Community mental health centers: returning to basics.

Community mental health centers (CMHCs) have made a significant contribution to making mental health services available to many Americans; in 1977 they served almost two million people. External fiscal constraints and internal service and accountability requirements now test the viability of CMHCs, but the most recent extension of the law allows increased flexibility on implementation, and the President's Commission on Mental Health has reinforced the original purpose of CMHCs by calling for an initiative to give special attention to the needs of children and youth, the elderly, minorities, the chronically mentally ill, and other underserved populations and areas.     

Survival strategies for community mental health services in the 1980s

Widespread reduction of financial resources has created a growing concern about the survival of community mental health services and their inherent concepts and ideals. To survive and, in some ways, grow, community mental health centers have used strategies such as incorporation, alternative services, innovative funding, and political activities. The authors discuss strategies that focus on the program management aspects of mental health. They theorize that if CMHCs can employ business techniques but retain the values of community mental health, a more efficient, yet still highly principled, system of mental health services can result.     

The role of the Community Mental Health Center in prevention of infant,child and adolescent disorders: Retrospect and prospect

The Congressional Joint Commission on Mental Health of Children 1965–67 gathered and published a great deal of data on Prevention and Early Intervention that was subsequently ignored by Congress and the Administration. Community Mental Health Centers, since their beginnings in the mid 60's, have not been able to concern themselves with prevention because of the overwhelming demands for treatment of a very psychiatrically disturbed adult population. The closing of State Hospitals without provision for community resources to care for these severely disturbed individuals, for economic and political reasons, unfairly burdened community mental health centers. In the intervening years, a great deal more has been learned about primary, secondary, and tertiary prevention for infants, children and adolescents. This paper describes some of the new knowledge and indicates how much of our current knowledge could be used by Community Mental Health Centers to take advantage of the new funding available in many prevention areas. A few early intervention and prevention projects are described.     

Quality care at risk in CMHCs: The need for Guidelines for Psychiatric Practice

The author discusses what he considers the inadequate attention paid to quality of care in many CMHCs. He suggests that the deterioration of quality is related to the exodus of competent psychiatrists. The Guidelines for Psychiatric Practice in Community Mental Health Centers should help to assure that quality care is delivered in a cost-effective manner. These guidelines should ultimately be incorporated into an accreditation process for CMHCs, and funding should be tied to such accreditation.This paper was presented at the Annual Meeting of the American College of Mental Health Administration, Woodstock, VT, March, 1988.     

Serving the mental health needs of the elderly: The case for removing barriers and improving service integration

Utilization rate information reveals that elderly persons are not adequately served by the existing mental health service system. The authors identify cultural, systems, and resource related barriers to full service, emphasizing psychological barriers which may be present in both the elderly client and the therapist. Overcoming these barriers will require, first, that professional training programs and local in-service training activities be modified to expand multi-disciplinary learning opportunities. Then, the authors advocate systems change to move through in-house outreach, advocacy and programming activities toward an integrated system of community services for the elderly. Mental health workers are seen as uniquely qualified to serve as standard-bearers in developing a locally integrated service delivery system.She has served as Vice President of the Georgia Gerontology Society, as Manager of Support Services in the Georgia State Office of Aging, and as a private human services consultant.Dr. Hagebak is Branch Chief for Georgia and Kentucky, Alcohol, Drug Abuse and Mental Health Administration, Public Health Service, Region IV HHS. He has served as a sub-state human resources network director and a community mental health center director in Georgia, and as a psychologist and dean in university settings in Minnesota and Wisconsin.The opinions and perspectives presented in this article are solely those of the authors, and are not intended to reflect the official position of either the Georgia Department of Medical Assistance or the Region IV Public Health Service, HHS.     

The impact of federally funded CMHCs on local mental health service systems. Community Mental Health Centers

To measure how much federally funded community mental health centers increased the quantity and range of mental health services, 63 catchment areas in which CMHCs began to receive federal funding in 1974-75 were matched individually with catchment areas that never received federal CMHC funding. The two groups of catchment areas were compared to determine average increases from 1973 to 1980 in amounts of services, mental health staff, expenditures, and accessibility and availability of services. Results showed that establishment of local CMHCs had a clear impact on the quantity and the availability and accessibility of services in the catchment area. The effect sizes resulting merely from the passage of time and from CMHC funding were compared.     

