. Manderscheid, Ph.D.;* Maxime C. Bokossa, Ph.D.; Christian Evans; and Alisa A. Male, M.A.

*Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; Synectics for Management Decisions, Inc.

Introduction

In 1997, the Survey and Analysis Branch, Division of State and Community Systems Development, Center for Mental Health Services (CMHS), SAMHSA, conducted a nationwide sample survey of persons receiving care in the inpatient, residential, and less than 24-hour care¹ programs of specialty mental health organizations, the 1997 Client/Patient Sample Survey (hereafter, 1997 CPSS). This survey was designed to collect statistical information on the demographic, clinical, and service use characteristics of this treated population, and to provide national estimates that reflect the current picture of this population within the Nation's specialty mental health service delivery system. The survey included a sample of persons who received care in a sample of the programs of specialty mental health organizations included in Chapter 14 of this publication. The following types of organizations were included: State and county mental hospitals, private psychiatric hospitals, the separate psychiatric services of the Department of Veterans Affairs (VA) medical centers and of non-Federal general hospitals, multi-service mental heath organizations, residential treatment centers for emotionally disturbed children, other residential programs, and freestanding outpatient clinics and partial care organizations.

The 1997 CPSS represents the first national cross-sectional sample survey since 1986 of persons served by specialty mental health organizations, and the first survey to collect such information about residential care programs. This chapter provides preliminary national estimates from the 1997 CPSS on the numbers and characteristics of persons admitted during 1997 and persons under care on a single day in 1997 in the inpatient, residential, and less than 24-hour care programs of specialty mental health organizations. These two groups of persons–– persons admitted during 1997 and persons under care on a single day, when added together, give us a picture of the total people receiving services within these mental health programs during 1997. Comparison of the numbers and characteristics of the two groups provides a way to look at changes over time in those receiving treatment; the longer persons remain in care, the more differences we can observe between persons entering the programs and those under care. A larger number of admissions than persons under care is an indication of turnover within the system, whereas larger numbers of persons under care reflect a more stable caseload. These types of interpretations might be useful tools to consider when reading subsequent sections of this chapter. Each section includes a brief analysis by program type (inpatient, residential, less than 24-hour) and by organization type for selected characteristics of the two client groups.

Overall, approximately 2.3 million persons were under care and 5.5 million persons were admitted during 1997 to specialty mental health inpatient, residential, and less than 24-hour care programs. These persons were largely concentrated in the less than 24-hour care programs, where approximately 2.2 million persons were under care and 3. 3 million persons were admitted in 1997 (Table 1). By contrast, inpatient programs had a little more than 116 thousand persons under care and an estimated 2 million admissions during 1997. Residential care programs were by far the smallest in size of the three program types, with about 83 thousand persons under care and 171 thousand admissions.

Figure 1 illustrates that the relative sizes of the under care and admission populations differed considerably among the three program types. In inpatient programs, where only small proportions of patients become part of the long-term caseload, the number of admissions was almost 18 times the number of persons under care. By contrast, persons tend to receive longer-term care in both residential care programs (where admissions were only about 2 times the number of persons under care) and less than 24-hour care programs (where admissions were about 1½ times the number of persons under care).

The text that follows presents major highlights on the gender, race, ethnicity, age, and diagnostic characteristics of these client/patient groups in the different types of mental health programs. Inpatient programs are described first, followed by residential, then less than 24-hour care programs. Within each section, each client/patient characteristic is examined for the under care population first, followed by the admission population.

In the 1997 CPSS, the following categories were used to report race: American Indian or Alaska Native, Asian or Pacific Islander, Black, and White. Ethnicity was collected through a separate question requesting information on Hispanic origin. Throughout this chapter, analyses combine race and ethnicity into these five categories: American Indian or Alaska Native (not Hispanic), Asian or Pacific Islander (not Hispanic), Black or African American (not Hispanic), White (not Hispanic), and Hispanic or Latino. In general, the three largest racial/ethnic groups were Black/African American, White, and Hispanic/Latino; the two remaining racial/ethnic categories had very small numbers of sample cases. For this reason, when comparing the distributions of race and ethnicity across organization types, analyses in this chapter focus primarily on the three largest groups.

A brief description of the survey design, estimation procedures, variance calculations, and statistical significance calculations is provided in Appendix B. All differences noted in the text are statistically significant at the p = 0.05 level or less. Lack of comment on the differences between any two estimates does not imply that a test was completed with a finding of no statistical significance. For example, the inpatient, residential, and less than 24-hour care programs of VA medical centers almost exclusively serve males. This could be expected and is not necessarily discussed further within the text, even though differences between males and females were statistically significant.

Counts presented in this chapter vary somewhat from totals shown in Chapter 14 for several reasons: (1) Estimates reported in this chapter are based on samples of organizations and persons rather than on complete enumerations. (2) SMHO totals for admissions are duplicated within an organization; 1997 CPSS estimates are not duplicated within the survey month, but they could be duplicated when inflating to an annual estimate of admissions. (3) The universe of mental health organizations used as the sampling frame for the 1997 CPSS was from the 1994 inventory; new mental health programs that came into existence between 1994 and 1997 were not included in the sampling frame. To the extent that rapid growth occurred in a particular type of program, counts based on estimates from the 1997 CPSS may be lower than SMHO totals and may be less representative of the entire client/patient population for that type of program in 1997. This could be expected to occur more frequently in less than 24-hour care programs than in inpatient. Thus, the sample produces a somewhat lower estimate than does the inventory. (4) Measurement and definitional errors stemming from lack of consensus within the mental health field itself are reflected in estimates from both surveys.

Inpatient Care Programs

Table 1 and Figure 2 show the distributions of the under care and admission populations in inpatient programs by type of organization. Almost half (46 percent) of the total 116,224 persons under care in inpatient programs were resident in State/county mental hospitals; one quarter (25 percent) were resident in non-Federal general hospitals. This contrasts with the admission population of 2,035,094; only 9 percent of admissions entered State/county mental hospitals, while more than half (51 percent) entered non-Federal general hospitals. Although the State/county mental hospital system has increasingly shifted its role over time from long-term care to acute care, it is still recognized as a major provider of long-term care within the specialty mental health sector. By contrast, the non-Federal general hospital system is devoted almost exclusively to acute care.

Gender, Race, and Ethnicity of Persons Under Care in Inpatient Programs

• Overall, of the estimated 116,224 persons under care in specialty inpatient programs on May 1, 1997, 71,909 (62 percent) were males, compared with only 44,315 (38 percent) females (Table 2). The proportion of males was much greater than that of females in State/county mental hospitals (70 vs. 30 percent) and in VA medical centers (95 vs. 5 percent); males and females were about equally represented in private psychiatric hospitals and non-Federal general hospitals. Greater percentages of males than females were under care within each racial/ethnic group, with the exception of Asians/Pacific Islanders, where differences observed were not statistically significant (Table 2). Only among Whites within non-Federal general hospitals did females comprise a significantly larger percentage of the under care caseload than males (57 vs. 43 percent).
  
  
• When compared with their numbers in the U.S. civilian population, similar findings also held for the rates of males versus females, overall (56 vs. 32 per 100,000 population) and within each racial/ethnic group, with the exception of Asians/Pacific Islanders, for whom rates were fairly close by gender (Table 2). The difference in under care rates among American Indians/Alaska Natives was particularly pronounced; the male rate was more than 3½ times the female rate (78 vs. 21 per 100,000 population). Similarly, the under care rates for males and females who were Black/African American differed considerably; the male rate was more than 2½ times the female rate (123 vs. 48 per 100,000 population).
  
  
• Overall, Whites accounted for 77.7 thousand— or two-thirds of the total of 116 thousand–– persons under care in inpatient settings (Table 2). Blacks/African Americans comprised the second largest racial/ethnic group, accounting for 26.7 thousand, almost one-fourth of the total persons under care, followed by Hispanics/Latinos, who accounted for 9.7 thousand, or about 8 percent of persons under care. The two remaining racial/ethnic groups each accounted for less than 1 percent of persons under care. Figure 3 shows that within each type of inpatient organization, Whites comprised the largest percentage of the under care population, followed by Blacks/African Americans, then Hispanics/Latinos. The single exception to this pattern occurred in private psychiatric hospitals, where the difference observed between the percentage of Blacks/African Americans and Hispanics/Latinos is not statistically significant.
  
  
• Compared with their numbers in the U.S. civilian population, overall, Blacks/African Americans had the highest under care rate (171 per 100,000 population), and Asians/Pacific Islanders had the lowest overall rate (23 per 100,000 population; Table 2); the rates for remaining racial/ethnic groups were generally clustered between these two extremes.
  
