The U.S. Mental Health System of the 1990s: The Challenges of Managed Care

International Journal of Law and Psychiatry, Vol. 23, No. 3–4, pp. 245–259, 2000Published by Elsevier Science Ltd

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245

The U.S. Mental Health System of the 1990s

The Challenges of Managed Care

Ronald W. Manderscheid,* Marilyn J. Henderson,† Michael J. Witkin,‡and Joanne E. Atay§

Introduction

Managed care has already had a profound effect on mental health care (Free-man & Trabin, 1994; Manderscheid & Henderson, 1996). Inpatient mentalhealth care has become less frequent, and ambulatory care has become morecommon. At present, the effects of these changes on quality and outcome ofcare are virtually unknown. It is clear, however, that mental health care hasbecome a commodity under managed care, and that cost is the principal mech-anism for assigning quality at present.

What is managed care? It is primarily a reform in the financing of carethrough which great reliance is placed on prior review to control who receiveswhat type and intensity of care. This review may be external or internal(Manderscheid & Henderson, 1996). An example of the former would be autilization review firm hired by a health insurance company to serve as a con-trol point from which providers must receive approval before giving care to aprospective client. An example of the latter would be a health maintenanceorganization (HMO) that both delivers care and monitors level of utilizationby clients.

The movement toward managed care is as profound as the deinstitutional-ization process of a generation ago (Bachrach, 1976). Hence, it is exceedinglyimportant to develop a statistical profile of the mental health care system priorto implementation of managed care. The purpose of this article is to offer sucha baseline, which can be used by students, faculty, researchers, and policy-

*Chief, Survey and Analysis Branch, U.S. Center for Mental Health Services, Rockville, MD, USA.

†Assistant Chief, Survey and Analysis Branch, U.S. Center for Mental Health Services, Rockville, MD, USA.

‡Retired, Supervisory Statistician, Survey and Analysis Branch, U.S. Center for Mental Health Services,Rockville, MD, USA.

§Statistician, Survey and Analysis Branch, U.S. Center for Mental Health Services, Rockville, MD, USA.

Address correspondence and reprint requests to Ronald W. Manderscheid, U.S. Center for MentalHealth Services, Room 15C04, Parklawn Building, 5600 Fishers Lane, Rockville, MD 20857, USA.

246 R. W. MANDERSCHEID et al.

makers as a framework for examining the effects of managed care. In a sense,this statistical profile can provide a window to the future.

Recent Descriptions of the Mental Health System

Relatively few synoptic descriptions of the mental health service systemhave been provided in the past. To develop those descriptions that are avail-able, researchers examined service delivery through the eyes of those who usecare or through the eyes of those who deliver care. Major examples of each ap-proach are provided below.

The Client’s Perspective

The Epidemiological Catchment Area (ECA) Project provided a classicalanalysis of the mental health service system. Based upon interviews of adultsin the community and in institutional settings conducted during the early1980s, Regier et al. (1993) compiled an overview of the de facto mental andaddictive disorders service system for adults in the United States. Currently,similar information is not available for children and adolescents, although theNational Institute of Mental Health has a project underway to develop this in-formation. The project is called Utilization, Needs, Outcomes, and Costs forChild and Adolescent Populations.

Figure 1 summarizes the major findings from the ECA work. For 1990, theresults showed that about 28.1% of the adult population of the UnitedStates—about 52 million persons—had a mental or addictive disorder duringthat year. However, only about 14.7% of the adult population—almost 27 mil-lion adults—received any care. More than half of all adults served had diag-noses in the year in which services were provided.

Mental health care was provided in several types of settings: by mentalhealth and substance abuse providers (5.9% of all adults were served); by pri-mary care physicians (5.0% of all adults were served); and by social serviceproviders or self-help groups (3.8% of all adults were served). These findingswere shown to be valid through independent data sources (Manderscheid,Rae, Narrow, Locke, & Regier, 1993).

