P.

3843

of these interventions showed that they were able to produce statistically significant
improvement in caregiver knowledge of the illness and ability to provide care and to alleviate
depression and burden. Although there was a great deal of variability in effectiveness within
each category, the psychoeducational and psychotherapeutic interventions were the most
consistently effective. These interventions tended to focus on emotions, isolation, difficulties
managing patient behavior, and reducing the physical burden of care. Psychoeducational
interventions also can potentially alter caregivers' appraisals of their ill relative's behavior by
improving knowledge, beliefs, and skills related to caregiving.
Some intervention studies have included only caregivers with significant psychological
morbidity, with the intention of helping those currently in greatest distress. Others have taken a
more preventive approach and have included all caregivers.
Individual interventions are more effective than group interventions, probably because they are
more able to adapt to the specific needs of the people that they are designed to help. Adult child
caregivers generally benefit more than spouse-caregivers. This may be partly because they
become involved in caregiving with less information and experience than spouse-caregivers and
are able to profit more immediately from the educational aspects of the interventions. Although
many interventions have not shown improvements in outcome measures, those that combine
supportive and cognitive components are more effective in improving psychological well-being.
Meeting Individual Needs
Evidence from several studies that have reported clinically significant results suggests that an
important aspect of effective interventions is that they be designed to respond to the specific
needs of each caregiver. An intervention developed by Henry Brodaty in Australia in the late
1980s included an intensive 10-day training program, as well as periodic booster sessions and
access to the services of a counselor. Caregivers and patients resided in a psychiatric hospital
during the training. Although the main focus of the intervention was to teach caregivers problem-
solving and coping skills, the possibility of calling a counselor after the formal training period
was completed made the intervention responsive to individual needs. This study, in which
caregivers were followed for many years, demonstrated the potential long-term effects of such an
intervention; not only did the intervention reduce caregiver stress, but also, 8 years after entering
the study, those who received the intervention were able to keep patients at home significantly
longer than those who did not. Although an intervention that requires participants to reside in an
inpatient setting may not be practical, the principles and content of the intervention can be
applied in other settings.
Multicomponent Interventions
The diversity and variability in caregiver problems suggest that multicomponent interventions
that provide a range of services designed to improve family support and to provide group support
to alleviate the burden of caring for relatives with Alzheimer's disease can have a greater impact
on caregiver well-being than narrowly focused interventions. Those that provide counseling and
support over long periods of time seem to be the most effective.
A small study conducted in London suggested the potential for a multicomponent individual care
package for people with dementia and their caregivers. The intervention included medication for
patients, psychological techniques, and social measures, such as respite, as needed. Results
suggested that the mental health of caregivers and the behavior of the patients improved in
comparison to a wait list control group.
Interventions for Caregivers with Significant Psychological Morbidity
Studies have demonstrated the effectiveness of psychotherapy for caregivers who satisfy
diagnostic criteria for psychiatric disorders. In one study, brief (16 to 20 sessions)
psychodynamic therapy and brief cognitive-behavioral therapy for caregivers who satisfied
diagnostic criteria for a depressive disorder provided such caregivers with significant benefits,
including reduction of symptoms of depression. Interestingly, psychodynamic therapy was more
effective early in the caregiving career, whereas cognitive-behavioral therapy appeared to be
more effective later in the caregiving career. This may reflect the greater need for reappraisal of
the patient's behavior and behavior management skills as the disease progresses.
Cognitive-behavioral family interventions, such as one conducted in Great Britain consisting of
14 sessions divided into three components'caregiver education, stress management, and coping
skills training'also can reduce stress in caregivers. Each component was designed for the
individual caregiver, based on his or her understanding of the illness, appraisal of the patient's
behavior, and personal coping style.
Example of a Multicomponent, Individualized Intervention That Provides Counseling and
Support over the Entire Course of the Disease
The New York University Silberstein Aging and Dementia Research Center (NYU-ADRC) has
been investigating the effects of counseling and social support on spouse-caregivers of
Alzheimer's disease patients since 1987. The study enrolled 406 caregivers over an 11-year
period. The intervention was designed to enhance social support to facilitate caregiver well-
being.
There is no other longitudinal study that has followed such a large number of dementia
caregivers participating in an intervention study for such an extended period of time. The study
has had an unusually high retention rate. Only 4.7 percent of caregivers refused to continue in the
study while the patient was still living at home. Interview and questionnaire data have been
obtained at regular intervals whether the patient is at home, in a nursing home, or deceased.
Assessments continue for 2 years after the patient dies.
Design
Study subjects were randomly assigned to a treatment group or a control group at baseline. The
treatment consists of three components: individual and family counseling sessions tailored to
each caregiver's specific situation, weekly support group participation, and ad hoc
counseling'continuous availability of counselors to caregivers and families to help them deal
with crises and the changing nature of the patient's symptoms over the course of the disease.
Counselors also provide resource information and referrals for auxiliary help, financial planning,
and management of patient behavior problems. An important component of the intervention is
the involvement of other family members in addition to the spouse. Each caregiver in the
treatment group receives all of the interventions, and each is provided with support for an
unlimited time. Control caregivers receive routine services'that is, resource information and help
on request.
The unifying theme of the intervention is that improving social support and minimizing family
conflict improves the ability of the caregiver to withstand the difficulties of caregiving and to
obviate or to defer the need for institutionalization of the patient. The focus is on diminishing the
negative aspects of family involvement with caregiving, while enhancing the positive supportive
aspects. A priority has been to increase the adequacy of support for the caregiver while still
assuring that the caregiver's expectations are realistic. The intervention has a secondary aim of
changing the caregiver's appraisal of the behavior problems exhibited by his or her spouse,
through education and support, thereby reducing the impact of the behavior on caregiver well-
being. The intervention also provides ongoing support, not only for the primary
P.3844

caregiver, but also for other family members. This is accomplished by the relationship
established with the counselor during the formal counseling sessions and the offer to be available
as needed from then on.
The structured counseling sessions occurred within a fixed period after caregivers enrolled and
before the first follow-up assessment. The results of the first assessment demonstrated the
immediate positive effects of the intervention. Family cohesion improved, as did the spouse-
caregiver's satisfaction with his or her social network. The fact that the formal part of the
intervention is short (six sessions) may be a factor in its acceptability to its recipients.
When caregivers in the treatment group enrolled in the study, they agreed that they would join
support groups that met weekly after the structured counseling sessions were completed. They
were also informed that they could telephone a counselor for advice or support (which is called
ad hoc counseling), as long as they continued to participate, whether their relative with
Alzheimer's disease was living at home or in a nursing home. Family members who had
participated in family counseling with the spouse-caregivers were also told that they could
telephone a counselor for additional counseling.
Effects of the Intervention
Female caregivers entered the study with an average of three more symptoms of depression than
male caregivers (as measured by scores on the Geriatric Depression Scale), a significant
difference (b = 3.13; t = 3.5; P <.001). In fact, 50 percent of the female caregivers had depression
scores of 11 or higher (indicative of possible clinical depression), compared to 30 percent of
male caregivers. As time went on, caregivers in the control group became more depressed,
whereas those in the treatment group did not, suggesting that the intervention, rather than
reducing depression, acted as a preventive treatment. The difference between the treatment and
control groups grew over time and became statistically significant by the end of the first year.
The intervention had no greater impact on female caregivers than on male caregivers.
