State Mental Health Agencies Research Articles

States' Priorities for Persons With Mental Illness in the Criminal Justice System

Back to table of contents Previous article Next article LetterFull AccessLetterErik Roskes M.D.Erik Roskes M.D.Search for more papers by this authorPublished Online:1 Dec 2007https://doi.org/10.1176/ps.2007.58.12.1606aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail States' Priorities for Persons With Mental Illness in the Criminal Justice SystemTo the Editor: Having read the State Mental Health Policy column in the September issue, "Critical Priorities Confronting State Mental Health Agencies," by Mazade and Glover ( 1 ), I find it striking that the authors—and apparently state mental health directors around the country—do not consider the vast number of individuals with mental illness in the criminal justice system to be a "priority." Given that there are nearly 300,000 individuals with mental illness currently incarcerated in the United States and about double that number on parole or probation ( 2 ), I would think that this ought to be at least one of the priority items listed. Each of the priorities listed by the authors applies in spades to those of our clientele who find themselves in the criminal justice system. They have a high rate of comorbid medical and addictive diseases, they are perhaps the least empowered of any person with mental illness one can imagine, there are all too few psychiatrists willing to serve this population, and state legislators and administrators are unwilling to spend what the illness burden of this population demands.Apart from all of that, it is simply morally wrong to think about the priorities of state mental health systems without considering this lost population. But then, once they are incarcerated, they are no longer a problem for the state mental health director, are they?Dr. Roskes is director of forensic treatment at Springfield Hospital Center, Sykesville, Maryland. The opinions expressed represent those of the author and do not necessarily reflect the views of the State of Maryland Mental Hygiene Administration.

Letter

Back to table of contents Previous article Next article LetterFull AccessLetterErik Roskes M.D.Erik Roskes M.D.Search for more papers by this authorPublished Online:1 Dec 2007https://doi.org/10.1176/ps.2007.58.12.1606aAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail States' Priorities for Persons With Mental Illness in the Criminal Justice SystemTo the Editor: Having read the State Mental Health Policy column in the September issue, "Critical Priorities Confronting State Mental Health Agencies," by Mazade and Glover ( 1 ), I find it striking that the authors—and apparently state mental health directors around the country—do not consider the vast number of individuals with mental illness in the criminal justice system to be a "priority." Given that there are nearly 300,000 individuals with mental illness currently incarcerated in the United States and about double that number on parole or probation ( 2 ), I would think that this ought to be at least one of the priority items listed. Each of the priorities listed by the authors applies in spades to those of our clientele who find themselves in the criminal justice system. They have a high rate of comorbid medical and addictive diseases, they are perhaps the least empowered of any person with mental illness one can imagine, there are all too few psychiatrists willing to serve this population, and state legislators and administrators are unwilling to spend what the illness burden of this population demands.Apart from all of that, it is simply morally wrong to think about the priorities of state mental health systems without considering this lost population. But then, once they are incarcerated, they are no longer a problem for the state mental health director, are they?Dr. Roskes is director of forensic treatment at Springfield Hospital Center, Sykesville, Maryland. The opinions expressed represent those of the author and do not necessarily reflect the views of the State of Maryland Mental Hygiene Administration.

Drug-Related Arrests in a Cohort of Public Mental Health Service Recipients

The excessive prevalence of comorbid substance abuse among persons with severe mental illness has been well established and identified as the source of numerous negative outcomes. An overlooked aspect of illicit drug use in this population is its illegality and the potentially dire criminal sanctions. This study examined the prevalence of drug arrests in a cohort of persons receiving services from a state mental health agency who were followed for roughly ten years.Data on arrest spanning from 1991 to 2000 were obtained for all individuals receiving inpatient, case management, or residential services from July 1991 to June 1992 (N=13,816). Reports of prevalence were based on the number with at least one drug-related arrest in the observation period.Five percent of individuals in the cohort experienced at least one drug-related arrest (N=720). These included simple possession as well as manufacturing and distribution. The prevalence was much higher (15%) among persons aged 18 to 25 years than in other age groups. Roughly 95% of persons with a drug arrest also had an arrest for another type of offense. This pattern is similar to that observed among persons with a drug-related arrest in the general population.Convictions on drug charges can void access to Section Eight housing and other benefits and are associated with other patterns of offending that also carry significant criminal sanctions. State mental health agencies may wish to target interventions toward youthful clientele by focusing specifically on the risks associated with involvement with illicit drugs.

