Use of services by persons with mental and addictive disorders. Findings from the National Institute of Mental Health Epidemiologic Catchment Area Program.

The use of ambulatory and inpatient mental health and addiction services in the United States was estimated by means of data from the National Institute of Mental Health Epidemiologic Catchment Area Program standardized to the 1980 US census for adults 18 years of age and older. In a 1-year period, 22.8 million people used ambulatory services for mental or addictive disorder treatment; 54% of them had a current Diagnostic Interview Schedule/DSM-III mental disorder and another 37.4% had a history of psychiatric disorder or significant psychiatric symptoms. A total of 325.9 million ambulatory visits were made, and the average number of visits per treated person per year was 14.3. There were 1.4 million persons admitted to at least one inpatient mental health or addiction setting during a 1-year period; 80% of them had a current DIS/DSM-III disorder, and the remainder had a history of psychiatric disorder or significant psychiatric symptoms. Results were determined for specific mental and substance use diagnoses and service settings. Among treated persons with any mental or addictive disorder, the majority of visits were to mental and addictive disorders specialty settings (40.5% of total visits) and to support networks composed of friends, relatives, and self-help groups (37.0% of total visits). Although a large number of persons with mental and substance use disorders were seen in the general medical sector for mental health or addiction problems, they were seen less frequently and therefore made fewer visits to this sector (10.9% of total visits).

Congruence of service utilization estimates from the Epidemiologic Catchment Area Project and other sources.

Service utilization estimates for inpatient and ambulatory mental health care from the Epidemiologic Catchment Area Project were compared with similar estimates from other sources, principally the Center for Mental Health Services National Reporting Program. Generally, results showed closer correspondence between estimates of the number of persons who used inpatient care than of similar estimates for ambulatory mental health care. Subtotal estimates for the specialty alcohol/other drug abuse/mental health and health care sectors were more similar than were estimates for individual settings. The specialty sector subtotals showed only a 7% difference in patient counts for inpatient care and 13% for ambulatory care, with an 11% difference in visits for the latter. Generally, a reasonable level of congruence was observed, given pronounced differences in methods, procedures, and instruments. Future directions may be able to close data gaps and improve the quality of the national mental health services database.

The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services.

After initial interviews with 20,291 adults in the National Institute of Mental Health Epidemiologic Catchment Area Program, we estimated prospective 1-year prevalence and service use rates of mental and addictive disorders in the US population. An annual prevalence rate of 28.1% was found for these disorders, composed of a 1-month point prevalence of 15.7% (at wave 1) and a 1-year incidence of new or recurrent disorders identified in 12.3% of the population at wave 2. During the 1-year follow-up period, 6.6% of the total sample developed one or more new disorders after being assessed as having no previous lifetime diagnosis at wave 1. An additional 5.7% of the population, with a history of some previous disorder at wave 1, had an acute relapse or suffered from a new disorder in 1 year. Irrespective of diagnosis, 14.7% of the US population in 1 year reported use of services in one or more component sectors of the de facto US mental and addictive service system. With some overlap between sectors, specialists in mental and addictive disorders provided treatment to 5.9% of the US population, 6.4% sought such services from general medical physicians, 3.0% sought these services from other human service professionals, and 4.1% turned to the voluntary support sector for such care. Of those persons with any disorder, only 28.5% (8.0 per 100 population) sought mental health/addictive services. Persons with specific disorders varied in the proportion who used services, from a high of more than 60% for somatization, schizophrenia, and bipolar disorders to a low of less than 25% for addictive disorders and severe cognitive impairment. Applications of these descriptive data to US health care system reform options are considered in the context of other variables that will determine national health policy.

Serious mental illness and disability in the adult household population: United States, 1989.

The major significance of the current report is that it provides estimates and characteristics for that portion of the civilian SMI population living in households. Survey results show that approximately 3.3 million adult Americans have mental disorders that seriously interfere with one or more aspects of daily life and that about 2.6 million of these persons are currently limited in one or more functional areas. These results suggest that the household component of the SMI population is comprised of between 2.6 and 3.3 million adults, depending upon the criteria employed for inclusion. Undoubtedly, both of these numbers are conservative because of the likelihood of underreporting in the survey. Placed in the context of the entire adult population, these findings suggest that the SMI population can be conservatively estimated to include 4 to 5 million adult Americans, or 2.1 to 2.6 øpercent of the adult population. In addition to the household population, it is estimated that 200,000 SMI persons are homeless on any given day (13). An additional 1 million to 1.1 million are residents of nursing homes (14), approximately 50,000 to 60,000 are patients of mental hospitals, and approximately 50,000 are inmates of State prisons (15). A major remaining need is to collect similar data on all SMI persons, whether their residence is a household, an institutional or noninstitutional group quarter, or some other setting, including streets and shelters. In order to formulate more effective national policy to address the needs of these disabled Americans, a need exists to examine the longitudinal relationship between course of disorder and functioning as they relate to service and program participation.

