The history, economics, and financing of mental health care. Part 3: The present

1. Health care system changes, particularly the managed care plans, are altering mental health practices in significant ways. The autonomy and independent judgment of clinicians are being limited. 2. Market expansion created child and adolescent hospitals in the private sector. This market was very favorable to growth because of the great ambiguity in diagnosis and treatment, and the nonexistence of commitment laws for this population. 3. While insurance coverage for psychiatric diagnoses has expanded, more affluent people, with good employment possibilities, still have better insurance than poor individuals.     

The history, economics, and financing of mental health care. Part 2: The 20th century

1. To understand how mental health nursing practice was affected by the financing and policy changes occurring rapidly in the second part of the 20th century, sources can only be found in the literature in psychiatry, the social sciences, and economics. There was no psychiatric nursing journal until the 1950s, and no article by a nurse in the general nursing literature about finances. 2. Deinstitutionalization was really transinstitutionalization. Changes in regulations in Medicaid allowed the shifting of mentally ill people who were older than age 65 to nursing homes. 3. Community mental health centers never developed programs to serve people who were seriously mentally ill. Rather than serving clients who were psychotic, the community mental health centers marketed their treatment programs to people with anxieties, who were undergoing divorce, or who had mildly troubled children.     

The mental health of the never-married

Although the interaction between mental health and marital status has been the object of much social scientific research, little is known about the mental health of never-married people. This article reviews research relevant to mental health and marital status as it pertains to never-marrieds. Methodological problems and current gaps in such research are pointed out. The mental health of never-marrieds is examined from three popular models of mental health—the social protection, social reaction, and social selection models. Each model offers competing explanations for differences in rates between married and unmarried people and between unmarried men and women. Suggestions are offered for improvement in researching the mental health of this neglected group.     

Issues in mental health care benefits: the costs of mental health parity

This Issue Brief discusses issues in mental health care benefits. It describes the current state of employment-based mental health benefits and discusses studies and issues regarding full mental health parity. It also includes an analysis of the effect of full mental parity on the uninsured population and the effects of the limited mental health parity provision contained in the VA-HUD appropriations bill. The final section discusses the implications of mental health parity for health plans and health insurers. When employers began to provide health insurance benefits to their employees and their families, they extended coverage to include mental health benefits under the same terms as other health care services. Many employers continued to add mental health benefits through the 1970s and early 1980s until cost pressures required employers to re-examine all health care benefits that were offered. They quickly found that, while only a small proportion of the beneficiaries used mental health care services, the costs associated with this care were very high. As a result, employers placed limits on mental health benefits in an attempt to make the insurance risk more manageable. The general strategies employers have used to manage their health care costs are cost sharing, utilization review, managed care, and the packaging of provider services. Employers' cost management strategies may be restricted, however. Five states have mental health parity laws, but three of the states--Rhode Island, Maine, and New Hampshire--apply these laws only to the seriously mentally ill. In addition, 31 states mandate that mental health benefits be provided. However, state mandates apply only to insured plans, not to self-insured employer plans, which are exempt from state regulation of health plans under the Employee Retirement Income Security Act of 1974 (ERISA). A number of recent studies have examined the effect of mental health parity on health insurance premiums in a "typical" preferred provider organization and on the uninsured. In general, the studies concluded that mental health parity could increase health insurance premiums, decrease health insurance coverage for non-mental health related illnesses, and increase the number of uninsured individuals. All studies of mental health parity, and mandated benefits in general, assume that there is a strong likelihood that increased health benefit costs would be passed along to workers in the form of higher cost sharing for health insurance, lower wage growth, or lower growth in other employee benefits.     

The MHSIP mental health report card. A consumer-oriented approach to monitoring the quality of mental health plans. Mental Health Statistics Improvement Program

Health care report cards have been endorsed as a mechanism for efficiently comparing key quantifiable aspects of performance across a range of health systems or plans. There are challenges in determining what to measure; how to gather and analyze data; and how to report, interpret, and use findings. Mental health has received little attention, and a consumer perspective is typically not included. The proposed MHSIP mental health report card (MMHRC) addresses these concerns. General issues for report cards are discussed, and the MMHRC is described in terms of content, data sources and quality, and analysis and reporting.     

Assessing quality in mental health care. The United Kingdom experience

Quality assessment in mental health services is undergoing change in the United Kingdom following the introduction of market reforms. Traditionally, service quality was monitored by professional practitioners with reference to user satisfaction. This became formalized, and the two main forms of quality assurance currently used are outlined. However, the government is concerned that this may be inadequate for the monitoring of quality standards, specified in contracts between service purchasers and providers, and that existing systems provide an insufficient indication of service outcome. As a consequence, the government financed the development of a new set of health outcome scales. The importance of these scales are discussed.     

