What is the National Mental Health Act (1946) (US)?

Introduction

The National Mental Health Act (1946) became law on 03 July 1946. It established and provided funds for a National Institute of Mental Health (NIMH).

An Act to amend the Public Health Service Act to provide for research relating to psychiatric disorders and to aid in the development of more effective methods of prevention, diagnosis, and treatment of such disorders, and for other purposes.

Background

The act made the mental health of the people a federal priority. It was inspired by alarm at the poor mental health of some draftees and veterans, and was demanded by veterans and their families. When veterans who were under stress during the war were later studied they displayed a high incidence of earlier mental health illness, completely aside from the problems that might have arisen from combat and wartime situations of high pressure.

Through the National Mental Health Act and the NIMH, a new form of diagnosis and treatment was created to better help those facing mental health problems. It was discovered during this time that mental health patients benefited more from evaluation and treatment rather than being institutionalized. The act redirected financing from the state level to a national level, and placed the NIMH as a leader for further research and analysis on the brain and psychiatric disorders.

In other words, wartime pressures had stirred up repressed mental illness in the soldiers, who were a representative statistical sample of the general population, gender aside. The government realised it had a very serious problem on its hands – a population with a high incidence of mental health illness and therefore should take care of it immediately via government intervention, aiming to cut off future social pathologies.

The Menninger brothers set about training analysts, to fill the vacuum that existed at that time.

Brief History

The act was first introduced by Congress in March, 1945, as the National Neuropsychiatric Institute Act. The name ultimately made its way to “Mental Health” to capture the importance of World War II and the problems associated with veterans returning from war.

Robert Felix, a psychiatrist appointed as director of the Public Health Service’s (PHS) Division of Mental Hygiene in 1944, did much work to try to pass the bill. William Menninger, Lawrence Kubie, and others helped Felix by testifying about how the lack of trained professionals in the field of mental health sometimes thwarted military morale and how intervening earlier rather than later actually helped the military in the long run by conserving personnel. They believed that if veterans received federal help and support through preventive services, professional training, and research they would transition back into post-war life quicker and easier. In addition, organisations like Mental Health America that advocated for changes in the psychiatric field helped push legislation towards action.

Before the act was passed, during World War II, there was a severe shortage of professionals in the mental health field, and advanced treatment and understanding of psychiatric disorders lagged behind the increasing numbers of problems in veterans returning from the war. This provided the foundation for the act and the reasoning behind it.

After the act was passed, many discoveries and breakthroughs regarding mental health diagnosis and treatment were made. These new drugs and treatments improved the lives of those previously suffering from psychosis and delusion, and were a result of the new funding and federal support that came from the National Mental Health Act of 1946.

What is the National Institute of Mental Health?

Introduction

The National Institute of Mental Health (NIMH) is one of 27 institutes and centres that make up the National Institutes of Health (NIH). The NIH, in turn, is an agency of the United States Department of Health and Human Services and is the primary agency of the United States government responsible for biomedical and health-related research.

NIMH is the largest research organisation in the world specialising in mental illness. The institute was first authorised by the US government in 1946, when then President Harry Truman signed into law the National Mental Health Act, although the institute was not formally established until 1949.

NIMH is a $1.5 billion enterprise, supporting research on mental health through grants to investigators at institutions and organisations throughout the United States and through its own internal (intramural) research effort. The mission of NIMH is “to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure.”

In order to fulfil this mission, NIMH “must foster innovative thinking and ensure that a full array of novel scientific perspectives are used to further discovery in the evolving science of brain, behavior, and experience. In this way, breakthroughs in science can become breakthroughs for all people with mental illnesses.”

Research Priorities

NIMH has identified four overarching strategic objectives for itself:

  • Promote discovery in the brain and behavioural sciences to fuel research on the causes of mental disorders.
  • Chart mental illness trajectories to determine when, where and how to intervene.
  • Develop new and better interventions that incorporate the diverse needs and circumstances of people with mental illnesses.
  • Strengthen the public health impact of NIMH-supported research.

