Chapter 11: Community Mental Health

Serious Mental Illness in People Who are Homeless

- 2.1 million adults experience homelessness over the course of the year - More exposed to environmental stresses and threats than people with homes. Half of all adults who are homeless have substance use disorder, major depression, and other co-occuring mental illness. Remain homeless and disengaged from services and rates of criminal behavior and victimization are higher. - Need for safe, affordable housing, and services

Treatment Approaches

- Goals for mental disorders: reduce symptoms, improve personal and social functioning, develop and strengthen coping skills, and promote behaviors that make a person's life better. - Includes psychopharmacology, psychotherapy, technology, self-help groups, and psychiatric rehabilitation

Psychiatric Rehabilitation

- Healthy People 2020 : Increase the proportion of adults with mental disorders who are receiving treatment - Mental disorders entails that neurobiological lesions that produce distortions in thinking and feeling and deficits in coping skills that damage relationship, and stigma that interferes with social acceptance. - mental disorders can last a lifetime and most live with their symptoms - primary objective is recovery rather than cure

Mental Health Care Concerns in the US Today

- Improved since the passage of the Community Mental Health Centers Act. - Today nearly all live in the community, receive at least some treatment, have disability income, and enjoy civil liberties, and some lead productive lives. - Challenges: How to help homeless people with serious mental illness and co-occuring substance use disorder, what to do about the perception that mental illness is linked to violence, resolving of people with mental illness becoming involved in criminal justice system and ending up in jail or prison.

The Affordable Care Act

- 2010, important role in covering individuals with mental disorders grew larger after the ACA. Most ambitious expansion and regulatory overhaul of the US healthcare system in 50 years. - federal legislation that expands eligibility for Medicaid and increases access to private insurance for low-income Americans not covered by employer-provided health insurance. Private insurance must voter 10 essential benefits - Millions of people have obtained coverage through Medicaid expansions, subsidies for private plans offered through state insurance exchanges, and the ACA provision that requires plans to cover children up to age 26 on parent policies. - Reported increased access to health care, reduced financial burden, and improvements in mental health (mostly depression) - Parity and ACA forged to integrate mental health and general medical care by making to deliver primary care and behavioral health services in the same community settings. - People with mental illness have low income and they stand to be consumers of care under the ACA could exacerbate shortcomings of mental health services and scarcity of professionals. Congress allows states to opt out expanding Medicaid. ACA can do little to improve access to help if communities lack infrastructure to serve those in need and thus impact of ACA on rate of recovery from serious mental illness remains to be seen. - Response to needs with mental illness vends on economics, the degree to which taxpayers have been personally touched by mental illness. and the degree to which they are willing to tolerate the spectacle of homeless people with mental illnesses in their communities and jails/prisons. - Find ways to unite formal services and informal supports to promote social inclusion and recovery.

Individual Placement and Support

- Challenge for people with mental illness is the lack of employment and third of them have incomes below 10,000. - Supported employment services can help those who want to work for a secure paid employment and with is a higher quality of life and greater community integration - An evidence-based model of employment services emphasizing real work opportunities, integrated mental health services, and individualized job supports - usually people with mental illness work part time and makes only a small difference in how much they earn and in their quality of life

The New Asylums: Mental Health Care in Jails and Prison

- Cognitive and emotional deficits imposed by mental illness, coupled with homelessness and other intense stressor, increase the risk of people with serious mental illness will commit criminal acts. - Reversed the policy that people with mental illness belonged in hospital rather than prisons. We decriminalized mental illness. Rates of serious mental illness in correctional facilities are three to four times the rates in the general population. - Inmates with mental illness must be monitored and receive medical treatment. Harsh and socially isolating conditions in jails or prison can exacerbate mental illness. Prisons are overcrowded and effective treatment requires space, sufficient number of qualified treatment personnel, and timely access to services. Juvenile justice centers receive little to no treatment. - When treatment is available severe mental illness can hinder inmates' cooperation with their prescribed medication schedules, and without medication these inmates may be incapable of good behavior. - Police are the authorities responsible for dealing with mentally ill people who are in crisis. 10% of police calls are about individual with mental illness, and police officers write one[third of emergency mental health referrals. Control and arrest techniques can escalate a mental health crisis, leading to injuries to officers and subjects and unnecessary arrest of persons who is just displaying symptoms of mental illness.