The Provider’s Perspective

Information from providers was used to develop a more detailed picture ofthe mental health care delivered by mental health practitioners and primarycare physicians. Schulberg and Manderscheid (1989) used survey data col-lected by the National Institute of Mental Health and the National Center forHealth Statistics to construct this picture. Findings regarding service use gen-erally confirmed those noted above for the ECA.

The results showed that major shifts have occurred since the 1950s in termsof the sites in which mental health care is delivered in the United States. How-ever, in the 1980s, the new patterns stabilized. Generally, with the advent ofdeinstitutionalization in the 1950s, the use of inpatient care stopped growing;the use of ambulatory care expanded dramatically; and service sites became

THE U.S. MENTAL HEALTH SYSTEM OF THE 1990

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considerably more heterogeneous. For example, the use of general hospitalpsychiatric services grew; partial care was introduced as an alternative to inpa-tient care; and a broad array of different organizations and practice arrange-ments were used to deliver ambulatory care. Of note, this work offers a similarperspective on patterns of care as that of the ECA.

A System Framework

To help organize client and provider information on mental health services,work has been undertaken to apply systems analysis to national data on men-tal health service delivery (Katzper & Manderscheid, 1984). As shown in Fig-ure 2, this work has resulted in a system framework through which such datacan be organized.

In summary, exogenous factors, such as population and socioeconomic andpolitical factors influence how the service system operates. The service system

FIGURE 1. Perspective on population problems and services delivered from theEpidemiologic Catchment Area Project. Adapted from “The de facto US Mental andAddictive Disorders Service System: Epidemiologic Catchment Area Prospective1-Year Prevalence Rates of Disorders and Services” by D. A. Regier, W. E. Narrow,D. S. Rae, R. W. Manderscheid, B. Z. Locke and F. K Goodwin, 1993, Archives ofGeneral Psychiatry, 50, p. 92. Copyright 1993 American Medical Association. Adaptedwith permission.


itself is comprised of four components, all of which interact internally. Theseare Infrastructure and Facilities, Financial Resources; Human Resources; andClients. In turn, these components and their interactions lead to Outputs toSociety. This system framework will be used to guide the present analyses.

The Current Mental Health System

In this section, findings will be presented from national surveys of specialtymental health services for 1990 and 1994. Although important, descriptions ofmental health care provided by primary care physicians, social service agen-cies, and self-help groups are beyond the scope of this paper. For the specialtymental health services covered in this report, detailed descriptions of the sur-veys that served as sources are available (Manderscheid, Witkin, Rosenstein, &Bass, 1986; Redick, Manderscheid, Witkin, & Rosenstein, 1983). The reader isreferred to those sources for further descriptions of the National ReportingProgram and the Mental Health Statistics Improvement Program.

To set the context for the picture presented below, it is important to specifywhat is and is not included in the findings. This can be done by looking at thepopulation that received care from the mental health organizations described.

FIGURE 2. System framework to organize information on the mentalhealth service delivery system. Adapted from “Applications of Sys-tems Analysis to National Data on the Mental Health Service DeliverySystem,” by M. Katzper and R. W. Manderscheid, 1984, PsychiatricAnnals, 14, p. 605. Copyright 1984, American Psychiatric Association.


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Recall from Figure 1 that 5.9% of the adult population received specialty men-tal health and/or substance abuse care in 1990. Overall, this represented about10.9 million adults in that year.

From information presented by Manderscheid et al. (1993), one can esti-mate that, of the 10.9 million adults who received specialty care in 1990, about5 million were cared for by private practitioners, slightly more than 1 millionwere cared for by substance abuse organizations, and about 5.8 million re-ceived care from the mental health organizations described below. (The totalof these numbers is greater than 10.9 million, since slightly more than half ofall persons who received inpatient care also received ambulatory care from aprovider organization or private practitioner in the same year.)

