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Mental Health (Care) Systems
From the Lunatic Asylum to a “Modern”
Mental Health System
Barbara A. Schindler, M.D.
Vice Dean, Educational and Academic Affairs
Professor of Psychiatry
Learning Objectives
1)
2)
3)
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5)
Be able to describe the components of the mental
health delivery system
Explain how mental health costs are covered
Describe the overall burden of illness of mental
disorders
Outline the barriers and limitations to obtaining
comprehensive mental health coverage
Describe the disparities between the scientific
knowledge base of mental illness/treatment and how
mental health care is actually delivered
Costs of Mental Illness
Global Burden of Illness
Percent of Total DALY’s*
All Cardiovascular Conditions
18.6
All Mental Illness
15.4
15
4.8
4.7
2.8
All Cancer
All Respiratory Conditions
All Alcohol Use
All Infectious and Parasitic
Diseases
All Drug Use
1.5
*DALY’s=Disability Adjusted Life Years
(Years lost to premature death or lived with
disability) Murray & Lopez, 1996
Leading Causes of Mortality and Burden of Disease
World, 2004
Mortality
DALYs
%
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Ischaemic heart disease
Cerebrovascular disease
Lower respiratory infections
COPD
Diarrhoeal diseases
HIV/AIDS
Tuberculosis
Trachea, bronchus, lung cancers
Road traffic accidents
Prematurity, low birth weight
%
12.2
9.7
7.1
5.1
3.7
3.5
2.5
2.3
2.2
2.0
2.
Lower respiratory infections
Diarrhoeal diseases
6.2
4.8
3.
Depression
4.3
4.
Ischaemic heart disease
HIV/AIDS
Cerebrovascular disease
Prematurity, low birth weight
Birth asphyxia, birth trauma
Road traffic accidents
Neonatal infections and other
4.1
3.8
3.1
2.9
2.7
2.7
2.7
1.
5.
6.
7.
8.
9.
10.
Ten leading causes of burden of disease,
world, 2004 and 2030
Leading causes of disease burden for women aged
15–44 years, high-income countries, and lowand middle-income countries, 2004
Top Ten Causes of Disability Worldwide Include:
 Unipolar
Major Depression
 Bipolar Disorder
 Schizophrenia
 Obsessive Compulsive Disorder
©2003-7 Barbara Schindler, MD
DUCoM
Indirect & Direct Costs:
The Global Burden of Disease
©2003-7 Barbara Schindler, MD
DUCoM
Indirect Costs
 $17
Billion loss in US economy
 $63 Billion morbidity cost
 $12 Billion mortality
 $4 Billion incarceration costs
©2003-7 Barbara Schindler, MD
DUCoM
Direct Costs
 $943
Billion total direct treatment health
care costs
 $99 Billion for mental disorders ($69
Billion), addictive disorders ($13 Billion)
and dementia ($18 Billion)
 7% total spending only when leading
cause of disability
©2003-7 Barbara Schindler, MD
DUCoM
Delivery of Mental Health Services
Providers & Sites
©2003-7 Barbara Schindler, MD
DUCoM
Delivery Systems from a Historic
Perspective
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Asylums (Colonial times)
– Otherwise jails, almshouses, workhouses
Moral Treatment* (early-mid 1800’s-Dorothea Dix, Horace
Mann))
Mental Hygiene Movement (Post-Civil War) with collapse of
public asylums (no $’s & overcrowded)
State Care Acts (early 1900’s) States assume responsibility for
care resulting in growth of state hospital system
General Hospital Inpatient Units (post WWII)
Community Mental Health System (1960’s)
Deinstitutionalization with change in commitment laws (1970’s)
Medicare (SSD) and Medicaid (1965)
*Return of individual to “reason” using psychologically oriented therapy
©2003-7 Barbara Schindler, MD
DUCoM
Current Mental Health/ Illness System
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Amalgamation/hybrid of public and private sector providers in variety of
sites, e.g. hospitals, clinics, pvt offices, ER’s, prisons, shelters, residential
programs
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No single guiding or organizing set of principles. What you can access
depends a lot on what you can afford.