The study also demonstrated that counseling and support enabled caregivers to postpone or to
avoid placing their relatives with dementia in nursing homes. The estimated median difference
between the treatment group and the control group in time from enrollment in the study to
nursing home placement was 329 days. Analysis of the data showed that the difference between
caregivers in the two groups in depressive symptoms and appraisal of the behavior of the person
with Alzheimer's disease accounted for a large part of the effect on their ability to keep their
relatives at home.
Realizing that Mrs. Travers felt depressed and defeated, Ms. Daniels praised her for her
commitment and loyalty to her husband. Mrs. Travers relaxed a little and agreed to Ms. Daniels'
suggestion that she consider going out without Mr. Travers occasionally to visit friends or family
and paying the housekeeper who had been taking care of their house for many years to stay with
Mr. Daniels. She didn't suggest a support group for Mrs. Travers or a day care center for her
husband, because she didn't think she was ready to accept a resource that would make his illness
public. It was clear that Mrs. Travers' emotional state prevented her from developing realistic
long-range plans and that she would not respond positively to pressure to make more changes
immediately. Ms. Daniels recommended that the daughter join a caregiver support group
affiliated with the Alzheimer's Association, where she could meet other people who might have
found ways of coping with similar situations. She also suggested that Mrs. Travers meet with her
again in a few weeks' time, along with any other family member who wanted to come. In the
meantime, she told them that they could call her on the phone if they needed more help or
information.
SUGGESTED CROSS-REFERENCES
Biology of memory is discussed in Section 3.4. Epidemiology is covered in Section 5.1. The
cognitive disorders are covered in Chapter 10.
REFERENCES
*Alspaugh ME, Stephens MA, Townsend AL, Zarit SH, Greene R: Longitudinal patterns of risk
for depression in dementia caregivers: Objective and subjective primary stress as predictors.
Psychol Aging. 1999;14:34.
Aneshensel CS, Frerichs RR: Stress, support, and depression: A longitudinal causal model. J
Commun Psychol. 1982;10:363.
Brodaty H, Gresham M: Effect of a training programme to reduce stress in carers of patients with
dementia. Br Med J. 1989;299:1375.
Brodaty H, McGilchrist C, Harris L, Peters K: Time until institutionalization and death in
dementia patients: Role of caregiver training and risk factors. Arch Neurol. 1993;50:643.
Clyburn LD, Stones MJ, Hadjistavropoulos T, Tuokko H: Predicting caregiver burden and
depression in Alzheimer's disease. J Gerontol. 2000;55:S2.
Connell CM, Gibson GD: Racial, ethnic, and cultural differences in dementia caregiving:
Review and analysis. Gerontologist. 1997;37:355.
Cooke DD, McNally L, Mulligan KT, Harrison MJ, Newman SP: Psychosocial interventions for
caregivers of people with dementia: A systematic review. Aging Ment Health. 2001;5:120.
Gallagher-Thompson D, Steffen AM: Comparative effects of cognitive-behavioral and brief
psychodynamic psychotherapies for depressed family caregivers. J Consult Clin Psychol.
1994;62:543.
Goode KT, Haley WE, Roth DL, Ford GR: Predicting longitudinal changes in caregiver physical
and mental health: A stress process model. Health Psychol. 1998;17:190.
Hepburn KW, Tornatore J, Center B, Ostwald SW: Dementia family caregiver training:
Affecting beliefs about caregiving and caregiver outcomes. J Am Geriatr Soc. 2001;49:450.
Hooker K, Manoogian-O'Dell M, Monahan DJ, Frazier LD, Shifren K: Does type of disease
matter? Gender differences among Alzheimer's and Parkinson's disease spouse caregivers.
Gerontologist. 2000;40:568.
Kennet, Burgio, Schulz R. Interventions for in-home caregivers: A review of research 1990 to
present. In: Schulz R, ed. Handbook of Dementia Caregiving: Evidence-Based Interventions for
Family Caregivers. New York: Springer; 2000.
Lawton MP, Moss M, Kleban MH, Glicksman A, Rovine M: A two-factor model of caregiving
appraisal and psychological well-being. J Gerontol. 1991;46:P181.
Livingston G, Manela M, Katona C: Depression and other psychiatric morbidity in carers of
elderly people living at home. Br Med J. 1996;312:153.
Lyons KS, Zarit SH, Sayer AG, Whitlach CJ: Caregiving as a dyadic process: Perspectives from
caregiver and care receiver. J Gerontol. 2002;57:P195.
Marriott A, Donaldson C, Tarrier N, Burns A: Effectiveness of cognitive-behavioural family
intervention in reducing the burden of care in carers of patients with Alzheimer's disease. Br J
Psychiatry. 2000;176:557.
*Mittelman MS, Epstein C, Pierzchala A. Counseling the Alzheimer's Caregiver. A Resource for
Health Care Professionals. Chicago: AMA Press; 2002.
Mittelman MS, Ferris SH, Shulman E, Steinberg G, Ambinder A, Mackell JA: A comprehensive
support program: Effect on depression in spouse-caregivers of AD patients. Gerontologist.
1995;35:792802.
*Mittelman MS, Ferris SH, Shulman E, Steinberg G, Levin B: A family intervention to delay
nursing home placement of patients with Alzheimer disease: A randomized controlled trial.
JAMA. 1996;276:1725.
*Pearlin LI, Mullin JT, Semple SJ, Skaff MM: Caregiving and the stress process: An overview
of concepts and their measures. Gerontologist. 1990;30:583.
Schulz R, O'Brien AT, Bookwala J, Fleissner K: Psychiatric and physical morbidity effects of
dementia caregiving: Prevalence, correlates, and causes. Gerontologist. 1995;35:771.
*Schulz R, O'Brien AT, Czaja S, Ory M, Norris R, Martire LM, Belle SH, Burgio L, Gitlin L,
Coon D, Burns R, Gallagher-Thompson D, Stevens A: Dementia caregiver intervention research:
In search of clinical significance. Gerontologist. 2002;42:589.
Sorensen S, Pinquart M, Duberstein P: How effective are interventions with caregivers? An
updated meta-analysis. Gerontologist. 2002;42:356.
Zarit SH, Orr NK, Zarit JM. Families under Stress: Caring for the Patient with Alzheimer's
Disease and Related Disorders. New York: New York University Press; 1985.
*
The consequences of the downward slide of the economy and the stock market in the first years
of the 21st century and the substantial losses incurred by many retirement plans remain to be
seen.
Editors: Sadock, Benjamin J.; Sadock, Virginia A.
Title: Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 8th Edition
Copyright ©2005 LippincottWilliams & Wilkins
> Table of Contents > Volume II > 52 - Hospital and Community Psychiatry > 52.1 Public and
Community Psychiatry
52.1 Public and Community Psychiatry
Leighton Y. Huey M.D.
Julian D. Ford Ph.D.
Robert F. Cole Ph.D.
Part of "52 - Hospital and Community Psychiatry"
Each term in the phrase public and community psychiatry is burdened by a complex past and
needs interpretation to clarify its contemporary meaning. The term public can refer to psychiatric
programs, treatment, or institutions paid for by public funds or as objects of public policy,
whether paid for or not. The traditional concept of public psychiatry has been expanded to
include medical and psychosocial initiatives directed for the public good, whether funded by
public or private funds, and directed in particular to those who are economically disadvantaged.