Thus, in 1990, the mental health organizations described below providedcare to about 5.8 million adults. To this number, one must also add childrenand adolescents under age 18 who received care from these organizations.Currently, exact person counts are not available for these children and adoles-cents, although findings provided below (see Table 7) suggest that the numbercared for by mental health organizations each year is approximately 1 million.

Service Organizations and Services

Although the overall number of mental health organizations grew from5,284 to 5,392 between 1990 and 1994, the distribution of organizationschanged only slightly (Table 1). Organizations that specialized in the provisionof inpatient and/or residential treatment comprised a smaller proportion of allorganizations in 1994 as compared with 1990. These include state and countymental hospitals, private psychiatric hospitals, general hospitals with separatepsychiatric services, and residential treatment centers (RTCs) for emotionallydisturbed children. On the other hand, organizations that provide services pre-dominantly in ambulatory settings such as outpatient or partial care settingscomprised a larger proportion of total organizations. These include freestand-ing psychiatric outpatient clinics, freestanding psychiatric partial care organi-zations, and multiservice mental health organizations, which are shown underthe rubric “all other organizations.”

In addition to the distribution of organizations, Table 1 also gives the distri-bution of services that are provided in specific settings. For “all other organi-zations,” the large increase in the proportion providing inpatient and/or resi-dential services was due to a change in definition rather than a change inservice delivery.

1

1

In 1990, if an organization was not classified as a psychiatric hospital, a general hospital, or a residentialtreatment center for emotionally disturbed children (RTC), and had one other service (e.g., partial oroutpatient care) in addition to residential

supportive

services, it was not counted as a multiservice mentalhealth organization, but as either a freestanding outpatient clinic or a freestanding partial care organization.In 1994, no differentiation was made between residential treatment and residential supportive services, as in1990, so that an organization, that had one other service in addition to

any

residential service would beclassified as a multiservice mental health organization, if it were not a psychiatric hospital, a generalhospital, or an RTC.


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251

Service Episodes

Table 2 gives the percent distribution and rates per 100,000 civilian popula-tion for total patient care episodes

2

by organization type, while Table 3 givesthe percent distribution of patient care episodes provided in 24-hour inpatientand/or residential care, and in less than 24-hour care settings. The overallnumber of patient care episodes increased from 8.6 to 9.6 million between1990 and 1994; the total episode rate per 100,000 civilian population increasedslightly from 3,488 to 3,702 (6.4%) (Table 2).

The largest percentage changes in rates were for RTCs and “all other orga-nizations,” which increased 22 and 17%, respectively; the largest percent de-creases in rates occurred in state and county mental hospitals, which decreased23%, and VA medical centers, which decreased 21% (Table 2). Each of thelatter organizations was downsizing with respect to numbers of episodes in the1990-94 time period for both settings (Table 3).

Financial Resources

The total expenditure by mental health organizations increased in actualdollars from $28.4 billion in 1990 to $33.1 billion in 1994; the expenditures percapita of the United States civilian population also increased from $116.39 to$127.98 (Table 4). However, if the expenditures are expressed in constant dol-lars, that is, adjusted by the medical care component of the consumer price in-dex (1970

5

100), the expenditures overall decreased from $5.6 billion in 1990to $5.0 billion in 1994 (10.7%) (data not shown). Organizations comprising alarger proportion of total expenditures in 1992, as compared with 1990, in-cluded RTCs and “all organizational types,” which predominantly provide ser-vices in less than 24-hour settings. State and county mental hospitals, privatepsychiatric hospitals, and VA medical centers (Table 4), three organizationswith decreasing numbers of patient days and shorter lengths of stay in 1994 ascompared with 1990 comprised a smaller proportion of total expenditures in1994 as compared with 1990.

To provide context for these numbers, additional information is required ontotal mental health spending. Frank, McGuire, Regier, Manderscheid andWoodward (1994) estimated the total funding for mental health services in1990 at $42.4 billion. With this figure as the denominator and the $28.4 billionshown above as the numerator, one can estimate that about two thirds ofspending on mental health care was organization based, with the remaindergoing principally to individual and group practitioners.