– Fragmentation and gaps in care for children*
– Fragmentation and gaps in care for adults with serious mental
illnesses*
– High unemployment and disability for people with serious mental
illnesses*
– Lack of care for older adults with mental illnesses*
– Lack of national priority for mental health and suicide prevention*
*President’s New Freedom Commission on Mental Health (2002)
©2003-7 Barbara Schindler, MD
DUCoM
Patient Presentations
Single Episode
 Recurrent episodes
 Seriously and persistently ill (Schizophrenia, Bipolar,
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Major Depression, Anxiety disorders, Alzheimer’s,
Substance Abuse or Dual Dx)
Responding to acute stressors/trauma
 Developmental disabilities
 Dementias/late onset brain failure
 Relationship problems
 Adaptation problems

©2003-7 Barbara Schindler, MD
DUCoM
Sectors of Care & Utilization by Sector
(15% Adults Use System in any given year)
1)
2)
3)
4)
Specialty Mental Health Sector (5.5%)
Human Services Sector (5%)
General medical/primary care sector (5.5%)
Voluntary Support Network Sector (3%)
©2003-7 Barbara Schindler, MD
DUCoM
1) Specialty Mental Health Services Sector
 Psychiatrists
 Psychologists
(Prescribing controversy)
 Psychiatric Social Workers
 Psychiatric Nurses
 Settings: Offices, clinics, private or
public hospitals, CMHC’s, prisons, other
agencies, schools
©2003-7 Barbara Schindler, MD
DUCoM
2) General Medical/Primary Care Sector
 Internists
Family Practice MD’s
 Pediatricians
 Consultation psychiatrists
 Social Workers
 Nurses
 PA’s
 Settings: Hospitals, offices, clinics, nursing
homes, hospices, prisons
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©2003-7 Barbara Schindler, MD
DUCoM
3) Human Services Sectors
 Social
Welfare System
 Criminal Justice System
 Educational, Religious, Charitable
services
 Settings: Shelters, prisons, boarding
houses, churches, schools
©2003-7 Barbara Schindler, MD
DUCoM
4) Volunteer Network
 Self-Help
groups
– AA, NA, Reach for Recovery, Zipper Club,
other medical Dx groups
 Public
Awareness
 Fund Raising
 Lobbying for increased $$’s
 Examples; NAMI, NMHA, Bazelon
Center for MH Law
©2003-7 Barbara Schindler, MD
DUCoM
Delivery Systems : Public & Private
©2003-7 Barbara Schindler, MD
DUCoM
Sites of Care Based on Duration of Care
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Acute
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Private office or clinic
ER
Psychiatric unit of a general hospital
Psychiatric hospital
General Hospital scatter beds
Acute partial programs
Long Term
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State hospitals
Mental health clinics
Residential programs (nurse, case managers)
Boarding Houses (nurse, case managers)
Home
Nursing home
©2003-7 Barbara Schindler, MD
DUCoM
Utilization of Services
©2003-7 Barbara Schindler, MD
DUCoM
Adult Utilization of Mental Health Services
 28% US adult
population has
diagnosable
mental or
Substance abuse
disorder
 1/3 patients
receive MH
services
 Majority get no
MH services
©2003-7 Barbara Schindler, MD
DUCoM
Child & Adolescent Utilization of Mental Health
Services
 21%
Child and
Adolescent
Population utilize
MH Services
 9% in Health Care
Sector
 17% in Human
Service Sector,
mostly schools
©2003-7 Barbara Schindler, MD
DUCoM
Financing Mental Health Services
©2003-7 Barbara Schindler, MD
DUCoM
Funds for Mental Health Programs
 State
and local government major payers
thru Medicare & Medicaid
 Additional federal initiatives
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CMHC Block Grants
Addiction Treatment Grants
Community Support Programs
PATH (homeless MI)
Comprehensive Mental Health Services for
children and their families
©2003-7 Barbara Schindler, MD
DUCoM
Source of Funding for Mental Health Services
©2003-7 Barbara Schindler, MD
DUCoM
Mental Health Payment Costs by Provider Type
©2003-7 Barbara Schindler, MD
DUCoM
Types of Accepted and Funded Treatment
 Psychosocial
– Psychotherapy: Cognitive/Behavioral,
psychodynamic, supportive
– Group, individual, family, couples
 Psychopharmacologic
 Both
usually more effective than either
separately
 Split Treatment: challenge of dual treators
©2003-7 Barbara Schindler, MD
DUCoM
Cost Control Efforts
 Hospital
lengths of stays
 Increasing numbers of
inpatient beds
 Emergence of managed care in
non-psychiatric medical care
and MH carve outs for MH
services, usually inadequate
MH benefits.