Mental Health Care before WW2

- Colonial America: distracted persons or lunatics were cared for by families or private caretakers and as a last resort became the responsibility of the local community. Institutionalization began in 18th century when people with mental disorders were placed in poorhouses or almshouses. Conditions got worse and they had to separate people by their type of disability. - Thomas Bond opens Pennsylvania Hospital: first institution in America that was designed to care for those with mental illnesses. Conditions and treatment in the hospital were harsh (1751).

cultural competence

- Differentiating people who are ill from who are well by behavior ties diagnosis to culture. Example, Hispanics are more likely to be diagnosed with major depression than whites and AA and AA are more diagnosed with schizophrenia. - Service provider's degree of compatibility with the specific culture of the population served, for example, proficiency in languages other than English, familiarity with cultural idioms of distress or body language, folk beliefs, and expectations regarding treatment procedures (like medication or psychotherapy) and likely outcomes. - Social context affects diagnosis. Like women are diagnosed with mood disorders more often than are men, but there are differences in smaller countries where there are not such gender roles. - Mental disorder can stigmatize a person by negative stereotypes, fewer opportunities, prejudice, and discrimination that lead to mental distress, shame, avoidance of treatment, and fewer opportunities related to work and independent living - stigma ay be the debilitating aspect of a mental illness

neuroleptic drug

- Drug that reduces nervous activity; another term for antipsychotic drugs.

Community Support Program

- Federal government responded to problems of deinstitutionalization and transinstitutionalization in 1977. First recognition that the problems of people with chronic mental illness are social welfare problems. - Offers grants to communities to help find resources for successful independent living, namely, income, housing, food, medical care, transportation, vocational training, and opportunities for recreation.

Mental Illness and Violence

- Large majority of people with serious mental illnesses are never violent. Histories of prior violence, substance use, and early trauma are likely to contribute to violence than mental illness. - Legally, authorities can act to prevent potential violence only when someone voluntarily seeks assistance or has made frank threats. Detaining larger numbers of people is unlikely to prevent violence. People with mental illnesses do not often seek treatment voluntarily and those who do may not even be engaged or cooperative. Lack of motivation and some psychiatric disorders are not responsive to therapy. - Those with serious mental illness are marginalized people who are unemployed, economically impoverished, live in disadvantaged neighborhoods, misuse alcohol and illicit drugs and are victimized and traumatized.

Crisis Intervention Team

- Mental health services need to be better integrated with law enforcement to increase the availability of service and reduce the burden on the police of being the primary responders. - Specially trained police in direct collaboration with mental health authorities to remove barriers to mental health care for people with mental illness involved in the justice system (like lack of beds and insurance processing delays) - Individuals with criminal involvement and serious mental illness who do not receive treatment are more likely to commit another offense. Constitute to a small proportion of the people with mental illness, these people resist participating in treatment and pose a danger to themselves or the public that can lead to psychiatric hospitalizations. Resorted to use of mandatory commitment to outpatient treatment, legal leverage to compel cooperation and special mental health courts. - Outpatient commitment, legal leverage, and mental health courts commit patient to participate in treatment and involuntarily commit the community mental health system to provide it. These policies are more successful if services are effective of targeting both psychiatric and criminogenic issues are available and the goals of treatment include meaningful recovery from mental illness or addiction

Community Mental Heath Centers

- Mental illness and treatment gained national attention when President JFK addressed Congress on the subject of mental health care. - Resulted in Mental Retardation Facilities and Community Mental Health Centers

Classification of Mental Disorders

- Most influential book in mental health: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition - Places disorders in discrete categories on the basis of behavioral signs and symptoms (not on definitive tests or measurements of the brain or another body system. - Controversy: A categorical system is hard to differentiate normal reactions of life from diagnosable disorder (severe grief VS major depression). Genetic research has blurred both the boundaries between mental disorders and boundaries between disorders and normal variations in behavior.

challenges in the mental health care in the US

- Multiple services are needed by people with severe or comorbid disorders and lack some services leads to limits on effectiveness of others - Staff turnover is needed. Successfully psychosocial rehabilitation requires sustained commitment by staff - Family members of people with mental illness need longer and immediate information, financial help, coping with stigma, and therapeutic support for themselves.