As is seen in this section, American psychiatry started out as a public endeavor through an act of
the Colonial Virginia Legislature and, for more than a century, found its principal domain in the
public state hospitals. Public psychiatry stands in stark contrast to personal or private psychiatry,
which is the entrepreneurial practice of delivering services to individuals having some means of
purchasing them. Public psychiatry is generally considered to be the care and treatment of adults
with serious mental illness or serious and persistent mental illness or of children with serious
emotional disorders who cannot access private mental health services. These categories identify
target or priority populations that usually consist of the presence of at least one qualifying major
mental illness, an assessment of its impact on ability to function in multiple areas, and an
evaluation of the individual's personal resources to obtain private mental health services (Table
52.1-1).
Table 52.1-1 Eligibility for Mental Health Service Grants

The following definitions are in the Federal Register and are currently used to determine
eligibility for services provided by the federal Center for Mental Health Services block grant
funds:
Adults with serious mental illness are persons:
18 Yrs of age and older,
Who currently or at any time during the past year
Have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet
diagnostic criteria specified within DSM-IV-TR,
Which has resulted in functional impairment that subsequently interferes with or limits one or
more major life activities and
Lasts less than 6 mos of the past year.
Adults with serious and persistent mental illnessare persons who are recently severely impaired,
and the duration of the impairment totals 6 mos or longer of the past year.
Children with a serious emotional disturbance are persons
From birth to as old as 18 yrs of age,
Who currently or at any time during the past year
Have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet
diagnostic criteria specified within DSM-IV-TR
That resulted in functional impairment that substantially interfered with or limited the child's
role or functioning in family, school, or community activities.

The care and treatment offered under public psychiatry are delivered in a variegated mosaic of
inpatient and community-based services that are more or less integrated into a coherent network
sponsored by public agencies. The term community, as historically applied to psychiatry,
connotes the mental health status of a specific, geographically defined population. It is
synonymous in all respects with not the state hospital and is contrasted to institutional care,
especially in the move to community mental health in the second half of the 20th century.
Community psychiatry in this context refers to psychiatric practice in the community as part of
the community effort to care for individuals afflicted with major mental illness in a specific
geographic catchment area. Community psychiatry initially was an attempt to break with
traditional public psychiatry. At the end of the 20th century, it obtained still broader connotation
in terms of the health of the community: Community psychiatry activities involve the impact of
psychiatric disorders in individuals on the health of the community and formulate treatment
strategies to improve community health.
The term psychiatry originally described the medical specialty focused on the care of persons
with mental illness in the state hospital setting. Its domain was strengthened by the dominant role
of the medical superintendents of the state hospitals and their medical colleagues in the latter half
of the 19th century and first half of the 20th century. However, in the era of community mental
health in the latter half of the 20th century, the term exploded to cover a host of disciplines and
new personnel recruited to staff the community-based supportive treatment systems that were
supposed to take the place of the institutions. Nursing, social work, clinical psychology, various
therapeutic specialties, and paraprofessional direct care functions all became labeled as part of
psychiatry.
The traditional concept of public and community psychiatry has had a narrow focus on the
psychiatrist in his or her role as the medical specialist, trained in the discipline of medical
science (which is increasingly important) and exercising medical and legal authority to take
defined actions on behalf of individual patients. In this paradigm, the public psychiatrist
practices psychiatry in publicly funded services and carries out programs that are mandated by
public policy. As a public and community psychiatrist, he or she is engaged with a specific
geographically defined population in terms of community programs for the care of its individuals
with mental illness and in terms of concern and action to improve the health of the community as
broadly defined.
Two contemporary considerations augment this basic (and rather narrow) conceptualization of
public and community psychiatry. The first is the realization that the impact and pervasiveness of
psychiatric disorders imposes a global burden on society. In the mid-1990s, a landmark study
called The Global Burden of Disease appeared. This study, funded by the World Health
Organization, the World Bank, and several foundations, considered the leading causes of
disability and premature death worldwide as a result of various health and situational problems.
Of the ten leading causes of disability worldwide, five are neuropsychiatric, with the leading
cause of disability being depression. When considering the leading causes of healthy years of life
lost using a concept of disability-adjusted life years (DALYs), which reflects premature death
and disability, depression was second in the United States and was expected to rank second in
the world by the year 2020. Although it has been known for some time that psychiatric disorders
by themselves and in comparison to other physical disorders are highly prevalent and have
significant impact on populations of people (e.g., Stirling County Study, Midtown Manhattan
Study, Epidemiological Catchment Area Study, National Comorbidity Study, Medical Outcomes
Study), the Global Burden of Disease report clearly cast the enormity of the problem in a
straightforward, unambiguous manner. The implications and the importance of properly
addressing primary and comorbid psychiatric disorders across a spectrum as part of enlightened
health policy are compelling. The
P.3846

prevalence of psychiatric disorders warrants a systems-based approach, which is the conceptual

strength of public and community psychiatry. A systems-based model of psychiatry involves
understanding and drawing on the wide range of biopsychosocial factors that underlie mental
illness to develop psychiatric treatment and rehabilitation interventions to reduce the disease
burden associated with severe and persistent mental illness.
The second consideration is a critical evaluation of American medical practice by the Institute of
Medicine in its report entitled Crossing the Quality Chasm: A New Health System for the 21st
Century. This is a call to American medicine to reform inadequate service delivery systems and
to apply effective practices systematically. It documents the need for a fundamental overhaul of
the entire American health care system, addresses the problems caused by insufficient quality in
the health care system, and offers a road map for creating a new health system. Accountability
for health care outcomes emerges as the primary public policy concern facing American
medicine. Public and community psychiatry comprises 70 percent of health care expenditures for
all behavioral health services in America and thus plays a critical role in health care's
reconfiguration. Simply maintaining the status quo and the historical manner in which health
care has been conducted is not sufficient. A reform approach as to how psychiatric services
should be provided, whether in the public or private sectors, is in keeping with the charge of the
Institute of Medicine.
Historically, the connotation associated with public and community psychiatry has been
synonymous with care for the poor and underprivileged, care for special populations normally
not attended to by the private sector, overwhelmed systems, low reimbursement, inferior and
unresponsive care, and a final common pathway for individuals no longer able to afford private
care. In general, these individuals as a group lack the most basic resources to sustain themselves
in society (food, clothing, housing, financial support, social support, etc.), and they are arguably
the group least likely to have the capacity to recover from this default position. As noted at the
outset of this section, a more encompassing construct could be considered in which, regardless of
funding (i.e., public or private), as long as the effort is directed at the public good with an eye
toward the economically disadvantaged, this could become a new definition of what constitutes
public and community psychiatry. In addition, the arbitrary segregation of public and community
psychiatry from the rest of psychiatry is more a reflection of the historical focus that the field has
had on the individual to the relative exclusion of the family, the school, the workplace, and the
community, representative of an insulation from an overall population-based perspective and
approach. Ironically, as more information becomes available about the most effective treatments
(i.e., those with the best outcomes delivered in the most appropriate and most cost-effective
manner), the importance, indeed, the necessity, of a broad systems approach to focused
assessment and treatment that considers individuals along a continuum is evident.
