The Journal of
Common Sense
Special Issue      Winter 2000/2001      Vol. 6 No. 3
The Unhealthy State of our Mental Health

Contents
Introduction
A Plea for Political Courage
History and Overview
A View from the Community
Now What? An Analysis of
    Recent Reports on
    NC Mental Health Services
 Some Findings and
    Recommendations
The Mental Health System
    and its Financing And Use:
    An Introduction
A Mental Health Glossary
The Stigma of Mental Illness
 Housing and the Disability of
    Extreme Poverty
Adult Care Homes
Treating Persons with
    Dual Disorders
Correctional Mental Health
    in NC:An
    Expensive Non-solution
Race and Mental Health
Richard's Story: One
     Family's Journey through
    the Mental Health System
Harmony in Three Parts:
     Why Is this
     a Utopian Scenario?
References
Recommendations
Mental Health Services
Current Area Programs
Seth Is His Name and
     He Needs Your Help
Some Findings and Recommendations from Reports on the Mental Health

The National Picture:
Selected Findings from the Surgeon General's Report

Treatment
  • The efficacy of mental health treatments is well documented
  • A range of treatments exists for most mental disorders
  • Nearly half of all Americans who have a severe mental illness do not seek treatment.
  • The principal barrier is the stigma that many in our society attach to mental illness and to people who have a mental illness.
    •  Prevalence
  • Mental illness is the second leading cause of disability and premature mortality in established market economies such as the U.S.
  • About one in five Americans experiences a mental disorder in the course of a year. Approximately 15 percent of all adults who have a mental disorder in one year also experience a co-occurring substance (alcohol or other drug) use disorder, which complicates treatment.
    •  Services
  • About 10 percent of the U.S. adult population use mental health services in the health sector in any year, with another 5 percent seeking such services from social service agencies schools, or religious or self-help groups.
  • Gaps exist between optimally effective treatment and what many individuals receive in practice settings.
    •  Children
  • Approximately one in five children and adolescents experiences the signs and symptoms of a DSM-IV disorder during the course of a year, but only about 5 percent of all children experience what professionals term "extreme functional impairment."
  • A broad array of factors places children at high risk of mental illness, including physical problems, intellectual disabilities (retardation), low birth weight, family history of mental and addictive disorders, multigenerational poverty, and caregiver separation or abuse and neglect.
  • Twenty-one percent of children ages 9 to 17 receive mental health services in a year.
    •  Financing
  • The U.S, mental health service system is complex and connects many sectors (public-private, specialty-general health, health-social welfare, housing, criminal justice, and education). As a result, care may become organizationally fragmented, creating barriers to access. The system is also financed from many funding streams, adding to the complexity, given sometimes competing incentives between funding sources.
  • Implementing parity has resulted in negligible cost increases where the care has been managed.
    •
    The North Carolina Crisis
    From the Fiscal Research Division of the General Assembly
    Impact of Selected Factors in the 1990s on the Current "Crisis"
    in the Area Program System (March 16, 1999)
    Dramatic system growth
  • New services created
  • Development of two-tiered service system (hospitals and community)
  • Increase in cost shifting from other local agencies
    •  Erosion of state support
  • Communication between State and Area Programs reduced
  • Reduced technical support
  • Continual erosion of funding for Area Program infrastructure
  • Significant staff turnover and problems attracting and retaining staff
  • Increased reliance on contract services
    •  Managed care initiatives
  • Improved services to children
  • Improved management of some Area Programs
  • Atmosphere of case management fostered
  • Reduction in rates began to drain resources for indigent clients
  • Created chaos for some Area Programs
    •  State policy to maximize Federal funds
  • Growth of MH service system
  • Development of specialized services
  • Area Programs increasingly reliant upon Federal funds
  • Increase in cost shifting at the local level
    •  Inadequate management and oversight
  • Poor budgeting and accounting practices
  • Fraud and abuse of Medicaid
  • Poor documentation for billing purposes
  • Cash advances required to maintain services in certain programs
  • Tri-county Area Program dissolved
  • System grew too quickly for infrastructure
    •
    Where We Stand Now
     From the NC Budget & Tax Center's Spring 1999 report for the Coalition 2001

         The State Budget is tight, despite a good economy.     In order to fund all of the commitments already made by the Governor and the House leadership, budget reductions of over $450 million will have to be made in the coming biennium to finance Smart Start, teacher pay increases and tax cuts.
         Federal and State support for individuals with disabilities totalled over $1.56 billion in 1997-98. Over 95 percent of the support for these programs came from three entities: the Division of Mental Health/Developmental Disabilities/Substance Abuse Services, the Division of Medical Assistance, and the Department of Public Instruction.
         Despite its size, the State General Fund support for DMH/DD/SAS programs has decreased over the past decade after adjusting for inflation and population growth. Receipts, especially from the Federal government, have compensated for the decline. Yet General Fund support would have to be $14 million higher to remain at levels provided in 1987 and $117 million higher if the Division's General Fund support would have grown at the same rate as the State General Fund budget as a whole.
         The system now relies heavily on area programs for services and those programs have expanded budgets built on Medicaid receipts. The trend away from State institutions continued in the last decade as they now account for just over one-half of the DMH/DD/SAS budget, down from two-thirds a decade ago. During the mid-1990s, area mental health programs have increased their reliance on Medicaid receipts from 13 percent to 38 percent in just four years.
         Federal and State support for individuals with disabilities vary widely by area program. The hodgepodge of budget history results in unequal funding for various area programs, when measured on a per capita basis.
    What the Right Has to Say
    From The John Locke Foundation Report:
    Rhetoric or Reform?: The Future of Mental Health in North Carolina

    While the Common Sense Foundation is often at odds with the John Locke Foundation, we concur with many of their recommendations for "radical reform" of North Carolina's Mental Health system. As you will see, they do mention privatization several times, in keeping with their political philosophy, which is not one of our recommendations. However, we wholeheartedly agree with the need for a unified, community-based system funded through a single, government-controlled stream.
    The solution to the problems discussed in this report lie in the will of policymakers to undertake not another study but a comprehensive plan to tear down the existing public mental health system and build a 21st century community-based mental health care service in North Carolina. The major feature of this plan would invite all nonpublic mental health entities operating resources available in the state to join in a single purchase-of-service/delivery-of-service mental health care superstructure under the statutory auspices of the North Carolina Department of Health and Human Services.
         Such a bold undertaking must not only address the physical construction of appropriate psychiatric facilities and patient care service delivery, but must also reflect an all-encompassing philosophy fashioned to accomplish a functional community-based mental health infrastructure of facilities and service treatment. The philosophical and operational premise is a simple one: all mental health resources in the state must be utilized as a systemic whole, regardless of whether they are (or started out as) state psychiatric hospitals, general hospital psychiatric wards, private psychiatric facilities and services, or private nonprofit psychiatric services and facilities.
         This philosophical premise must contain the following basic tenets: (a) community-based service and treatment with proximity to the home as the main feature; (b) systemic deinstitutionalization that accommodates a variety of mental conditions via the application of modern-day clinical casework practice; (c) use of legal policy linkages between "commitment" and "conditional release" requirements; (d) a unified mental health superstructure; (e) establishment of an efficiency-based operating system which has as its foundation a promulgated privatization policy for both management support products and services, and professional medical and related services and treatments; and (f) a single funding stream for the unified mental health superstructure.

    The Journal of Common Sense is published by The Common Sense Foundation.