REPORTS

MENTAL HEALTH, UNITED STATES, 2002EXECUTIVE SUMMARY

Ronald W. Manderscheid and Marilyn J. Henderson

Mental Health, United States, 2002,encompasses 21 chapters organized intosix sections. These six sections are Look-ing Back, Looking Forward; SupportingGood Decision Making; PopulationDynamics; Insurance for Mental HealthCare; Status of Mental Health Services;and National Mental Health Statistics.Brief descriptions of chapter content areprovided below.

LOOKING BACK, LOOKINGFORWARD

Bernard Arons and colleagues (Chap-ter 1) describe the evolution of the Cen-ter for Mental Health Services over itsfirst decade. With the public healthmodel as a framework, descriptions areprovided for key Center programs, andtheir growth is traced over the decade.Systems of care have been developed,consumer and family perspectives havebecome fundamental to all programs,and prevention/early interventionapproaches have been implemented. Keyexternal events–the Surgeon General’sReport on Mental Health; the White HouseConference on Mental Health; the tragicevents of September 11, 2001; and Presi-

dent Bush’s New Freedom Initiative andCommission–are viewed as critical factorsin shaping the current and future agendaof the Center.

From a broader 40-year perspective,Charles Ray and William Kanapaux (Chap-ter 2) analyze the development and evolu-tion of community mental health centers(CMHCs). With their origins in legislationsubmitted by President Kennedy in 1963,the CMHCs grew until 675 were fullyfunded by the end of the 1970s through acombination of federal staffing and con-struction grants. These CMHCs repre-sented slightly less than half of thenumber originally proposed. With theadvent of federal block grants in the early1980s, CMHCs became more closelyaligned with state governments, and in the1990s, they have become linked to man-aged care arrangements. Throughout thishistory, population and service require-ments have changed, and key movements,such as deinstitutionalization, have had adramatic impact on program operations. Amajor recurrent theme over the 40 yearshas been the necessity to modify opera-tions as funding sources have shifted,often with dramatic effects upon the struc-ture and capacity of CMHCs. These shift-ing requirements continue down to thepresent time. The introduction of evi-dence-based practices shows promise ofstabilizing these linkages.

Address for correspondence: Ronald Mander-scheid, Ph.D. E-mail: rmanders@samhsa.gov.

Administration and Policy in Mental Health, Vol. 32, No. 1, September 2004 (� 2004)

49 � 2004 Springer Science+Business Media, Inc.

Wilks and colleagues (Chapter 3) lookto the future to examine potentialchanges in the availability of mentalhealth providers. The chapter presentsinformation about the conditions thatmay influence short-term trends in thenumber of active providers and traineesin the major mental health service provid-ing disciplines; the key sociodemographic,system, technological, and psychopharma-cological factors that may affect thesenumbers; and estimates of the short-termchanges in the numbers of providers andtrainees. The chapter was prepared byrepresentatives of each of the disciplinesexamined: psychiatry, psychology, socialwork, psychosocial rehabilitation, psychiat-ric nursing, counseling, marriage andfamily therapy, pastoral counseling, andsociology.

SUPPORTING GOOD DECISION–MAKING

Because of rapid change and increas-ing complexity, a need exists to develop atypology through which we can under-stand and organize our approach to thebehavioral health care system. Rosenthaland colleagues (Chapter 4) have devel-oped such a typology as part of the SAM-HSA initiative on Decision Support2000+. The typology is based upon func-tion (sponsoring, purchasing, and provid-ing care) in contrast to structure, theemphasis is on relationships among func-tions, and behavioral health care is differ-entiated from general health care. Theactual typology results from the crossingof three dimensions: delegation of func-tions, partitioning the purchase of behav-ioral health and health care, and transferof financial risk by the sponsor. Whencrossed, these dimensions result in 16 dif-ferent types, nine of which are observedin practice. The chapter describes thesenine types, discusses limitations, and out-lines a series of policy questions that arisefrom the typology.

In 2001, the Mental Health StatisticsImprovement Program (MHSIP) cele-brated its 25th anniversary in conjunctionwith the 50th Annual National Confer-ence on Mental Health Statistics. Smithand colleagues (Chapter 5) describe thepast, present, and future of the MHSIP.Over the past quarter century, MHSIPhas followed the principles of collabora-tion and consensus building. Data stan-dards and their implementation havealways been a cornerstone of this work,but the perspective has been broadenedto include the consumer view andbroader stakeholder participation. Thechapter provides a summary of majorMHSIP products and initiatives. For thefuture, major directions include the revi-sion of the MHSIP Consumer-OrientedReport Card and collaboration on Deci-sion Support 2000+. Challenges willinclude ability to influence diverse datainitiatives, informal organizational struc-ture, public-private and specialty-primarycare partnerships, funding, and recogni-tion of expertise.