Human Resources

As shown in Table 5, the number of full-time equivalent (FTE) staff (basedon a 40-hour workweek) increased from 563,619 in 1990 to 579,062 in 1992(3.8%). The relative distribution of patient care staff to administrative, cleri-

2

Patient care episodes are defined as the number of persons receiving services at the beginning of theyear plus the number added to the rolls during the year.


cal, and maintenance staff decreased from nearly 3 to 1 in 1990 to 2 to 1 in1994 (Table 5).

However, within specific staff disciplines of the patient care staff, notablechanges occurred between 1990 and 1994. With the exception of registerednurses and psychologists, all professional staff disciplines comprised a smallerproportion of total staff in 1994 as compared with 1990, a possible indicationthat mental health organizations may be relying more on temporary employ-ees for whom they do not pay benefits.

Other mental health workers, including aides and orderlies, decreased as in-patient units downsized, particularly those in state and county mental hospi-tals. Administrative, clerical, and maintenance workers comprised larger pro-portion of total staff in 1994 as compared with 1990.

Service Recipients

The most recent national information about characteristics of service recipi-ents dates from 1986. Information is presented for two groups of recipients, thosecontinuing care at a point in time (beginning of the survey), as well as those ad-mitted during a 1-year period. Adding these two groups together provides an es-timate of the total number of recipients within the year. Approximately 5.7 mil-

TABLE 2Distribution of Patient-Care Episodes and Rates and Percent Change by Organization Type,

United States, 1990 and 1994

Total patient care episodesin thousands

Total episode rates per 100,000civilian population

1990 1994

% Changein rate

1990–941990 1994Change in %

1990–94

Total 8,617 9,584 3,487.8 3,701.5

% Distribution Rate distribution

Organization typeState and county mental

hospitals 6.0 4.3

2

1.7 207.7 159.7

2

23.1Private psychiatric

hospitals 7.9 8.5 0.6 276.8 315.5 14.0Non-Federal general

hospitals with separatepsychiatric services 23.7 21.1

2

2.6 827.7 781.1

2

5.6VA medical centers 8.2 6.1

2

2.1 285.0 225.7

2

20.8Residential treatment

centers for emotionallydisturbed children 3.4 3.9 0.5 118.1 144.2 22.1

All other organizations

a

50.8 56.1 5.3 1,772.5 2,075.3 17.1

a

Includes freestanding psychiatric outpatient clinics, freestanding partial care organizations, and multiservicemental health organizations not elsewhere classified.


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lion people were seen in the inpatient, partial care, and outpatient programs ofspecialty mental health organizations in 1986. Outpatient programs providedcare to the largest number, approximately 3.6 million persons. Slightly less than 2million persons were seen within inpatient programs, and a much smaller group,under 300 thousand persons, was seen within partial care programs.

Striking differences existed among inpatient, outpatient, and partial careprograms with respect to the number and locus of care for persons admittedduring the year versus those in active treatment at the beginning of the year(Table 6). In outpatient and partial care programs, the numbers of persons un-der care at a point in time and those admitted during the year were approxi-mately equal and were concentrated primarily in multiservice mental healthorganizations. In inpatient programs, this was not the case. The number of ad-missions overall was much higher than the number of residents. Over half ofresidents under care were in state and county mental hospitals, and anotherone fifth of residents were in non-Federal general hospital psychiatric services.Among persons admitted, these percentages were reversed, consistent withthe shorter stays and greater turnover found in the general hospital psychiatricsettings. With the increased emphasis on short inpatient stays within psychiat-ric hospitals, it is not surprising to find a smaller number of persons under care

TABLE 3Number of Episodes, Percent Distribution, and Change in Percent by Service Type and