Mental Health Care after WW2

- New feelings of optimism. Testimony before the US Congress by the military and civilian experts resulted in the passage of the National Mental Health Act of 1946 established the NIMH.

Meeting the Needs of People with Mental Illness

- Obligation to provide cost-effective prevention, treatment, and rehabilitation services to people with mental illnesses.

The Moral Treatment Era

- Philippe Pinel of France created humane approach called moral treatment. Became overcrowded with immigration and urbanization and indigent patients ended up in poor houses. - Dorothea Lynde Dix campaigned for public hospitals that provide care to indigents with mental illness. Federal law failed but worked on state-by-state. Found 32 public mental hospitals funded by individual states.

Prevention

- Primary prevention: reduces the incidence (rates of new cases) of mental illness and related problems. Example: Moving to Opportunity program; those that received vouchers reported better mental health and higher subjective well-being than did other homeless people. Shows that mental health is determined by individual vulnerabilities and social determinants like neighborhood quality and other environmental and economic circumstances. - Secondary Prevention can reduce the prevalence by shortening the duration of episodes through prompt intervention. Example can be soldiers exposed to high levels of combat receive intensive cognitive skills training are less likely to experience symptoms of PTSD and depression. Examples: employee assistance programs, juvenile delinquency diversion programs, and crisis interventions can be provided. - Tertiary prevention, treatment and rehabilitation lessen the symptoms of illness and prevent further problems for the individual and community. Examples: Intensive community treatment programs

The State Hospitals

- Suppose to supply environment where therapeutic care was based on personal relationships between patients and staff members (methods of moral treatment). - Maximum capacities were reached and had to be revised upward. - Personalized care was impractical and physical restraints were used the most. States cut funding for institutions - 1940 population in state mental institutions grown to one half million and caseloads were large, only subsistence care was possible. Treatment that were developed electroconvulsive therapy (ECT) and lobotomy

Technology

- Technology (telephone, conferencing, Internet, email, and computer software can deliver flexible help directly to client's living environments while lowering the cost - Allows people to monitor their own states and can be used to infer information relevant to behavioral and mental health (like the level of stress and quality and duration of sleep). Can complete more traditional steps in psychotherapy - Can increase privacy and reduce feelings of coerciveness. - Computer therapy and in-person therapy are about the same in effectiveness.

National Institute of Mental Health (NIMH)

- Under the umbrella of National Institutes of Health. - Purpose: Foster and aid research related to the cause, diagnosis, and treatment of neuropsychiatric disorders. To provide training and award fellowship and grants for work in mental health. Aid states in prevention, diagnosis, and treatment of neuropsychiatric disorders. - The nation's leading mental health research agency, housed in the National Institutes of Health.

Government Policies and Mental Health Care

- Until deinstitutionalization began, the state hospital system served as de facto social insurance program for mental illness in the US. And the federal government's role in mental health funding and policy became substantial - Medicaid program pays more than half of publicly funded mental health care, and its policies and regulations, impact what services are covered. Depending on state policy, Medicaid may pay for traditional services but not newer approaches like psychiatric rehabilitation

moral treatment

- a 19th century treatment in which people with mental illness were removed from everyday life stressors of their home environments and given asylum in a rural setting, including rest, exercise, fresh air, and amusements

Mental Retardation Facilities and Community Mental Health Centers (CMHC) Act

- a law that made the federal government responsible for assisting in the funding of mental health facilities and services - promised funding to establish one fully staffed, full time community mental health center (CMHC)

Psychotherapy

- a treatment that involves verbal communication between the patient and a trained clinician - known as psychosocial therapy - approaches can include: interpersonal, couple, group, and family formats - Psychodynamic psychotherapy examines current problems as they related to earlier experiences. Cognitive psychotherapy focuses on current thinking patterns that are faulty or distorted - Most likely to be successful in less severe cases of emotional distress or when used in conjunction with other approaches

Bipolar disorder

- an affective disorder characterized by distinct periods of elevated mood alternating with periods of depression

