Community mental health
Community mental health is a decentralized pattern of mental health, mental health care, or other services for people with mental illnesses. Community-based care is designed to supplement and decrease the need for more costly inpatient mental health care delivered in hospitals. Community mental health care may be more accessible and responsive to local needs because it is based in a variety of community settings rather than aggregating and isolating patients and patient care in central hospitals. Community mental health assessment, which has grown into a science called psychiatric epidemiology, is a field of research measuring rates of mental disorder upon which mental health care systems can be developed and evaluated.
Community mental health centers
In the United States, a modern increase in community mental health care delivery began in the 1960s when President John F. Kennedy signed the 1963 Community Mental Health Centers (CMHC) Act (Public Law #88-164). Growing community mental health capacities were intended to complement and mirror trends toward fewer hospital stays and shorter visits for mental illness (see Deinstitutionalization ). This restructuring of mental health service delivery has occurred in the context of evolving fiscal responsibilities, however. The goals and practices of community mental health have been complicated and revised by economic and political changes.
The National Institute of Mental Health (NIMH) initially developed a CMHC program in the 1960s. CMHCs were designed to provide comprehensive services for people with mental illness, locate these services closer to home, and provide an umbrella of integrated services for a catchment area of 125,000-250,000 people. CMHCs were designed to provide prevention, early treatment, and continuity of care in communities, promoting social integration of people with mental health needs.
Competing public interests
At the outset, CMHCs were providing outpatient care to people with less severe, episodic, or acute mental health problems. In the 1980s, more people with serious mental illness began using CMHCs, due in part to deinstitutionalization, and following the redirection and capping of federal funds for local mental health care. With growing awareness of the homeless mentally ill, state-funded CMHCs faced new challenges, and their work became fragmented according to catchment areas of responsibility, leaving some urban centers overburdened, while others maintained locally funded operations, limiting responsibility for their area only.
The growth of local community mental health centers was an example of competing governmental interests and authorities. Growing numbers of CMHCs were mandated federally and to be funded by local communities, bypassing state control. This growth in outpatient capacity was later used to complement decreases in inpatient hospital care, or deinstitutionalization, which reduced the costs of diminishing and state-funded mental hospitals.
Policies to improve public mental health care
Community mental health centers were the first of several programmatic attempts to improve mental health care in the latter part of the twentieth century. A second was when the federal government recommended Community Support Programs (CSPs) in 1977-78 in response to problems associated with deinstitutionalization. CSPs focused on providing direct care and rehabilitation for the chronically mentally ill. However, federal support for mental health care and CMHCs in particular was reduced in 1980-81, with the repeal of the Mental Health Systems Act and the federal budgeting actions that cut funding and provided it through block grants to states.
A third initiative has been to expand the national capacity for children's mental health care under the Child and Adolescent Service System Program (CASSP), beginning in the 1980s. Principles for this system of care included a continuum of services, including mental health. The expansion of mental health classification systems and the Diagnostic and Statistical Manual of Mental Disorders has helped identify and treat a growing number of children and youth. A fourth initiative was a joint effort by the Robert Wood Johnson Foundation and the department of Housing and Urban Development. Their Program on Chronic Mental Illness (PCMI) promoted the integration of regional mental health authorities in nine cities. Coordinated local mental health systems run by local mental health authorities remain an important goal of mental health policy.
Finally, many private and public health systems have moved towards managed mental health care, which has become also known as behavioral health care. This form of cost containment is a constellation of organizational reforms, financing systems, and regulatory techniques. Managed care expanded throughout health care in the 1990s, providing new challenges to mental health care policy. While federal health policy and medical assistance provide reimbursement for mental health care and for people with mental illness, the regulation of these systems has grown increasingly complex.
While the ideals of community mental health were supplemented with new ideals in the years following the CMHC Act, they were not forgotten. Thanks to the work of NIMH, Medicare and Medicaid legislation (1965), and Supplemental Security Income legislation (1972), communities were able to provide mental health care for growing populations in need. National epidemiological studies in the 1980s and 1990s reinforced the large-scale need for mental health care, as CMHCs and subsequent organizational forms provided services to the nation.
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American Psychiatric Association. 1400 K Street NW, Washington D.C. 20005. <http://www.psych.org> .
American Sociological Association. 1307 New York Ave., Washington DC 20005-4701. <http://www.asanet.org> .
National Institute of Mental Health. 6001 Executive Boulevard, Rm. 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. <http://www.nimh.nih.gov> .
Substance Abuse and Mental Health Services Administration (SAMHSA). Center for Mental Health Services (CMHS), Department of Health and Human Services, 5600 Fishers Lane, Rockville MD 20857. <http://www.samhsa.org> .
Michael Polgar, Ph.D.