Organization Type, United States, 1990 and 1994

24-hour hospital inpatient andresidential care episodes

in thousandsLess than 24-hour careepisodes in thousands

1990 1994Change in %

1990–94 1990 1994Change in %

1990–94

Total number 2,263 2,502 5,810 7,082

% of total % of total

Organization typeState and county mental

hospitals 16.4 12.5

2

3.9 2.1 1.4

2

0.7Private psychiatric

hospitals 19.3 20.4 2.1 3.4 4.3 0.9Non-Federal general

hospitals with separatepsychiatric services 44.1 44.1 0.0 16.8 13.0

2

3.8VA medical centers 9.5 7.6

2

1.9 7.8 5.6

2

2.2Residential treatment

centers for emotionallydisturbed children 3.1 3.0

2

0.1 3.4 4.2 0.8All other organizations

a

7.6 12.4 4.8 66.5 71.5 5.0

a

Includes freestanding psychiatric outpatient clinics, freestanding partial care organizations, and multiservicemental health organizations not elsewhere classified.


at any one time, and a larger number of persons moving in and out of care. Itcould be expected that this pattern will become more pronounced over time.

Table 7 summarizes the basic characteristics of gender, race, and age. Withthe exception of persons under care in outpatient programs, males comprisedslightly larger percentages of recipients than females, even though they madeup slightly less than half (48%) of the civilian population in 1986. Persons whowere White made up the preponderance of persons under care and admittedto each program type, but were particularly highly represented in outpatientprograms. Inpatient programs tended to have higher proportions of personswho were from races other than White, particularly among the under-carepopulation, where minority races made up 28% of residents, as compared withonly 15% of the U.S. civilian population in 1986.

In all settings, persons between the ages of 15 and 44 made up the largestpercentage of the recipients (Table 7). Both the elderly and children andyouth populations tended to be underrepresented within specialty inpatient,outpatient, and partial-care programs, when compared with their numbers inthe general population. Children and youth under 18 represented a higher per-centage of persons in ambulatory care settings than in inpatient settings, afinding consistent with the emphasis on providing services in the least restric-tive settings, particularly for children and youth.

Differences also existed in the diagnostic distributions for persons seen withinthe three service settings. To illustrate differences among the settings, Table 8

TABLE 4Number, Percent Distribution, Change in Percent of Expenditures, and Expenditures per Capita in

Mental Health Organizations, United States, 1990 and 1994

Expenditures inthousands of dollars

Change in %1990–94

Expendituresper capita

1990 1994 1990 1994

Total $28,410,261 $33,136,440 $116.39 $127.98

% DistributionPer capitaDistribution

Organization typeState and country mental

hospitals 27.4 23.6

2

3.8 31.85 30.22Private psychiatric hospitals 21.5 19.5

2

2.0 24.99 24.98Non-Federal general

hospitals with separatepsychiatric services 16.4 16.1

2

0.3 19.10 20.64VA medical centers 5.2 4.2

2

1.0 6.06 5.35Residential treatment

centers for emotionallydisturbed children 6.9 7.1 0.2 8.07 9.12

All other organizations

a

22.6 29.5 6.9 26.32 37.67

a

Includes freestanding psychiatric outpatient clinics, freestanding partial care organizations, and multiservice mental health organizations not elsewhere classified.


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presents several major groupings of principal diagnoses: alcohol related disorders,drug-related disorders, major affective disorders, schizophrenia and related disor-ders, personality disorders, and adjustment disorders. Approximately two thirdsof the persons under care in inpatient and partial-care programs received princi-pal diagnoses within the groupings of either affective disorder or schizophrenia,and about half of persons admitted to inpatient and partial care programs re-ceived these diagnoses. Persons diagnosed with schizophrenia and related disor-ders tended to have longer hospital stays, and hence, were concentrated withinthe under-care caseload counts when compared with admission counts.

As could be expected, in outpatient settings, more focus was given to lesssevere disorders, such as adjustment disorders and social conditions. Thispoints to very different groups of people being seen in each setting. The ques-tion of which programs will serve more severely ill persons as the system con-tinues to decrease the use of inpatient care and the length of stay for such careremains to be resolved.