A major need of the field has beenthe development of appropriate perfor-mance indicators to permit benchmark-ing so that decision-making about qualityimprovement and service effectivenesscan be enhanced. With these goals inmind, Lutterman and colleagues (Chap-ter 6) report the findings from a 16-statestudy on mental health performancemeasures. The study is a joint federal-state initiative, conducted over a three-year period, on 32 performanceindicators. The project has had majorimpact on current efforts to collect per-formance measures through the Commu-nity Mental Health Services Block Grantusing the Uniform Reporting System.The measures address the dimensions ofaccess, quality, and outcome of care.Findings are presented for each measure,and implications are derived for futurework. Each author participated in one ormore workgroups over the three-yearproject period.

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POPULATION DYNAMICS

Since the tragedy of the terroristattacks on September 11, 2001, muchconcern has been expressed about theeffects of these events upon the preva-lence of mental disorders. Galea and col-leagues (Chapter 7) report the results oftwo telephone surveys conducted in Man-hattan one and four months after theseevents. The major diagnostic foci forthese surveys were post-traumatic stressdisorder (PTSD) and depression. Thespecific prevalence due to the attacks wasbetween 7% and 7.5% for PTSD, andbetween 9.7% and 10.1% for depression.Use of mental health services and psycho-tropic medications also increased afterthe attacks. Implications of the findingsare discussed for future disasters, and lim-itations of the study are noted.

Dickey and Blumberg (Chapter 8)present annual prevalence estimates fromthe 1999 National Health Interview Sur-vey for major depression, generalizedanxiety, and panic attack in the U.S.adult population, age 18 and older. Find-ings are based on the Composite Interna-tional Diagnostic Interview-Short Form(CIDI-SF). An estimated 6.3% (12.5 mil-lion adults), 2.8% (5.4 million adults),and 2.7% (5.3 million adults) of the civil-ian, noninstitutionalized population hadmajor depression, generalized anxiety,and panic attack, respectively, over theprevious 12 months. For those with majordepression or generalized anxiety, morethan three-quarters experienced some ora lot of interference in life activities.Moreover, for those with each type of dis-order, about one-third contacted a men-tal health professional in the previous12 months. Approximately 18.5% ofadults with any of the three mental disor-ders were uninsured, compared to 13.1%for those without these disorders. Fur-ther, 11.7% of those with one of the dis-orders recognized a mental health needthat could not be met due to cost. Thisfigure grew to 20.7% for those with atleast two of the disorders.

From the 1998 and 1999 NationalHealth Interview Surveys, Simpson andcolleagues (Chapter 9) report findings onthe prevalence of problems and serviceuse for attention deficit disorder, devel-opmental delay, learning disability,unhappiness/depression, and overallmental health problems in the U.S. childand adolescent population age 5–17.Respective prevalence rates for theseproblems were 6.6% (3.4 million chil-dren), 3.6% (1.9 million children), 8.2%(4.3 million children), 3.7% (1.9 millionchildren), and 13.6% (7 million chil-dren). Considerable co-morbidity wasobserved among the different problems.Approximately 6.5% of U.S. children hadcontact with a mental health professionalin the previous 12 months, and 6.6%received special education services. How-ever, more than 500,000 children (1.1%)could not afford mental health care, andmore than 4.3 million (10.1%) had per-ceived unmet medical needs.

Very little information exists regardingparental mental illness and its impactupon the wellbeing of children. Nicholsonand colleagues (Chapter 10) investigatethis issue. From the National ComorbiditySurvey, the authors estimate that 68% ofwomen and 54% of men with a lifetimeprevalence of psychiatric disorder are par-ents. Parallel figures for adults meeting cri-teria for severe and persistent mentalillness are 67% and 75%, respectively.Looked at from the reverse point of view,among those who are parents, almost half(47%) of the mothers and almost a third(29%) of the fathers have a lifetime preva-lence of mental disorder. Socio-demo-graphic characteristics of these groups arediscussed. From a separate survey con-ducted by the University of MassachusettsMedical School, findings indicate that lessthan one-fourth of state mental healthagencies formally identify adult clients asparents; just over one-quarter have servicesor programs for adult clients who are par-ents; and less than 10% have written poli-cies or practice guidelines in this area.Based on these findings, the authors make

