Community Psychiatry

Related Fields

Various and possibly confusing terms are (imprecisely) used interchangeably with the term community psychiatry (e.g., social psychiatry, community mental health, public psychiatry, and population-based psychiatry ). The theory of social psychiatry accentuates the sociocultural aspects of mental disorders and their treatments. Research to advance this theory views psychiatry and psychological features as variables to predict, describe, and mediate the expression of social problems. Community psychiatry is a clinical application of this theory with the mandate to develop an optimal care system for a given population with finite resources. Clearly, goal achievement entails working with individuals, groups, and systems, but that is the extent of agreement (in the field and over time) on the appropriate emphasis, boundaries, core services, and guiding principles of community psychiatry. The following quoted definitions hint at this lack of consensus:

“… the body of knowledge, theories, methods and skills in research and service required by psychiatrists who participate in organized community programs for the promotion of mental health and the prevention, treatment and rehabilitation of the mental disorders in a population.” “… focusing on the detection, prevention, early treatment, and rehabilitation of emotional disorders and social deviance as they develop in the community rather than as they are encountered at large, centralized psychiatric facilities.” “… subspecialty area in which psychiatrists deliver mental health services to populations defined by a common workplace, activity, or geographical area of residence.” “… responsible for the comprehensive treatment of the severely mentally ill in the community at large. All aspects of care—from hospitalization, case management, and crisis intervention, to day treatment, and supportive living arrangements—are included.”

Community mental health (CMH), as defined by the Community Mental Health Center (CMHC) Acts of 1963 (Public Law 88-164) and 1965 (Public Law 89-105), was envisioned to be an inclusive, multi-disciplinary, systemic approach to publicly funded mental health services provided for all in need, residing in a given geographical locale (i.e., catchment area), without consideration of ability to pay. Catchment (from sanitation engineering: a cistern into which the sewage of a defined area is dumped) refers to a CMH service area with a population of 75,000 to 200,000. Public psychiatry, a system of government-funded inpatient and outpatient services also initially conceived to meet the needs of all, has actually narrowed its focus on the seriously mentally ill who are unable to access appropriate services in the “private” sector (e.g., as fee-for-service, or as paid by third-party insurance). A trend to privatize (i.e., to put out to private sector bid with government oversight) the public sector services threatens to further confuse the definition and blur the public/private distinction. In population-based psychiatry, the population may be defined by geography, or by any of a number of other attributes (e.g., payer, employer, guild, or care system). However the population is defined, the system (e.g., a health maintenance organization [HMO]) is accountable for all members, as well as for an individual seeking treatment.

Social and Public Health Terms

Deinstitutionalization was a sociopolitical and economic trend to discharge long-term psychiatric inpatients to live and receive services in the community. More appropriately called de hospitalization (or trans institutionalism ), patients were merely maintained in non-hospital institutional settings. This trend was evident, however, long before the term (and such associated terms as policy or movement ) ever appeared in the psychiatric literature, which suggests the convergence of multiple precipitants, but no formal, purposeful, or driving policy.

The public health model describes three levels of prevention. Primary prevention is concerned with measures to decrease the new onset (incidence) of disease (e.g., causative agent eradication, risk factor reduction, host resistance enhancement, and disease transmission disruption). Such measures, highly effective in the realms of infectious disease, toxins, deficiency states, and habit-induced chronic illnesses (e.g., lung and heart diseases), are less efficacious in the psychiatric realm where the non-intervention outcome is less predictable. Nonetheless, putative programs and clinical activities of primary prevention include anticipatory guidance (e.g., for parents with young children), enrichment and competence-building programs (e.g., Head Start, Outward Bound), social support or self-help programs for at-risk individuals (e.g., bereavement groups), and early or crisis intervention following trauma (e.g., on-site student counseling after a classmate's suicide). Secondary prevention is concerned with measures to decrease the number of disease cases in a population at a given point in time (prevalence) by early discernment (case finding) and timely treatment to shorten the course and to minimize residual disability. An educational campaign and screening for peripartum depression would be a psychiatric example of secondary prevention. Tertiary prevention is concerned with measures to decrease the prevalence and severity of residual disease-related defect or disability. Because optimal function in the setting of serious psychiatric illness is so allied with adherence to treatment, examples of tertiary prevention in psychiatry would include case management and other measures to promote continuous care and treatment.