  
• Where comparisons are possible across the various types of organizations, it can be seen that State/county mental hospitals had the highest under care rates per 100,000 population, for all racial/ethnic groups combined, as well as for Blacks/African Americans, Whites, and Hispanics/Latinos, both overall and for males (Table 2). The male rate in State/county mental hospitals was 29 per 100,000 population; the second highest rate among males under care was found in non-Federal general hospitals (10 per 100,000 population). In general, among females, the rates per 100,000 population varied less across organization types than male rates. The rates for females in State/county mental hospitals and non-Federal general hospitals were about the same (12 and 11 per 100,000 population, respectively), and greater than the rates for females in private psychiatric hospitals (6 per 100,000 population) and VA medical centers (less than 1 per 100,000 population).

Gender, Race, and Ethnicity of Persons Admitted to Inpatient Programs

• Of the estimated 2,035,094 million inpatient admissions in 1997, approximately 1,097,127 (54 percent) were males and 937,967 (46 percent) were females (Table 3). Similar to the finding for persons under care in inpatient programs, males comprised the majority of admissions, overall, and within State/county mental hospitals and VA medical centers. Males and females were about equally represented within private psychiatric hospitals and non-Federal general hospitals.
  
  
• In general, differences between the proportions of males and females were less striking among admissions than among persons under care. The overall percentage of males admitted to all inpatient care programs (54 percent; Table 3) was significantly lower than the percentage of males under care in these programs (62 percent; Table 2). However, when broken down by race/ethnicity, no significant differences existed between the proportions of males and females admitted and under care.
  
  
• Comparing rates per 100,000 population shows that similar to the under care population, for all inpatient programs combined, the male admission rate per 100,000 U.S. civilian population was higher than the female rate (848 vs. 687 per 100,000 population; Table 3). However, comparisons by race/ethnicity reveal that male rates were not significantly higher than female rates for each racial/ethnic group, holding true only among Blacks/African Americans (1,498 vs. 903 per 100,000 population).
  
  
• Unlike the under care population, where rates were highest for State/county mental hospitals, admission rates were highest in non-Federal general hospitals, further emphasizing the general hospital focus on acute care and the State/county hospital use for long-term care mentioned previously. Where comparisons can be made by race/ethnicity across organizations, data show that non-Federal general hospitals had higher admission rates than other inpatient organizations, both overall, and for both males and females within each racial/ethnic group, with the exception of Hispanics Latinos, whose admission rates to private psychiatric hospitals and non-Federal general hospitals did not differ significantly (Table 3).
  
  
• The overall size of the admission population was dramatically larger than the under care population (2 million vs. 116 thousand; Tables 2 and 3). Similarly, rates for persons admitted were considerably greater than those for persons under care in inpatient care settings, overall, and for males and females within each of the various organizations and within each of the three largest racial/ethnic groups, Blacks/African Americans, Whites, and Hispanics/Latinos (Tables 2 and 3).
  
  
• Although the differences in size between the admission and under care populations were large, the racial/ethnic compositions of the two groups were very similar. Whites comprised the largest concentration, 1.4 million or 70 percent of total persons admitted, followed by Blacks/African Americans, 379 thousand (19 percent) and Hispanics/Latinos, 181 thousand (9 percent). Figure 4 shows that similar racial/ethnic distributions were found for State/county mental hospitals, non-Federal general hospitals, and VA medical centers. As with the under care population, the difference noted for private psychiatric hospitals between the percentages of Hispanics Latinos and Blacks African Americans is not statistically significant.
  
  
• When compared with their numbers in the U.S. civilian population, American Indians/Alaska Natives, as well as Blacks/African Americans, had higher rates of admission, overall, than did persons of other racial/ethnic groups (Table 3). This finding held true for males and females with several exceptions; the rates of admission for American Indian/Alaska Native males, White males, and Hispanic/Latino males did not differ significantly, nor did the rates for American Indian/Alaska Native females and White females.
  
  
• Similar to their under care counterparts, Asians/Pacific Islanders had the lowest rates of admission compared with persons of other racial/ethnic groups; this was true overall, and for both males and females. It also held for State/county mental hospitals and non-Federal general hospitals, overall (Table 3).
  
  
• Across organization types, Figure 4 shows that Blacks/African Americans comprised a greater proportion of persons admitted to VA Figure 3. Race/ethnicity of the under care population in inpatient programs of specialty mental health organizations, United States, 1997 medical centers (33 percent) than they did of those admitted to private psychiatric hospitals (16 percent) and non-Federal general hospitals (18 percent). A greater percentage of Whites were admitted to non-Federal general hospitals (73 percent) than to VA medical centers (60 percent). Private psychiatric hospitals admitted a greater percentage of Hispanics/Latinos (15 percent) than did non-Federal general hospitals and VA medical centers (6 percent each). Remaining observed differences are not statistically significant.

Age of Persons Under Care in Inpatient Programs

• Persons between the ages of 25 and 44 comprised the largest age group of persons under care overall, 49, 532 (43 percent) in inpatient programs (Table 4). Twenty-seven percent of those in the under care caseload were ages 45 to 64; 14 percent, ages 65 and older; 11 percent, under age 18; and 6 percent, ages 18 to 24.
  
  
• The 25 to 44 age group accounted for the largest percentage of persons under care in State/county mental hospitals and non-Federal general hospitals (47 percent each; Table 4). In private psychiatric hospitals, persons ages 25 to 44 accounted for one-third (34 percent), and children and youth under age 18 accounted for another one-third (34 percent), of those under care. This latter finding is in contrast to the relatively low proportions of children and youth under care in other organization types: 8 percent in non-Federal general hospitals and 5 percent in State/county mental hospitals. Given their nature, in VA medical centers, the under care population tended to be older; children and youth were not part of the under care caseload and persons ages 45 to 64 accounted for half of all residents.
  
  
• Although children and youth under age 18 were oversampled within the 1997 CPSS, there were still very few sample persons within these younger age groups in inpatient programs. Where comparisons can be made of the detailed younger age groups, youth ages 13 to 17 comprised the largest age group, overall (7 percent), and within State/county mental hospitals (4 percent), private psychiatric hospitals (20 percent), and non-Federal general hospitals (6 percent; Table 4). Private psychiatric hospitals had much greater percentages of children and youth under care in each age group— 5 to 9, 10 to 12, and 13 to 17— compared with all other types of inpatient programs.
  
  
• Although overall, State/county mental hospitals had a higher under care rate than other inpatient programs, by age, this held only for persons in the 25 to 44 and 45 to 64 year age groups relative to their numbers in the U.S. civilian population ( Table 4). Children and youth under age 18 had much higher under care rates in private psychiatric hospitals than in State/county mental hospitals and non-Federal general hospitals, holding true for each age group of children and youth— 5 to 9, 10 to 12, and 13 to 17.
  
  
• For all inpatient care programs combined, children and youth under age 18 and persons ages 18 to 24 had lower under care rates per 100,000 civilian population than did persons in the older age groups (Table 4). Youth ages 13 to 17 had higher rates than children ages 5 to 9 and 10 to 12, overall, and within State/county mental hospitals, non-Federal general hospitals, and private psychiatric hospitals, with one exception; the observed difference among these youth and children ages 10 to 12 within private psychiatric hospitals is not statistically significant. Within State/county mental hospitals, elderly persons ages 65 and older had a significantly lower under care rate (19 per 100,000 population) than the 25 to 44 and 45 to 64 age groups (30 per 100,000 population each); such differences did not exist within other organizations.

Age of Persons Admitted to Inpatient Programs

• Similar to the finding for the under care population, the 25 to 44 age group comprised the largest proportion of inpatient admissions, overall, 963 thousand or 47 percent (Table 5). Only 14 percent of admissions were children and youth under 18 years of age, while 11 percent were ages 65 or older.
  
  
• As was true for the under care population, private psychiatric hospitals admitted a higher percentage of children and youth under age 18 to their inpatient programs than did other types of organizations (Figure 5 and Table 5). Children and youth under age 18 comprised 30 percent of the admission population in private psychiatric hospitals, compared with only 10 percent in State/county mentalhospitals and 8 percent in non-Federal general hospitals.
  
  
• Comparisons among the detailed age groupings for children and youth under age 18 reveal that the largest concentration of admissions among this young population was found for youth ages 13 to 17, overall, and within State/county mental hospitals and private psychiatric hospitals (Table 5). Similar to the under care population, private psychiatric hospitals had the largest proportion of children admitted in the 5 to 9, 10 to 12, and 13 to 17 age groups compared with all other types of organizations, and also the highest rates under care per 100,000 population for the 5 to 9 and 13 to 17 age groups.
  