A community paradigm in which public health concepts of education, prevention, and early
identification are integrated with acute and chronic illness care management with outcomes
assessment must result in healthier communities and, therefore, healthier individuals. Such a
paradigm encompasses a broad range of necessary services from institution to community, based
on the individualized assessment of need. This then becomes the new standard of what
constitutes contemporary successful care, whether in the private or public sectors. In short, the
most effective approach to public psychiatry involves the development of a coherent system of
care for each individual within the context of his or her family, community, and culture. It is in
this context that this section is written. It begins with a brief historical review of public and
community psychiatry in America and a discussion of contemporary themes and movements in
public and community psychiatry. The discussion identifies, but does not dwell on, the
difficulties and frustrations that have arisen in the last quarter-century in the movement from
institutions to community mental health and the radical changes brought about with managed
care. This is a period of some degree of entropy, that is, chaos, in American health care'a time to
build anew, based on the lessons of the past.
HISTORICAL PERSPECTIVE OVERVIEW
Mental health policy and treatment has been a public issue in America from the beginning. A
broad brush overview of this complex history can distinguish four stages. Colonial times and the
early years of the republic were the era of the poorhouse during which the great majority of
persons with mental illness found refuge or were confined for their own and others' protection as
part of local community management. Care and custody were the operative functions, and
treatment was nonexistent. In the mid-19th century, the pioneering work of Dorothea Dix
ushered in the age of the asylum, during which public inpatient facilities, generically called state
hospitals, were constructed in every state. A century later, advances in medicine, psychodynamic
psychiatry, and biological psychiatry along with a remarkable policy consensus moved federal
legislation to shift from institutionally based care to an era of community mental health. Finally,
as health care costs began to soar at the end of the 20th century, and as employer purchasers and
government moved to create market-driven health care, mental health policy has moved to
tightly organized systems of care that focus on prevention, early intervention, community
support, and recovery for children with severe emotional disturbances and adults with serious
acute and persistent mental illnesses.
P.3847

The movement of history is best understood at its transition points. To get a sense of this history,
the following quick review of public and community psychiatry in America focuses on three
vignettes at the transition points that separate these stages.
From the Poorhouse to the Asylum
Now for near five years I have been indulged by the gracious Heaven in my long holiday in this
goodly house of mine entertaining and entertained by so many worthy and gifted friends and all
this time poor Nancy Barron the madwoman has been screaming herself hoarse at the poorhouse
across the brook and I still hear her whenever I open my window.
--Ralph Waldo Emerson, Journals, 1840
In the American colonies and in the early days of the republic, the care of the mentally ill was
modeled on the practices of 18th century England, where the Enclosure Laws disrupted the rural
social order and set thousands on the road to seek shelter and employment in the cities. People
with mental disabilities were at a particular disadvantage. They were saved from vagrancy by
confinement in poorhouses, prisons, and jails, along with criminals, debtors, and other people
with disabilities. In the American colonies, most towns would establish a poorhouse, and persons
with mental illness, especially those who were found to be disruptive, would be committed by
the actions of local government to extended stays in them. It is not that there were no hospitals.
The construction of a public hospital was first proposed in Virginia in 1766. The money was
appropriated in 1770, and the Public Hospital at Williamsburg opened in 1773, which was the
first public mental hospital in the Colonies. In Massachusetts, McLean Asylum opened in
Charlestown in 1818. This was a community effort endowed by more than 50 philanthropists led
by a Scottish businessman to support the work of a young minister caring for persons who had
gone mad at sea and had found themselves delivered to the Boston docks. Even though this was
privately financed, it was a public cause. Only a few years before his journal entry, Emerson had
had to commit his brother, who experienced bipolar illness, to the McLean Asylum in
Charlestown. This may have heightened his sympathy for poor Nancy Barron. Shortly thereafter,
the first large state hospital opened in Worcester, Massachusetts in 1833.
The physician superintendents of these early hospitals were the reformers of the era, following
the ideas of moral management put forth by the French reformer, Philippe Pinel. He believed
that, if people were removed from their urban environments, were relocated to an asylum in a
beautiful pastoral setting, were engaged in agriculture and the trades, lived in close proximity
with staff, and were treated with kindness, then soon they would fully recover from the
behavioral changes that they manifested as a result of having lived in a stressful, demanding
environment. The English Quaker, William Tuke, built a private asylum near York, England,
called the Retreat and pursued similar approaches to the humane care of persons with mental
illness. Benjamin Rush, a signer of the Declaration of Independence, considered the founder of
American psychiatry, applied many of these theories and methods of his own in the treatment of
the insane in the years after 1783 in the Philadelphia Hospital.
The great majority of those who experienced mental illness, however, were kept in poorhouses or
jails under deplorable conditions and became a cause for reform. In the year of Emerson's journal
entry, the Unitarian reformer, Dorothea Dix, had begun a 2-year survey of the conditions in
which these people lived. In 1843, she compiled her findings in a Memorial to the Legislature of
Massachusetts: I tell what I have seen, to present the state of the insane persons confined within
the Commonwealth in cages, closets, cellars, stalls, pens! Chained, naked, beaten with rods, and
lashed into obedience! The long lists of the facts from her findings began with the following
entry: Concord. A woman from the [Worcester] hospital in a cage in the almshouse'likely the
same Nancy Barron over whose agonies Emerson had reflected.
After the Massachusetts Legislature appropriated funds for a substantial expansion of the
Worcester Hospital, Dix proceeded to write memorials for states up and down the eastern
seaboard and the western states as far as Wisconsin. In the 10 years between 1844 and 1854, she
traveled more than 30,000 miles, visiting hundreds of prisons, almshouses, jails, and hospitals,
collecting data and arousing public opinion to her cause. In 1848, seeking federal support similar
to that given to education, she sought federal support for national hospitals. The 12,225,000 Acre
Bill finally passed both houses of Congress in 1854. It was vetoed by President Franklin Pierce,
who stated: I cannot find any authority in the Constitution that makes the Federal Government
the great almoner of public charity throughout the United States. Public mental health was, for
the next century, exclusively in the hands of the states and the state hospitals that continued to be
built only to be quickly filled and hopelessly overcrowded.
Community Mental Health
I am proposing a new approach to mental illness and to mental retardation. This approach is
designed, in large measure, to use Federal resources to stimulate state, local, and private action.
When carried out, reliance on the cold mercy of custodial isolation will be supplanted by the
open warmth of community concern and capability. Emphasis on prevention, treatment, and
rehabilitation will be substituted for desultory interest in confining patients in an institution to
wither away.
--John F. Kennedy, Message from the President of the United States Relative to Mental Illness
and Mental Retardation, February 5, 1963
In a little more than a century after President Pierce blocked the federal government from
involvement in the problem of mental illness, another President reversed this direction and
committed the federal government to the cause of persons with mental disabilities and their
families. President John F. Kennedy signed the Mental Retardation Facilities and Community
Mental Health Centers Construction Act (PL 88-164) in October 1963. He did so perched on a
wave of reform that defined a new era of community mental health. The reform was founded on
a century of steady progress in which asylums were built and their weaknesses discovered. The
advances of medicine offered new hope to psychiatry, and that optimism gathered the
momentum of public opinion. Consumers and advocates for the mentally ill found their voice in
the mental hygiene movement. A series of research-oriented institutions were established.
Significant therapeutic improvements were discovered. Finally, a coalition of skillful
bureaucrats, advocates, and politicians set the scene for the public policy shift that President
Kennedy declared would supplant the cold mercy of custodial isolation with the open warmth of
community concern and capability. It is a fascinating story, and here is a review of its high
points.