Brief History

Organisational History

Throughout its history the NIMH has witnessed a number of name and organisational changes, including:

  • PHS Narcotics Division (1929-1930).
  • PHS Division of Mental Hygiene (1930-1943).
  • Mental Hygiene Division, within the PHS Bureau of Medical Services (1943-1949).
  • National Institute of Mental Health (NIMH), one of the National Institutes of Health (NIH, 1949-1967).
  • NIMH as an independent division of the PHS (1967-1968).
  • NIMH, within the Health Services and Mental Health Administration (1968-1973).
  • NIMH, within NIH (1973).
  • NIMH, within the Alcohol, Drug Abuse, and Mental Health Administration (1973-1992).
  • NIMH, within NIH (1992-present).

In 1992, when the Alcohol, Drug Abuse, and Mental Health Administration was abolished, NIMH was transferred to NIH, retaining its research functions while its treatment services were transferred to the new Substance Abuse and Mental Health Services Administration.

Functions

Mental health has traditionally been a state responsibility, but after World War II there was increased lobbying for a federal (national) initiative. Attempts to create a National Neuropsychiatric Institute failed. Robert H. Felix, then head of the Division of Mental Hygiene, orchestrated a movement to include mental health policy as an integral part of federal biomedical policy. Congressional subcommittees hearings were held and the National Mental Health Act was signed into law in 1946. This aimed to support the research, prevention and treatment of psychiatric illness, and called for the establishment of a National Advisory Mental Health Council (NAMHC) and a National Institute of Mental Health. On 15 April 1949, the NIMH was formally established, with Felix as director. Funding for the NIMH grew slowly and then, from the mid-1950s, dramatically. The institute took on a highly influential role in shaping policy, research and communicating with the public, legitimising the importance of new advances in biomedical science, psychiatric and psychological services, and community-based mental health policies.

In 1955 the Mental Health Study Act called for “an objective, thorough, nationwide analysis and re-evaluation of the human and economic problems of mental health.” The resulting Joint Commission on Mental Illness and Health prepared a report, “Action for Mental Health”, resulting in the establishment of a cabinet-level interagency committee to examine the recommendations and determine an appropriate federal response.

In 1963, Congress passed the Mental Retardation Facilities and Community Mental Health Centres Construction Act, beginning a new era in Federal support for mental health services. NIMH assumed responsibility for monitoring the Nation’s community mental health centres (CMHC) programmes.

During the mid-1960s, NIMH launched a campaign on special mental health problems. Part of this was a response to President Lyndon Johnson’s pledge to apply scientific research to social problems. The institute established centres for research on schizophrenia, child and family mental health, suicide, as well as crime and delinquency, minority group mental health problems, urban problems, and later, rape, aging, and technical assistance to victims of natural disasters.

Alcohol abuse and alcoholism did not receive full recognition as a major public health problem until the mid-1960s, when the National Centre for Prevention and Control of Alcoholism was established as part of NIMH; a research program on drug abuse was inaugurated within NIMH with the establishment of the Centre for Studies of Narcotic and Drug Abuse.

In 1967, NIMH separated from NIH and was given bureau status within PHS. However, NIMH’s intramural research program, which conducted studies in the NIH Clinical Centre and other NIH facilities, remained at NIH under an agreement for joint administration between NIH and NIMH. Secretary of Health, Education, and Welfare John W. Gardner transferred St. Elizabeth’s Hospital, the Federal Government’s only civilian psychiatric hospital, to NIMH.

In 1968, NIMH became a component of PHS’s Health Services and Mental Health Administration (HSMHA).

In 1970 the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act (P.L. 91-616) established the National Institute of Alcohol Abuse and Alcoholism within NIMH.

In 1972, the Drug Abuse Office and Treatment Act established a National Institute on Drug Abuse within NIMH.

