Community Mental Health Chapter 11 Community Mental Health

Chapter Objectives (1 of 2) After studying this chapter, you will be able to: Define mental health and mental disorders, and explain the prevalence of mental disorders in the United States. Explain what the DSM-5 is, and give an example of its limitations. Give an example of how cultural differences can impact the diagnosis of mental disorder. Cite specific examples of the causes of mental disorders. Define stress and explain its relationship to physical and mental health. Briefly trace the history of mental health care in America, highlighting the major changes both before and after World War II. Define the term deinstitutionalization and list and discuss the forces that brought it about. Describe community mental health centers as alternatives to state psychiatric hospitals. Identify the major problems faced by people with mental illness who are homeless. Describe some legal and practical issues affecting how society should deal with the problem of mental illness and violence.

Chapter Objectives (2 of 2) Describe mental health courts, outpatient commitment, and the use of “legal leverage” to compel treatment. Describe the challenges facing law enforcement personnel when dealing with community residents who are struggling with acute symptoms of severe mental illness. Define primary, secondary, and tertiary prevention as they relate to mental disorders, and give an example of each. List and briefly describe the basic approaches to treating mental disorders. Define self-help groups, give examples, and explain how they are helpful to their members. Describe what “recovery” means for people with mental illness in the U.S., and for those in less developed countries such as India or Tanzania. Explain what is meant by psychiatric rehabilitation and list the kinds of services provided by effective programs. Identify key clinical, multicultural, practical, and political challenges faced by the community mental health care system today. Explain the federal government’s role in supporting healthcare services to people with mental illness with respect to “parity” in insurance coverage, the Affordable Care Act, and integrative care.

Introduction (1 of 2) Mental illness – leading cause of disability in North America and Europe ~20% of American adults have diagnosable mental disorders during a given year Only 38% receive treatment Needs of people with mental illnesses diverse Services required to meet needs include therapeutic and social services

Introduction (2 of 2) President's New Freedom Commission on Mental Health (2003). Achieving the Promise: Transforming Mental Health Care in America. Rockville, MD: Author, 20. Causes of disability for all ages combined: United States, Canada, and Western Europe, 2000.

Definitions Mental health Mental illness Mental disorders Emotional and social well-being Mental illness All diagnosable mental disorders Mental disorders Health conditions characterized by alterations in thinking, mood, or behavior associated with distress and/or impaired functioning

Good Mental Health Adults with good mental health are able to: Function under adversity Change or adapt to changes around them Maintain control over their tension and anxiety Find more satisfaction in giving than receiving Show consideration for others Curb hate and guilt Love others

Classification of Mental Disorders Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Published by American Psychiatric Association Most influential book in mental health Classifies disorders based on behavioral signs and symptoms rather than definitive tests or measurements of brain or another body system Challenges to diagnosis include comorbidity and lack of cultural competence

Causes of Mental Disorders Symptoms can arise from various causes: Poor prenatal care, postnatal environment, genetics, environmental factors, brain function impairment, substance abuse, maladaptive family functioning, stress PTSD

Stress: A Contemporary Mental Health Problem Stress – one’s psychological and physiological response to stressors Stressors General adaptation syndrome Fight or flight reaction Diseases of adaptation Experts recommend combination of physical, social, environmental, and psychological approaches to managing stress Courtesy of Cpl. Brian Reimers/U.S. Marines

Suicide and Substance Abuse Led to an unexpected rise in death rates among middle-aged white Americans between 1999 and 2014 Prevalence of alcohol and other drug abuse a social indicator of mental illness problems

History of Mental Health Care in the United States Response to mental illness characterized by periods of enthusiastic reform followed by periods of widespread ambivalence

Mental Health Care before World War II Colonial America – people with mental illness cared for by families or private caretakers Institutionalization first appeared in 18th century Population growth led to institution growth Harsh treatments and unpleasant conditions

The Moral Treatment Era Began in 1792 Belief that environmental changes can affect the mind and alter behavior Move people from settings causing life stressors into rural, peaceful setting Appeared to have success and became widely acceptable Overcrowding due to population growth

The State Hospitals (1 of 2) Supposed to provide therapeutic environment, based on close personal relationships between patients and well-trained staff Deterioration of services occurred as chronic nature of mental illness was discovered; long-term or lifetime stays were the norm Maximum capacities quickly reached; personalized care lost; restraints became more practical; staff turnover high