It has been said that American medicine reached a critical juncture at the turn of the 20th
century. Science and medicine had established a strong alliance in the major university medical
schools, and the profession established a powerful public credibility as breakthrough
P.3848

after breakthrough transformed medicine. Psychiatrists were not in the forefront of this
transformation, but they were profoundly affected by it. One of the most prominent psychiatrists
of the period, from 1890 until his retirement at the eve of World War II, was Adolf Meyer, and
his life and career may be thought of as representative of what was happening to psychiatry.
Meyer was born in Switzerland (1866) and was trained as a neurologist. He came to America in
1892 and worked for 8 years in state hospitals in Illinois and Massachusetts. In this sense, he
came from the ranks of the asylum psychiatrists who were the bulwark of the state hospital
system that had, by that point, spread throughout the country.
The first public psychiatrists were state hospital superintendents, responsible for all institutional
clinical and administrative functions. Within a few short years, the populations of state hospitals
grew, so that their treatment function was eclipsed by care and custody concerns. The
superintendent became more of a manager and administrator than a treatment provider. The
ability to organize and to bring order to the institution became a necessary skill. Although these
early psychiatrists reluctantly accepted care and custody functions as part of their
responsibilities, succeeding generations found themselves struggling with that issue, as well as
new problems.
The New York State Hospital system had established, in 1895, the Pathological Institute, which
had two mandates: the study of mental diseases from the standpoint of cellular biology and the
offer of instruction in brain pathology to state hospital physicians. The Institute sought to
become the cutting edge of reform, not without opposition from the asylum psychiatrists who
were more oriented toward managerial and administrative concerns and clear demarcation of the
diseased state of institutional inmates from the normality of functioning people in the
community. Meyer became its director in 1901. When Henry Phipps endowed a psychiatric
clinic at Johns Hopkins, Meyer was chosen as its first head. From Johns Hopkins, he played a
leading role in American psychiatry for more than three decades.
In the beginning of the 20th century, the concept of dynamic psychiatry opened the possibility of
psychiatry practiced in the community. Dynamic psychiatry blurred the distinction between
health and disease and saw mental illness on a continuum. This allowed the center of attention
for psychiatric practice to move beyond the institutions and to include troubled individuals in the
early stages of illness. This approach elevated the significance of the life history and prior
experience of each person. It was a short leap of faith to suggest that early community treatment
might prevent the onset of severe mental illnesses that, up to then, had required
institutionalization. The once strong bond between the asylum and psychiatry was unraveling.
Dynamic psychiatry expanded the jurisdictional boundaries to include psychologically troubled
individuals, as well as allegedly dysfunctional social structures and relationships. From 1880 to
1940, psychiatrists identified new careers outside of institutions. Psychiatrists articulated novel
theories and therapies; expanded jurisdictional boundaries to include not only mental disorders,
but also the problems of everyday life; proposed solutions for society's ills; and defined a
preventive role. Despite its good intentions, it was, in retrospect, gross overstatement based more
on conjecture and opinion than a scientific basis.
Meyer was a leading figure in advocating a fresh and courageous pragmatism and held a
biological conception of human beings. We must accept the statement that all mental activity
must have its physiological side and its anatomical substratum. He developed a genetic-dynamic
or developmental approach to mental illness, which he named psychobiology. He stressed the
interaction of the organism to its environment and defined mental disorders in behavioral terms,
tracing their origins to defective habits. He recognized the importance of consumer advocacy and
supported Clifford Beers, a former mental patient, who wrote a celebrated work, A Mind That
Found Itself, and who founded the mental hygiene movement.
Meyer was an empiricist, urging his colleagues to assemble and to catalogue facts. He was not a
theoretician or a systematizer. Perhaps he realized that biology did not yet have the scientific
tools to construct adequate theories about human mental processes. In this regard, he did not
favor Sigmund Freud and what he viewed as the tendencies to dogmatic pronouncement. The
eminent social historian of American mental health policy, Gerald Grob, observes that
psychoanalytic concepts had far greater influence on culture and thought than on medicine in
general or psychiatry in particular. This seems to overstate the case, given the great enthusiasm
for psychoanalysis that came after World War II and that dominated popular perceptions of
psychiatry. However, Grob appears to place figures like Meyer more at the real center of
psychiatry in the period, especially as it related to medicine in medical science.
On the eve of World War II, as Meyer retired, public psychiatry had advanced on three fronts.
On the first, research institutes and psychopathic hospitals were developed alongside the state
asylums in which research and training would benefit the care of persons with mental illness. In
addition to the New York Pathological Institute and the Phipps Clinic, where Meyer had worked,
a Psychopathic Hospital was developed at the University of Michigan Medical School in Ann
Arbor, the Boston Psychopathic Hospital (later known as Mass Mental) was developed at
Harvard Medical School, and similar institutes were developed in a number of states. These
hospitals and institutes had limited success in that their research efforts to establish the efficacy
of psychodynamic treatment progressed slowly, and they suffered a degree of mission drift away
from the seriously and persistently mentally ill in the asylums and toward less severe mental
health problems in the community. Second, an active consumer advocacy movement began in
the founding of the National Committee for Mental Hygiene in 1909, which developed into a
national movement focusing first on the plight of individuals in the asylums and then on mental
health issues in the community. Finally, the ideas of dynamic psychiatry made it possible to
think of the various stages of mental illness and the possibility of the prevention and
amelioration of mental disease.
Before World War II, there were fewer than 3,000 psychiatrists in the United States, with more
than one-half of them working in the public sector. At war's end, the American Psychiatric
Association (APA) still represented hospital psychiatry. However, a bitter and divisive power
struggle ensued. By 1950, the APA had been transformed into a visible and active organization
that represented psychodynamic and psychoanalytic viewpoints. Adherents to these perspectives
controlled virtually all university departments, ensuring that psychiatrists trained in the 1950s
and 1960s shared these concepts. By 1957, only 1,700 of the 10,000 APA members worked in
state hospitals. Within less than 20 years, the overwhelming majority of psychiatrists in America
went from working in state hospitals to working in other settings that had little or no interface
with the populations having serious mental illness or serious and persistent mental illness, or
with children with serious emotional disorders.
As World War II ended, two factors entered the American public psychiatry arena that would
have a catalytic effect. The first was the corps of 2,400 physicians assigned to psychiatry along
with prominent leaders in American psychiatry who had screened recruits and successfully
treated neuropsychiatric symptoms in noninstitutional settings. Many psychiatrists left military
life convinced of the need for change in the ways in which the needs of persons with severe
P.3849

mental illness and individuals with mental health problems were addressed. They entered the
nonmilitary world confirmed in the ideas that dynamic psychiatry had articulated. The second
factor was the appearance of the so-called French drug, chlorpromazine (Thorazine).
Chlorpromazine was tested in a Parisian mental hospital after encouraging findings of its effect
on trauma patients in the war. The positive findings of these trials led to its marketing under the
name Thorazine in the United States in the early 1950s. The new drug was cautiously and
ambivalently received by psychiatrists committed to psychodynamic concepts, but it opened a
new world of possibilities for the academics and researchers who came to represent biological
psychiatry.
The 1950s were a time of great therapeutic optimism. Biological psychiatrists pointed to the
efficacy of drug therapy; their psychodynamic colleagues could point to psychological,
psychosocial, and environmental therapies that would reach the most severely disabled
institutionalized patients. Milieu therapy (the therapeutic community) arose in this period and
had much in common with moral therapy. Pioneered by Maxwell Jones, milieu therapy
recognized the impact of the hospital environment on patients and the possibility of employing it
as an active component of treatment. It appeared that medications were going to allow patients to
engage in the therapeutic community, and then other innovations, such as unlocked wards and
partial or day hospitals, were going to help some chronic patients transfer to the community.