In 1973, NIMH went through a series of organisational moves. The institute temporarily re-joined NIH on 01 July with the abolishment of HSMHA. Then, the DHEW secretary administratively established the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) – composed of the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and NIMH – as the successor organisation to HSMHA. ADAMHA was officially established in 1974.

The President’s Commission on Mental Health in 1977 reviewed the mental health needs of the nation and to make recommendations to the president as to how best meet these needs in 1978.

In 1980 The Epidemiologic Catchment Area (ECA) study, an unprecedented research effort that entailed interviews with a nationally representative sample of 20,000 Americans was launched. The field interviews and first wave analyses were completed in 1985. Data from the ECA provided a picture of rates of mental and addictive disorders and services usage.

The Mental Health Systems Act of 1980 – based on recommendations of the President’s Commission on Mental Health and designed to provide improved services for persons with mental disorders – was passed. NIMH participated in development of the National Plan for the Chronically Mentally Ill, a sweeping effort to improve services and fine-tune various Federal entitlement programs for those with severe, persistent mental disorders.

In 1987, administrative control of St. Elizabeth’s Hospital was transferred from the NIMH to the District of Columbia. NIMH retained research facilities on the grounds of the hospital. The NIMH Neuroscience Centre and the NIMH Neuropsychiatric Research Hospital, located on the grounds of St. Elizabeth’s Hospital, were dedicated in 1989.

In 1992, Congress passed the ADAMHA Reorganisation Act, abolishing ADAMHA. The research components of NIAAA, NIDA and NIMH re-joined NIH, while the services components of each institute became part of a new PHS agency, the Substance Abuse and Mental Health Services Administration (SAMHSA). The return to NIH and the loss of services functions to SAMHSA necessitated a realignment of the NIMH extramural program administrative organisation. New offices were created for research on Prevention, Special Populations, Rural Mental Health and AIDS.

In 1994 The House Appropriations Committee mandated that the director of NIH conduct a review of the role, size, and cost of all NIH intramural research programmes (IRP). NIMH and the National Advisory Mental Health Council (NAMHC) initiated a major study of the NIMH Intramural Research Programme. The planning committee recommended continued investment in the IRP and recommended specific administrative changes; many of these were implemented upon release of the committee’s final report; other changes – for example, the establishment of a major new programme on Mood and Anxiety Disorders – have been introduced in the years since.

In 1996 NIMH, with the NAMHC, initiated systematic reviews of a number of areas of its research portfolio, including the genetics of mental disorders; epidemiology and services for child and adolescent populations; prevention research; clinical treatment and services research. At the request of the National Institute for Mental Health director, the NAMH Council established programmatic groups in each of these areas. NIMH (National Institute of Mental Health) continued to implement recommendations issued by these Workgroups.

In 1997, NIMH realigned its extramural organisational structure to capitalise on new technologies and approaches to both basic and clinical science, as well as changes that had occurred in health care delivery systems, while retaining the Institute’s focus on mental illness. The new extramural organisation resulted in three research divisions: Basic and Clinical Neuroscience Research; Services and Intervention Research; and Mental Disorders, Behavioural Research and AIDS.

Between 1997 and 1999 NIMH refocused career development resources on early careers and added new mechanisms for clinical research.

In 1999 The NIMH Neuroscience Centre/Neuropsychiatric Research Hospital was relocated from St. Elizabeth’s Hospital in Washington, D.C. to the NIH Campus in Bethesda, Maryland, in response to the recommendations of the 1996 review of the NIMH (National Institute of Mental Health) Intramural Research Programme by the IRP Planning Committee.

The first White House Conference on Mental Health, held 07 June, in Washington, D.C., brought together national leaders, mental health scientific and clinical personnel, patients, and consumers to discuss needs and opportunities. The National Institute on Mental Health developed materials and helped organise the conference.

US Surgeon General David Satcher released The Surgeon General’s Call To Action To Prevent Suicide, in July, and the first Surgeon General’s Report on Mental Health, in December. NIMH, along with other federal agencies, collaborated in the preparation of both of these landmark reports.