Drug-Related Arrests in a Cohort of Public Mental Health Service Recipients

The excessive prevalence of comorbid substance abuse among persons with severe mental illness has been well established and identified as the source of numerous negative outcomes. An overlooked aspect of illicit drug use in this population is its illegality and the potentially dire criminal sanctions. This study examined the prevalence of drug arrests in a cohort of persons receiving services from a state mental health agency who were followed for roughly ten years. Data on arrest spanning from 1991 to 2000 were obtained for all individuals receiving inpatient, case management, or residential services from July 1991 to June 1992 (N=13,816). Reports of prevalence were based on the number with at least one drug-related arrest in the observation period. Five percent of individuals in the cohort experienced at least one drug-related arrest (N=720). These included simple possession as well as manufacturing and distribution. The prevalence was much higher (15%) among persons aged 18 to 25 years than in other age groups. Roughly 95% of persons with a drug arrest also had an arrest for another type of offense. This pattern is similar to that observed among persons with a drug-related arrest in the general population. Convictions on drug charges can void access to Section Eight housing and other benefits and are associated with other patterns of offending that also carry significant criminal sanctions. State mental health agencies may wish to target interventions toward youthful clientele by focusing specifically on the risks associated with involvement with illicit drugs.

State Mental Health Policy: Critical Priorities Confronting State Mental Health Agencies

The authors of this column report on an environmental scan conducted via intensive interviews of the 55 state and territorial state mental health agency (SMHA) directors who collectively oversee a $28 billion budget and serve nearly six million Americans who have a serious mental illness. Currently, a dynamic set of forces are substantively reshaping the role, resources, and capacities of the SMHA within the larger fabric of state government. As such, SMHA directors developed year 2007 priorities. These priorities include integrating health and mental health care, enhancing consumer empowerment, addressing mental health workforce crises (for example, training and recruitment), and ensuring financial stewardship.

State Mental Health Policy: Critical Priorities Confronting State Mental Health Agencies

The authors of this column report on an environmental scan conducted via intensive interviews of the 55 state and territorial state mental health agency (SMHA) directors who collectively oversee a $28 billion budget and serve nearly six million Americans who have a serious mental illness. Currently, a dynamic set of forces are substantively reshaping the role, resources, and capacities of the SMHA within the larger fabric of state government. As such, SMHA directors developed year 2007 priorities. These priorities include integrating health and mental health care, enhancing consumer empowerment, addressing mental health workforce crises (for example, training and recruitment), and ensuring financial stewardship.

Patterns and Prevalence of Arrest in a Statewide Cohort of Mental Health Care Consumers

Patterns and Prevalence of Arrest in a Statewide Cohort of Mental Health Care Consumers

Evidence-Based Practice for Psychiatric Rehabilitation in the United States

In 1999, the landmark Mental Health: A Report of The Surgeon General in the United States, urged mental health systems to utilize knowledge gained from research to improve service delivery in mental health. These services have been called evidence-based practice (EBP). The implementation of EBP is rapidly becoming standard practice and required by most funding sources in the United States. By 2003, forty-eight states responded to the country’s State Mental Health Agency Profiles System shows that all responded states are actively working to provide EBP to mental health consumers (National Association of State Mental Health Program Directors Research Institute [NRI], 2004). This movement of implementing evidence-based practice is becoming the trend for psychiatric rehabilitation in the United States. The purposes of this article are to introduce and provide an overview of the six EBPs for psychiatric rehabilitation which are developed and implemented in the United States and to identify some of the opportunities for occupational therapy services based on these EBPs.