Assertive Community Treatment (ACT)

- best known psychiatric rehabilitation services - service that uses active outreach by a team of providers over an indefinite period of time to deliver intensive, individualized services - Reduce hospital use but expensive and questioned on reliance legal leverage and other coercive techniques that undermine privacy and autonomy of recovery

integrative care

- care a patient receives from a team of primary health care and behavioral health clinicians, working together with patients and families, using shared, cost-effective care plans that incorporate patient goals -increases the opportunities for prevention through primary care practices like behavioral health screening for depression, substance abuse, and domestic violence

social determinants

- causes of the causes - inequality, discrimination and social exclusion, poor education, unemployment, poverty, housing instability, and poor access to care and other resources - middle aged white Americans (especially those with a high school education or lower) suicides and substance abuse led to rise in death rates in 1999 and 2014. Healthy People 2020 aimed to improve mental health status of Americans by reducing suicide rate. Community-we education campaigns can improve public knowledge and attitudes regard suicide (not known though). - Prevalence of alcohol, tobacco, and other drug abuse in the US is another indicator of mental illness problem

Causes of Mental Disorders

- comorbidity suggests they symptoms are discrete conditions, each with a unique case - Genetic influences on complex brain functions that control a person's thoughts and emotions: older father, intrauterine infections, preterm birth, postnatal exposure to physical, chemical, and biological agents (secondhand smoking), head injury, and diseases (syphilis, cancer, or stroke) - Brain is sensitive to stress and other environmental influences as it develops during childhood and adulthood. One in five children experiences a mental disorder and less than half of them who need services receive them. - Life long mental disorders can have onset in adolescence, when physical and hormonal changes intensify emotional reactivity, sensitivity to peer influence, impulsivity, and novelty-seeking, undermine self control and regulation needed for effective participation in society - Stress, social support, coping, and motivation to recover, making social experience a determinant. Poverty, abuse, loss, neglect, trauma, and parental psychiatric disorder. early and cumulative adversity and maltreatment harm development of the brain and affect depression, PTSD, suicide attempts, drug and alcohol misuse, and criminal behavior. Bullying associated with anxiety and mood disorders. - "causes of the causes" - Significant cause of mental illness is stress. PTSD.

History of Mental Health Care in the US

- cyclical periods of reform often began existing approaches to caring for those with mental illness became intolerable for society, and ended when their economic burden became unbearable

mental health care system

- decentralized and fragmented with many different kinds of providers - Medical practitioners treat the largest number of people with mental disorders. Specialty mental health providers, human services, self-help groups, and various combinations serving the rest. - Patient sex, ethnicity, geography, immigration status, sexual orientation, and income are related to receiving help (like minorities are less engaged in therapy than whites). Can be due to the lack of cultural competence on the part of providers regarding their multicultural patient's attitudes towards medications and medication side effects, and patients' misguided expectations of treatment in context of religious, spiritual, or folk beliefs - People with serious mental disorders tend to be the poorest members of society and live in neighborhoods where crime, drugs, victimization, homelessness, unemployment, and social disorganization are rampant

Mental health

- emotional and social well-being, including one's psychological resources for dealing with day-to-day problems of life - state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and ability t o adopt to change and cope with adversity - Good mental health: good self-image, positive feelings about other people, and being able to see the demands of everyday life. Function under adversity, change/adapt to changes, manage tension and anxiety, find satisfaction in giving than receiving, show considerations for others, curb hate and guilt, love others

Self-Help Groups

- group of concerned members of the community who are united by a shared interest, concern, or deficit not shared by other members of the community - shared characteristic is stigmatizing or isolating and look as abnormal - meet regularly, share leadership responsibilities, and the roles of help-cover and help-receiver are interchangeable - replace the community that was lost through stigmatization or isolation - supply feedback and guidance to their members on insights from recovery and provide members with adaptive attitudes and expectations about the future - Examples: National Alliance on Mental Illness (NAMI), Recovery Inc, Alcoholics Anonymous

mental disorders

- health conditions characterized by alterations in thinking, mood, or behavior associated with distress and/or impaired functioning - have neurobiological disorders that prevent them from functioning in society, treated with medications and other forms of help

tardive dyskinesia

- irreversible condition of involuntary and abnormal movements of the tongue, mouth, arms, and legs, which can result from long term use of certain antipsychotic drugs (chlorpromazine)