Since the appointment of Thomas R. Insel as Director of NIMH in 2002, the institute has undergone organisational changes to better target mental health research needs (the expansion from three extramural divisions to five divisions, with the two new divisions focusing on adult and child translational research). NIMH also weathered several years of controversy due to conflict of interest and ethics violations by some of its intramural investigators. This situation cast light on an area that affected all of NIH, and resulted in more stringent rules about conflict of interest for all of NIH. Recently, Congressional interest turned to ethics and conflict of interest concerns with external investigators who receive NIMH or other NIH support. Current federal law has responsibility for managing and monitoring conflict of interests for external investigators with their home institutions/organisations. NIH responded to these new concerns by initiating a formal process for seeking public input and advice that will likely result in a change to the rules for monitoring and managing conflict of interest concerns for externally supported investigators. Finally, the past decade has also been marked by exciting scientific breakthroughs and efforts in mental illness research, as new genetic advances and bioimaging methodologies have increased understanding of mental illnesses. Two notable consequences of these advances are the Institute’s collaboration with the Department of Army to launch the Study To Assess Risk and Resilience in Service Members (STARRS), a Framingham-like effort scheduled to last until 2014 and the Research Domain Criteria (RDoC) effort, which seeks to define basic dimensions of functioning (such as fear circuitry or working memory) to be studied across multiple levels of analysis, from genes to neural circuits to behaviours, cutting across disorders as traditionally defined.

A collection of interviews with directors and individuals significant in the foundation and early history of the institute conducted by Dr. Eli A. Rubenstein between 1975 and 1978 is held at the National Library of Medicine in Bethesda, Maryland.

Noted Researchers

In 1970, Julius Axelrod, a NIMH researcher, won the Nobel Prize in Physiology or Medicine for research into the chemistry of nerve transmission for “discoveries concerning the humoral transmitters in the nerve terminals and the mechanisms for their storage, release and inactivation.” He found an enzyme that terminated the action of the nerve transmitter, noradrenaline in the synapse and which also served as a critical target of many antidepressant drugs.

In 1960s-70s John B. Calhoun, ethologist and behavioural researcher studied the population density and its effects on behaviour in the NIMH facility in Maryland. Later his work become renowned after several publications, including article in Scientific American and a widely known “Universe 25” story predicting anti-utopian future based on rodent experiments in overpopulated environment.

In 1984, Norman E. Rosenthal, a psychiatrist and NIMH researcher, pioneered seasonal affective disorder, coined the term SAD, and began studying the use of light therapy as a treatment. He received the Anna Monika Foundation Award for his research on seasonal depression.

Louis Sokoloff, a NIMH researcher, received the Albert Łasker award in Clinical Medical Research for developing a new method of measuring brain function that contributed to basic understanding and diagnosis of brain diseases. Roger Sperry, a NIMH research grantee, received the Nobel Prize in Medicine or Physiology for discoveries regarding the functional specialisation of the cerebral hemispheres, or the “left” and “right” brain.

Eric Kandel and Paul Greengard, each of whom have received NIMH support for more than three decades, shared the Nobel Prize in Physiology or Medicine with Sweden’s Arvid Carlsson. Kandel received the prize for his elucidating research on the functional modification of synapses in the brain. Initially using the sea slug as an experimental model but later working with mice, he established that the formation of memories is a consequence of short and long-term changes in the biochemistry of nerve cells Greengard was recognised for his discovery that dopamine and a number of other transmitters can alter the functional state of neuronal proteins, and also that such changes could be reversed by subsequent environmental signals.

Nancy Andreasen, a psychiatrist and long-time NIMH grantee, won the National Medal of Science for her groundbreaking work in schizophrenia and for joining behavioural science with neuroscience and neuroimaging. The Presidential Award is one of the nation’s highest awards in science.