Case, or care, managers (usually social workers or mental health clinicians) assist in the patient's negotiation of a fragmented, complex system of agencies, providers, and services, with the goal of care being continuity and coordination through better inter-provider communication. Obviously, patients with more, and more complex, needs also require more intensive care management. The greater the intensity of the management needs, the fewer cases a manager can adequately handle. The care manager is the member of the treatment team who follows the patient through all care levels (e.g., inpatient, aftercare, residential), types (e.g., mental health, substance use, physical health), and agencies or services (e.g., housing, welfare, public entitlements).

Terms of Managed Care

Not to be confused with care management, managed care, primarily a cost-containment strategy, manages payment for care of a population through monitoring of services allocated to members of the specified population. Prior authorization, primary care provider (PCP) specialty referral (i.e., a gatekeeper system), and concurrent (or utilization) review are strategies commonly employed to manage health care expenditure. They are also increasingly recognized as vehicles to coordinate care, to gather evidence for best practices, to promote development of alternative levels of care, and to monitor treatment outcomes. Managed care organizations (MCOs) have proliferated to provide this service for public and private insurers. Contracts between insurers and MCOs may include penalties for exceeding the service budget or financial incentives to hold service payments within a fixed budget. Health care costs have long been a concern of both providers and recipients of health care, but managed care has imposed the payer's interests into the doctor–patient relationship. While critics believe this has negatively affected the therapeutic process, proponents believe it has promoted greater transparency, standardization, and evidence-based care (and possibly paved the way for numerous pay-for-performance [P4P] initiatives ).

HMOs, a type of MCO, generally contract for global health care services for a specified population by paying the provider a set amount, based on a rate (i.e., cap) per member, per month (i.e., capitation). Capitation plans have spurred initiatives to develop coordinated and collaborative systems of cost-effective, high-quality care, to maintain a high standard of overall health for the entire (covered) population. However, some MCOs, including capitated plans, separate the benefit management of physical health from mental health and substance use (i.e., “behavioral health [BH]”) services: that is, such plans “carve out” BH benefit management. Companies that manage only these carved-out benefits are called managed behavioral health organizations (MBHOs). The advent of carve-outs set the stage for cost-shifting, which is changing the care site (e.g., medical unit versus psychiatric unit) and thereby shifting the cost of care (e.g., from the physical health capitation pool to the mental health capitation pool). This may or may not affect the overall quality or cost of the care, but it shifts the financial burden from (in this example) MCO to MBHO. This split-pot arrangement is antithetical to the collaborative efforts incentivized by single (i.e., global) cap programs. Cost-shifting also occurs between other care/payer systems, such as state and federal (e.g., moving patients from state-funded hospitals to the community where they are eligible for federal subsidies and entitlements), public and private (e.g., privatization shifts the risk for burgeoning BH care costs from states to MCOs or MBHOs), and mental health to physical health (e.g., when patients bypass the mental health system and seek services in the physical health care system either for their mental health problems or for vague somatic complaints). Some also argue that cost-shifting occurs from BH to correctional system because the disenfranchised (e.g., the seriously mentally ill, the dually diagnosed, and substance users) may receive consistent care only when incarcerated.

A cadre of oversight and accrediting agencies has evolved to ensure that MCOs balance their focus on cost containment with quality of care. The National Committee for Quality Assurance (NCQA), the largest such accrediting body for MCOs, includes accreditation standards for MBHOs, as well as for the BH portion of non-carve-out MCOs. NCQA standards address accessibility and availability of appropriate, culturally-sensitive services, coordination between BH and physical health care services, communication between all care providers, and disease management/preventive health services. Both over- and under-utilization of services must be managed to ensure that patients receive care appropriate to their needs. MCOs are also required to have a straightforward grievance and appeal process for patients when the MCO (or its MBHO) initially denies a request for care or particular services. Another form of oversight, the Federal Interim Final Rule Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAE) of 2008 (Interim Final Rule on Parity) states, in general terms, that BH benefits may not be managed more restrictively than a plan's physical health benefits, “except to the extent that recognized clinically appropriate standards of care may permit a difference.” To the extent that NCQA appreciates the difference between BH and physical health care, entities who meet NCQA standards should also continue to meet the requirements of the Parity Law.

The Age of Enlightenment

The “first psychiatric revolution” occurred late in the eighteenth century when French alienist (i.e., psychiatrist), Philippe Pinel, endorsed physical work and fresh air to return the mentally ill to a state of mental health and well-being. Moral treatment dawned as Pinel released the insane from their shackles. By the early nineteenth century, the movement had found its way to the US, where Dorothea Dix promoted the development of village-style asylums for the mentally ill to retreat from the stresses of daily living. The government-funded construction of institutions for the behaviorally deviant and mentally ill.