  
• Although the overall number of admissions was much larger than the number of persons under care, approximately the same numbers of elderly persons were admitted to State/county mental hospitals as were under care in these programs (about 6.5 thousand each; Tables 4 and 5). Hence, elderly persons represented a much smaller percentage of admissions than of persons under care (3 vs. 12 percent). In VA medical centers, no significant difference existed between the proportion of persons ages 65 or older in the under care and admission caseloads; similar to the under care caseload, persons ages 45 to 64 comprised more than half of VA admissions (Table 5).
  
  
• The rates for persons admitted to inpatient care were greater than the rates for persons under care in inpatient care programs for all age groups within each organizational setting with one exception. Because equal numbers of elderly persons were admitted and under care in State/county mental hospitals, admission and under care rates for elderly persons were also equal (19 per 100,000 population each; Tables 4 and 5). As noted, the elderly under care rate within State/county mental hospitals was lower than rates for the 25 to 44 and 45 to 64 year groups. This pattern was also very pronounced among admissions to State/county mental hospitals; the rate for the 25 to 44 year group was seven times the admission rate for elderly persons (131 vs. 19 per 100,000 population), and the admission rates for the 13 to 17, 18 to 24, and 45 to 64 year groups were each around 4 times higher than the elderly admission rate (Table 5).
  
  
• Overall, for all inpatient program types combined, persons ages 25 to 44 and 13 to 17 had higher rates of admission than other age groups, each more than 1,000 per 100,000 population, while children ages 5 to 9 had the lowest admission rate (169 per 100,000 population; Table 5). Within State/county mental hospitals, non-Federal general hospitals, and VA medical centers, persons in the 25 to 44 age group had the highest rates of admission of any age group, whereas within private psychiatric hospitals, youth ages 13 to 17 had the highest admission rate. Of the under age 18 population overall, youth ages 13 to 17 had higher rates than children ages 5 to 9 and 10 to 12; this finding also held true within State/county mental hospitals and private psychiatric hospitals.
  
  
• Unlike the under care population, where State/county mental hospitals had the highest rates for persons in the 25 to 44 and 45 to 64 age groups, admission rates were highest in non-Federal general hospitals for the 18 to 24, 25 to 44, 45 to 64, and 65 and older age groups (Table 5).

Principal Psychiatric Diagnosis² of Persons Under Care in Inpatient Programs

• Table 6 presents the frequency of selected principal psychiatric diagnoses among the under care population in inpatient programs. Overall, schizophrenia was the most frequently reported diagnostic grouping (46 percent), followed by affective disorders (25 percent).
  
  
• Considerable differences occurred across organization types in the relative frequency of these two major diagnostic groupings. In private psychiatric hospitals, affective disorders accounted for the largest percentage of persons under care (41 percent), followed by schizophrenia (19 percent; Table 6). In State/county mental hospitals and VA medical centers, schizophrenia was the predominant diagnostic grouping (64 and 40 percent, respectively), while the percentage of persons under care diagnosed with affective disorders was lower in State/county mental hospitals (13 percent) than in any other type of inpatient program. Note that differences observed between the proportion of persons under care diagnosed with schizophrenia and affective disorders in non-Federal general hospitals (30 and 39 percent, respectively) are not statistically significant.
  
  
• The percentage of persons under care with a diagnosis of alcohol-related disorders tended to be larger in VA medical centers, but the only statistically significant difference was between the VA medical centers and State/county mental hospitals (13 vs. 2 percent; Table 6). This finding was also true for persons under care with a diagnosis of drug-related disorders; 7 percent in VA medical centers versus 2 percent in State/county mental hospitals.

Principal Psychiatric Diagnosis 2 of Persons Admitted to Inpatient Programs

• Overall, the most frequently occurring diagnostic grouping among admissions to inpatient psychiatric programs was affective disorders (40 percent), followed by schizophrenia (20 percent; Table 7), a reversal compared with the under care population.
  
  
• Similar to the under care population, persons diagnosed with affective disorders were predominant among admissions to private psychiatric hospitals (48 percent). Persons with diagnoses of schizophrenia and affective disorders comprised the largest proportions of the admission population in State/county mental hospitals (29 and 24 percent, respectively; Table 7). In non-Federal general hospitals, differences within the admission population were more striking than within the under care population; affective disorders ranked first (44 percent), followed by schizophrenia (22 percent), among admissions to this inpatient setting.
  
  
• In VA medical centers, the proportion of admissions with a diagnosis of alcohol-related disorders (20 percent) was considerably greater than in each of the remaining organization types, where the percentages of admissions with alcohol-related disorders ranged from 5 to 11 percent (Table 7).
  
  
• A comparison of the admission and under care populations in inpatient programs clearly shows that, in State/county mental hospitals and VA medical centers, persons diagnosed with schizophrenia comprised much higher percentages of the under care populations than of the admission populations (Figure 6 and 7). In State/county mental hospitals, the percentage of persons diagnosed with schizophrenia was 64 percent for the under care population and only 29 percent among admissions; in VA medical centers, 40 percent of persons under care were diagnosed with schizophrenia compared with 24 percent of admissions.
  
  
• By contrast, in State/county mental hospitals, a much greater percentage of persons admitted than persons under care had a diagnosis of affective disorders (24 vs. 13 percent; Figure 6).

Figure 6. Comparison of the percentages of the under care and admission populations diagnosed with affective disorders or schizophrenia in inpatient programs of specialty mental health organizations, United States, 1997

Residential Care Programs

An estimated 83 thousand persons were under care in residential care programs of specialty mental health organizations in 1997 and more than twice as many, an estimated 171 thousand persons, were admitted to these settings in that year (Table 1).

Because of the relatively small sizes of the residential care programs in State/county mental hospitals, private psychiatric hospitals, non-Federal general hospitals, VA medical centers, and multiservice mental health organizations, the 1997 CPSS was not designed to provide separate estimates for residential care in each of these organizations. Hence, the characteristics of their residents are not detailed separately in the text that follows or in Tables 8 to 13, but are summed together under the general heading all other organizations. Only residential treatment centers (RTCs) for emotionally disturbed children are analyzed separately from other residential programs.

Gender, Race, and Ethnicity of Persons Under Care in Residential Programs

• Overall, among the estimated 82, 916 persons under care in residential care programs during 1997, most were males, accounting for 64 percent of the total; females comprised 36 percent of the total (Table 8). This finding held within RTCs for emotionally disturbed children as well as for the all other organizations grouping.
  
  
• Where comparisons can be made by gender within each racial/ethnic group, data show that the proportion of males was greater than the proportion of females among Blacks/African Americans and Whites, overall (Table 8). Within RTCs for emotionally disturbed children, males predominated for Blacks/African Americans, Whites, and Hispanics/Latinos; within the other organizations group, this held among Whites only (other differences are not statistically significant for this setting).
  
  
• As Figure 7 shows, Whites represented the majority of persons under care in residential care programs in 1997. Blacks/African Americans comprised the next largest proportion, followed by Hispanics/Latinos. This finding is similar to that found overall for inpatient care programs.
  
  
• When compared with their numbers in the U.S. civilian population, males had higher under care rates than females overall (Table 8). Among Blacks/African Americans and Whites, the rates for males were twice the rates for females. Within RTCs for emotionally disturbed children, males also had higher rates than females among Hispanics/Latinos in addition to Blacks/African Americans and Whites.
  
  
• Among Whites, males and females in RTCs for emotionally disturbed children had lower under care rates per 100,000 civilian population than did males and females in the other residential organizations group; among Hispanics/Latinos, this was also true for females (Table 8).

• Of the estimated 171,407 persons admitted to residential care programs, most were males (63 percent); females accounted for 37 percent of total persons admitted (Table 9). Overall, these proportions were similar to those found for males and females under care in residential care programs (Table 8). Similar proportions were found among admissions to each of the two groupings of residential programs (RTCs and other residential organizations).
  
  
• Males comprised the majority of Blacks/African Americans and Whites admitted to residential care overall, and the majority of Whites in each of the two residential care settings (Table 9). Although it appears that there were greater proportions of Hispanic/Latino males than females, caution must be used when comparing these data because the differences are not statistically significant.
  
  
• Overall, the proportions that males and females comprised of the admission population in residential care programs did not differ significantly from the proportions that they represented in the under care population for this program setting (Tables 8 and 9). This finding also held true within each racial/ethnic group.
  
