Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 2
Overview of Mental Health Services
Over the past three centuries, the complex patchwork of mental health services in the United States has become so fragmented that it is referred to as the de facto mental health system (Regier et al., 1993b). Its shape has been determined by many heterogeneous factors rather than by a single guiding set of organizing principles. The de facto system has been characterized as having distinct sectors, financing, duration of care, and settings (see Figure 2-4).
The four sectors of the system are the specialty mental health sector, the general medical/primary care sector, the human services sector, and the voluntary support network sector. Specialty mental health services include services provided by specialized mental health professionals (e.g., psychologists, psychiatric nurses, psychiatrists, and psychiatric social workers) and the specialized offices, facilities, and agencies in which they work. Specialty services were designed expressly for the provision of mental health services. The general medical/primary care sector consists of health care professionals (e.g., family physicians, nurse practitioners, internists, pediatricians, etc.) and the settings (i.e., offices, clinics, and hospitals) in which they work. These settings were designed for the full range of health care services, including, but not specialized for, the delivery of mental health services. The human services sector consists of social welfare, criminal justice, educational, religious, and charitable services. The voluntary support network refers to self-help groups and organizations. These are groups devoted to education, communication, and support, all of which extend beyond formal treatment.
Financing of the de facto system refers to the payer of services. The system is often described as being divided into a public (i.e., government) and a private sector. The term “public sector” refers both to services directly operated by government agencies (e.g., state and county mental hospitals) and to services financed with government resources (e.g., Medicaid, a Federal-state program for financing health care services for people who are poor and disabled, and Medicare, a Federal health insurance program primarily for older Americans and people who retired early due to disability). Publicly financed services may be provided by private organizations. The term “private sector” refers both to services directly operated by private agencies and to services financed with private resources (e.g., employer-provided insurance).
Figure 2-4. The mental health service system
The duration of care is divided between services for the treatment of acute conditions and those devoted to the long-term care of chronic (i.e., severe and persistent) conditions, such as schizophrenia, bipolar disorder, and Alzheimer’s disease. The former, provided in psychiatric hospitals, psychiatric units in general hospitals, and in beds “scattered” in general hospital wards, includes brief treatment-oriented services. Long-term care includes residential care as well as some treatment services. Residential care is often referred to as “custodial,” when supervised living predominates over active treatment.
The settings for care and treatment include institutional, community-based, and home-based. The former refers to facilities, particularly public mental hospitals and nursing homes, which usually are seen by patients and families as large, regimented, and impersonal. They often are removed from the community by distance and frequency of contact with friends and family. In contrast, community-based services are close to where patients or clients live. Services are typically provided by community agencies and organizations. Home-based services include informal supports provided in an individual’s residence.
Chapter 6 examines the impact of recent changes in financing and organizing services on access and quality of care. Many of these issues also are addressed in Chapters 3 to 5, where they are discussed in the context of care and treatment at each stage of the life cycle. The following material provides general information on current patterns of use and focuses on the historical origins of mental health services.
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