The State Hospitals (2 of 2) 1940, population in state mental institutions was nearly a half million Staff case loads so large, only subsistence care possible Electroconvulsive Therapy (ECT) introduced in response Lobotomies practiced Appearance of new medications in 1950s made widespread use unnecessary

Mental Health Care after World War II National Institute of Mental Health (NIMH) established To foster and aid research related to cause, diagnosis, and treatment of neuropsychiatric disorders To provide training and award fellowships and grants for work in mental health To aid states in the prevention, diagnosis, and treatment of neuropsychiatric disorders

Deinstitutionalization Deinstitutionalization – discharging of thousands of patients from state mental hospitals Propelled by economics, idealism, legal considerations, and antipsychotic drugs

Community Mental Health Centers Mental Retardation Facilities and Community Mental Health Centers Act Community mental health centers – fully staffed centers originally funded by the federal government providing comprehensive mental health services to local populations Five core services Problem of transinstitutionalization Community Support Program

Mental Health Care Concerns in the United States Today Experiences of people with serious mental illness have improved significantly in past 50 years Challenges remain: How to provide services to the homeless Changing perception that mental illness is linked to extreme violence Resolving problems of those with mental illness who are incarcerated

Homelessness 2.1 million adults experience homelessness over the course of a year 80% temporarily homeless, 10% episodically homeless, 10% chronically homeless About half of all homeless adults have substance use disorders, major depression, and other co-occurring mental illness Successful interventions include provision of housing and services they need

Mental Illness and Violence Extreme violence relatively rare in people with mental disorders Much of risk attributable to comorbid factors What should be done to prevent violence is unclear Constitutional issues related to individual freedoms, privacy, and other rights

Mental Health Care in Jails and Prisons Rates of serious mental illness in U.S. correctional facilities are three to four times the rates in the general population Correctional facilities designed to confine and punish, not to treat disease Lack of space, adequate number of qualified treatment personnel, and timely access to services Once released back into community, more likely to commit crime if untreated

Prevention Primary, secondary, and tertiary prevention applicable to mental disorders Primary – reduces incidence of mental illness and related problems Secondary – reduces prevalence by shortening duration of episodes Tertiary – treatment and rehabilitation

Treatment Approaches Goals of treatment of mental disorders Reduce symptoms Improve personal and social functioning Develop and strengthen coping skills Promote behaviors that make a person’s life better

Psychopharmacology Psychopharmacological therapy – treatment with medications Conditions for which medications exist include schizophrenia, bipolar disorder, major depression, anxiety, panic disorder, and obsessive-compulsive disorder Other biomedical therapy – ECT

Psychotherapy Psychotherapy – treatment through verbal communication Numerous approaches Cognitive-behavioral therapy More likely to be successful in less severe cases or when used in conjunction with other approaches

Technology Use of technology in treatment via telephone, video conferencing, Internet, email, computer software Benefits Delivers flexible help directly to clients’ living environments Lowers cost to patient Increases privacy of patient May reduce feelings of coerciveness

Self-Help Groups Self-help groups –concerned members of the community who are united by a shared interest, concern, or deficit not shared by other members of the community National Alliance on Mental Illness (NAMI)

Psychiatric Rehabilitation Primary objective is most often recovery rather than cure Psychiatric Rehabilitation – current recovery-oriented services Services include medication, therapy, adaptive skills, changing environment through accommodations at work or school Practices must be evidence-based

Challenges Facing Mental Health Care in the United States Multiple services needed Staff turnover relatively high System is decentralized and fragmented Lack of licensed providers in rural and low-income counties Lack of cultural competence among providers

Government Policies and Mental Health Care Following deinstitutionalization, government’s role in funding and policy became substantial Medicaid Mental Health Parity and Addiction Act of 2008 Parity – concept of equality in healthcare coverage for people with mental illness and those with other medical issues or injuries

The Affordable Care Act of 2010 Medicaid coverage for individuals with mental disorders grew Individuals with mental disorders disproportionately benefit from coverage expansions They tend to have lower incomes and are less likely to be insured Communities may lack infrastructure to adequately meet needs of newly insured

Discussion Questions How can community mental health centers work to reach 100% of their territory in need? What role can schools play in supporting mental health in children and adolescents?