  
• Where comparisons can be made by gender within racial/ethnic groups, the data show that a greater percentage of White males were admitted to residential care programs than to inpatient care programs (64 vs. 53 percent; Tables 3 and 9). Conversely, a greater percentage of White females were admitted to inpatient than to residential care programs (47 vs. 36 percent).
  
  
• Figure 8 shows that, similar to the finding for the residential under care population, Whites accounted for the majority of persons admitted to residential care programs. A larger proportion of Whites were admitted to the all other organizations group (73 percent) than to RTCs for emotionally disturbed children (55 percent).
  
  
• Overall, when compared with their numbers in the U.S. civilian population, the rate of admission to residential care programs was greater for males than females (84 vs. 46 per 100,000 population; Table 9). Note, however, that this difference between males and females does not hold statistically for either RTCs for emotionally disturbed children or the other residential group when considered separately.
  
  
• The rates for persons admitted were greater than the rates for persons under care in residential care programs overall, as well as for males and females ( Tables 8 and 9). This held true within the all other residential organizations group, but not within RTCs for emotionally disturbed children; in this latter setting, only the admission rate for females exceeded the female under care rate.
  
  
• Where comparisons can be made by race/ethnicity, it is seen that the rates of admission to residential care programs were lower for Asians/Pacific Islanders than for Blacks/African Americans, Whites, and Hispanics/Latinos, overall. Among males overall, Asians/Pacific Islanders had the lowest admission rate of any racial/ethnic group ( Table 9). Additional comparisons by race/ethnicity reveal that Blacks/African Americans were also admitted to residential care programs at a greater rate than Whites and Hispanics/Latinos, both overall and among females ( Table 9). The only statistically significant difference in the rate of admission for males and females is found among Whites, for whom the rate for males exceeded that for females.
  
  
• Within RTCs for emotionally disturbed children, the rates of admission for Blacks/African Americans were greater than those for Whites, both overall and for males and females; the rate for Black/African American females was also greater than the rate for Hispanic/Latino females (Table 9). In the other residential organizations grouping, Asians/Pacific Islanders were admitted at a much lower rate than Blacks/African Americans and Whites (31, 136, and 98 per 100,000 population, respectively).
  
  
• Comparisons with the under care population in residential care programs reveal that Whites had higher admission than under care rates, both overall and for males and females; this held true for the other residential organizations group, but not for RTCs ( Tables 8 and 9). Admission rates were also higher than under care rates for Hispanics/Latinos, overall and among males for all residential program types combined.
  
  
• When comparing residential and inpatient admission populations, it can be seen that persons admitted to inpatient care programs had substantially higher rates than persons admitted to residential care programs; this finding held for all racial/ethnic groups and for males and females within those racial/ethnic groups where comparisons can be made (Tables 3 and 9).

Age of Persons Under Care in Residential Programs

• Overall, children and youth under age 18 and persons ages 25 to 44 accounted for the largest percentages of persons under care in residential care programs (40 and 30 percent, respectively; Table 10). As could be expected, within RTCs for emotionally disturbed children, the under age 18 population predominated, accounting for 95 percent of all persons under care; youth ages 13 to 17 comprised the largest subgroup of those under 18, accounting for 65 percent of total persons under care in this setting. For the all other organizations group, persons ages 25 to 44 accounted for the largest proportion of persons under care (45 percent), followed by those ages 45 to 64 (30 percent). Clearly, the two subgroups of residential programs served very different populations with respect to age.
  
  
• When inpatient and residential under care caseloads are compared, overall for all organization types combined, results show that, as could be expected, children and youth under age 18 made up a considerably greater proportion of the residential caseload than of the inpatient caseload (40 vs. 11 percent; Tables 4 and 10). Similarly, the under care rates for children and youth under age 18 were larger in residential than in inpatient care programs, while the under care rates for persons in the 25 to 44, 45 to 64, and 65 and older age groups were larger in inpatient than in residential care programs.
  
  
• When looking specifically at the detailed age groups for children and youth under age 18, it can be seen that overall, and for both categories of residential programs, the under care rates were progressively greater from the youngest to the oldest age group where comparisons can be made. Youth ages 13 to 17 had a particularly high under care rate (122 per 100,000 population), twice the size of the next largest under care rate, found for children ages 10 to 12 (58 per 100,000 population).
  
  
• Where comparisons can be made by age across residential care settings, the data show that the under care rates for each of the children and youth age groups under age 18 were greater in RTCs for emotionally disturbed children than in the other residential organizations group; conversely, the under care rates for persons ages 18 to 24 and 25 to 44 were greater in other residential care organizations than in RTCs for emotionally disturbed children.

Age of Persons Admitted to Residential Programs

• Similar to the residential under care population, admissions to residential care programs were concentrated largely in the under 18 and 25 to 44 age groups (38 and 36 percent, respectively; Table 11). Among the under age 18 admissions population, most children and youth were ages 13 to 17.
  
  
• In RTCs for emotionally disturbed children, 97 percent of admissions were under the age of 18, with most ages 13 to 17 (71 percent of total admissions; Table 11). As with the under care population, the proportion of children and youth under age 18 was significantly higher in RTCs than in the all other organizations grouping (19 percent). Persons in the 25 to 44 age group comprised the largest percentage of persons admitted to the all other organizations group (48 percent).
  
  
• Within residential programs in the other organizations group, persons ages 45 to 64 accounted for only 20 percent of admissions, but 30 percent of the under care population; hence, admissions tended to be a somewhat younger group than persons under care (Tables 10 and 11).
  
  
• A comparison of the admission populations in residential and inpatient care programs reveals that the percentage of children and youth under age 18 was almost three times greater in residential than in inpatient care programs (38 vs. 14 percent; Tables 5 and 11). This finding also held for youth ages 13 to 17, who comprised 29 percent of admissions to residential care programs compared with 10 percent of admissions to inpatient care programs.
  
  
• Among all persons admitted to residential care programs, youth ages 13 to 17 were admitted at the greatest rate when compared with their numbers in the population (259 per 100,000 population); this finding held true within RTCs for emotionally disturbed children (Table 11).
  
  
• Comparisons between the admission and under care populations in residential care programs reveal that, overall, the rates of admission were somewhat higher than the under care rates for most age groups (Tables 10 and 11), but they did not differ nearly as much as for inpatient programs.

Principal Psychiatric Diagnosis² of Persons Under Care in Residential Programs

• More than one-third of all persons under care in residential care programs had a diagnosis of schizophrenia (35 percent; Table 12). Those diagnosed with affective disorders and attention/conduct disorders accounted for the next largest concentrations of persons in the under care population of residential care programs (18 and 16 percent, respectively).
  
  
• In RTCs for emotionally disturbed children, persons diagnosed with attention/conduct disorders predominated (39 percent), followed by persons diagnosed with affective disorders (17 percent; Table 12 and Figure 9). By comparison, one-half of all persons under care in the all other organizations group had a diagnosis of schizophrenia. The second largest concentration of persons under care in these settings had diagnoses of affective disorders (18 percent). Just as with age, it is clear that the two subgroups of residential programs served very different populations with respect to diagnosis.
  
  
• A look at the proportions of selected principal diagnoses for the under care population compared with the under care population in inpatient care programs reveals significant differences. Residents with diagnoses of affective disorders were much more frequently found in inpatient than in residential care programs (25 vs. 18 percent;Tables 6 and 12). In addition, the percentage of residents in inpatient care programs with diagnoses of organic disorders (6 percent) was much greater than the percentage for their counterparts in residential care programs (1 percent).

Principal Psychiatric Diagnosis² of Persons Admitted to Residential Programs

• Overall, a diagnosis of schizophrenia was twice as likely to be found among persons under care than among persons admitted to residential care programs (35 vs. 18 percent; Tables 12 and 13). This finding also held true for the other organizations group; 50 percent of the under care population versus 23 percent of admissions. While there appear to be many additional marked differences between the overall diagnostic distribution of residential care program admissions and the under care population in these programs, they are not statistically significant.
  
  
• Within all residential care programs combined, affective disorders represented a larger percentage of the admission diagnoses than any other diagnostic grouping, with the exception of schizophrenia (where the difference noted is not statistically significant; Table 13). Within RTCs for emotionally disturbed children, most admissions had a diagnosis of attention/conduct disorders, accounting for one-third (34 percent) of all admissions to this setting.
  
  
• Overall, admissions to residential care programs were significantly less likely to have diagnoses of affective disorders compared with admissions to inpatient care programs (24 vs. 40 percent; Tables 7 and 13).

Less Than 24-Hour Care Programs

Unlike previous national client/patient sample surveys, which collected and reported data separately for the outpatient and partial care programs of specialty mental health organizations, 1997 CPSS combined these two program types into the single category "less than 24-hour (and not overnight)." This category is consistent with that used in Chapter 14.