Major Current Trends

The information presented above tells an important story. It also providesan essential baseline for current developments. Several of the most significantof these current trends are described below.

Dramatic Growth of Managed Care

Currently, about 124 million persons are covered by private managed be-havioral health-care plans, and 35 states have received waivers from the U.S.

TABLE 5Number, Percent Distribution, and Change in Percent, Full-Time Equivalent (FTE) Staff, by Staff

Discipline, Mental Health Organizations, United States, 1990 and 1994

Number of FTE staffChange in %

1990–941990 1994

Total staff 563,619 579,062

% of total

Staff disciplinePatient-care staff 73.8 64.2

2

9.9Psychiatrists 3.3 3.5 0.2Other physicians 0.7 0.5

2

0.2Psychologists 4.0 2.4

2

1.6Social workers 9.5 7.1

2

2.4Registered nurses 13.8 14.3 0.5Other mental health professionals (B.A. and above) 14.9 11.7

2

3.2Physical health professionals and assistants 2.3 1.1

2

1.2Other mental health workers (less than B.A.) 25.3 23.6

2

1.7Administrative, clerical, and maintenance workers 26.2 35.8 9.6


Health Care Financing Administration to convert their Medicaid mentalhealth programs to managed care (Manderscheid & Henderson, 1997). Therate of conversion to managed care has been unprecedented, especially sincethe demise of President Clinton’s national health-care reform initiative.

Managed care will lead to dramatic changes in the statistical profile pre-sented above. For example, the number of mental health organizations willlikely decrease; the use of inpatient care will diminish further; the number ofproviders will become smaller; provider composition will change; financial re-sources will shrink; and client characteristics will change. The entire mentalhealth delivery system will change, as control of care moves from individualproviders to the entities that pay for care and their representatives. The effectsthat these profound changes will have upon quality and outcome of care areyet to be determined.

Further Evolution of a Multi-Tiered System

Historically, a strong distinction has existed between private mental healthcare and that provided by public sector organizations (Nakao, Milazzo-Sayre,Rosenstein, & Manderscheid, 1986). When private insurance benefits were ex-hausted, the consumer of care moved from the private to the public sector.

TABLE 6Distribution of Persons Under Care and Admitted: Inpatient, Outpatient, and Partial Care

Programs, United States, 1986

Persons under care Persons admitted

Organization type Inpatient OutpatientPartialcare Inpatient Outpatient

Partialcare

Total number 170,486 1,405,076 133,194 1,687,464 2,180,507 156,912

% of total

State and countymental hospitals 59.1 3.9 2.9 20.3 2.7 4.3

Private psychiatrichospitals 10.1 3.3 5.9 13.1 4.0 3.7

VA medical centers 7.7 5.2 7.6 10.6 2.7 3.0Non-Federal general

hospitals 20.2 13.5 8.1 50.4 14.5 16.0Multiservice mental

health organizations 2.8 56.0 69.0 5.5 56.1 67.7Residential treatment

centers for emotionallydisturbed children – 0.7 1.9 – 1.0 2.4

Freestanding partial careorganizations – – 4.7 – – 3.0

Freestanding outpatientclinics – 17.3 – – 19.1 –


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Such “dumping” had the effect of keeping private sector insurance costs artifi-cially low, while encouraging the development of a large public safety net ofmental health services.

Modern managed care replicates this historic pattern. Because of the failureof national health care reform, the United States does not have universal healthinsurance coverage. Currently, more than 40 million Americans are without anyhealth insurance (U.S. Bureau of the Census, 1996). At the same time, privateand public managed care plans are being developed independently. This multi-tiered system encourages dumping from one level to another, that is, dumpingfrom private to public settings and dumping from public settings to the streets orjails. Clearly, we have yet to develop a comprehensive solution to this problem.

Consumers as Providers

Another hallmark of the present era is the dramatic growth of a mental healthconsumer movement in the United States. Over the past 20 years, consumershave organized affinity groups that have articulated common consumer values(Consumer Managed Care Network, 1996). Among these values are conceptsrelated to care—personhood, recovery, independence—and concepts related toparticipation—organization, operation, and evaluation of care systems. Therapid expansion of self-help approaches attests to the expression of these values.