Care of persons with schizophrenia: a statistical profile.

This article presents the latest information available from the National Reporting Program for Mental Health Statistics on the distribution and characteristics of persons with schizophrenia served by organized, specialty inpatient, outpatient, and partial care mental health programs. Results are presented separately for persons under care at one point in time and for persons admitted over a 1-year period, in order to examine the potential for change in each type of care. Findings show that about 900,000 persons with schizophrenia were served in 1986; that inpatient and outpatient programs were relatively equivalent in total numbers served, but that considerably more patient turnover occurred in inpatient programs; and that partial care programs, although small, were evolving as a locus of care for persons with schizophrenia. Some variations were observed among the different types of organizations offering each type of care, and characteristics of clients/patients that could lead to changes in each type of care were evident. Overall, the findings present a useful composite picture of specialty mental health care for persons with schizophrenia. The need for longitudinal, prospective research is noted.

Persons with substance use disorders in mental health organizations in the United States in 1988.

Data from a 1988 enumeration of mental health organizations and separate psychiatric services of non-Federal general hospitals in the United States were used to derive estimates of the number of person with alcohol and/or drug abuse (substance use) disorders in these organizations. For all organizations combined, the percent of persons with substance use disorders were 8% each in inpatient, residential treatment, and outpatient care and only 3% in partial care program elements. However, within type of program element, there was variation according to type of organization. It should be noted that the percent of persons with substance use in mental health organizations would be even greater than reported if: (1) the universe of mental health organizations surveyed was expanded; (2) the reporting period included persons receiving services throughout the year rather than on a single day; and (3) provision was made for including persons with a secondary diagnosis of substance abuse.

The prevalence and correlates of untreated serious mental illness.

OBJECTIVE: To identify the number of people in the United States with untreated serious mental illness (SMI) and the reasons for their lack of treatment. DATA SOURCE/STUDY DESIGN: The National Comorbidity Survey; cross-sectional, nationally representative household survey. DATA COLLECTION: An operationalization of the SMI definition set forth in the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act identified individuals with SMI in the 12 months prior to the interview. The presence of SMI then was related to the use of mental health services in the past 12 months. PRINCIPAL FINDINGS: Of the 6.2 percent of respondents who had SMI in the year prior to interview, fewer than 40 percent received stable treatment. Young adults and those living in nonrural areas were more likely to have unmet needs for treatment. The majority of those who received no treatment felt that they did not have an emotional problem requiring treatment. Among those who did recognize this need, 52 percent reported situational barriers, 46 percent reported financial barriers, and 45 percent reported perceived lack of effectiveness as reasons for not seeking treatment. The most commonly reported reason both for failing to seek treatment (72 percent) and for treatment dropout (58 percent) was wanting to solve the problem on their own. CONCLUSIONS: Although changes in the financing of services are important, they are unlikely by themselves to eradicate unmet need for treatment of SMI. Efforts to increase both self-recognition of need for treatment and the patient centeredness of care also are needed.

The National Reporting Program for Mental Health Statistics: history and findings.

The National Reporting Program for Mental Health Statistics had its origins in the decennial U.S. census, with enumeration of the "insane and idiotic" in 1840. A series of special censuses of the insane and feebleminded in public and private hospitals and other institutions began in 1904, and annual censuses of patients in mental institutions were conducted from 1926 to 1946. The National Institute of Mental Health of the Public Health Service took over responsibility for the annual census of patients in mental institutions in 1947. Coverage and content remained the same until the mid-1960s, when only State and county mental hospitals were included in the census. Because the annual census could not provide the data needed, separate programs were begun for inpatient and outpatient service. These were integrated into the National Reporting Program in 1966. Trend data for the last 40 years describe how the specialty mental health sector has developed. Non-Federal general hospitals with separate psychiatric services increased dramatically, from 81 in 1940 to 1,531 in 1982, as did community mental health centers, from 125 in 1965 to 691 in 1980. There was generally less emphasis on inpatient care and more on outpatient care. Full-time equivalent staff in specialty mental health facilities increased from about 325,000 in 1970 to about 432,000 in 1982. Expenditures by facilities also increased dramatically.