Less than 24-hour care services accounted for a much larger proportion of the total number of persons under care in organized mental health settings than in either inpatient or residential care programs (Table 1). An estimated 2.2 million persons were under care and another 3.3 million persons were admitted to this program setting during 1997. The bulk of less than 24-hour care service provision occurred within multiservice mental health organizations, which accounted for 885 thousand persons under care (41 percent) and 1.4 million persons admitted (41 percent). The second largest concentration of persons under care was found within freestanding outpatient clinics/partial care organizations (640 thousand or 30 percent), followed by non-Federal general hospitals (301 thousand or 14 percent), and VA medical centers (150 thousand or 7 percent). RTCs for emotionally disturbed children, private psychiatric hospitals, and State/county mental hospitals had the smallest numbers of persons under care in less than 24-hour care programs (less than 100 thousand persons each).

Figure 10 illustrates that the admission population in less than 24-hour care programs was similarly distributed across the various types of organizations. As already noted, multiservice mental health organizations accounted for the largest concentration of total persons admitted (41 percent), followed by freestanding outpatient clinics/partial care organizations (893 thousand or 27 percent), and non-Federal general hospitals (597 thousand or 18 percent). State/county mental hospitals admitted the smallest number of persons (only 34 thousand persons or 1 percent of the total less than 24-hour admissions).

Gender, Race, and Ethnicity of Persons Under Care in Less Than 24-Hour Care Programs

• Of the estimated 2,150,662 persons under care in less than 24-hour care programs in 1997, males and females comprised nearly equal proportions (51 and 49 percent, respectively) of the total population, unlike the findings for populations in residential and inpatient under care programs, where males predominated (Tables 2, 8, and 14). By race/ethnicity, however, males did predominate among Hispanics/Latinos and among Asians/Pacific Islanders under care in less than 24-hour care programs.
  
  
• The percentage of females under care actually exceeded that of males in non-Federal general hospitals (57 vs. 43 percent) and multiservice mental health organizations (53 vs. 47 percent; Table 14). In non-Federal general hospitals, this was true for Whites and Blacks/African Americans; in multiservice mental health organizations, this was true only for Whites. It did not hold for Hispanics/Latinos under care in either type of organization.
  
  
• In a comparison of less than 24-hour, residential, and inpatient care programs (Tables 2, 8, and 14), it can be seen that overall, a larger percentage of females were under care in less than 24-hour care programs (49 percent) than in residential (36 percent) and inpatient care programs (38 percent). By racial/ethnic group, the large percentage of females held only for Whites; for Blacks/African Americans, only the difference between less than 24-hour and inpatient care programs is statistically significant; for other racial/ethnic groups, less than 24-hour programs did not differ from residential and inpatient programs. When comparing specific types of organizations providing both inpatient and less than 24-hour care, it can be seen that overall, the percentage differences for gender held only within State/county mental hospitals.
  
  
• The racial/ethnic composition of the under care population in less than 24-hour care programs was similar to both residential and inpatient care programs (Figures 3, 7, and 11). Whites accounted for the majority of persons under care (67 percent). Blacks/African Americans comprised the next predominant racial/ethnic group (20 percent), followed by Hispanics/Latinos (11 percent). One interesting difference was found, however, for the under care populations of Hispanics/Latinos. The percentage under care in the less than 24-hour care programs of non-Federal general hospitals was three times that of Hispanics/Latinos under care in the inpatient care programs within this organization type (18 vs. 6 percent).
  
  
• The rate per 100,000 civilian population for persons under care in less than 24-hour care programs was highest in multiservice mental health organizations (332 per 100,000 population), followed by freestanding outpatient clinics/partial care organizations (240 per 100,000 population; Table 14). This pattern was also true for both males and females as well as all racial/ethnic groups, with a few exceptions. Among Asians/Pacific Islanders, differences in under care rates for non-Federal general hospitals and multiservice mental health organizations are not statistically significant; and among Hispanics/Latinos, under care rates did not differ appreciably for multiservice mental health organizations, freestanding outpatient clinics/partial care organizations, and non-Federal general hospitals (522, 474, and 380 per 100,000 population, respectively; Table 14).
  
  
• Under care rates in less than 24-hour care programs did not differ appreciably by gender, with the exception of VA medical centers (Table 14). However, notable differences existed by race/ethnicity. Asians/Pacific Islanders had the lowest under care rates of any racial/ethnic group (472 per 100,000 population); this held among both males and females, overall, as well as for multiservice mental health organizations (106 per 100,000 population), and freestanding outpatient clinics/partial care organizations (260 per 100,000 population; with the single exception of Hispanics/Latinos in these latter programs).
  
  
• American Indians/Alaska Natives and Blacks/African Americans had the highest overall under care rates (2,784 and 2,631 per 100,000 population, respectively; Table 14). This pattern held within multiservice mental health organizations and for Blacks/African Americans in freestanding outpatient clinics/partial care programs. By gender, Blacks/African Americans had higher rates than Whites and Hispanics/Latinos for both males and females; additionally, American Indian/Alaska Native males had a higher under care rate than White males.
  
  
• Overall, Whites and Hispanics/Latinos did not differ appreciably with respect to under care rates. This pattern held for both males and females and overall for each type of organization (Table 14).
  
  
• When rates per 100,000 population for persons under care in less than 24-hour, inpatient, and residential care programs are compared, it is seen that rates were consistently higher in less than 24-hour than in inpatient and residential care programs (Tables 2, 8, and 14). This was true, overall, for both males and females, and also within each racial/ethnic group.
  
  
• When comparing under care rates for persons in less than 24-hour and inpatient care programs within specific types of organizations, several notable differences emerge (Tables 2 and 14). In private psychiatric hospitals, the under care rates for Blacks/African Americans were approximately equal in inpatient and less than 24-hour programs; this pattern also held for Hispanics/Latinos. Interestingly, within State/county mental hospitals, differences between the two program settings were very slight, and in fact, under care rates for Whites were actually higher in inpatient than in less than 24-hour programs, both overall and for males.

Gender, Race, and Ethnicity of Persons Admitted to Less Than 24-Hour Care Programs

• The estimated number of admissions to less than 24-hour care programs during 1997 was 3,333,215 (Tables 1 and 15). Overall, males and females accounted for about equal proportions of total admissions to this program setting (49 and 51 percent, respectively), similar to the overall finding for the under care population receiving less than 24-hour care. In addition, while the proportions of male and female admissions appear to differ, both genders were about equally represented within each racial/ethnic group for all organization types combined.
  
  
• When comparisons by gender are made across organizational settings, data show that, as was true for the under care population in less than 24-hour care programs, more females than males were admitted to non-Federal general hospitals, overall (56 vs. 44 percent; Table 15). Observed differences in the proportions of males and females in other organizations were not found to be significant.
  
  
• Overall, the racial/ethnic composition of the admission population in less than 24-hour care programs was similar to inpatient and residential care programs. Whites accounted for the vast majority of persons admitted to less than 24-hour care (70 percent; Figure 12); Blacks/African Americans were second (17 percent), followed by Hispanics/Latinos (10 percent). This was true within VA medical centers, multiservice mental health organizations, and RTCs for emotionally disturbed children. While most persons admitted to State/county mental hospitals, private psy-chiatric hospitals, non-Federal general hospitals, and freestanding outpatient clinics/partial care organizations were White, the proportions of Hispanics/Latinos and Blacks/African Americans admitted to each of these types of organizations did not differ significantly.
  
  
• Within private psychiatric hospitals, Whites comprised a much larger percentage of admissions to less than 24-hour care (83 percent) than to inpatient care (67 percent; Figures 4 and 12). However, the percentage of Hispanics/Latinos admitted to less than 24-hour care in private psychiatric hospitals was only one-third as great as the percentage admitted to inpatient care (5 vs. 15 percent). By contrast, within non-Federal general hospitals, the percentage of Hispanics/Latinos admitted to less than 24-hour care was more than twice that for Hispanics/Latinos admitted to inpatient care (15 vs. 6 percent).
  
  
• Significant differences by race/ethnicity were also found within VA medical centers where Whites made up a much larger percentage of admissions to less than 24-hour care programs than to inpatient care programs (73 vs. 60 percent; Figures 4 and 12). Also within VA medical centers, the percentage of Blacks/African Americans admitted for less than 24-hour care was about half that of Blacks/African Americans admitted for inpatient care (17 vs. 33 percent).
  