51Ronald W. Manderscheid and Marilyn J. Henderson

a series of recommendations to the states.At the federal level, no existing federalprograms or policies explicitly considerthe circumstances of adults with mental ill-ness as parents. Key federal programs andlegislation, such as Medicaid, the Commu-nity Mental Health Services Block Grant,the Adoption and Safe Families Act, theAmericans with Disabilities Act, etc., arereviewed and opportunities identified foraddressing the issue of parental mental ill-ness.

Ellison and colleagues (Chapter 11)provide a detailed analysis of the epide-miology and treatment of attention defi-cit-hyperactivity disorder (AD/HD). Thisdisorder affects approximately 5–7% ofschool age children, and about 80% exhi-bit persistent AD/HD features into ado-lescence and into young adulthood.Approximately 14% of youth seen inorganized mental health settings areassigned a diagnosis of AD/HD. Recentresearch shows that evidence-based prac-tices are being developed for AD/HD.Combining behavioral and psychosocialinterventions with medication manage-ment is effective for reducing core AD/HD symptoms, psychosocial problems,and oppositional behavior in children.An urgent need exists to develop aresearch infrastructure so that longitudi-nal studies can investigate medicationoutcomes that are integrated with psycho-social and behavioral interventions overthe lifespan.

Recognizing the need to develop ashort screening instrument to identifyadults with a serious mental illness (SMI),Kessler and colleagues (Chapter 12)tested three different instruments in atwo-stage general population conveniencesample: the Composite InternationalDiagnostic Interview-Short Form (CIDI-SF), a modified version of the K10/K6scales of nonspecific psychologicaldistress; and the World Health Organiza-tion-Disability Assessment Schedule(WHO-DAS). Persons with SMI were iden-tified through use of the Structured Clini-cal Interview for DSM-IV (SCID) and the

Global Assessment of Functioning (GAF),and the predictability of the three instru-ments was assessed. The K6 scale per-formed the best. However, optimalcalibration rules need to be developed inlarge samples for demographic subgroupsbecause the probability of SMI for an indi-vidual with a given K6 score varies withthe prevalence of SMI in the populationfrom which the sample is drawn. This cali-bration work is currently underway inthe National Comorbidity Survey Replica-tion (NCSR). Scoring rules will beposted at http://www.hcp.med.harvard.edu/ncs/. Even prior to this calibration, preli-minary estimates can be presented fromthe National Health Interview Survey(NHIS): the 30-day prevalence of likelySMI is 3.3% in 1997; 3.0% in 1998; and2.4% in 1999. The preliminary estimateof the 12-month prevalence of SMI fromthe NCSR is 7.2%. The demographic riskprofile of SMI includes being female,young or middle-aged, unmarried, andof low economic status, and is signifi-cantly related to substance use disorders.A recommended approach for conduct-ing county-level surveys is described.

INSURANCE FOR MENTALHEALTH CARE

Finkelstein and colleagues (Chapter13) present updates of earlier estimatesfor payments and service use for mentalhealth and substance abuse beneficiariesfrom Medicaid, Medicare, and private sec-tor health plans. Medicaid data are fromall claims for 1994 in New Jersey, Michi-gan, and Washington, and for 1995 inPennsylvania. Medicare data are from thestandard five-percent sample for 1995;private sector data are from a range ofemployer plans in 1995 that are represen-tative of different industries and regions.The authors provide comparable esti-mates across the three types of insurancefor mental health, substance abuse, andcomorbidity, and for children (Medicaidonly); costs of specialty and general health

52 Administration and Policy in Mental Health

care; and comparative costs between themental health/substance abuse popula-tion and a random sample from a popula-tion without these disorders, as well as forsamples of persons with asthma and diabe-tes. The authors conclude by discussingplanned future analyses.

