Current Medical Diagnosis & Treatment in Psychiatry

History of Services Research

Mental health services research has been slow to evolve; however, much of the current thinking in the field has stemmed from ideas formed decades ago. Mental health services, since the beginning of the 20th century, have been influenced more by federal initiatives than by individuals. From the 1930s through the 1960s, the mental health field did not focus on its relationship with other agencies (eg, schools, juvenile courts), nor did it seem to be concerned with social problems influenced by poverty. In essence, mental health services were isolated from other agencies dealing with those in need.

The National Mental Health Act in 1946 was critical in the creation of the National Institute of Mental Health. This legislation promoted a social model of mental disorders and encouraged community-based treatment as opposed to institutionally based treatment. With the Joint Commission on Mental Illness and Health in the 1950s recommending the establishment of community mental health centers (CMHCs), the late 1950s witnessed a deinstitutionalization movement, although there were few resources to support deinstitutionalized individuals. In the 1960s welfare reforms and other social programs further promoted deinstitutionalization. Medicaid and Medicare encouraged a reduction in psychiatric hospital beds and at the same time stimulated placement in alternative settings such as nursing homes. In recent decades, there has been some growth in insurance coverage for treatment of chronic mental health disorders, which has further encouraged care in community settings. Recently the emphasis on managed mental health care has influenced mental health services in many ways (discussed later in this chapter).

In the 1960s the community mental health movement flourished. The rapid expansion of federal support of CMHCs dramatically improved the living conditions for individuals with mental disorders. However, it was not until 1965 that any national initiatives paid attention to mental health services for children. Amendments to the Social Security Act that year mandated that a program be created to examine the “resources, methods, and practices for diagnosing or preventing emotional illness in children and of treating, caring for, and rehabilitating children with emotional illnesses” (Joint Commission, 1969, p. 2, as cited in Meyers 1985). In 1969 the Joint Commission on Mental Health of Children produced an 800-page report called Crisis in Children’s Mental Health: Challenge for the 1970’s. The report detailed the number of children in need of services and those who were at risk. It also emphasized the role of early intervention and prevention.

A decade later, little had been done in response to the Crisis in Children’s Mental Health report. For this reason, President Carter’s Commission on Mental Health identified children and adolescents as an underserved population with available resources unable to meet the needs. The Mental Health Systems Act passed into law in 1981 recommended an increase in funding for all mental health services, particularly for individuals with severe psychiatric disorders. The Act was intended to promote the design of a coordinated national plan for comprehensive services, quite a breakthrough for mental health. However, as often happens in the political arena, things went awry, and when President Reagan came into office, the law was repealed.

In the children’s field, however, the Children’s Defense Fund’s report, Unclaimed Children, was influential in highlighting, once again, the disparity between the number of children in need and those actually receiving services (Knitzer, 1982). The report identified fragmentation of the service system as a major problem, and 4 years later, the Congressional Office of Technology Assessment produced a report that documented the gap between the number of children in need of treatment and those who received treatment. This unmet need influenced the call for more coordinated systems of care so that children and families could access a wide range of community-based services.

CASSP was developed by NIMH to support state and local systems of care for children and adolescents with serious emotional problems and their families. CASSP also developed principles to be followed in the creation of systems of care for children. Some of these principles include that services should be family focused, children should be served in the least restrictive environment possible, services should be appropriate to the child and family’s needs, and the services should be community based.

In an effort to better coordinate mental health services, Stroul and Friedman (1986) developed a system-of-care conceptual model to provide a framework for communities trying to develop a service delivery system. The model’s seven dimensions of service include mental health services, social services, educational services, health services, vocational services, recreational services, and operational services. The goal for the system is to provide all the services necessary to meet the comprehensive needs of children and their families.

In addition, a variety of innovative community services have been developed both for adults and children. Included among these new services are intensive home-based services, therapeutic foster care, individualized wrap-around services, and crisis services as well as developments in prevention and early intervention. Many of these services have focused on the risk factors for mental illness.

More recently, some large-scale evaluations in the field have been undertaken. For example, the Fort Bragg Evaluation Project compared mental health outcome between children served in a system with a full continuum of care and those served in a more fragmented service system restricted primarily to inpatient and outpatient services. The Robert Wood Johnson Foundation funded the national Mental Health Services Program for Youth to demonstrate the feasibility of coordinated systems that integrate services across a community’s service agencies. Other projects evaluating children’s mental health services have emerged across the country, from the National Adolescent and Child Treatment Study in Florida, to the evaluation of California’s system of care. A major multisite initiative to develop interagency systems of care for children with serious emotional disturbance has been led by the Center for Mental Health Services (CMHS) of the Substance Abuse and Mental Health Services Administration. Since beginning in 1992, CMHS has awarded millions of dollars matched by dozens of project sites. CMHS funded 13 new projects in 1998 and 20 projects in 1999 at an annual cost of over $70 million.

In the adult field, two major epidemiologic studies of the prevalence of mental illness have been conducted. Between 1980 and 1985, the Epidemiologic Catchment Area (ECA) study surveyed respondents older than 18 years of age about their need for, use of, and access to mental health services. The second study, the National Comorbidity Survey (NCS), was conducted between 1990 and 1992. More recent studies in adult mental health services research include investigations focusing on outcomes of mental health services, particularly for capitated (ie, fixed) systems.

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