Datapoints: State-Administered Spending on Mental Health Services by Type of Service

29 T report of the President’s New Freedom Commission on Mental Health has renewed attention to programs designed to reduce unnecessary institutionalization and promote community living. Spending for different types of care provides one important indicator of states’ support of such programs. Traditionally, the primary source of such information has been from the budgets of state mental health agencies. In fiscal year 2002 two-thirds of spending by state mental health agencies went to community mental health services, with 30 percent going to state mental hospitals (1). Increasingly though, such budget data provide only a partial picture of states’ mental health spending. For example, mental health agency data do not usually include spending by other agencies or spending for mental health services provided by nonspecialty providers. A broader picture of total spending by states on mental health services can be derived from estimates of national spending for mental health and substance abuse services (2). One feature of these estimates is the calculation of payment for mental health services by major payer categories. Two of these categories—Medicaid and other state and local government funding—make up most of the spending for mental health services that states and localities administer. The estimates show spending by type of provider, such as general hospitals, and by type of service— inpatient, outpatient, residential, or prescription drugs. This type of calculation provides a different perspective on spending, because many providers, such as hospitals, deliver multiple types of services. State-Administered Spending on Mental Health Services by Type of Service

A Service System Planning Model for Individuals With Serious Mental Illness

An institutional-based care system in mental health has been replaced by a network of community-based services with different levels of structure and support. This poses both an opportunity and a challenge to provide appropriate and effective care to persons with serious mental illnesses. This paper describes a simulation-based approach for mental health system planning, focused on hospital and residential service components that can be used as a decision support tool. A key feature of this approach is the ability to represent the current service configuration of psychiatric care and the client flow pattern within that framework. The strength of the simulation model is to help mental health service managers and planners visualize the interconnected nature of client flow in their mental health system and understand possible impacts of changes in arrival rates, service times, and bed capacity on overall system performance. The planning model will assist state mental health agencies to respond to requirements of the Olmstead decision to ensure that individuals with serious mental illness receive care in the least restrictive setting. Future plans for refining the model and its application to other service systems is discussed.

Understanding the Policy Context for Supporting Students with Psychiatric Disabilities in Higher Education

Interest in postsecondary education for persons with psychiatric disabilities is high among consumers and advocates. However, the existence of program supports for higher educational goals is very uneven across U.S. states. This study was designed to examine the policy context in which states and educational institutions address needs of individuals with psychiatric disabilities to attend and succeed in postsecondary education. In 10 selected states, telephone interviews were conducted with key informants in state agencies of mental health, vocational rehabilitation, and higher education, as well as representatives of state-level advocacy organizations. Additionally, a search of websites relevant to state policy was conducted. The findings identify factors that facilitate and inhibit the development of policy and programs supportive of students with psychiatric disabilities. Facilitating factors include a strong community college system, progressive philosophy of the state mental health agency, and interest of consumers and the advocacy community. Inhibiting factors include political and budgetary uncertainty, competing priorities in the mental health system, emphasis on a medical rather than rehabilitative model, regulations of the VR system, and lukewarm enthusiasm of the advocacy community. Implications for community mental health services are included, particularly related to further policy development in support of students with psychiatric disabilities.

The Effects of Federal Versus State Funding and Academic Affiliation on Mental Health Services

This study compares mental health services in three facilities on two domains: federal versus state funding and academic affiliation. Data from a cross-sectional study of psychiatric outpatients is utilized to compare 196 VA patients to 337 non-VA patients treated in two state mental health agencies. The strength of academic affiliation of the facilities and the degree of participation in research and training activities differs significantly across facilities but is not associated with quality of care, clinical outcomes, or satisfaction with care. Compliance with schizophrenia PORT treatment recommendations is low but similar across sites. These findings suggest that, unlike findings from the general medical literature, academic affiliation is unrelated to the quality and delivery of mental health care.