Parity of mental health and substanceabuse insurance benefits with those forphysical health care remains a major con-cern. Hennessy and Barry (Chapter 14)present an overview of a parity initiativefor these benefits in the Federal Employ-ees Health Benefits (FEHB) Program. Forthis program, parity is defined in a fairlyinclusive manner, and means that aplan’s coverage for mental health andsubstance abuse must be identical withregard to traditional medical care deduct-ibles, coinsurance, co-payments, and dayand visit limitations. To implement Presi-dent Clinton’s 1999 directive that paritybegin in 2001, the FEHB Program fol-lowed three principles: coverage of clini-cally proven treatments for all disordersrecognized in the Diagnostic and StatisticalManual, Fourth Edition (DSM-IV); exten-sion of parity only to in-network facilitiesand providers; and expansion of access toin-network providers. In 2000, the U.S.Department of Health and Human Ser-vices and the U.S. Office of PersonnelManagement were charged with conduct-ing an evaluation of the parity initiative.The evaluation had three goals: to assesshow parity affects benefit design andmanagement, service access and use,costs, quality, and satisfaction; to examinethese effects across plan, provider, andbeneficiary subgroups; and to examinethe effects of benefit design upon theother variables. The evaluation design isquasi-experimental, small plans areexcluded from the evaluation, and theevaluation is only partially complete.Early data on benefit design show thatthe plans being analyzed have imple-mented parity. Median co-payments fellfrom $20 to $10 per visit, and mediancoinsurance rates dropped from 50% to15%. Results also suggest that plans man-

age benefits more closely since parity hasbeen implemented.

STATUS OF MENTAL HEALTHSERVICES

Levine and Jaffe (Chapter 15) presentinformation on anti-psychotic medicationuse in a state hospital system between 1994and 2000. The report covers all anti-psy-chotic prescriptions written in this seven-year period at the 17 adult hospitals oper-ated by the New York State Office of Men-tal Health. In this period, the total dailycensus of these hospitals declined fromabout 8,500 to 4,500. Between 1994 and2000, the use of a single typical agentdropped from 70.2% of prescribing epi-sodes to 10.3%. In the same interval, atypi-cal medications increased from 8.6% ofmedication episodes to 78.7%. Co-pre-scribing of more than one anti-psychoticmedication increased from 11.4% to38.6% of medication episodes. Moreover,the use of augmentation agents increasedrapidly during this period. Characteristicsof persons prescribed anti-psychotic medi-cations were examined for a single year,1999. The bulk of the prescriptions wereto white males with a diagnosis of schizo-phrenia or schizoaffective disorder.Other socio-demographic and diagnosticdifferences were also found. As newanti-psychotic agents were introduced, sub-stitution did not occur. Total anti-psy-chotic usage incre- ased, and combinationstrategies grew.

For the first time, a chapter is includedon Employee Assistance Programs (EAPs).Masi and colleagues (Chapter 16) presentan overview of the EAP field. After a briefhistory, current challenges and opportuni-ties are outlined. A major current chal-lenge is the lack of an integrated allianceto represent the field. Program modelsand funding mechanisms are alsodescribed. Major program dimensions areservice configuration, degree of integra-tion, location, and provider type. Fundingmodels include management, colleague,

53Ronald W. Manderscheid and Marilyn J. Henderson

consortium, labor/management, andunion. Integration of services is underway,and several developments are outlinedregarding managed behavioral healthcare, work/life services, web-based services,drug-free workplace programs, and criticalincident and psychiatric disability pro-grams. Certification, accreditation, andtraining practices are reviewed, and theresearch on EAPs is summarized. Futuredirections focus on quality improvementand performance measurement, andexpanded international cooperation.

Evidence-based practices (EBPs) are animportant potential means of qualityimprovement. Leff (Chapter 17) examinesthe application of EBPs to mental health.EBPs refer to practices that have beentested through specific scientific methodsand shown to be safe, efficacious, andeffective. The history dates to the original1906 Food and Drug Act and its amend-ments that defined what is safe and effica-cious, and also set standards of researchfor acceptable evidence. Much later, quasi-experimental designs and meta-analysisbecame additional tools to help in defin-ing evidence. Mental health EBPs can orig-inate from several sources includingacademic researchers, the Cochrane Col-laboration, the Campbell Collaboration,professional/trade organizations, and fed-eral agencies. Several concerns exist aboutEBPs in mental health: the democraticconcern that all should participate indefining EBPs, the concern that tradi-tional science is too limited, the overstate-ment concern, the concern that‘‘untested’’ will be treated as equivalent to‘‘ineffective,’’ and the concern that know-ing is not equivalent to practicing. For thefuture, a need is evident for well-orderedscience to address these concerns, and agovernmental infrastructure to provideleadership to the enterprise.