Ethnicity,social status,and families' experiences of caring for a mentally ill family member

There is growing attention to the role of families as caregivers of family members with serious mental illness. This paper presents data from a multicultural sample of 90 family caregivers from diverse ethnic backgrounds. The paper examines families' experiences with mental health services; their support networks and family burdens; and their conceptions of mental illness. The paper both provides one of the first comparative studies of family caregivers from different ethnic groups and suggests an agenda for future research in this area.Peter J. Guarnaccia, Ph.D., is affiliated with the Institute for Health, Health Care Policy and Aging Research, Rutgers University. Pilar Parra, Ph.D., is affiliated with the Dept. of Nutritional Sciences, Cornell University.The study reported on in this paper was carried out as part of the larger research program of the Center for Research on the Organization and Financing of Care to the Severely Mentally Ill at the Institute for Health, Health Care Policy and Aging Research, Rutgers University. The Center is funded by the National Institute of Mental Health (MH43450-04). The specific research project on minority family caretakers of mentally ill family members was supported by a grant from the Robert Wood Johnson Foundation (#13180) and by funding from the Center. Dr. Parra was supported by a Minority Investigator Supplement from the National Institute of Mental Health (5P50 MH43450).We would like to thank all of the families who shared their experiences and insights with us. Our hope is that this work will serve to improve their lives. We also wish to thank the staff of the various mental health programs who collaborated with us in the study through identifying families and through providing us feedback on our research results. We would like to thank Nuri Argiles, Dr. Aura Deschamps and Glen Milstein who interviewed families and participated in discussions and presentations of the results of the study. Dr. Hilton Miller has contributed to both presentations of the research and discussion of research findings. Henry Henderson was actively involved in the analysis of data.     

Pakistan mental health country profile

The Republic of Pakistan is a South East Asian country with a population of over 140.7 million. Its population is fast growing and the majority (70%) live in rural areas with a feudal or tribal value system. The economy is dependent on agriculture and 35% of the population live below the poverty line. Islam is the main religion and ‘mental illnesses’ are stigmatized and widely perceived to have supernatural causes. The traditional healers along with psychiatric services are the main mental health service providers. The number of trained mental health professionals is small as compared to the population demands and specialist services are virtually non-existent. Lack of data on prevalence of various mental illnesses and monitory constraints are the major hurdles in the development of mental health services. A number of innovative programmes to develop indigenous models of care like the ‘Community Mental Health Programme’ and ‘Schools Mental Health Programme’ have been developed. These programmes have been found effective in reducing stigma and increase awareness of mental illness amongst the adults and children living in rural areas. Efforts by the government and mental health professionals have led to the implementation of a ‘National Mental Health Policy’ and ‘Mental Health Act’ in 2001. These aim at integrating mental health services with the existing health services, improving mental health care delivery and safeguarding the rights of mentally ill people. A favourable political will and the help of international institutions like the World Health Organization are required to achieve these aims.     

Evaluation of a prepaid mental health plan for business

Mental health organizations are continually in search of approaches to improve their visibility, to improve attitudes surrounding mental health services, and to secure stable sources of funding. Findings from a study of a prepaid mental health plan for employee groups indicate a significant positive relationship between such a program and several key variables related to client awareness and attitude, demographics, service utilization, and revenue generation. Results have implications related to the direct contracting for mental health services by large employee groups.Acknowledgement is given to support of this research by a National Institute of Mental Health grant Ro1MH31701.     