  
• Comparisons by gender and race/ethnicity between the admission and under care populations in less than 24-hour care programs reveal that, overall, among Asians/Pacific Islanders, females comprised a greater percentage of the admission than the under care population (58 vs. 28 percent), and conversely, males comprised a much larger percentage of the under care than admission population (72 vs. 42 percent; Tables 14 and 15).
  
  
• A total of 1,253 persons per 100,000 population were admitted to less than 24-hour care programs (Table 15). The highest rate of admission was for persons in multiservice mental health organizations (513 per 100,000 population); the second highest rate, for persons in freestanding outpatient clinics/partial care organizations (336 per 100,000 population); next highest, for persons in non-Federal general hospitals (224 per 100,000 population). This pattern also held by gender. Overall, the lowest rate of admission was for persons in State/county mental hospitals (13 per 100,000 population); this was also true for both genders (with the exception of the extremely low admission rate for females in VA medical centers).
  
  
• In general, each racial/ethnic group had highest admission rates in multiservice mental health organizations and freestanding outpatient clinics/partial care organizations, when compared with other types of less than 24-hour programs (Table 15). Among Hispanics/Latinos, however, rates of admission to these two organization types did not differ significantly from non-Federal general hospitals.
  
  
• When compared with their respective numbers in the U.S. civilian population, males and females were admitted to less than 24-hour care programs at about the same rate, overall, and within each organizational setting, with the exception of VA medical centers (Table 15).
  
  
• Overall, for all less than 24-hour programs combined, Asians/Pacific Islanders had the lowest rates of admission (1,115 per 100,000 population), irrespective of gender (Table 15). American Indians/Alaska Natives and Blacks/African Americans had the highest admission rates, overall (4,425 and 3,540 per 100,000 population, respectively). By gender, it can be seen that among males these two racial/ethnic groups also had higher rates than Whites, and Blacks/African Americans had a higher admission rate than Hispanics/Latinos. Fewer differences existed among females, for whom Blacks/African Americans had a higher admission rate than Whites.
  
  
• By type of organization providing less than 24-hour care, it can be seen that specific organizations varied from the pattern noted above to differing degrees (Table 15). In multiservice mental health organizations, American Indians/Alaska Natives and Blacks/African Americans had the highest admission rates. In non-Federal general hospitals, Asians/Pacific Islanders had the lowest rate of admission compared with all other racial/ethnic groups in this setting. In freestanding outpatient/partial care programs, this was true only among male admissions. In private psychiatric hospitals, admission rates for Asians/Pacific Islanders as well as for Hispanics/Latinos were lower than rates for Whites. In VA medical centers, Hispanic/Latino males had lower rates of admission than White and Black/African American males. By contrast, in State/county mental hospitals and RTCs for emotionally disturbed children, the admission rates for Blacks/African Americans, Whites, and Hispanics/Latinos did not differ from each other, overall or among males and females.
  
  
• A number of notable differences by gender and race/ethnicity existed between the rates for persons admitted and the rates for persons under care in less than 24-hour care programs (Tables 14 and 15). Because many more persons were admitted than under care, the overall admission rate of 1,253 per 100,000 population was much higher than the under care rate of 808 per 100,000; this pattern held for males and females, overall and within private psychiatric hospitals, non-Federal general hospitals, multiservice mental health organizations, and freestanding outpatient clinics/partial care organizations. It also held overall for each racial/ethnic group with the exception of American Indians/Alaska Natives (because of relatively small sample sizes for this racial/ethnic group).
  
  
• Given the considerable difference in the numbers of persons admitted to less than 24-hour care programs and those admitted to residential care programs, it follows that the rates of admission were substantially greater in less than 24-hour than in residential care programs, overall, for males and females, and for each racial/ethnic group (Tables 9 and 15).
  
  
• Similarly, the overall rate at which persons were admitted to less than 24-hour care programs was much greater than the overall rate for persons admitted to inpatient care programs; this was true as well for total males and females (Tables 3 and 15). However, the reverse was true within certain organizations providing care in the two program settings; in State/county mental hospitals, private psychiatric hospitals, and non-Federal general hospitals, admission rates for persons in inpatient care programs were greater than the rates for persons in less than 24-hour care programs, overall, as well as among males and females.
  
  
• Additional comparisons between less than 24-hour care programs and inpatient programs by race/ethnicity reveal that Whites and Hispanics/Latinos were admitted to less than 24-hour care at greater rates than to inpatient care programs; these findings are also observed among males and females of these two racial/ethnic groups, and among Asian/Pacific Islander males and Black/African American females (Tables 3 and 15).
  
  
• Differences are also noted in the rates at which persons were admitted for less than 24-hour and inpatient care programs by race/ethnicity within the various organizations providing care in these two settings (Tables 3 and 15). Blacks/African Americans and Whites had greater rates of admission to the inpatient care programs than to the less than 24-hour care programs of State/county mental hospitals, private psychiatric hospitals, and non-Federal general hospitals; these findings also held true for males and females of both racial/ethnic groups, with the exception of White females in private psychiatric hospitals (where the admission rates do not differ statistically).
  
  
• Similarly, Hispanics/Latinos had greater rates of admission to the inpatient than to the less than 24-hour care programs of State/county mental hospitals and private psychiatric hospitals; this pattern held true for males within both types of organizations and for females within private psychiatric hospitals (Tables 3 and 15). By contrast, the admission rates for Whites, overall, and among males were greater in the less than 24-hour than in the inpatient care programs of VA medical centers.

Age of Persons Under Care in Less Than 24-Hour Care Programs

• Of the estimated 2.2 million persons under care in less than 24-hour care programs, most were in the 25 to 44 year age group (816 thousand or 38 percent), followed by persons ages 45 to 64 (26 percent) and children and youth under age 18 (24 percent; Table 16). The 18 to 24 and 65 and older age groups were much smaller in size (6 percent each).
  
  
• When looking at the age distribution of persons under care within each type of less than 24-hour care program, it can be seen that multiservice mental health organizations and freestanding outpatient clinics/partial care organizations had very similar age distributions; in both of these organization types, the 25 to 44 year group accounted for the largest percentage of persons under care, and the 45 to 64 year group and under age 18 group were about equal (Table 16). Private psychiatric hospitals and non-Federal general hospitals differed slightly with respect to age distributions; in these two organization types, all three age groups (under 18, 25 to 44, and 45 to 64) were essentially equally represented.
  
  
• The age distributions of persons under care in State/county mental hospitals, VA medical centers and RTCs for emotionally disturbed children, however, differed considerably from the other organization types (Table 16). Within State/county mental hospitals, more than one-third of total persons under care were in the 25 to 44 age group, another one-third were ages 45 to 64, and persons under age 18 were much less common (only 11 percent). As could be expected, more than half (53 percent) of all persons under care in VA medical centers were persons ages 45 to 64 and the remaining half were about equally distributed between the 25 to 44 and 65 and older age groups. By contrast, nearly half (47 percent) of persons under care in RTCs were children and youth under age 18. Adults under care in RTCs were mostly concentrated in the 25 to 44 and 45 to 64 age groups (28 and 17 percent, respectively).
  
  
• Figure 13 shows that when comparing across inpatient, residential, and less than 24-hour care programs, residential care programs had the largest percentage of children and youth under age 18 under care (40 percent), followed by less than 24-hour programs (24 percent); the percentage of inpatient programs was much smaller (11 percent). By contrast, the proportion of elderly persons ages 65 and older under care in inpatient care programs was more than twice that of elderly persons under care in less than 24-hour care programs (14 vs. 6 percent).
  
  
• The greater percentage of children and youth under care in residential care programs than in less than 24-hour care programs was due totally to youth ages 13 to 17 (Tables 10 and 16); children ages 5 to 9 actually represented a larger percentage of those under care in less than 24-hour (7 percent) than in residential care programs (3 percent).
  
  
• Within less than 24-hour care programs overall, elderly persons ages 65 and older had the lowest under care rate (368 per 100,000 population) compared with all other age groups, except when looking at detailed children and youth rates, where children under the age of 5 had an extremely low under care rate (104 per 100,000 population; Table 16). By contrast, persons ages 10 to 12, 13 to 17, 45 to 64, and 25 to 44 each had under care rates close to or higher than 1,000 per 100,000 population.
  
  
• In multiservice mental health organizations and in freestanding outpatient clinics/partial care organizations, children under age 5 had the lowest under care rate, and elderly persons the next lowest rate; in non-Federal general hospitals, children under 5 had the lowest rate, but the under care rate for elderly persons did not differ appreciably from other age groupings (Table 16). By contrast, within RTCs for emotionally disturbed children, children and youth under age 18, as well as the individual age groups of children ages 5 to 9, children ages 10 to 12, and youth ages 13 to 17, had higher under care rates than those for each age group 18 and older.
  