The history, economics, and financing of mental health care. Part 1: 17th to 19th centuries

Families in colonial times cared for their mentally ill members at home, with little assistance from their communities. Community treatment is an old idea, not a new one. Early laws about containing the disturbances created by individuals with mental illness made no mention of clinical dimensions. The focus was strictly on the social and economic consequences of the mental disorders. Legislation about public mental hospitals in the mid-19th century was hardly enlightened. There were no particular plans, other than not to expend more dollars than actually necessary.     

Tracing disorder across theories of autism,empathy, and mental health care

Abstract

Categories of mental disorders are generally understood through a biomedical paradigm of clinical research, diagnosis, and intervention. Here, diagnoses operate as professional tools, facilitating care organization and information exchange across diverse social contexts. In this article, I focus on how the diagnosis of autism-spectrum disorder operates in this manner. Autism conceived as a biomedical disorder is then contrasted with proposals by the neurodiversity movement, who understand core qualities of autism as alternative expressions of otherwise normal processes of brain development. Finally, I supplement these conversations with insights from Gerald Edelman’s theory of neural plasticity and Felix Guattari’s paradigm of ethico-aesthetic care. Understood together, these allow mental disorders and community care generally to be reconceived in terms of networks of expressive, embodied, and dynamically embedded rhythms that transcend individual persons. This serves, additionally, to illustrate a concept of empathy that traverses neurological, psychological, and sociocultural domains.     

The history of college health nursing

Almost from the beginning of formal college health programs in the second half of the 19th century, college health nurses were there to care for students in college and university settings. By the end of the 20th century, the role of college health nurses had evolved with the nursing field in general, but with enough unique features for the American Nurses' Credentialing Center to recognize college health nursing as a professional subspecialty and administer the first College Health Nurse Certification examinations. In addition, new nurse practitioner programs provided practicing nurses with more independence, and their duties continued to expand beyond care of the sick to include health promotion, administrative, and teaching activities. As a result of these changes, college health nurses now play a larger role in the life of students and promoting a healthy campus community than ever before in the history of college health.     

An investigation of mental health and personality in Swedish social work students upon entry to university training

The aims were to describe Swedish social work students' personality characteristics upon entry to their training and to analyze relationships between personality traits, mental health, and some sociodemographic variables. One hundred and twenty-one female social work students completed a sociodemographic form, the Temperament and Character Inventory, and the Symptom Checklist. They scored significantly higher on harm avoidance, reward dependence, and self-transcendence and reported more somatization, obsessive compulsive, and phobic-anxious symptoms, and less hostility, than Swedish individuals from the general population of the same age. Personality traits significantly predicted the various mental symptom scores. It is recommended to implement modules or training courses within social work training in Sweden that bring an improvement of self-directedness and cooperativeness character trait into focus.     

The validity of assessing mental health needs with social indicators.

Selection of the appropriate number and types of social indicators for use in mental health planning has been a perennial problem. Social indicators have been associated with several concepts (quality of life, community disorganization, populations at risk) of varying relevance for planning mental health services, and abstracting social indicators from these conceptual domains poses a variety of validity issues. The issues are discussed, and the viability of social indicators in mental health planning is reexamined.     

Evaluation in a down-loaded mental health system.

Speculation that policy and funding shifts in the nation's mental health system would negatively impact program evaluation services in community mental health centers (CMHC) is substantiated. Performance of program evaluation activities was investigated in 71 CMHCs in 15 states over a two-year period. Twenty-five percent of the centers reported cutbacks, including staff attrition and diminished funding devoted to evaluation functions. The majority of centers reported no changes, but many directors representing these centers also indicated that they had never fully developed a capacity for performing evaluations and would cease to devote attention to these activities without available funding. In some centers evaluation functions are being transferred to clinical administrators; integrated into quality assurance activities; performed "as needed' by external consultants; or ignored altogether. Many centers are developing or enhancing a computerized information system to improve internal efficiency and to meet state accountability requirements. The professional issues raised to these trends as well as their implications for federal and state policy are discussed.     

The mental health clinician in the affluent public school setting

This article explores problems and pitfalls confronting the mental health clinician working within a highly affluent public school setting. The special resources which affluent families bring to the assessment and treatment process are noted. Coping styles specific to very affluent and educated families are discussed which are brought into play in response to school dysfunction in a member and which can prove problematic for alliance building and effective intervention. Countertransference responses are discussed that relate to the particular status of the mental health clinician working as a member of the school staff with a wealthy client population. Bases for enhancing effectiveness are discussed, including recognition and management of countertransferance issues.