Aaron Beck, a psychiatrist, received the 2006 Albert Lasker Award for Clinical Medical Research. Often called “America’s Nobels”, the Laskers are the nation’s most distinguished honour for outstanding contributions to basic and clinical medical research. Beck developed cognitive therapy – a form of psychotherapy – which transformed the understanding and treatment of many psychiatric conditions, including depression, suicidal behaviour, generalised anxiety, panic attacks and eating disorders.

In 2010, Mortimer Mishkin was awarded the National Medal of Science. Mishkin is chief of the NIMH’s Section on Cognitive Neuroscience, and acting chief of its Laboratory of Neuropsychology. He is the first NIMH intramural scientist to receive the medal. Due in part to work spearheaded by Mishkin, science now understands much about the pathways for vision, hearing and touch, and about how those processing streams connect with brain structures important for memory.

What is a Community Mental Health Service?

Introduction

Centre for Mental Health Services, also known as community mental health teams (CMHT) in the United Kingdom, support or treat people with mental disorders (mental illness or mental health difficulties) in a domiciliary setting, instead of a psychiatric hospital (asylum). The array of community mental health services vary depending on the country in which the services are provided. It refers to a system of care in which the patient’s community, not a specific facility such as a hospital, is the primary provider of care for people with a mental illness. The goal of community mental health services often includes much more than simply providing outpatient psychiatric treatment.

Community services include supported housing with full or partial supervision (including halfway houses), psychiatric wards of general hospitals (including partial hospitalisation), local primary care medical services, day centres or clubhouses, community mental health centres, and self-help groups for mental health.

The services may be provided by government organisations and mental health professionals, including specialised teams providing services across a geographical area, such as assertive community treatment and early psychosis teams. They may also be provided by private or charitable organisations. They may be based on peer support and the consumer/survivor/ex-patient movement.

The World Health Organisation (WHO) states that community mental health services are more accessible and effective, lessen social exclusion, and are likely to have fewer possibilities for the neglect and violations of human rights that were often encountered in mental hospitals. However, WHO notes that in many countries, the closing of mental hospitals has not been accompanied by the development of community services, leaving a service vacuum with far too many not receiving any care.

New legal powers have developed in some countries, such as the United States, to supervise and ensure compliance with treatment of individuals living in the community, known as outpatient commitment or assisted outpatient treatment or community treatment orders.

Brief History

Origins

Community mental health services began as an effort to contain those who were “mad” or considered “lunatics”. Understanding the history of mental disorders is crucial in understanding the development of community mental health services. As medical psychology developed as a science and shifted toward the treatment of the mentally ill, psychiatric institutions began to develop around the world, and laid the groundwork for modern day community mental health services.

Pre-Deinstitutionalisation

On 03 July 1946, US President Harry Truman signed the National Mental Health Act which, for the first time in the history of the United States, generated a large amount of federal funding for both psychiatric education and research. The passing of this Act eventually led to the founding of the National Institute of Mental Health (NIMH) in 1949. At the end of the 1940s and moving into the beginning of the 1950s, the governor of Minnesota Luther Youngdahl initiated the development of numerous community-based mental health services. He also advocated for the humane treatment of people in state institutions.

Deinstitutionalisation

Philippe Pinel played a large role in the ethical and humane treatment of patients and greatly influenced Dorothea Dix. Dix advocated the expansion of state psychiatric hospitals for patients who were at the time being housed in jails and poor houses. Despite her good intentions, rapid urbanisation and increased immigration led to a gross overwhelming of the state’s mental health systems and because of this, as the 19th century ended and the 20th century began, a shift in focus from treatment to custodial care was seen. As quality of care declined and psychotropic drugs were introduced, those with mental illnesses were reintroduced to the community, where community mental health services were designated as primary care providers.

Mental Health Movements

Reform MovementEraSettingFocus of Reform
Moral Treatment1800-1850AsylumHumane, restorative treatment
Mental Hygiene1890-1920Mental hospital or clinicPrevention, scientific orientation
Community Mental Health1955-1970Community mental health centreDeinstitutionalisation, social integration
Community Support1975-PresentCommunitiesMental illness as a social welfare problem (e.g. treatment housing, employment, etc.)