NATIONAL MENTAL HEALTHSTATISTICS

Manderscheid and colleagues (Chapter18) provide an overview of mental health

organizations in 2000, together withmajor national and state trends. In 2000,a total of 4,546 mental health organiza-tions were operating. These organizationsmaintained 215,221 inpatient and resi-dential treatment beds. Inpatient and res-idential treatment additions numbered2,152,874, and additions to less than24-hour services numbered 4,615,125.Residents of inpatient and residentialtreatment services on the first day of theyear numbered 221,216. Total episodes ofcare in mental health organizations in2000 grew to 10,741,243. In conjunctionwith these findings from 2000, the chap-ter also presents 1998 staffing and finan-cial data, and trend data for selectedyears back to 1970. Episode data from1955, the year that marks the beginningof deinstitutionalization for the statemental hospitals, are contrasted with epi-sode data for 2000. Policy implications ofthe observed trends are discussed, andstate maps are presented for 2000 inpa-tient and residential treatment beds andadditions, and for additions to less than24-hour services. All results are from theSurvey of Mental Health Organizationsand General Hospital Mental HealthServices.

The only source of national survey dataon the characteristics of persons served inmental health organizations is the Client/Patient Sample Survey (CPSS) conductedperiodically by CMHS. Milazzo-Sayre andcolleagues (Chapter 19) report informa-tion from the 1997 CPSS on level of func-tioning and length of stay for adults servedin mental health organizations. Basedupon modified Global Assessment of Func-tioning (GAF) scores, it is very clear thatthe preponderance of adults served in theinpatient, residential, and less than24-hour care programs of mental healthorganizations are quite disabled (GAFscores of 60 or below). With only theexception of persons aged 18–44 undercare in residential programs or amongadmissions to less than 24-hour careprograms, at least three-quarters of alladults served in all settings are sufficiently

54 Administration and Policy in Mental Health

disabled to meet the official criteria estab-lished by CMHS for adults with a seriousmental illness (SMI). The median lengthsof stay for inpatient programs mirror theeffects of managed care throughoutthe 1990s. Across all inpatient programs,the maximum median length of stay isabout seven days. When analyzed by type ofhospital, median lengths of stay are longestin the VA Medical Centers, where somemedians approach 10 days for particulardemographic and diagnostic subgroups. Instate/county mental hospitals, privatepsychiatric hospitals, and non-federalgeneral hospitals, median lengths of stayrarely exceed seven days for any subgroup.

A parallel chapter on children andadolescents who receive services frommental health organizations has also beenprepared from the CPSS. Pottick and col-leagues (Chapter 20) examine the evolu-tion of care as reflected in changesobserved between the 1986 and 1997CPSSs. Both the number and rate of chil-dren and adolescents admitted to caregrew dramatically between 1986 and1997. The number admitted grew fromabout 703,000 to about 1.3 million duringthis period, and the rates per 100,000youth grew from 1,118 to 1,889. Further,both inpatient and ambulatory care expe-rienced increases. The number of chil-dren and adolescents admitted toinpatient care grew from about 117,000to 286,000 during this period, and ratesper 100,000 grew from 188 to 411. Forambulatory care, the number of admis-sions grew from 585,000 to 963,000, andthe rates per 100,000 grew from 930 to

1,383. For 1997, large socio-demographicdifferences were noted among the chil-dren and adolescents admitted, and clini-cal characteristics and level offunctioning (GAF) varied among care set-tings. Sources of payment also showedconsiderable variation.

Duffy and colleagues (Chapter 21)continue a series begun in Mental Health,United States, 1990, to provide periodicupdates on the size and composition ofthe human resources in mental healthand the number of trainees preparing towork in the field. The authors of thischapter represent each of the disciplinesthat comprise the mental health field.This chapter provides a description ofthe demographic and training character-istics, and professional activities of psy-chiatrists, psychologists, social workers,psychiatric nurses, mental health coun-selors, marriage and family therapists,psychosocial rehabilitation counselors,school psychologists, pastoral counselors,and sociologists. Information includesthe total number in each discipline, byyear; their sex, age, and racial/ethniccomposition; their distribution by stateand region; their years since completionof highest professional degree; theiremployment status and setting; and theirdistribution of work activities. Informa-tion on trainees is presented for each ofthe same disciplines, by year. Theauthors of this chapter are collaboratingwith the SAMHSA Decision Support2000+ initiative to define a new commonhuman resources data set for the mentalhealth field.

55Ronald W. Manderscheid and Marilyn J. Henderson