Trends in state and county mental hospitals in the U.S. from 1970 to 1992.

OBJECTIVE: The authors document changes in state mental hospitals from 1970 to 1992 in four areas: the number of hospitals, the average daily census, expenditures, and number of full-time-equivalent staff. METHODS: Data examined were derived from information collected in the Inventory of Mental Health Organizations and General Hospital Mental Health Services. RESULTS: From 1970 to 1992, the number of state hospitals dropped from 310 to 273, and their inpatient populations were drastically reduced (a 77 percent decrease), a continuation of a trend that began in 1956. Most of the reduction was due to the downsizing of existing hospitals rather than to hospital closings. A complex combination of medical, social, economic, legal, and political factors were responsible for the decrease. Although expenditures for state hospitals were nearly $8 billion in 1992, a 339 percent increase over 1970, the level of expenditures in current dollars has leveled off in recent years, and expenditures measured in constant dollars (adjusted for inflation) have actually decreased since the early 1980s. The number of professional patient care staff increased by about half, while nonprofessional staff decreased by about the same proportion. CONCLUSIONS: In the near future, it appears that state hospitals will continue to reduce their patient populations, although at a slower rate than in the past, and will continue to care for large numbers of persons who either are involuntarily admitted or do not have alternative living arrangements. However, state hospitals are likely to decrease in importance.

Principles for assessment of patient outcomes in mental health care.

With the dramatic changes that are occurring in mental health and substance abuse treatment systems, it is imperative that the field keep its focus on the patient and the patient's outcomes of care. Outcomes management systems that measure the processes of care, the patient's characteristics, and the patient's outcomes of care can be helpful in maintaining this focus. To facilitate the development of these systems, the Outcomes Roundtable, a group of mental health consumer, professional, service, and policy-making organizations, has articulated a set of 12 broadly applicable principles of outcomes assessment. The principles call for outcomes assessments that are appropriate to the question being answered, that use tools with demonstrated validity and reliability and sensitivity to clinically important changes over time, and that always include the consumer perspective. In addition, the principles recommend outcomes assessments that create minimal burden for respondents and are adaptable to different health care systems, that include general health status as well as mental health status, and that include consumers' evaluation of treatment and outcomes. Outcomes assessment tools should quantify the type and extent of treatment, should include generic and disorder-specific information, and should measure areas of personal functioning affected by the disorder. Outcomes should be reassessed at clinically meaningful points in time. Outcomes assessment should use appropriate scientific design and representative samples and should examine outcomes of consumers who prematurely leave treatment as well as those who continue in treatment.

Conducting state and local health needs assessments. Designs and strategies.

A comprehensive set of five needs assessment techniques designed to facilitate informed decisions about mental health services planning at the state or local level are presented. These include: (1) estimating the size of the target population based on statistical extrapolations from prevalence rates or inferences from indirect indicators; (2) surveys of institution-based populations; (3) surveys of service providers; (4) client-targeted surveys; and (5) surveys of key informants. Each technique is discussed in terms of its unique design considerations, strengths and weaknesses, the phase's association with its application, and estimated resource requirements. Mental health needs assessments can be conducted in a cost-effective manner, especially important in an era when rational decisions about the allocation of scarce resources are essential.

The new informatics of national healthcare reform.

The President's Health Security Act has succeeded in attracting America's attention. Several of its initiatives have been well-publicized and hotly debated in Congress. The act also includes a number of implications for healthcare informatics, and devotes an entire chapter to this subject, although this area has not received as much publicity. Every behavioral healthcare provider's information system would be significantly affected by enactment of the Health Security Act. Selected forms and data elements for the management and delivery of behavioral healthcare services would need to be standardized. Organizations of behavioral healthcare providers, managed care companies and purchasers would increasingly share selected patient and subscriber information in aggregated form, for a variety of purposes. As a result, tougher laws to protect patient data privacy will likely be forthcoming. The following article gives an overview of the informatics needs of the soon-to-be reformed American healthcare system, into which behavioral healthcare will be integrated. As part of the larger system, behavioral healthcare services and information systems will need to comply with the same guidelines and requirements, outlined below, as other healthcare providers. Preparation to meet the information demands of the evolving healthcare system will require adaptation of existing computerized information systems, utilization of new technology, consultation with the system's major shareholders and attention to continuous quality improvement processes.