Post-Deinstitutionalisation

Following deinstitutionalisation, many of the mentally ill ended up in jails, nursing homes, and on the streets as homeless individuals. It was at this point in history that modern community mental health services started to grow and become influential. In 1955, following a major period of deinstitutionalisation, the Mental Health Study Act was passed. With the passing of this Act, the US Congress called for “an objective, thorough, nationwide analysis and re-evaluation of the human and economic problems of mental health.” Following Congress’ mandate, the Joint Commission on Mental Illness conducted numerous studies. For the next four years this Commission made recommendations to establish community mental health centres across the country. In 1963, the Community Mental Health Centres Act was passed, essentially kick-starting the community mental health revolution. This Act contributed further to deinstitutionalisation by moving mental patients into their “least restrictive” environments. The Community Mental Health Centres Act funded three main initiatives:

  • Professional training for those working in community mental health centres;
  • Improvement of research in the methodology utilised by community mental health centres; and
  • Improving the quality of care of existing programmes until newer community mental health centres could be developed.

That same year the Mental Retardation Facilities and Community Mental Health Centres Construction Act was passed. President John F. Kennedy ran part of his campaign on a platform strongly supporting community mental health in the United States. Kennedy’s ultimate goal was to reduce custodial care of mental health patients by 50% in ten to twenty years. In 1965, the Community Mental Health Act was amended to ensure a long list of provisions. First, construction and staffing grants were extended to include centres that served patients with substance abuse disorders. Secondly, grants were provided to bolster the initiation and progression of community mental health services in low-SES areas. Lastly, new grants were established to support mental health services aimed at helping children. As the 20th century progressed, even more political influence was exerted on community mental health. In 1965, with the passing of Medicare and Medicaid, there was an intense growth of skilled nursing homes and intermediate-care facilities that alleviated the burden felt by the large-scale public psychiatric hospitals.

20th Century

From 1965 to 1969, $260 million was authorised for community mental health centres. Compared to other government organisations and programmes, this number is strikingly low. The funding drops even further under Richard Nixon from 1970-1973 with a total of $50.3 million authorised. Even though the funding for community mental health centres was on a steady decline, deinstitutionalisation continued into the 1960s and 1970s. The number of state and county mental hospital resident patients in 1950 was 512,501 and by 1989 had decreased to 101,402. This continuing process of deinstitutionalisation without adequate alternative resources led the mentally ill into homelessness, jails, and self-medication through the use of drugs or alcohol. In 1975, Congress passed an Act requiring community mental health centres to provide aftercare services to all patients in the hopes of improving recovery rates. In 1980, just five years later, Congress passed the Mental Health Systems Act of 1980, which provided federal funding for ongoing support and development of community mental health programmes. This Act strengthened the connection between federal, state, and local governments with regards to funding for community mental health services. It was the final result of a long series of recommendations by Jimmy Carter’s Mental Health Commission. Despite this apparent progress, just a year after the Mental Health Systems Act was passed, the Omnibus Budget Reconciliation Act of 1981 was passed. The Omnibus Act was passed by the efforts of the Reagan administration as an effort to reduce domestic spending. The Act rescinded a large amount of the legislation just passed, and the legislation that was not rescinded was almost entirely revamped. It effectively ended federal funding of community treatment for the mentally ill, shifting the burden entirely to individual state governments. Federal funding was now replaced by granting smaller amounts of money to the individual states. In 1977, the National Institute of Mental Health (NIMH) initiated its Community Support Program (C.S.P.). The C.S.P.’s goal was to shift the focus from psychiatric institutions and the services they offer to networks of support for individual clients. The C.S.P. established the ten elements of a community support system listed below:

  • Responsible team.
  • Residential care.
  • Emergency care.
  • Medicare care.
  • Halfway house.
  • Supervised (supported) apartments.
  • Outpatient therapy.
  • Vocational training and opportunities.
  • Social and recreational opportunities.
  • Family and network attention.