  
• Multiservice mental health organizations and freestanding outpatient clinics/partial care organizations generally had the highest under care rates for persons irrespective of age group when compared with other types of organizations (Table 16). The only exceptions were for elderly persons under care, whose rates in these two settings did not differ from those in VA medical centers and non-Federal general hospitals, and for the 18 to 24 year group, for whom no statistical difference was found between the under care rates for non-Federal general hospitals and freestanding outpatient clinics/partial care organizations.
  
  
• Similar to their respective numbers, persons within each age group had substantially higher under care rates in less than 24-hour care programs than in residential and inpatient care programs, overall (Tables 4, 10, and 16). However, in State/county mental hospitals, the under care rate for elderly persons ages 65 and older was actually lower in less than 24-hour than in inpatient care programs (8 vs. 19 per 100,000 population).

Age of Persons Admitted to Less Than 24-Hour Care Programs

• As was true for the under care population, the largest concentration of the 3.3 million persons admitted to less than 24-hour care programs was found among those ages 25 to 44 (1. 4 million or 41 percent; Table 17). Children and youth under age 18 comprised the next largest concentration of admissions to this setting, accounting for 966 thousand admissions (29 percent). Elderly persons, ages 65 and older, represented a very small proportion, only 140 thousand admissions (4 percent).
  
  
• The 25 to 44 and under 18 age groups comprised the largest percentages of admissions within each organization type, with a few exceptions (Table 17). Within non-Federal general hospitals, no statistically significant difference was found between the percentage of children and youth under age 18 and persons ages 45 to 64 who were admitted (28 vs. 18 percent). In State/county mental hospitals, the 25 to 44 age group (39 percent) did not differ significantly from persons ages 45 to 64 (26 percent), and children and youth under age 18 did not represent a major group of admissions (18 percent).
  
  
• Given the nature of the VA medical centers, it could be expected that the age distribution of admissions would also differ considerably from other types of less than 24-hour programs. The largest concentration of persons admitted to VA medical centers was found among persons ages 45 to 64 (47 percent); the second largest among persons ages 25 to 44 (34 percent); and the next largest among persons ages 65 and older (18 percent; Table 17).
  
  
• Overall, among the under age 18 population, more youths ages 13 to 17 were admitted to less than 24-hour care programs than were younger children ages 10 to 12, 5 to 9, and under 5 (Table 17). This finding was true for private psychiatric hospitals and multiservice mental health organizations. Significantly larger proportions of youth ages 13 to 17 were admitted to RTCs for emotionally disturbed children (24 percent) and private psychiatric hospitals (22 percent) than to non-Federal general hospitals (11 percent), multiservice mental health organizations (13 percent), and freestanding outpatient clinics/partial care organizations (13 percent).
  
  
• A comparison of the relative sizes of the admission and under care populations in less than 24-hour care programs by age reveals that, overall, more persons were admitted than under care for specific younger age groups: total under 18, under 5, 13 to 17, and 18 to 24 (Tables 16 and 17). By contrast, overall, a greater proportion of persons ages 45 to 64 were under care than were admitted to less than 24-hour care programs.
  
  
• Comparisons of the age distributions for persons admitted to inpatient, residential, and less than 24-hour care programs reveal a number of differences among the three program types (Tables 5, 11, and 17). Overall, a significantly greater percentage of children and youth under age 18 were admitted to less than 24-hour programs than to inpatient care programs (29 vs. 14 percent); this was also true for each specific children/youth age group. Similar results were found within non-Federal general hospitals. Not surprisingly, overall, the percentage of youth ages 13 to 17 admitted to residential care programs was even greater than for less than 24-hour care programs, more than twice as high (29 vs. 13 percent). By contrast, a greater proportion of persons in the 25 to 44 age group were admitted to inpatient programs than to less than 24-hour care programs, overall, and within non-Federal general hospitals (50 vs. 38 percent).
  
  
• For all organization types combined, elderly persons ages 65 and older were more frequently admitted to inpatient than to less than 24-hour care programs (11 vs. 4 percent; Tables 5 and 17); this finding also held true within private psychiatric hospitals.
  
  
• Figure 14 illustrates that when compared with their numbers in the U.S. population, youth ages 13 to 17 were admitted to less than 24-hour care programs at the greatest rate (2,211 per 100,000 population; Table 17). Children under age 5 and elderly persons ages 65 and older were admitted at the lowest rates of any age group.
  
  
• Similar to the under care population within less than 24-hour care programs, multiservice mental health organizations and freestanding outpatient clinics/partial care organizations had the highest rates of admission for each age group, with a few exceptions (Table 17). For persons in the 10 to 12 and 45 to 64 year age groups, differences between freestanding outpatient clinics/partial care organizations and non-Federal general hospitals were not statistically significant. Among elderly persons ages 65 and older, admission rates to multiservice mental health organizations and freestanding outpatient clinics/partial care organizations were about equal with those for non-Federal general hospitals and VA medical centers.
  
  
• Comparisons between the rates of admission and under care rates for less than 24-hour care programs reveal that overall, the rates for persons admitted were greater than the rates for persons under care in all age groups, with the exception of those ages 45 to 64 and elderly persons ages 65 and older (Tables 16 and 17).
  
  
• Comparisons of the admission rates for persons in less than 24-hour care programs with the admission rates for persons in residential and inpatient care programs reveal that, overall, persons in every age group were admitted at substantially greater rates to less than 24-hour programs than to residential care programs (Tables 11 and 17). This finding also held true in a comparison with inpatient care programs, with the exception of elderly persons ages 65 and older; persons in this age group were admitted to inpatient care at a greater rate than they were admitted to less than 24-hour care, both overall and within each organization type, except VA medical centers (Tables 5 and 17).
  
  
• Inpatient admission rates were also higher than less than 24-hour care rates in State/county mental hospitals and private psychiatric hospitals for all age groups except children ages 5 to 9 (Tables 5 and 17). In non-Federal general hospitals, all adults 18 and older were admitted to inpatient care at greater rates than they were admitted to less than 24-hour care; for children and youth under age 18 and, specifically, children ages 5 to 9, the reverse was true.

Principal Psychiatric Diagnosis² of Persons Under Care in Less Than 24-Hour Care Programs

• The diagnostic grouping of affective disorders was the most predominant grouping reported for persons under care in less than 24-hour care programs (32 percent), followed by schizophrenia (22 percent), attention/conduct disorders (10 percent), and adjustment disorders (8 percent; Table 18).
  
  
• This pattern held somewhat true across the various types of less than 24-hour care programs (Table 18). In freestanding outpatient clinics/partial care organizations, affective disorders ranked first and schizophrenia ranked second. In private psychiatric hospitals and non-Federal general hospitals, affective disorders ranked first, but the percentage diagnosed with schizophrenia was not significantly greater than that for other selected diagnoses. In State/county mental hospitals and multiservice mental health organizations, affective disorders and schizophrenia ranked as the leading diagnostic groupings over other diagnoses. Schizophrenia and affective disorders were also fairly common diagnoses among persons under care in VA medical centers, but the percentages of persons diagnosed with schizophrenia and alcohol disorders did not differ significantly. In RTCs for emotionally disturbed children, affective disorders ranked first, with the exception of attention/conduct disorders.
  
  
• Overall, the percentage of persons under care in less than 24-hour care programs with diagnoses of affective disorders was greater than that found for the inpatient under care population (32 vs. 25 percent; Tables 6 and 18). However, across the specific types of programs, this finding held true only within State/county mental hospitals.
  
  
• For persons under care diagnosed with schizophrenia, a different picture emerges between inpatient and less than 24-hour care programs; the percentage of persons with diagnoses of schizophrenia in inpatient care programs was twice that of their counterparts in less than 24-hour care programs, overall (46 vs. 22 percent; Tables 6 and 18). Figure 15 shows that this was also true within non-Federal general hospitals (30 vs. 15 percent), and VA medical centers (40 vs. 18 percent), and that the difference was also considerable within State/county mental hospitals (64 vs. 40 percent).
  
  
• Other notable comparisons between less than 24-hour care programs and their inpatient counterparts can be seen in the distribution of persons diagnosed with adjustment disorders and organic disorders (Figure 15 and Table 18). The percentage of persons diag-nosed with adjustment disorders was greater in less than 24-hour care programs, overall, and in private psychiatric hospitals and non-Federal general hospitals. By contrast, the percentage of persons diagnosed with organic disorders was greater in inpatient care programs, overall, and in non-Federal general hospitals
  
  
• When compared with the under care population in residential care programs, the percentage of persons diagnosed with affective disorders was much greater in less than 24-hour than in residential care programs (32 vs. 18 percent; Tables 12 and 18). By contrast, the percentages of persons under care with diagnoses of schizophrenia and attention/conduct disorders were significantly greater in residential care programs than in less than 24-hour care programs.

