HSCI 678 Intro to US Healthcare System The Care of Special Populations and Special Disorders Chapter 18 Dr. Tracey Lynn Koehlmoos

Introduction Defining special populations Systems that exist Types of providers Policy issues

American Psychiatric Assoc. A mental disorder is a clinically significant behavior or psychologic syndrome or pattern that occurs in an individual and that is typically associated with either a painful symptom (distress) or impairment in one or more important areas of functioning (disability). (APA 1980)

Conceptualization Mind/Body Schism—historical Emotional/Mental distress = Morbidity –Immune functions –Cancer –Heart Disease Biologically perceived health is a strong predictor of mortality

Defining Mental Illness Multiple disorders - More than 15% (30% annually) - 1% unable to care for themselves Common diagnoses –Schizophrenia, Schizoaffective, Bipolar Notable Exclusions –Developmental disabilities –Substance abuse: lack of data/excessive care

Providers Psychiatrists, psychologists, counselors, therapists, social workers, ARNP, etc. Numerous facilities –State, VA –Private (health plan participants)

Public/Governmental Role Chronic Mental illness: some can be treated/some limited recovery options Government institutions (48 states) Mental health care unresponsive to financial incentives; outside continuum of care State mental hospitals—long tradition –80% had chronic mental illness in the 1930’s –Population peaked at ~1/2 million in 1955

Movement toward Community Care Shift of psychiatrists out of mental hospitals/replaced by FMGs—problematic Psychoanalytical transition—little proof Social welfare increases RESULTS: Smaller in-patient population Allowed for treatment/ not warehousing Only care for severely mentally ill

Deinstitutionalization 33-40% homeless, chronic illness Elderly residents—to nursing homes (Medicaid/ Medicare) Payment shift from State to Federal govt. Federal programs: –SSDI –SSI MEDICAID big payer for mental health services

Un-met Need About 150,000 chronic residential patients Where is everyone else? –No access to care –15% uninsured—hard to get to Medicaid –Private insurance—inadequate provisions –Managed care—discourage enrollment –Social stigma

Policy Issues Physical/Mental health schism Institution/Community schism Unmet treatment needs –Substance abuse –Young, disturbed and alcoholic Stigma, stigma, stigma Managed Care-advent of mental healthcare

Conclusion Diverse population--disparities Difficult to reach Difficult to treat Difficult to project prognosis Lack of advocacy Lack of parity