Introduction

- major health issue - leading cause of disability in North America and Europe, and costs the US more than half a trillion dollars per year in treatment and other expenses - associated with smoking, reduced activity, poor diet, obesity and hypertension, and contributes to unintentional or intentional injuries - reduce life expectancy, same amount as smoking more than 20 packs a day - 20% of American adults or 45 million have diagnosable mental disorders. 5% adults in the US have serious mental illness (illness that interferes with some aspect of social functioning). 38% that are diagnosed with mental illness are treated - Virginia Tech and Northern Illinois Universities brought issue of mental disorders in college students to national attention. Half of college students show a 12-month prevalence of mental disorder (common alcohol use disorder) and less than 25% receive treatment. - 2010, 2.9 million youths received treatment or counseling for problems with emotion or behavior - services are therapeutic services and social services that require community resources

Chlorpromazine

- medication helped deinstitutionalization - the first and most famous antipsychotic drug, introduced in 1954 under the brand name Thorazine - described as neuroleptic drug - Acute side effects: Blurred vision, weight gain, and constipation. Can cause compliance failures that results in relapses or in attempts to self-medicate with other frugs. - Long-term use can impair central nervous system, and produce tardive dyskinesia

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

- published by the American Psychiatric Association - Identifies mental disorders, provides information and diagnostic instruction, implication for who merits a diagnosis, whether treatment should be reimbursed by insurance, what school and social services a person is entitled to, top priorities for mental health research, and what new therapeutic medications should be developed - "living document", disorders classified in the DSM-5 are listed

Deinstitutionalization

- the process of discharging, on a large scale, patients from state mental hospitals to less-restrictive community settings - High rates in the early 1950s - Not a preplanned policy. Propelled by four forces: Economics, idealism, legal considerations, and the development and marketing of antipsychotic drugs. - Economically, states needed to reduce expenditures so that money was available for other budgetary items (education, roads, and welfare). Medicare and Medicaid legislation provided federal funds to reimburse costs of outpatient and inpatient services for eligible people. - American Bar Association pointed out that people with mental disorders (even when institutionalized, had certain rights (right to treatment). Courts focused on protection from inappropriate involuntary commitment and less concern for society's right to be protected from individuals. Involuntary civil commitment became one of whether these individuals could be considered dangerous to themselves or others. - Phenothiazines are used to treat patients with severe disorders.

cognitive-behavioral therapy

- treatment based on learning new thought patterns and adaptive skills, with regular practice between therapy sessions - focuses on current thinking patterns that are faulty or distorted and how maladaptive feelings and behaviors are the result of distorted thinking, and uses exercises, role playing, and other structured procedures to promote new thought patterns, and regular homework between sessions to practice more effective coping responses.

Psychopharmacology therapy

- treatment for mental illness that involves medications - Views mental disorders as medical illnesses and can be treatable with drugs. Introduction to chlorpromazine lead to the growth of medications to treat mental disorders and sharp increases in medication have been used to treat children and adolescents. - Medications exist for: schizophrenia, bipolar, major depression, anxiety, panic disorder, and obsessive compulsive disorder. - Half of patients may not cooperate fully in taking they medications because some drugs can have serious side effects and the nature of mental illness itself. - Biomedical therapy: ECT Used for severe depression, selected cases of schizophrenia, suicide ideation. Uses low doses of electric shock to the brain and anesthetics to reduce the unpleasant side effects

Diseases of adaptation

Disease that result from chronic exposure to excess levels of stressors, which produce a General Adaptation Syndrome response

comorbidity

Half of the people with mental illness (46.4%) are diagnosed with more than one disorder, a problem known as comorbidity. ex. Depression and anxiety are separate categories but they are found together in many individuals and have similar genetic risk factors.