Principal Psychiatric Diagnosis² of Persons Admitted to Less Than 24-Hour Care Programs

• Similar to the finding for the under care population in less than 24-hour care programs, overall, and for a number of organization types, the diagnostic grouping of affective disorders was predominant among persons admitted to less than 24-hour care (27 percent; Table 19). This finding held true within private psychiatric hospitals, non-Federal general hospitals, VA medical centers, and multiservice mental health organizations.
  
  
• Within State/county mental hospitals, the proportions of persons admitted who were diagnosed with affective disorders (27 percent) and with schizophrenia (20 percent) predominated over other diagnostic groupings (Table 19). Within freestanding outpatient clinics/partial care organizations, the proportion of persons admitted with diag-noses of affective disorders or adjustment disorders (21 percent, each) predominated over other diagnostic groups; the schizophrenia diagnostic grouping was not nearly so common in these organizations (only 8 percent) as in State/county mental hospitals. In RTCs for emotionally disturbed children, affective disorders were joined by adjustment disorders and attention/conduct disorders as the most frequently occurring diagnoses among those under care (25, 22, and 18 percent, respectively).
  
  
• Diagnoses of schizophrenia were somewhat less predominant among admissions than among those under care in less than 24-hour care programs (10 vs. 22 percent; Tables 18 and 19). The proportion of persons admitted to less than 24-hour care programs with diagnoses of adjustment disorders was twice that of their counterparts under care in this setting (16 vs. 8 percent).
  
  
• The percentage of admissions with affective disorders was considerably higher in the less than 24-hour care programs of private psychiatric hospitals and non-Federal general hospitals (40 and 38 percent, respectively), compared with most other organization types (differences were not statistically significant with State/county mental hospitals; Table 19). In State/county mental hospitals, the percentage of admissions with schizophrenia (20 percent) tended to be higher than that found for most other organization types (differences were not statistically significant with VA medical centers and multiservice mental health organizations). In VA medical centers, the proportion of persons admitted with diagnoses of alcohol-related disorders (14 percent) was greater than that for most other types of organizations (differences are not statistically significant with State/county mental hospitals and private psychiatric hospitals).
  
  
• A look at the diagnostic distributions of inpatient, residential, and less than 24-hour care programs reveals a number of interesting comparisons (Tables 7, 13, and 19). The percentage of persons admitted with diagnoses of schizophrenia was greater overall in inpatient (20 percent) and residential (18 percent) than in less than 24-hour care programs overall (10 percent). Comparison of inpatient and less than 24-hour care by organization type reveals that this was also true for private psychiatric hospitals, non-Federal general hospitals, and VA medical centers.
  
  
• Conversely, the percentage of persons admitted with diagnoses of adjustment disorders was greater in less than 24-hour (16 percent; Table 19) than in inpatient and residential care programs overall (4 and 6 percent, respectively; Tables 7 and 13). By specific type of organization, this difference between inpatient and less than 24-hour care held within private psychiatric hospitals and non-Federal general hospitals.
  
  
• Additionally, the overall percentage of persons admitted with affective disorders was greater in inpatient than in less than 24-hour care programs (40 vs. 27 percent; Tables 7 and 19); however, the opposite was true within VA medical centers, where 27 percent of persons admitted to less than 24-hour care programs had diagnoses of affective disorders, compared with 17 percent admitted to inpatient care settings.

Summary

This chapter presents some basic national information and highlights differences in the characteristics of persons who received treatment in the inpatient, residential, and less than 24-hour care programs of specialty mental health organizations during 1997. Overall, approximately 2.3 million persons were under care and 5.5 million were admitted to these programs during 1997. As could be expected, with the current, continuing emphasis on provision of care in the least restrictive community setting, a greater number of persons received mental health services in less than 24-hour care programs than in inpatient and residential programs.

The number of admissions outnumbered the under care population by a wide margin in all three program types, and this differential was most dramatic for inpatient care programs, where almost 20 times as many persons were admitted during 1997 as were under care at a point in time. Non-Federal general hospitals had the most inpatient admissions, and State/county mental hospitals had the largest number of persons under care. In less than 24-hour care programs, multiservice mental health organizations were the largest program type for both the under care and admission populations, accounting for 41 percent of each.

More males than females were treated in inpatient and residential programs, while both genders were fairly equally represented in less than 24-hour care settings. Whites comprised the preponderance of persons receiving service in 1997; Blacks/African Americans and Hispanics/Latinos also accounted for large numbers of persons receiving service. Relative to their numbers in the U.S. population, American Indians/Alaska Natives and Blacks/African Americans tended to have higher rates of care, whereas Asians/Pacific Islanders tended to have lower rates of care than other racial/ethnic groups.

Persons ages 25 to 44 comprised the largest proportion of persons receiving care in inpatient and less than 24-hour care programs. In residential programs, children and youth and persons ages 25 to 44 comprised approximately equal proportions of persons receiving services. As a group, admissions tended to be younger than persons under care in each of the three types of programs surveyed. A particularly dramatic finding, however, was the extremely large proportion of children and youth under age 18 in the under care caseload of private psychiatric hospital inpatient programs. Overall, private psychiatric hospitals had larger percentages of children and youth in inpatient care programs than other types of specialty mental health organizations. Residential care programs, specifically RTCs for emotionally disturbed children, were even more focused on children and youth.

Persons with principal diagnoses of schizophre-nia and affective disorders comprised fairly large proportions of the caseloads in all three types of programs. Schizophrenia was less frequent in less than 24-hour care programs than in inpatient and residential programs, with the exception of RTCs for emotionally disturbed children. Persons diagnosed with schizophrenia also generally made up larger proportions of the under care populations than of the admissions populations in all three program settings, indicating the tendency for persons with these diagnoses to accumulate as part of the long-term caseloads. State/county mental hospitals and VA medical centers were particularly highly invested in the care of persons diagnosed with schizophre-nia.

Differences in characteristics of persons served in the three types of mental health programs and different organization types illustrate potential issues around access and availability of care. It is critical to monitor these types of information about persons actually receiving services as the mental health system continues to evolve over time. This chapter provides a first look at these national data; further analyses are planned that will shed further light on mental health services availability to different subgroups of persons.

FOOTNOTES

1. The term "less than 24-hour care programs" refers to mental health services that are not provided overnight; included are outpatient and partial care services provided in organized mental health care settings. Previous client/patient sample surveys collected data separately for the outpatient and partial care programs of specialty mental health organizations.
2. The diagnostic groupings used in Chapter 15 are defined as follows:

Alcohol-related disorders: 291; 303; 305. 0.
Drug-related disorders: 292; 304; 305.1–305.9.
Organic disorders: 290; 293; 294; 310; 780.09.
Affective disorders: 296; 298. 0; 300. 4; 301. 11; 301.13.
Schizophrenia: 295; 299.
Personality disorders: 301 (except 301.11 and 301.13); 312.3.
Adjustment disorders: 309 (except 309.21, 309.81 and 309.82).
Attention/conduct/developmental disorders: 312 (except 312.3); 313.81; 314; 315 (except 315.4).

The codes are combined DSM– IV (American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author) and ICD-9-CM (National Center for Health Statistics. (1980). International Classification of Diseases, Clinical Modification (9th ed., Vol. I). DHHS Pub. No. (PHS) 80–1260. Washington, DC: U.S. Government Printing Office).

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.
² Before 1994, residential supportive care was excluded from the data. In 1994, data for residential supportive care were included. However, this should have no material effect on the data except for "multiservice mental health organizations."
³ In 1994, no distinction was made between outpatient and partial care on the Inventory, and the categories "24-hour hospital care" and "less than 24-hour care" were used. As a result, data for all years before 1994 have been restated to show the combined outpatient and partial care totals.
⁴ In 1993, CMHS changed the name of its Mental Health Statistical Note series to Data Highlights. In addition, instead of presenting detailed and relatively long descriptive reports, the new reports were reduced in size, and generally present not only descriptive data as in the past, but also give interpretations of the trends and policy implications. Some excerpts from those publications are incorporated into the discussion above. The policy implications cover topics from each of the broad system foci of this chapter, namely, availability, volume of service, staffing, and financing. They can help policymakers and legislators make decisions regarding the types and volume of mental health services to be included as benefits in health care reform legislation at all levels of Government, and can provide baseline data for years prior to the implementation of managed care.

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