Finally, an extensive network of community services would help these individuals reintegrate
into society by providing for their psychiatric, social, and financial support. The Milbank
Memorial Fund celebrated all of these causes for optimism in a series of conferences and
monographs that modeled a new approach to public psychiatry and a new social policy.
As all of this momentum for change was building, a remarkable partnership for political action
was developing between Robert Felix, the head of the newly formed National Institute for
Mental Health, Senator Lister Hill, and Representative J. Percy Priest. In a carefully orchestrated
process, hearings were held, aimed at focusing public attention on mental health problems and
thus strengthening the case for an enhanced federal role. The Mental Health Study Act was
passed in July 1955, creating the Joint Commission on Mental Illness and Mental Health
(JCMIMH). The JCMIMH final report, Action for Mental Health, did not make a clear-cut
distinction between individuals with serious and persistent mental illness and psychologically
troubled individuals. The report favored a shift of funding support to accommodate the needs of
the latter without addressing the implications of such a shift. The report criticized the mental
hygiene movement for diverting attention from the core problem of major mental illness (i.e.,
serious and persistent mental illness) by emphasizing primary prevention, but it also emphasized
the need to provide treatment to psychologically troubled individuals. It supported community-
based and hospital-based services, proposing that regional psychiatric inpatient treatment centers
limited to no more than 1,000 acutely ill patients be established. It said that existing institutions
of more than 1,000 beds should be gradually converted to long-term-care facilities for all chronic
illness. It also insisted that aftercare and rehabilitation be integrated with all other services to
limit the need for hospitalization or rehospitalization.
Although the JCMIMH report was obviously a compromise among the 26 participating
constituency organizations, there was strong support for fundamental change. Faith in the
effectiveness of treatment in community programs was based on belief in the efficacy of early
intervention, psychodynamic theories, epidemiological efforts to elucidate the prevalence of
mental illness in the community, and the putative identification of environmental variables.
Altogether, it was believed that one could predict who was at risk of developing mental illness
by identifying environmental factors that promoted or retarded the onset of symptoms, thus
allowing for the opportunity to intervene early.
At the end of the decade, with a new administration with an aggressive domestic agenda, the
National Institute of Mental Health (NIMH) convened the Interagency Task Force on Mental
Health, which developed the Blueprint for Action and, more importantly, activated the political
coalition that made President Kennedy's initiative possible. The final policy side-stepped the
provisions recommended by the JCMIMH for the refurbishment of the state hospitals and
providing acute institutional care for the most severely disabled and devoted its attention to
community mental health clinics, which it recommended to be enhanced to comprehensive
community mental health treatment centers'the community mental health centers (CMHCs).
The Construction Act for the Community Mental Health Centers was followed by the Staffing
Law, which was signed by President Johnson in 1965 after President Kennedy's tragic death. The
national program for comprehensive CMHCs was in place. For the next 15 years, grants flowed
to the localities and then through the states to the localities to the new centers, and states
proceeded to build community systems while beginning the process of phasing out the old state
hospitals. The immediate discovery was that the CMHCs were able to expand mental health
services for the communities but were not at all prepared to care for persons with serious and
persistent mental illness who had spent most of their lives in state institutions. The discharge of
90 percent of the state hospital population (the deinstitutionalization process) without adequate
community resources available was chaotic and often precipitous. It led to a class of homeless
and generally untreated or transinstitutionalized individuals (put into nursing homes, prisons,
squalid rooming houses and hotels, etc.) who deteriorated outside the state hospitals. There also
arose a peripatetic subpopulation (the young adult chronic population) with serious mental illness
and serious and persistent mental illness, who often had comorbid substance abuse and who
generally avoided any beneficial involvement in treatment for a significant portion of the early
phase of their illness. However, the states, to varying degrees, were set on a course of
dismantling state hospitals that were becoming increasingly expensive. As federal staffing grants
to the CMHCs were phased out, and state contract dollars replaced them, the states gradually
narrowed the focus of the community programs to its priority clients, the former residents of the
state hospitals. Special programming models were developed to provide supportive programming
for them that focused on community support and rehabilitative approaches rather than clinical
ones.
As community mental health programs developed, it became clear that psychiatrists were, for the
most part, playing limited roles: Reimbursement could not support them full time, and they
gravitated to private practice models that were appropriate for individuals with less severe
mental health issues. The psychiatrists who were involved in the early CMHCs were quickly
outnumbered by the other disciplines and often sidelined themselves in private practice models
in which they could treat educated and functional people with relatively mild disorders. These
practice models limited their ability to treat persons with severe mental health disabilities
without appropriate outreach and supportive care. The Hill-Burton Act, which had provided
substantial funding for general hospital construction, had led to the development of acute
psychiatry units in most hospitals. The establishment of psychiatric services in these hospitals
was encouraged by the movement of psychiatrists into private practice, their need for some type
of hospital facility, and the
P.3850

growth of third-party health insurance. The psychiatrists who moved to this kind of model
effectively left the care of the most severely disabled to the public agencies and the CMHCs.
It was a chaotic period in American mental health. The different states advanced unevenly in the
development of community programs, while, uniformly, political pressure built to reduce the
census in the expensive state hospitals. In some cases, appropriate community-based
programming was ready to receive the newly discharged individuals, but in many cases it was
not. There are those who have come to look back in dismay at the massive changes that the
federal community mental health programs put in motion. The durable and revered concept of
the asylum was to be abandoned in this process. With the picture of many deinstitutionalized
former state hospital residents, homeless or living marginally, especially in the nation's cities, the
optimism and faith in the effectiveness of the new treatment modalities that drove these policy
decisions might be judged (in hindsight) to be unwarranted. The process had been driven by
rhetoric and enthusiasm, and, strangely, NIMH had ignored the more balanced recommendations
of the JCMIMH report that supported improvement measures for the hospital facilities and the
community programs.
Many mistakes were made, but many valuable lessons were learned. In 1977, President Carter
signed an executive order creating the President's Commission on Mental Health to review the
progress and needs of the national programs and to make recommendations. His wife, Rosalynn
Carter, served as honorary chairperson and played a critical role in its deliberations. The reports
and monographs prepared by the Commission documented and catalogued the learnings that had
been gleaned from the development of community programs and the process of
deinstitutionalization that had ensued. Overall, they represented a more balanced and informed
conceptualization of the agenda and the problems that needed to be addressed. The
Commission's findings led to the passage of the Mental Health Systems Act (PL 96-398), which
President Carter signed in October 1980. It enabled a National Plan for the Chronically Mentally
Ill, which was released a month after his defeat for reelection. Under his successor, President
Ronald Regan, the Omnibus Budget Reconciliation Act, 1981, repealed most of the Mental
Health Systems Act in favor of block grants to states. The role of federal leadership and national
policy was substantially diminished, and the states were largely on their own.
Organized Systems of Care
The psychiatric hospital is a special target of health care corporations. Its profit margins are
large, investment costs are low, inpatient psychiatric care is now widely insured, and the
complexity (and perhaps ambiguity) of psychiatric diagnosis and treatment makes cost control
efforts by insurers and the government difficult. In 1968, for-profit hospital chains were
nonexistent in psychiatric care. In 1980, investor chains owned 25 percent of private psychiatric
hospitals and, just two years later, these corporations owned a full 43 percent market share.