Establishing an Integrated Health Care Clinic in a Community Mental Health Center: Lessons Learned

Integrating primary care with behavioral health services at community mental health centers is one response to the disparity in mortality and morbidity experienced by adults with serious mental illnesses and co-occurring substance use disorders. Many integration models have been developed in response to the Primary and Behavioral Health Care Integration (PBHCI) initiative of the Substance Abuse and Mental Health Services Administration (SAMHSA). One model is a primary care clinic co-located within the mental health center. The Connecticut Mental Health Center (CMHC) Wellness Center is one such co-located clinic developed as a partnership between CMHC and a Federally Qualified Health Center (FQHC). In this article, we describe the process of developing this on-site clinic along with lessons learned during implementation. We review different aspects of building and maintaining such a clinic and outline lessons learned from both successes and challenges. We briefly describe the demographics and health characteristics of the patient population served in this clinic. We make recommendations for providers and agencies that are considering or are already developing a model for integrating care. Finally, we briefly review status of our clinic after completion of grant funding.     

Entrepreneurship and state/mental health center relationships

An effective Community Mental Health Center (CMHC) program in entrepreneurship—the provision of services in the marketplace at a profit to subsidize other programs—requires the support and encouragement of the state-level mental health authority. This paper discusses potential financial, programmatic, political, and managerial risks and rewards to CMHCs and to state authorities from such efforts. As each party faces certain risks as well as rewards from such efforts, it is important that they participate in a process of mutual risk involving: 1) Documenting and legitimizing the entrepreneurship program; 2) Separating funding for seed monies and working capital for ventures, 3) Restructuring the Centers' finances and/or corporate structure to reduce the problems of funds diversion and comingling, 4) Negotiating in advance how the proceeds of the ventures will be used to benefit programs, and 5) Providing technical assistance to enhance the probabilities of success in such ventures. For these steps to work the state authorities must be willing to give up some financial and programmatic control to motivate entrepreneurship on the part of CMHCs.     

Pakistan mental health country profile

The Republic of Pakistan is a South East Asian country with a population of over 140.7 million. Its population is fast growing and the majority (70%) live in rural areas with a feudal or tribal value system. The economy is dependent on agriculture and 35% of the population live below the poverty line. Islam is the main religion and 'mental illnesses' are stigmatized and widely perceived to have supernatural causes. The traditional healers along with psychiatric services are the main mental health service providers. The number of trained mental health professionals is small as compared to the population demands and specialist services are virtually non-existent. Lack of data on prevalence of various mental illnesses and monitory constraints are the major hurdles in the development of mental health services. A number of innovative programmes to develop indigenous models of care like the 'Community Mental Health Programme' and 'Schools Mental Health Programme' have been developed. These programmes have been found effective in reducing stigma and increase awareness of mental illness amongst the adults and children living in rural areas. Efforts by the government and mental health professionals have led to the implementation of a 'National Mental Health Policy' and 'Mental Health Act' in 2001. These aim at integrating mental health services with the existing health services, improving mental health care delivery and safeguarding the rights of mentally ill people. A favourable political will and the help of international institutions like the World Health Organization are required to achieve these aims.     

Medicare provider status for Community Mental Health Centers: An overdue reform

Though mandated to provide a broad range of mental health services, regardless of ability to pay, the majority of CMHCs are not eligible for Medicare reimbursement for those services provided by nonphysician staff. Medicare provider status, such as that recently accorded nonphysician-oriented rural health clinics, would assure reimbursement for those services and could potentially produce better mental health care for all CMHC clients, particularly for the elderly mentally ill.Gordon R. Seidenberg, M.P.A., M.P.H., former Chief, Quality Assurance and Standards Program, Mental Health Care and Service Financing Branch, Division of Mental Health Service Programs, NIMH, is Special Assistant to the Director, Division of Biometry and Epidemiology, NIMH. Jacqueline Parish, M. S., R. N. is Public Health Analyst, Community Support and Rehabilitation Branch, Division of Mental Health Service Programs, NIMH. Reprint requests should be directed to Mr. Seidenberg at NIMH/ADAMHA, 5600 Fishers Lane, Room 18C-26, Parklawn Bldg., Rockville, MD 20857.     

