This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network |
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This Web site is a component of the SAMHSA Health Information Network. |
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A Fragmented Mental Health SystemThe mental health services system defies easy description. Loosely defined, the system collectively refers to the full array of programs for anyone with mental illness. The programs deliver or pay for treatments, services, or any other types of supports, such as disability, housing, or employment. These programs are found at every level of government and in the private sector. They have varying missions, settings, and financing. The mission could be to offer treatment in the form of medication, psychotherapy, substance abuse treatment, or counseling. Or it could be to offer rehabilitation support. The setting could be a hospital, a community clinic, a private office, or in a school or business. The financing of care, which amounts to at least $80 billion annually1, could come from at least one of a myriad of sources— Medicaid, Medicare, a state agency, a local agency, a foundation, or private insurance. Each funding source has its own complex, sometimes contradictory, set of rules. Taken as a whole, the system is supposed to function in a coordinated manner; it is supposed to deliver the best possible treatments, services, and supports—but it often falls short. Consider the daunting scenario for someone with both a serious mental illness and a substance use disorder, the most disabling sets of disorders according to the study by the World Health Organization (Figure 1). Three million adults have this combination of conditions (NHSDA, 2002). Mental illness is often treated in one setting (e.g., a mental health clinic or a psychiatric hospital), while substance abuse treatment is often given in another (e.g., a detox program or a methadone program). The rules governing eligibility for care often vary across those settings. And the rules governing payment vary too, depending on which funding sources apply. Many rules also differ for children and adults, a precarious problem for adolescents whose benefits may be lost as they enter adulthood. Because mental illnesses and substance use disorders are often long-term in nature, the inconsistencies of the system play out day-to-day, week-to-week, and year-to-year. "When I turned 18, I lost all my services." The reasons for fragmentation of the mental health system are complex and driven by historical forces (DHHS, 1999). The milestone carrying the greatest significance traces back to the 1950s, with the move away from care in institutions to care in communities. Long-term institutional care was expensive, neglectful, ineffective, and sometimes harmful. But the care was provided under one roof. The movement away from institutions, known as de-institutionalization, was motivated by reformers' desire to bring services to people in their communities. The unintended consequence is that responsibility is scattered across levels of government and across multiple agencies. New programs created to fill gaps in care added to the complexity and fragmentation. The Federal government pays for most services for people with a serious mental illness, while responsibility for providing them rests with states and localities. Compounding this problem, most Federal resources are in mainstream programs (e.g., Medicaid, Medicare, Vocational Rehabilitation, housing) that are not tailored to the requirements of good mental health care. While many providers are very dedicated and make valuable contributions despite the disorganization of the system, no one is ultimately responsible. Tragically, consumers and families are left with the struggle to find services, all the while coping with disorders that strike the mind and often cripple the ability to plan, manage, and advocate for care. It is no wonder that people with mental illness, by the very nature of the illness, are the least equipped to navigate their way through the complexities of the mental health system. "When my son first became ill we were totally adrift … help from the 'system' was difficult to obtain … he was unable to remember appointments. Confidentiality was given as the reason why we, as his parents, could not be advised of date and time for appointments. Therefore, he did not receive needed help. Any other illness would have been treated quite differently. When he was released from a hospital, local wrap-around services were almost impossible to obtain. Case management was fragmented, case managers seemed to have no training … some really tried and cared, but they soon burned out and left …" The reality is that the mental health system looks more like a maze than a coordinated system of care. When the system fails to deliver the right types and combination of care, the results can be disastrous for our entire Nation: school failure, substance abuse, homelessness, minor crime, and incarceration. While there are 40,000 beds in state psychiatric hospitals today (NASMHPD, 2001), there are hundreds of thousands of people with serious mental illness in other settings not tailored to meet their needs—in nursing homes, jails, and homeless shelters2. The rates of serious mental illness among incarcerated persons are about three to four times those of the general U.S. population (Teplin, 1990)3. Something is terribly wrong, terribly amiss, with the mental health system. The unmet needs are likely to deepen with the aging of the population and the demographic growth of minority populations (DHHS, 1999; DHHS, 2001). Fulfilling even the existing unmet needs means addressing fragmentation, as well as inadequate capacity to train personnel, monitor quality of care, and give information to consumers, families, and providers about best practices. |
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