Implementing Evidence-Based Psychosocial Practices: Lessons Learned from Statewide Implementation of Two Practices

As part of this national project, we examined barriers and strategies to implementation of two evidence-based practices (EBPs) in Indiana. Despite many advances in the knowledge base regarding mental health treatment, the implementation of EBPs in real-world setting remains poorly understood. The National EBP Project is a multi-state study of factors influencing implementation of EBPs. Over a 15-month period we observed eight assertive community treatment (ACT) programs and six integrated dual disorders treatment (IDDT) programs and noted pertinent actions taken by the state mental health agency influencing implementation. We created a database containing summaries of monthly visits to each program and interviews with key leaders. Using this database and clinical impressions, we rated barriers and strategies at each site on seven factors: Attitudes, Mastery, Leadership, Staffing, Policies, Workflow, and Program Monitoring. At the site level, the most frequently observed barriers were in the areas of leadership, staffing and policies for ACT, and mastery and leadership for IDDT. Overall, barriers were more evident for IDDT than for ACT. Strategies were less frequently noted but generally paralleled the areas noted for barriers. However, our central finding was that ACT was generally more successfully implemented than IDDT throughout the state, and that this difference could be traced in large part to state-level factors relating to historical preparation for the practice, establishment of standards, formation of a technical assistance center, and funding. In this case study, both state-level and site-specific factors influenced success of implementation of EBPs. To address these factors, the field needs systematic strategies to anticipate and overcome these barriers if full implementation is to be realized.

A single Funding Source for Public-Sector Care

Back to table of contents Previous article Next article LettersFull AccessA single Funding Source for Public-Sector CareJohn L. Kuehn, M.D.John L. KuehnSearch for more papers by this author, M.D.Published Online:1 Feb 2004https://doi.org/10.1176/appi.ps.55.2.192AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In the Taking Issue commentary in the September issue of Psychiatric Services, William Hughes (1) observed that although the report of the President's New Freedom Commission on Mental Health endorsed state plans to coordinate services, it did not go far enough. I agree with Mr. Hughes' proposal of single-source funding of care for the severely mentally ill population. Ideally, the United States should have a nonprofit single-payer health care system, such as Medicare. However, given the current economic and political situation, I doubt that people my age—73 years—will see it during our lifetime. Thus we need to search for partial solutions, particularly at the state level of government.Several months ago Michael Hogan, Ph.D., who was chair of the New Freedom Commission and who is director of the Ohio Department of Mental Health, gave a most interesting lecture at Akron General Hospital on the background of the commission and the nature of its findings. He made several important points. First, the Bush Administration made it quite clear that the report must be "budget neutral," which seems to guarantee that the outcome of the report will amount to little more than rearranging the deck chairs on the Titanic. Dr. Hogan further noted that in light of the requirement for "no new money," the only substantive practical recommendation that the commission could make to raise more funds for direct care was the elimination of disability payments as we now know them for people with severe mental illness, and particularly for those with dual diagnoses. In other words, we should stop paying people for being mentally ill, although we should continue to maintain their health care benefits.The only note of hope that Dr. Hogan injected was that the report would be passed along to the U.S. Public Health Service and the National Institute on Mental Health and that maybe these organizations would find ways to "adjust" some of their current programs in the direction of the commission's recommendations without incurring further expense.So what can be done now? One approach may be to focus on change at the state level, which, because of current economic conditions and national priorities, may be the only level at which informed citizens can take meaningful action. I challenge the American Psychiatric Association, the National Alliance for the Mentally Ill, and the readers of Psychiatric Services to bring pressure to bear to abolish the irrelevant "pass through" regional and community mental health boards—including the Ohio boards—that provide no direct care themselves, do not effectively monitor the quality of care, and fritter away precious treatment resources on administrative costs—a sort of welfare program for some mental health administrators. (These remarks do not apply to mental retardation boards, many of which, at least in Ohio, do provide direct care and assertive case management teams for residents and clients.)We should return the funds given to these boards to the state mental health agencies, which can then purchase more assertive community and residential treatment for the thousands of people with severe mental illness who now languish in jails or who wander the streets for lack of appropriate care.Dr. Kuehn is clinical professor of psychiatry at Northeastern Ohio Universities College of Medicine in Rootstown, Ohio.Reference1. Hughes W: Unified funding: New Freedom Commission's only hope. Psychiatric Services 54:1189, 2003Link, Google Scholar FiguresReferencesCited byDetailsCited byNone Volume 55Issue 2 February 2004Pages 192-192 Metrics PDF download History Published online 1 February 2004 Published in print 1 February 2004

The Campaign for Mental Health Reform: a new advocacy partnership.