The Australian experience of deinstitutionalization: interaction of Australian culture with the development and reform of its mental health services

OBJECTIVE: To describe the Australian experience of deinstitutionalization of the Australian National Mental Health Strategy in the context of the history of mental health services in Australia, and of Australian culture. METHOD: The development of Australian Mental Health Services is described with reference to developments in both psychiatric intervention research and Australian culture. The effects and achievements of national mental health reforms are described and critically examined. RESULTS: The relationship in Australia between the development of mental health services and the development of Australian society includes the stories of colonization, gold rush, suppression of indigenous peoples' rights, incarceration of mentally ill people, and incompatible state service systems. Mental health services required reform to provide consistent services and support for full citizenship and rights for such individuals who are still on the margins of society. Recent national developments in service models and service system research have been driven by the Australian National Mental Health Strategy. The translation of national policy into state/territory mental health service systems has led to a 'natural' experiment between states. Differing funding and implementation strategies between states have developed services with particular strengths and limitations. CONCLUSION: The effects of competition for limited resources between core mental health service delivery and the shift to a population-based public health approach (to prevention of mental illness and promotion of mental health), leaves our services vulnerable to doing neither particularly well. The recent loss of momentum of these reforms, due to failure of governments to continue to drive and fund them adequately, is causing the erosion of their considerable achievements.     

Identifying and Reducing Disparities in Mental Health Outcomes Among American Indians and Alaskan Natives Using Public Health,Mental Healthcare and Legal Perspectives

The purpose of this paper was to investigate disparities in mental healthcare delivery in American Indian/Alaska Native populations from three perspectives: public health, legal policy and mental healthcare and provide evidence-based recommendations toward reducing those disparities. Data on mental health funding to tribes were obtained from the Substance Abuse and Mental Health Services Administration. As a result of analysis of these data, vital statistics and current literature, we propose three recommendations to reduce mental health disparities. First, where possible, increase mental health funding opportunities for federally-recognized tribes. Second, model funding practices on principles of tribal self-determination. Finally, support diverse interventions that are culturally-based and culturally-appropriate.     

Building a science of partnership-focused research: forging and sustaining partnerships to support child mental health prevention and services research

Building on growing interest in translational research, this paper provides an overview of a special issue of Administration and Policy in Mental Health and Mental Health Service Research, which is focused on the process of forging and sustaining partnerships to support child mental health prevention and services research. We propose that partnership-focused research is a subdiscipline of translational research which requires additional research to better refine the theoretical framework and the core principles that will guide future research and training efforts. We summarize some of the major themes across the eight original articles and three commentaries included in the special issue. By advancing the science of partnership-focused research we will be able to bridge the gap between child mental health prevention and services research and practice.     

The contrasting careers of two structural types of CMHCs

Changes in funding, clientele, and services from 1971 to 1980 were examined cross sectionally and with cohorts for two types of CMHCs that differ in their structure for providing inpatient service. Inpatient provider CMHCs grew in revenues and shifted from reliance on federal funds to revenues from services and states. Inpatient-affiliated CMHCs fell in revenues (in constant dollars) and changed little in their proportional reliance on federal dollars. Inpatient provider CMHCs averaged more additions and episodes of care than inpatient-affiliated CMHCs. Inpatient-affiliated CMHCs grew more from 1971 to 1976, but from 1976 to 1980 inpatient provider CMHCs grew, while inpatient-affiliated CMHCs dropped or grew less. The relatively poor final showing of inpatient-affiliated CMHCs parallels findings with total revenues.The views expressed are those of the authors and do not necessarily represent the views of the National Institute of Mental Health. The authors are indebted to Ronald Manderscheid, Ph.D., and James Thompson, M.D., for suggestions.     

The federal mental health program: past, present, and future.

Dr. Brown traces the history of America's federal mental health program from its beginning in the early 1900s. NIMH, the institute he currently directs, was established in 1946 for the treatment and prevention of mental and emotional illnesses through research,training, and services. It is now one of the institutes of the Alcohol, Drug Abuse, and Mental Health Administration of the Department of Health, Education, and Welfare. Dr. Brown describes its continuous progress toward providing high-quality mental health care to the entire population, and discusses priorities for the future that include continuation of research on schizophrenia and depression and research that will benefit children and the elderly.