By the end of the century, however, these institutions and asylums were hopelessly run-down and overcrowded. In concert with the Industrial Revolution (focused on organization and productivity), moral treatment was replaced by custodial care and regimentation, and a wave of neglect. Even worse, however, was the onslaught of unproven, unbeneficial, and possibly harmful somatic therapies. Among these “scientific” treatments, only two were found to have merit for select patients. Many institutionalized patients actually suffered from the general paretic form of tertiary neurosyphilis, which was found to resolve with the high fevers of malaria. Patients with conversion (and possibly other) disorders were helped by Freud and his disciples, who used psychological understanding in their treatment.

Early Twentieth-century Awareness

Urbanization of the Industrial Revolution spurred the preventive, public health movement, a necessity for sanitation and infection control. This was paralleled by the mental hygiene movement promoted by the writings of Adolph Meyer on prevention and the social context of mental illness. In 1908, Clifford Beers exposed the deplorable conditions inside mental institutions in his first-person account of living in one. Beers joined forces with Meyer and William James to found the National Association for Mental Health, in 1909. The mental hygiene movement advocated for smaller hospitals and the establishment of community-based outpatient evaluation clinics. These clinics (variously viewed as the forerunners or beginnings of community psychiatry ) were less stigmatizing than large state hospitals, and they concentrated on evaluation, prevention, and the differentiation between persistent and acute disorders. They also emphasized inter-disciplinary training, affiliation with medical schools and mainstream medicine, and the use of applied psychodynamic theory and principles.

An extension of the mental hygiene movement, the child guidance movement proposed to apply psychodynamic theory in childhood to prevent the development of adult pathology. However, such assumptions proved difficult to substantiate, leading to apathy and discouragement. This wave of neglect coincided with the Great Depression. Along with dwindling funds, professional in-fighting, and long wait-lists, rigid acceptance criteria led to disillusionment and to abandonment of these programs.

Mid-twentieth Century

The confluence of military experience, pharmacological breakthroughs, and epidemiological research provided the platform for mental health legislation to both advance knowledge and improve care. During World War II, the armed services had difficulty filling the ranks as new recruits were outnumbered by those either rejected or removed from service because of psychiatric casualty. In response, military psychiatrists were urged to lower acceptance standards and to move treatment interventions to the battlefield in an effort to reduce the number of psychiatric evacuees. Coupled with the post-war optimism, three central tenets of community psychiatry were culled from this experience: immediacy, proximity, and expectancy. Briefly stated: treatment should occur without delay, on site, and with the expectation of improvement/resolution. Treatment in, or near, the patient's usual environment decreased the likelihood of secondary gain and the development of avoidance. Far from being custodial, the care system was to support the concept of recovery and to promote the expectation that the patient would return to baseline function.

In 1946, at the pinnacle of custodial care, with over 550,000 state hospital inpatients, Congress passed the National Mental Health Act, approving federal funds for mental health training and research. This Act also founded the National Institute of Mental Health (NIMH) in 1949. Shortly thereafter, chlorpromazine (Thorazine) was first used in the US, with a concomitant decrease in psychotic symptoms and behavioral problems in long-institutionalized state hospital patients. More patients could now be treated at home with chlorpromazine, and they had far superior outcomes (e.g., symptomatic relief, improved cognition, overall function). Also in the mid- to late-1940s, several expository works heightened recognition of the apathy and other damaging effects of prolonged institutional living (e.g., poor social function and self-care skills). The depiction of overcrowded, dehumanizing conditions in large state institutions inspired another surge of public outrage. In 1955, the Mental Health Study Act established the Joint Commission on Mental Illness and Health, providing funds to assess the nation's available treatment services for the mentally ill. By the end of the decade, deinstitutionalization was in full swing, state hospital beds had dwindled to 100,000, and the insufficiency of community resources became glaringly obvious. Long-hospitalized patients, often estranged from their families, lacked the coping and social skills to manage and advocate for themselves outside of the institution. Eighty percent were re-hospitalized within 2 years, a phenomenon called the revolving door policy.

The Joint Commission reported in 1961 on its nation-wide assessment, and it recommended smaller hospitals with greater resources, and funds targeted to improve services for the most severely ill patients (i.e., patients with psychosis and major mental illness). Around this time, several epidemiological studies exposed the prevalence of psychiatric symptomatology and impaired function, pervasive across rural, urban, and suburban populations. At least one study also demonstrated that the population in greatest need had the least access to mental health services.