This conceptualisation of what makes a good community programme has come to serve as a theoretical guideline for community mental health service development throughout the modern-day United States psychological community. In 1986, Congress passed the Mental Health Planning Act of 1986, which was a Federal law requiring that at the state government level, all states must have plans for establishing case management under Medicaid, improving mental health coverage of community mental health services, adding rehabilitative services, and expanding clinical services to the homeless population. More specifically, community mental health providers could now receive reimbursement for services from Medicare and Medicaid, which allowed for many of the centres to expand their range of treatment options and services. As the 1990s began, many positive changes occurred for people with mental illnesses through the development of larger networks of community-based providers and added innovations with regards to payment options from Medicare and Medicaid. Despite these advancements, there were many issues associated with the increasing cost of health care. Community mental health services moved toward a system more similar to managed care as the 1990s progressed. Managed care as a system focuses on limiting costs by one of two means: either keeping the total number of patients using services low or reducing the cost of the service itself. Despite the drive for community mental health, many physicians, mental health specialists, and even patients have come to question its effectiveness as a treatment. The underlying assumptions of community mental health require that patients who are treated within a community have a place to live, a caring family, or supportive social circle that does not inhibit their rehabilitation. These assumptions are in fact often wrong. Many people with mental illnesses, upon discharge, have no family to return to and end up homeless. While there is much to be said for the benefits that community mental health offers, many communities as a whole often harbour negative attitudes toward those with mental illnesses. Historically, people with mental illnesses have been portrayed as violent or criminal and because of this, “many American jails have become housing for persons with severe mental illnesses arrested for various crimes.” In 1999 the Supreme Court ruled on the case Olmstead v. L.C. The Court ruled that it was a violation of the Americans with Disabilities Act of 1990 to keep an individual in a more restrictive inpatient setting, such as a hospital, when a more appropriate and less restrictive community service was available to the individual.

21st Century and Modern Trends

In 2002, President George W. Bush increased funding for community health centres. The funding aided in the construction of additional centres and increased the number of services offered at these centres, which included healthcare benefits. In 2003, the New Freedom Commission on Mental Health, established by President Bush, issued a report. The report was in place to “conduct a comprehensive study of the United States mental health delivery system…” Its objectives included assessing the efficiency and quality of both public and private mental health providers and identifying possible new technologies that could aid in treatment. As the 20th century came to a close and the 21st century began, the number of patients diagnosed with a mental health or substance abuse disorder receiving services at community mental health centres grew from 210,000 to approximately 800,000. This nearly four-fold increase shows just how important community mental health centres are becoming to the general population’s wellbeing. Unfortunately, this drastic rise in the number of patients was not mirrored by a concomitant rise in the number of clinicians serving this population. The staggering new numbers of patients then are being forced to seek specialised treatment from their primary care providers or hospital emergency rooms. The unfortunate result of this trend is that when a patient is working with their primary care provider, they are more likely for a number of reasons to receive less care than with a specialised clinician. Politics and funding have always been and continue to be a topic of contention when it comes to funding of community health centres. Political views aside, it is clear that these community mental health centres exist largely to aid areas painfully under resourced with psychiatric care. In 2008, over 17 million people utilised community mental health centres with 35% being insured through Medicaid, and 38% being uninsured. As the 2000s continued, the rate of increase of patients receiving mental health treatment in community mental health centres stayed steady.

Purpose and Examples

Cultural knowledge and attitude is passed from generation to generation. For example, the stigma with therapy may be passed from mother to daughter. San Diego county has a diverse range of ethnicities. Thus, the population diversity in San Diego include many groups with historical trauma and trans-generational trauma within those populations. For example, witnesses of war can pass down certain actions and patterns of survival mechanism to generations. Refugee groups have trans-generational trauma around war and PTSD. Providing services and therapy to these communities is important because it affects their day-to-day lives, where their experiences lead to trauma or the experiences are traumatic themselves. Knowledge and access to mental health resources are limited in these multicultural communities. Government agencies fund community groups that provide services to these communities. Therefore, this creates a power hierarchy. If their missions do not align with each other, it will be hard to provide benefits for the community, even though the services are imperative to the wellbeing of its residents.