The Campaign for Mental Health Reform: a new advocacy partnership.

State agency policy and program coordination in response to the co-occurrence of HIV, chemical dependency, and mental illness.

The co-occurrence of HIV infection, chemical dependency, and mental illness challenges federal and state governments to develop flexible and coordinated health policy and financing for public health services. State agencies play a critical role in the organization and support of these services at the local level. With emerging stress upon state government budgets and concomitant increasing need for publicly funded services, state agency coordination may be an important policy safety net to assure services for populations at the margins of health systems. Despite this important potential role, nothing is known about the degree to which state HIV, substance abuse, and mental health agencies coordinate policies and/or programs in response to these co-morbid conditions. This study sought to establish a conservative and initial understanding of state HIV, substance abuse, and mental health agency coordination of policy and program in response to the co-occurrence of HIV, chemical dependency, and mental illness. Estimation of coordination was accomplished through the comparison of three surveys conducted among state substance abuse directors (1998), state AIDS directors (1999), and state mental health directors (2000). Data from 38 states were reviewed. The most frequently reported state agency activities included coordinating funding, engaging in integrative planning activities, and conducting staff cross-training. When compared for association with state characteristics, coordination among state agencies was found to be associated with Early Intervention Services (EIS) designation, higher rates of AIDS generally, higher rates of AIDS among African Americans, and higher rates of AIDS among Hispanic populations. Given the limitations of comparing three disparate surveys, we determined the estimate of interagency coordination to be conservative and preliminary. While this study was useful as an initial step toward identifying state interagency policy and program coordination in response to the co-occurrence of HIV, chemical dependency, and mental illness, there were methodological challenges that should be addressed in future studies of state agency coordination. Several recommendations were advanced.

Utilization of public mental health services by children with serious emotional disturbances.

The Integrated Database (IDB) was created to provide a broad picture of the use of state-funded mental health (MH) and substance abuse (SA) services. Assembled separately for three states (Delaware, Oklahoma, and Washington), the IDB links client-level and service-level data maintained by the state MH, SA, and Medicaid agencies. This study used the IDB to examine public MH services for children with serious emotional disturbances (SED) in 1996. Children with SED represented 9% to 22% of all children with MH service use. Between one half and two thirds of children with SED received psychotropic medication; 20% to 40% had a MH inpatient or residential stay. Medicaid was the primary funder of MH services for children with SED; only 2% to 12% of children with SED received services solely through the state MH agency.

The relationship between the fiscal structure of mental health care systems and cost.

The authors, using State Mental Health Agency (SMHA) data from the National Association of State Mental Health Program Directors' Research Institute, show that the amount of state hospital (SH) expenditures is related to suicide rate (SR) as well as to cost per capita for mental health care. The relationship is much stronger for cost per capita especially when the range of SH expenditures is 31-55%, or 43 +/- 12%, of total expenditures. This article hypothesizes that maximum system efficiency occurs when the funding structure of the delivery system reflects a 57%:43% (community [C]/SH) ratio. This ratio was the mean for the 50 states of the United States in 1997, when the national mean SR was 13 per 100,000 of general population. This ratio is identical to the C-to-SH inpatient bed ratio derived theoretically in a previously reported study focusing on fractal (self-similar on all scales) demand for mental health services. The potential for national saving with the redistribution of funding may be as high as $4.5 billion per year, or 23% of SMHA expenditures.