Of particular note in the present context is the rapid expansion of consumeraffairs offices in State mental health agencies and the emergence of consumersin the role of peer counselors. The consumer affairs offices provide policy

TABLE 7Client Characteristics for Persons Under Care and Admitted: Inpatient, Outpatient, and Partial Care



Client characteristic Inpatient Outpatient Partial care Inpatient Outpatient Partial care

Total number 170,486 1,405,076 133,194 1,687,464 2,180,507 156,912

% of total

GenderMale 59.1 48.7 55.6 56.7 52.4 56.7Female 40.9 51.3 44.4 43.3 47.6 43.3

RaceWhite 71.8 84.6 75.9 75.7 85.0 80.5Races other

than White 28.2 15.4 24.1 24.3 15.0 19.5Age

Under 18 9.8 16.3 13.0 7.0 26.2 11.718–24 11.8 9.3 9.7 13.5 14.0 17.025–44 47.7 45.9 44.1 52.1 44.7 48.745–64 19.3 22.1 25.4 18.7 12.0 17.865 and over 11.4 6.4 7.9 8.7 3.1 4.8


guidance on the organization and operation of state systems; peer counselorsprovide direct care in local communities. These trends are altering our con-cepts of care delivery and the statistical profile presented above.

Growth of Population-Based Planning

To be most efficient and effective, modern managed care needs to engage inpopulation-based planning. Information of the type presented in the ECA studydescribed above is required to define the mental health status of populations;their needs for mental health interventions; and potential directions for preven-tion activities. Only through a comprehensive, population-based approach willlevel of service needs be controlled and the effects of prevention optimized.

State mental health agencies have begun to engage in population-based plan-ning for adults and children with serious mental disorders. This effort has beenfacilitated through the planning requirements of the Community Mental HealthServices Block Grant administered by the U.S. Center for Mental Health Ser-vices (authorized by Part B of Title XIX of the Public Health Service Act—42U.S.C. 300x et seq.). Similar planning has been initiated in the private sectoraround particular mental health benefit plans. Thus, current efforts could besaid to reflect planning for particular population segments, without comprehen-sive planning for all persons in a geographical area. More comprehensive geo-graphically based planning approaches can be expected in the future.

Conclusions and Next Steps

It is critical to reiterate the importance of system descriptions as bench-marks against which future developments can be assessed. The statistical in-

TABLE 8Selected Diagnoses for Persons Under Care and Admitted: Inpatient, Outpatient, and Partial Care



Diagnostic grouping Inpatient Outpatient Partial care Inpatient Outpatient Partial care

Total number 170,486 1,405,076 133,194 1,687,464 2,180,507 156,912

% of total

Alcohol-relateddisorders 6.2 4.9 1.8 14.4 9.4 9.3

Drug-relateddisorders 3.0 1.9 1.1 6.4 3.1 2.1

Affective disorders 21.7 22.1 17.0 31.7 14.3 22.5Schizophrenia and

related disorders 43.6 21.3 47.4 23.0 7.7 32.0Personality disorders 2.4 6.0 4.9 1.8 6.7 3.8Adjustment disorders 3.8 16.7 5.2 7.4 23.0 11.1


S

259

formation presented in this report can serve as an important benchmark forexamining the effects of the trends described above. Hence, a critical applica-tion of the information presented in

Mental Health, United States

(Mander-scheid & Sonnenschein, 1994, 1996), a biennial statistical publication of the U.S.Center for Mental Health Services is to benchmark the developments that areoccurring. Sociologists are well-trained to study and explain these trends, and tohelp plan new and improved systems for the future. The critical challenges cur-rently faced in mental health will require the very best that can be offered.

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Documents

The U.S. Mental Health System of the 1990s: The Challenges of Managed Care