The combination of a mental illness as a clinical diagnosis, functional impairment with one or more major life activities, and distress is highest in ages 18-25 years old. Despite the research showing the necessity of therapy for this age group, only one fifth of emerging adults receive treatment. Psychosocial interventions that encourage self-exploration and self-awareness, such as acceptance and mindfulness-based therapies, is useful in preventing and treating mental health concerns. At the Centre for Community Counselling and Engagement, 39% of their clients are ages 1-25 years old and 40% are in ages 26-40 years old as well as historically underrepresented people of colour. The centre serves a wide range of ethnicities and socio-economic statuses in the City Heights community with counsellors who are graduate student therapists getting their Master’s in Marriage and Family Therapy or Community Counselling from San Diego State University, as well as post-graduate interns with their master’s degree, who are preparing to be licensed by the state of California. Counselling fees are based on household incomes, which 69% of the client’s annual income is $1-$25,000 essentially meeting the community’s needs. Taking into account of San Diego’s population, the clinic serves as an example of how resources can be helpful for multicultural communities that have a lot of trauma in their populations.

Future

On one hand, despite the field’s movement toward community mental health services, currently “insufficient empirical research exists regarding the effectiveness of community treatment programmes, and the evidence that does exist does not generalise to all types of community treatment.” In addition to the fact that community mental health’s overall success must be further evaluated, in the times when it has proved effective, very little research exists to help in understanding what exact aspects make it effective. Effective and insightful research will be crucial in not only evaluating, but also improving the techniques community mental health utilises. On the other hand, the demand for and necessity of community mental health is driving it into the future. With this seemingly unrelenting increase in the number of people experiencing mental health illnesses and the number of people reporting these problems, the question becomes what role community mental health services will play. In 2007, almost 5% of adults in the United States reported at least one unmet need for mental health care. Funding has historically been and continues to be an issue for both the organisations attempting to provide mental health services to a community and the citizens of the community who are so desperately in need of treatment. The community mental health system’s goal is an extremely difficult one and it continues to struggle against changing social priorities, funding deficits, and increasing need. Community mental health services would ideally provide quality care at a low cost to those who need it most. In the case of deinstitutionalisation, as the number of patients treated increased, the quality and availability of care went down. With the case of small, private treatment homes, as the quality of the care went up their ability to handle large numbers of patients decreased. This unending battle for the middle ground is a difficult one but there seems to be hope. For example, the 2009 Federal Stimulus Package and Health Reform Act have increased the funding for community health centres substantially. Undoubtedly as community mental health moves forward, there will continue to be a juggling act between clinical needs and standards, political agendas, and funding.

Developing the Capacity for a New Generation of Implementation Studies in Mental Health

Research Paper Title

Capacity-building and training opportunities for implementation science in mental health.

Background

This article traces efforts over the past decade by the National Institute of Mental Health, of the US National Institutes of Health, and other US organisations to build capacity for mental health researchers to advance activities in implementation science.

The authors briefly chronicle the antecedents to the field’s growth, and describe funding opportunities, workshop and conferences, training programmes, and other initiatives that have collectively engaged hundreds of mental health researchers in the development and execution of implementation studies across the breadth of contexts where mental health care and prevention programs are delivered to those in need.

The authors summarise a number of key initiatives and present potential next steps to further build the capacity for a new generation of implementation studies in mental health.

Reference

Chambers, D.A., Pintello, D. & Juliano-Bult, D. (2020) Capacity-building and training opportunities for implementation science in mental health. Psychiatry Research. doi: 10.1016/j.psychres.2019.112511. Epub 2019 Aug 9.