System Integrates Medicaid Patients, Substance Abuse, MH Care

Back to table of contents Previous article Next article Government NewsFull AccessSystem Integrates Medicaid Patients, Substance Abuse, MH CareJim RosackJim RosackSearch for more papers by this authorPublished Online:21 Sep 2001https://doi.org/10.1176/pn.36.18.0007The federal Substance Abuse and Mental Health Services Administration (SAMHSA) last month released its initial findings from a pilot project to integrate data from state-supported mental health service agencies, substance abuse treatment agencies, and Medicaid.Participating StatesThree states participated in the project, conducted by the Center for Substance Abuse Treatment (CSAT) and Center for Mental Health Services (CMHS), to track mental health and substance abuse patients, their use of services, and levels of expenditures.“This study represents an important advance in health services management,” said Joseph H. Autry, M.D., acting administrator of SAMHSA. “We now have a more complete picture of the clients seen and services needed in state-supported care. It also provides us with a tool that can assess the impact of initiatives, such as policy changes that affect the delivery of care.”The Integrated Data Base Project (IDB) compiled data from Delaware, Oklahoma, and Washington. The preliminary report, released at a SAMHSA press conference last month, contains data only from 1996; however, analysis is being completed on data from 1997 and 1998 as well.Treatment ReceivedOverall, about 4 percent of the population in each of the three initial states was reportedly treated for some sort of psychiatric and/or substance abuse disorder during 1996 by a state-supported mental health and/or substance abuse agency, or a Medicaid-funded agency.The overwhelming majority of patients—68 percent—received mental health services only, 21 percent received substance abuse services only, and 11 percent received both.Although significant variation was evident, many patients who received care for a mental illness did so only through the Medicaid program, ranging from 26 percent to 52 percent across the three states. Patients receiving treatment for substance abuse were cared for largely by state-supported substance abuse agencies, ranging from 65 percent to 97 percent across the three states.Clients with comorbid mental health and substance abuse disorders were more likely to receive care from the mental health and substance abuse agencies than through Medicaid. Those receiving care through state-supported agencies primarily received their care from a combination of both mental health and substance abuse agencies, while the minority received all care from mental health agencies only.“Lessons that we learn from integrating data may be transferable to other states,” said H. Westley Clark, M.D., J.D., M.P.H., director of CSAT, “and may also facilitate the integration of data from other service systems that provide care, such as primary health care and correctional, housing, and other social services.”Clark told those attending the press conference that such a comprehensive compilation of data on utilization would be valuable in planning for future trends.CMHS Director Bernard S. Arons, M.D., agreed. “We need to know which public entities are purchasing mental health and substance abuse treatment services. Only with this information will we be able to determine how to coordinate services in order to use our resources to serve more individuals.”Other states are invited to integrate their own mental health and substance abuse–related data into the growing IDB. State regulators interested in doing so can find technical information on the project’s Web site at www.samhsa.gov/centers/csat/content/idbse/index/htm.The project’s preliminary report, “Mental Health and Substance Abuse Treatment: Results From a Study Integrating Data From State Mental Health, Substance Abuse, and Medicaid Agencies,” is available from the SAMHSA Clearinghouse on Alcohol and Drug Information by calling (800) 729-6686. It can also be downloaded from the SAMHSA Web site at www.samhsa.gov/centers/csat/content/idbse/linkrpt.asp. ▪ ISSUES NewArchived

Impact of VA bed closures on use of state psychiatric services.

This study examined whether inpatient bed reductions at a Department of Veterans Affairs (VA) medical center increased VA patients' use of state mental health agency services. Veterans residing in two Connecticut cities who used VA psychiatric services during fiscal years 1993 through 1998 (n = 2,943) were identified from computerized files. Then their records were merged with state files. Coinciding with the time of VA bed closures, the proportion of VA patients who used any state services increased from 2.6%, 2.8%, and 2.7% from 1993 through 1995 to 3.6%, 3.5%, and 3.6% from 1996 through 1998 (p < .03). These changes reflect increased likelihood of state outpatient service use, but not inpatient services. No statistically significant changes occurred in the cost of state services used by VA patients. Bed closure impact may be reflected in increased cross-system service use, which may be a useful indicator of unmet needs resulting from system changes.