Health Affairs, 26, no. 6 (2007): 1548-1550 doi: 10.1377/hlthaff.26.6.1548 © 2007 by Project HOPE	New Online   Pay Cuts For Medicare Docs   Access To Care Woes   Public Coverage More Efficient   Empowering Consumers

This Article Abstract Reprint (PDF) Submit a response to this article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to Citation Manager Reprints & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Mechanic, D. Search for Related Content PubMed PubMed Citation Articles by Mechanic, D. Related Collections Health Reform Mental Health/Substance Abuse

Perspectives

PERSPECTIVE

Mental Health Services Then And Now

Abstract

 
Over the past twenty-five years, psychiatric services have shifted from hospital to community. Managed care reinforces this trend. Mental illness is better understood and less stigmatized, and services are more commonly used. But many in need do not receive care consistent with evidence-based standards, or at all. Challenges are greatest for people with serious and persistent mental illnesses who depend on generic health and welfare programs and integrated services. Evidence-based rehabilitative care is often unavailable. Failures in community care lead to arrest; jail diversion and treatment are required. Despite progress, implementing an effective, patient-centered care system remains a formidable challenge.

Deinstitutionalization and neglect. Massive deinstitutionalization in the 1970s and 1980s, well before communities had organized reasonable community services, contributed to neglect of people with mental illnesses and homelessness. Major changes in mental health law made coercive interventions less possible. Some commentators in the media saw this as "crazy on the streets" and "rotting with one’s rights on." Although we already had some reasonably effective antipsychotic and antidepressant medications, they had many serious side effects, patients found them aversive, and nonadherence to medication was rampant. Residence in the community also allowed access to street drugs and alcohol, resulting in substantial increases in psychiatric and substance abuse comorbidities. These patients posed serious treatment and management problems and were increasingly arrested and jailed.

A move to the neurosciences. In the meantime, psychodynamics, and especially psychoanalysis, which had dominated psychiatric practice in earlier years, lost much of its currency, and psychiatry moved closer to medicine, to the neurosciences, and to biological factors. Medication and short, focused psychotherapy, such as cognitive therapy, replaced much of the earlier Freudian and psychodynamic emphasis. The period 1990–2000 was declared the decade of the brain, and research in the neurosciences was favored. During this period Prozac and other selective serotonin reuptake inhibiters (SSRIs) dominated treatment of depression. Although no more effective than earlier antidepressants, they were more acceptable to patients and doctors, and their use increased threefold. Primary care physicians now more commonly medicated patients for depression and anxiety, although this often was inconsistent with practice standards.

New atypical antipsychotic drugs were also introduced and aggressively marketed by pharmaceutical companies as more effective and more benign than earlier medications. Psychiatric pharmaceuticals have become a massive business, but recent rigorous clinical trials do not support the optimistic claims of increased effectiveness or benign side effects. Medication adherence remains an enormous problem. Medication costs are now the largest component of Medicaid spending for people with mental illnesses. The involvement of pharmaceutical companies in almost every aspect of mental health treatment—including clinical trials, professional education, physician and direct-to-consumer advertising, professional meetings, and designing diagnostic practices and practice standards—raises many concerns about the reliability of the medical literature and practice patterns.

Impact of managed care. Managed behavioral health care (MBHC) also became dominant in the 1990s, and unlike in general medicine, MBHC did not retrench with the public backlash. Now almost all mental health care in both the private and public sectors is managed, often by large private organizations. MBHC reinforced the avoidance of hospital admission, and reduced inpatient length-of-stay, through stringent utilization management. In addition, it reduced costs by substituting other mental health personnel for psychiatrists and reduced professional remuneration. Mental health services appear to be managed much more rigorously than most medical and surgical services. For the population as a whole, managed care has made specialty mental health services more accessible and reduced the intensity of service and cost without obvious reduction in quality. These trends are more problematic in the case of people with serious and persistent mental illnesses, who often require a high intensity of service.²

Signs of major progress. Looking back, major progress is evident. We have improved medical and rehabilitative care, although psychosocial evidence-based services are not widely accessible. More people now receive mental health services, and we have a much clearer view of evidence-based care. Too much care, however, still lacks an evidential basis. Care is more patient centered than before, and the consumer movement is strong. Health policymakers are more interested in mental health than in earlier decades, and mental health is now more a part of the broader health care discussion. Progress in achieving mental health parity is apparent in many states as well as federally. The public is more acceptant of mental illness, but stigma remains strong, especially for people with psychotic illnesses and with substance abuse disorders.

Challenges ahead. Much remains to be done. We require better evidence-based treatments and greater use of those already available. Many of the generic programs on which people with mental illnesses depend need modifications to better fit their special needs. Much needs to be done to prevent criminalization of people with mental illnesses and to emphasize diversion from jail. Mental health services provided in such institutions—what some call the new custodial mental hospitals—need improvement and increased efforts in helping clients make the transition to community life, including housing; medical services; supported employment; and timely, continuing mental health care. Integrating mental health with health and other sectors, organizationally and financially, and overcoming the cultural and bureaucratic barriers to collaboration are difficult. The President’s New Freedom Commission was clear in its aspirations for a patient-centered and responsive mental health system aimed at maximizing function and productive community participation of people with mental illnesses. Implementation of these high aspirations remains a formidable challenge.

Editor's Notes

 
David Mechanic (mechanic{at}rci.rutgers.edu) is director of the Institute for Health, Health Care Policy, and Aging Research and the René Dubos Professor of Behavioral Sciences at Rutgers, the State University of New Jersey, in New Brunswick.

NOTES

Top NOTES

 

1. See R.G. Frank and S.A. Glied, "Mental Health in the Mainstream of Health Care," Health Affairs 26, no. 6 (2007): 1539–1541.[Abstract/Free Full Text]
2. Extensive discussion of these trends with documentation can be found in D. Mechanic, Mental Health and Social Policy: Beyond Managed Care, 5th ed. (Boston: Allyn and Bacon, 2008).

                      What's this?