Mental Health Parity and Addiction Act of 2008

Requires that id health care coverage include mental health or substance abuse disorders there must be parity with physical disorders in any limitations or restrictions (any limits on the number of visits per year, annual or lifetime dollars spent, and deductibles or copayments must be the same for both mental and physical disorders.

mental illness

a collective term for all diagnosable mental disorders

Chemical straitjacket

a drug that subdues a psychiatric patient's behavior

community mental health center (CMHC)

a fully staffed center originally funded by the federal government that provides comprehensive mental health services to local populations - Provides five core services: inpatient care, outpatient services, 24 hour day emergency care, day treatment or other partial hospitalization services and consultation and education - Problem was that many older patients with chronic mental illness never returned to community but were transinstitutionalized to nursing homes. Struggled to serve deinstitutionalized persons living in the community.

National Alliance on Mental Illness

a national self-help group that supports the belief that major mental disorders are brain diseases that are of genetic origin and biological in nature and are diagnosable and treatable with medications

major depression

an affective disorder characterized by a dysphoric mood, usually depression, and/or loss of interest or pleasure in almost all usual activities or pastimes

Fight or flight reaction

an alarm reaction that prepares one physiologically for sudden action

mental health courts

court where judges have special training and use non adversarial procedures that mandate treatment and rehabilitation rather than incarceration if a person with mental illness is found guilt of a crime - If they do not adhere, court can revoke the suspended sentence or charge the patient with violating the terms of probation - evidence indicates that it can lower recidivism, improve mental health outcomes, and reduce the risk of violence by justice-involved persons with mental disorders

psychiatric rehabilitation

intensive, individualized services encompassing treatment, rehabilitation, and support delivered by a team of providers over an indefinite period to individuals with severe mental disorder to help them maintain stable lives in the community - current recovery-oriented services - modeled on rehabilitation practices for people with physical and developmental disabilities and its services carry the modifier support in keeping with patient self-determination - services include medication, therapy, and adaptive skills and changing the environment through accommodations at work or school - providers of psychiatric rehabilitation services represent diverse professional backgrounds and work collaboratively as integrated team - Example: Assertive Community Treatment, Individual Placement and Support - Recovery from disorders like schizophrenia tends to be better (longer remission and fewer relapses) in the developing world like Africa India and Indonesia. Non-western cultures use less stigmatizing explanations fr mental illness and prescribe recovery process that has collaborative roles for everyone (patient, family, and community). Learned that mental disorders are not just broken brains but also cultural determined social and moral phenomena that involve all of us.

outpatient commitment

laws mandating involuntary psychiatric treatment for individuals who do not understand their illness to protect the individual from harm and safeguard the public - orders a person to obtain psychiatric treatment against their will or is sanctions up to and including forced hospitalization - interred to secure services for individuals who do not understand their illness and the risk of refusing treatment, protect the individual from imminent harm through suicide or self-neglect, and safeguard the public from acts of violence perpetrated by the individual

electroconvulsive therapy (ECT)

method of treatment for mental disorders involving the administration of electric current to the scalp to induce convulsions and unconsciousness used on people with severe depression who have not responded to medication or imminent risk of suicide or other acute clinical condition

recovery

outcome sought by most people with mental illness; includes increased independence, effective coping, supportive relationships, community participation, and sometimes gainful employment - Recovery from mental illness is social and economic and psychiatric - basic "personhood" that is mental and physical well-being, supportive relationships, opportunities to spend the time productively, and self-determination in exercising the adult rights and privileges that come with community life - requires change (community participation, volunteer, forming new relationships, and sometimes parenthood)

legal leverage

service controlling the disability income or other benefits received by a person with mental illness to enforce participation in treatment in return for suspending a criminal sentence imposed by a court of law - attempts to balance the values of civil rights and normalization with that of public safety

lobotomy

surgical severance of nerve fibers of the brain by incision popularized by Antonio Moniz and Walter Freeman. Freeman developed ice-pick lobotomy. One-third of patients showed stable improvement and the other third were worse off. appearance of antipsychotic and anti-depressive drugs in 1950 made lobotomies unnecessary

parity

the concept of quality in healthcare coverage for people with mental illness and those with other medical illness or injuries

transinstitutionalization

transferring patients from one type of public institution to another, usually as a result of policy change

evidence-based

way of delivering services to people using scientific evidence that shows that he services actually work - consistent evidence that show that they improve patient outcomes