Between 1982 and 1983, the number of investor-owned psychiatric hospitals rose 42.5 percent,
from 106 to 151. The increase was partly attributable to investor groups' acquisition of existing
facilities, but new construction of psychiatric hospitals, which grew 53.3 percent, accounted for
most of the growth. Ad-Psych (Adolescent Psychiatry) units are so lucrative that corporations
have closed units providing other types of services in order to establish the more profitable
adolescent units. Admission data reflect the current domination of the private sector in the
provision of adolescent inpatient psychiatric services. In 1980, for example, private facilities
admitted 61 percent of all adolescents who underwent psychiatric hospitalization; since that time,
juvenile admissions to these facilities have increased substantially.
--Lois A. Weithorn, Stanford Law Review, 1988
American health care costs began to increase dramatically in the 1970s. By the end of the 1980s,
they were spiraling. The article by Lois Weithorn in the Stanford Law Review addressed the
possible violation of children's rights posed by their involuntary hospitalization in commercially
operated psychiatric hospitals. It documented a trend of which American employers'and the
insurance companies that they hired to administer their health benefits'were all too aware. While
employee health care costs overall were climbing, behavioral health expenditures were
increasing by 50 percent each year. Venture capital had discovered a chink in the armor of health
care finance. Even though there were lifetime limits for mental health benefits, a substantial
amount of money lay in those coffers. Psychiatric hospitals were relatively cheap to build and
could be designed to be converted to elderly housing facilities once the gap was closed. The
criteria for mental illness were sufficiently permeable and standards of care were sufficiently
undefined that decisions for hospitalizations were made on behalf of many patients where more
considered judgments would have found other alternatives. In fact, many hospitals launched
deliberate marketing campaigns to fill their beds, and many practitioners followed. The trend
was an abuse. Its most cynical aspect was that benefit dollars that could have been devoted to the
care of persons with severe mental illness were quickly extracted'a $50,000 lifetime limit could
be spent in 60 days of private hospital care'so that sick patients were discharged to the care of
public sector agencies.
Although several examples of health maintenance organizations had demonstrated their
effectiveness in improving the health status of enrolled populations for several decades,
American employers were reluctant to require their employees to sign up for a plan instead of the
traditional indemnity (or fee-for-service) health insurance. However, the growth of behavioral
health expenditures was so dramatic that they overcame their reluctance for this sector. Within a
few years, an industry of managed behavioral health organizations was created by the contracting
activities of human resource executives of the major American corporations. The new companies
were staffed by a corps of seasoned mental health professionals, most of whom had been
prepared in the ranks of the community mental health movement. They introduced, in a business-
like fashion, utilization review techniques reinforced by elaborate information and
communication technology. They selected panels of providers who could be trusted to care for
enrolled members without inappropriate or extended use of hospital or other expensive care.
Their impact was dramatic: Within a few years, behavioral health expenditures stabilized.
The success of the carve out of behavioral health care inspired employers to apply their
contracting techniques to the rest of health care. By 1990, 95 percent of insured employees were
enrolled in some form of managed care. Simultaneously, in the early 1990s, President Clinton
undertook a health care reform that attempted to provide universal health care as a highly
regulated public entitlement. The Clinton health plan was labeled managed competition as a nod
to the rapid move to competitive health care markets. However, the originators of that term, an
assembly of business and health care experts known as the Jackson Hole Group, were much
clearer about an approach in which government and government regulation would play a
minimal role.
P.3851

Nonetheless, a health care marketplace was created in the course of the failed Clinton health care
reform. A wide variety of health care entrepreneurs would organize providers to bring their
products to the markets, and consumers were encouraged to make choices that would ensure the
value of the care that they would receive. The employers, through their contracting practices,
sought to apply the principles of industrial organization to health care delivery to advance the
ideal of organized systems of health care that were accountable and attractive to value-driven
consumers. Although, certainly, some excellent health care delivery systems have developed,
most have fallen far short of these ideals in a full array of organizational structures. All of these
structures and models fell under the term managed care. In their early years, these approaches
were dramatically successful in stabilizing health care costs. However, soon cost control
measures and the pressure of competition among health care systems began to cut into the bone
by denying appropriate services in some instances. Quality and accountability began to dominate
the health care market by the end of the 1990s, and consumers were encouraged to look to
quality ratings by major accreditation organizations in making their choices. Although it has
been opined that, as it enters the new century, managed care is faltering, as patient rights
legislation hovers in Congress, reports of its demise may be exaggerated. It has certainly had an
indelible impact on the American health care system, and issues of quality and accountability,
reinforced by the Institute of Medicine's report, Crossing the Quality Chasm: A New Health
System for the 21st-Century, and the growing population of uninsured Americans will continue
to goad the reform impulse.
What has happened to public and community psychiatry in this turbulent period for American
health care? It is a story of strengths and weaknesses. The repeal in 1981 of the Mental Health
Systems Act, which was a national plan for the chronically mentally ill, forced NIMH (apart
from its research agenda) to narrow its focus to two areas of initiative: community support
systems for adults with serious and persistent mental illness and the child and adolescent service
system program (CASSP). In both areas, the agency provided the states with modest grants to
help them pursue the reforms and improvements to the public community mental health systems
that had been laid out in the blueprint of the President's Commission on Mental Health. The
states, on the other hand, proceeded on a fast track to wind down the state hospitals and, in most
cases, to build community support programs. This too was uneven. In many large cities, persons
discharged from the hospitals with serious mental illness joined the ranks of the homeless or
lived in substandard conditions in welfare hotels or board-and-care facilities.
Current Status
At the level of service delivery, public and community psychiatry is currently driven by the
complex interplay of three factors: the need for focus, the impact of managed care, and the
interplay of science and delivery systems. The first is the need for public agencies to focus their
resources on their mandated target populations. Departments of mental health are narrowing their
responsibilities to the needs of persons with severe and persistent mental illness, providing,
through their contract agencies, a broad array of community support services to help them
function in the community. Prevention activities or services to the general population are left to
the health care system and to managed care plans that administer it. Children's agencies are much
more complex, involving child welfare, primary health care, education, juvenile justice, and
substance abuse. Mental health public agencies divert a relatively small part of their attention to
child and adolescent mental health. These agencies are just beginning to focus their attention, in
a more or less fragmented way, on children with serious emotional disturbances. The Substance
Abuse and Mental Health Services Administration (SAMHSA), an agency devoted to service
delivery programs, formed in the early 1990s to parallel the NIMH, offers, along with other
federal categorical agencies, generous funding to encourage local agencies to integrate their
efforts to create coherent service delivery systems for children and their families. These efforts
have grown out of the CASSP grants in the 1980s.
In addition to NIMH, two other agencies within the National Institutes of Health (NIH) have
been created to advance scientific knowledge concerning substance use disorders: the National
Institute on Alcohol Abuse and Alcoholism (NIAAA; founded in 1970 as a component of
NIMH, established as an independent agency in 1974, and subsequently incorporated within NIH
as a distinct institute) and the National Institute on Drug Abuse (NIDA; founded to oversee
federally funded drug abuse services and research programs in 1974 and incorporated within
NIH as a distinct institute in 1992). While NIMH, NIAAA, and NIDA historically have taken the
lead in federal support and oversight of psychiatric research, a separate agency, SAMHSA, was
established within the federal Public Health Service as the counterpart of the NIH institutes, with
the mission of advancing the delivery and real-world evaluation of mental health and substance
abuse services for adults and children. SAMHSA has three primary component divisions, the
Center for Mental Health Services (CMHS), the Center for Substance Abuse Prevention (CSAP),
and the Center for Substance Abuse Treatment (CSAT).
