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PROLOGUEAlong The Care ContinuumJust a few decades ago, the U.S. mental health care continuum was defined by two points: inside a psychiatric hospital, or out in the cold. The rich mentally ill went off to private institutions; those less well off ended up in public facilities—the so-called shame of the states—many of whose deprivations have been well chronicled. Meanwhile, for a handful of well-to-do patients still in the community, there were private caretakers as well as psychiatrists. For everyone else, there was essentially nothing. Happily, the advent in recent years of effective medications and optimal behavioral therapy have increased the number of distinct points along this continuum. Mental health services are now far more integrated than ever before into the larger health care system and the community. But although these changes have vastly improved care and outcomes, they require constant reevaluation and recalibration. Each of the papers in this section demonstrates how failure to monitor and adapt creates critical needs for corrective policy interventions. Several authors cast an eye on today’s mental health institutions—both those created for that purpose and others that are morphing into them. In this issue’s Report from the Field, Steve Bogira chronicles the squeeze on mental health services—and the often adverse effects on patients with few options. William Fisher and colleagues describe underappreciation of, and inadequate support for, state psychiatric hospitals. These continue to provide vital care for those not well served elsewhere, such as those with criminal backgrounds or others with complex conditions. Steven Sharfstein and Faith Dickerson look at mental health care in short-stay acute hospitals and find that managed care has produced an unintended consequence: a shortage of psychiatric beds. Next, David Grabowski and coauthors examine patterns among the roughly half-million of the mentally ill who live in U.S. nursing homes. They note fivefold variations in admission rates across states—possibly attributable to differences in Medicaid payment and the robustness of the local mental health care infrastructure. Turning to care in the community, Marcela Horvitz-Lennon and colleagues point to the slow spread of evidence-based treatments for patients with schizophrenia. Among other remedies, they suggest improved educational curricula and training for mental health care providers. Samuel Zuvekas and Chad Meyerhofer analyze data from the Medical Expenditure Panel Survey; they show that high out-of-pocket spending for frequently costly prescription drugs is a major burden for those with mental illnesses, as it is for many with chronic illnesses of any type.
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