 Formularies
©2003-7 Barbara Schindler, MD
DUCoM
Current Managed Mental Health System
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Increasing enrollment
MH and SA merged into Managed Behavioral Health
Organization (MBHO) mostly private (except
Philadelphia=CBH)
– Formulary & laboratory with medical MCO
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Fewer MBHO’s with larger and larger contracts and
increase financial difficulty
Both Medicare and Medicaid increasingly managed
Tight control of access
Higher co-payments in some plans
©2003-7 Barbara Schindler, MD
DUCoM
Quality And Management Efforts
 Credentialing
Access requirements
 Strong utilization review procedures
 Monitoring patient satisfaction
 System expected to maximize convenience for
patients
 Wait time for appointment specified
 NCQA developing behavioral health standards
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©2003-7 Barbara Schindler, MD
DUCoM
Changes in Spending for
Mental Health Services Over Past Decade
 Declined
as a % of overall health care
 Increased amount by public rather than
private payers (from 49% to 53%)
 Outpatient prescription drugs grew by 9%
(Usually covered under general medical
expenses and only 1/3 Rxed by psychiatrists)
 Increased barriers to service: stigma &
vulnerable population
©2003-7 Barbara Schindler, MD
DUCoM
Parity: New Federal Law 2008 Passed
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Mental Health Parity and Addiction Equity Act of 2008.
Effective date: Jan 1, 2010; regulations to be developed
Initial Mental Health Parity Act of 1996 ineffective
Mental Health coverage at same level as physical health for
lifetime and annually
No limits on hospital stays and physician visits; same co-pays
and deductibles
Employers with fewer than 50 employees and individual
health policies exempt.
Costs issues persist despite data; premiums up 0.4%
1999 Surgeon General: $70B direct business cost from lack of
parity: lost productivity from absenteeism & sick leave,
increase use of health services.
©2003-7 Barbara Schindler, MD
DUCoM
Caring Together Program
A Dual Dx Program for Women and Their Children
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Components
– Intake evaluation, Psychiatric evaluation and
treatment, individual and group addiction
treatment, specialized groups (TREM, Life Skills)
 Staff: Psychiatrist, Social Worker, Addiction
Counselors, Early Childhood Development Specialist,
Case Manager,
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Funding
– CODAAP (Philadelphia) from Federal Grant to
State –Set aside $$’s for women’s and children’s
programs (2/3 budget)
– 1/3 budget from clinical income thru CBH
Major Trends in Mental Health Care Last 25 Years
 Explosion
in scientific knowledge:
brain and behavior; growth of NIMH
budget
 Increased range of effective treatments
for most mental disorders
 An approach to organization and
financing of mental health services
(MC carve outs, parity)
 Emergence of powerful consumer and
family groups decreasing stigma,
increasing access and research
 Influence of pharmaceutical industry
©2003-7 Barbara Schindler, MD
DUCoM
Consumer Movement Books to Read
A Mind that Found Itself- Clifford Beers
(1908)
 I Never Promised You a Rose Garden- Hannah
Green (1964)
 On Our Own- Judi Chamberlin (1978)
 Darkness Visible: A Memoir of MadnessWilliam Styron (1990)
 A Brilliant Madness: Living with Manic
Depressive Illness (1997)
 An Unquiet Mind-Kay Redfield Jamison
(1997)
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Challenges
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15-20% population uninsured for MH services
Lack of true parity for MH services (Law passed Oct 2008)
Stigma
Barriers to access
Coordination of care for most seriously ill
Managing split between primary care and mental health
treatment
Integrating treatment when psychotherapy and
pharmacologic treatment split
Informed consent for clinical trials
Access to appropriate care e.g. MCO formulary
restrictions
Non-compliance ( side effects, cost, stigma)
Hopelessness associated with mood disorders
©2003-7 Barbara Schindler, MD
DUCoM
Take Home Messages
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Ideal mental health system does not yet exist
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Presidential Goals (2002)*
– Understand that mental health is essential to overall
health
– Mental health is consumer & family driven
– Disparities in mental health services are eliminated
– Early mental health screening, assessment, and referral
to services are common practices
– Excellent mental health care is delivered and research is
accelerated
– Technology is used to access mental health care and
information
*http://www.mentalhealthcommission.gov/reports/FinalReport
©2003-7 Barbara Schindler, MD
DUCoM
Take Home Messages
 Leading
cause of disability/morbidity &
mortality but significant under funded when
compared to other high profile illnesses, e.g.
CVD, cancer
 Split treatment increases costs to individual
patients and society, but saves insurers $$’s
 Sharp contrast between scientific knowledge
base & ability to deliver quality mental health
care to all in need.
WHO Mental Health Gap Action Program
http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html
Mental Health
A Report of the Surgeon General
Executive Summary
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
U.S. Public Health Service
http://www.surgeongeneral.gov/library/menta
lhealth/summary.html

©2003-7 Barbara Schindler, MD
DUCoM