The second factor is the deliberate move toward managed care on the part of the Medicaid
program in almost every state. State Medicaid programs have adopted some form of managed
care, often contracting with managed care companies. The impact on public and community
psychiatry has been complicated. The problem is that managed care products are generally
designed to provide health care for large populations with general health care needs. This is
appropriate for the 75 percent of the Medicaid population that is composed of generally healthy
mothers and their children: It is very awkward for the 25 percent of the Medicaid program that
consists of persons who are elderly and frail or who have severe disabilities. The standard
managed care products are generally not suitable for them, whereas specialized disease
management models (sophisticated chronic illness care management, such as community support
programs) are appropriate. However, there is a further complication, in that states are transferring
categorical programs (i.e., programs funded in categorical public agencies, such as mental health
or mental retardation) and their budgets into the managed care Medicaid program to capture
federal financial participation in the state expenditures. This often entails replacing the
administrative and programmatic infrastructure of sophisticated chronic illness care management
programs with the managed care products that are suitable for health care delivery for general
populations. These trends are obviously at cross purposes and threaten to weaken delivery
systems for persons with serious and persistent mental illness and to neglect the needs of poor
people with less serious mental health needs.
Finally, the third factor is the interplay of science-based psychiatry and the development of
coherent and effective delivery systems. In the year 2000, the Nobel Prize in Medicine was
awarded to Arvid Carlsson, Paul Greengard, and Eric Kandel for their discoveries concerning
signal transduction in the nervous system'work that explained at the level of molecular biology
the effect of the so-called French drug (chlorpromazine) and the psychotropic medications that
followed it. In June of that same year, the Human Genome Project of the U.S. Department of
Energy announced the completion of a working
P.3852

draft of the entire human genome sequence. Biological psychiatry has made remarkable strides in
the last half of the 20th century and promises still more in the 21st century. Nonetheless,
President George W. Bush's New Freedom Commission on Mental Health reported in July 2003
that there are hopeless fragmentation and gaps in care for children and adults, that people
disabled with serious mental illness are unemployed, that older adults with mental illness are
neglected, and that prevention is not yet a national priority. The challenge for public and
community psychiatry is to match the progress of science-based psychiatry with the development
of effective service delivery systems and structures that will bring psychiatric care into the
mainstream of American medicine.
Reprise
It may appear that, in two centuries, American mental health has come full circle, that
individuals severely disabled by mental illness are back in communities and wander through
cities without appropriate care. There is certainly much truth in this. However, on the very spot
where Nancy Barron was restrained in the poor house and screamed through the day in
Emerson's Concord, there now stands a community residential program for adolescent girls with
serious emotional disturbances that is part of a community system of care. They are treated by
doctors who understand the brain chemistry that causes their illnesses and who have
pharmaceuticals that can alleviate them. There are many shortfalls in current mental health
policies and practices. However, progress has been made, and the stage is set for even greater
progress.
CONTEMPORARY PUBLIC AND COMMUNITY PSYCHIATRY
There are five themes around which the discussion of contemporary public and community
psychiatry is structured: public health, public agencies, evidence-based psychiatry, roles for
psychiatrists, and delivery systems.
Public Health
Public health is not simply publicly funded health care but rather a specific discipline and
tradition. It is a complicated field that historically has been defined negatively by the dominance
of personal health, that is, the health care delivery systems that take care of individual patients.
Until the advent of managed care in the 1990s, American health care was an industry organized
largely as individual doctor-entrepreneurs. Each jurisdiction uniquely defines and organizes its
public health programs, but, as a discipline and tradition, public health's mission is to assure the
conditions in which people can be healthy. Public health consists of organized community efforts
aimed at the prevention of disease and the promotion of health. It involves many disciplines, but
rests on the scientific core of epidemiology.
Mental illness and substance abuse problems certainly are public health concerns. Mental illness
affects the lives of as many as one in four individuals across all walks of life, with as many as 6
percent of all adults (i.e., more than ten million adults in the United States alone) experiencing
mental illness that is so severe and persistent as to constitute a major impairment to the ability to
live and to work safely, independently, happily, and productively. Mental illness and substance
abuse constitute an enormous financial burden on communities and states, as well as the federal
government. As community mental health efforts developed in the past 50 years, mental health
professionals increasingly have assumed the responsibilities called for by the Institute of
Medicine's Committee for the Study of the Future of Public Health, which include fostering the
development of competent people, effective leadership, a scientifically sound knowledge base,
the tools to monitor health problems and measure progress, a productive organizational structure,
adequate financial resources, and a legal foundation that supports effective action, all motivated
by a vision of the public's health that is understood and supported by that public.
The 2000 Surgeon General's report on mental health underscored the necessity of a public health
approach to care and rehabilitation for people experiencing mental illness that is broader in focus
than medical models that concentrate on diagnosis and treatment. Although diagnosis and
treatment is a core expertise for all psychiatrists, the Surgeon General recommended that'even
when psychiatric diagnosis or treatment is the primary focus for practitioners, researchers, or
educators'they should ground their professional activities in a vision and knowledge base that is
population-based encompass[ing] a focus on epidemiologic surveillance, health promotion,
disease prevention, and access to services. These fundamental public health functions define the
public health perspective in public and community psychiatry.
Epidemiology
More than one-half of people experiencing a mental illness actually have more than one distinct
psychiatric disorder and, often, as many as three or four comorbid disorders that complicate
diagnosis and treatment. It is important for psychiatrists to be prepared to identify not just the
most obvious psychiatric disorder, but also other potential comorbid disorders, and to recognize
the potential impact of culture and socioeconomic status on the ways in which people describe
and understand the illness and their expectations for care.
An immediate implication of population-based epidemiological studies is the need for timely
identification of people with or at high risk for psychiatric disorders. When systematic research
diagnostic studies are done in the most accessible arena for risk factor surveillance'primary and
specialty medical care settings'the findings consistently demonstrate that most psychiatric
disorders are underdiagnosed (by 25 to 75 percent). Subthreshold psychiatric disorders (i.e.,
significant symptoms and impairment but not sufficient to meet full diagnostic criteria), although
potentially more responsive to treatment and often associated with substantial psychosocial
impairment, are even less well identified. Despite the existence of strong evidence from
prospective risk factor studies, surveillance of the principal risk factors for psychiatric disorders
(e.g., family history, life stressors, and prodromal signs and symptoms) is not systematically
done by most psychiatrists nor by the public mental health treatment system in most states and
local communities.
Health Promotion
People experiencing mental illness or addiction can benefit from enhanced physical and mental
health, as well as from the alleviation or management of psychiatric symptoms. Achieving or
regaining physical or mental health (i.e., recovery) depends on not only genetic and biological
factors, but also a person's or family's access to social and psychological resources and
integration in supportive social networks. Illness management (also known as disease
management or chronic illness care management) is a framework that has been adapted from
medicine to guide mental health professionals in delivering services that go beyond traditional
diagnostic treatment to promote the health and recovery of people with mental illness or
addiction. Illness management has been defined as professional-based interventions designed to
help people collaborate with professionals in the treatment of their mental illness, reduce their
susceptibility to relapses, and cope more effectively with their symptoms [to] improve self-
efficacy and self-esteem and to foster skills that help people pursue their personal