This Web site is a component of the SAMHSA Health Information Network
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Section 3: Status of Mental Health Services at the MillenniumChapter 7. Mental Health Policy at the Millennium: Challenges and OpportunitiesDavid Mechanic, Ph.D. Institute for Health, Health Care Policy and Aging Research Rutgers, the State University of New Jersey Background The past 50 years have been an extraordinary time for mental health. There have been significant improvements in treatment, public attitudes, and services organization, and enormous growth in mental health insurance coverage, treatment resources, episodes of care, and research of all kinds (Mechanic, 1999). Systems of care have been transformed from largely psychotherapy for the affluent and custodial institutional care for all others to a range of outpatient services, inpatient care in various settings, residential care, and housing alternatives. Mental health care provision, once almost exclusively an activity of State government or fee-for-service private practice, has become an integrated component of health care funded through private and public insurance programs and grants, and appropriations from State, Federal, and local government. State governments that ran most mental health facilities have now substantially reduced their direct role and increasingly are purchasers of care provided by private sector organizations and professionals. The change now transforming mental health care is the rapid introduction and growth of managed behavioral health care and the numerous ways it is shaping the provision of mental health services and the work of mental health professionals. Managed behavioral health care is very much a work in progress and its ultimate outcomes remain unclear. It offers considerable potential to better organize and rationalize services, and bring to them a more evidence-based culture, but it also presents risks, threatening innovation and appropriate provision of care. These risks seem particularly large for persons with severe and persistent mental illnesses who are more difficult to treat and who may lose ground with the "democratization of care" that occurs under managed behavioral health care (Mechanic & McAlpine, 1999). In beginning a new century, it is important to look back at both the gains and the unanticipated consequences of mental health policy, and the implications they have for what lies ahead. Health organization and policy never arise anew. They evolve from prior culture and understandings, health care arrangements, health professional organizations, and political and economic processes. Mental health has been shaped as much by cultural changes and major social policies designed with other populations in mind as by the efforts of persons working in the mental health field itself. These changes and policies include the broader economic, political, and legal ideologies and influences that supported deinstitutionalization of persons with mental illness and those with other types of disabilities; the introduction of major national health insurance programs such as Medicaid and Medicare, which stimulated the development of new facilities, professionals, and incentives; and Social Security Disability Insurance and Supplemental Security Income (SSI), which facilitated community residence and subsistence. In the past several decades, there were advances in drugs and other technologies, in ways of managing patients within community programs, and in increased consumer involvement and public acceptance. Taking advantage of these changes, however, requires an appropriate institutional framework for financing, organization, and delivery, which are highly dependent on macro social policy. As we proceed into a new century, mental health policy and services remain areas with considerable controversy. There have been significant research advances and improvements in treatment, but experts continue to disagree on the nature of mental illness and what dysfunctions are diseases in a medical sense and which are extensions of normal distress. The longstanding debate on the extent to which mental disorders are discrete categorical conditions or part of a broad continuum also persists. Underlying differences in perspective then link to philosophical and public policy questions such as the degree to which persons with mental disorders should be held responsible for their behavior and the tradeoffs between coercion and liberty in decisions about involuntary treatment. These perspectives also affect broader public reactions such as stigmatization and discrimination against persons with mental illness and the willingness of the public to support the necessary investments to close the gaps between unmet need and treatment. This chapter is organized around six areas: deinstitutionalization; improved treatment technologies; the larger societal context and debates concerning parity; the legal context; managed behavioral health care; and the growth of consumer involvement. In each case, tensions are evident in seeking the appropriate balance among contending interests, philosophies, and research perspectives. For each major point, there are counterpoints reflecting the continuing struggle over defining the appropriate domains of mental disorder and the distribution of responsibilities among the Federal Government, State and local governments, the nonprofit and private sectors, the helping professions, and persons with mental illness and their families. Deinstitutionalization The most enduring change in the post World War II period has been the deinstitutionalization of persons with mental illness (Grob, 1994), a trend now continuing under managed care arrangements (Mechanic, 1998a). Many factors contributed to this movement including social ideologies, the introduction of new drugs, changing social attitudes toward persons with mental illness and toward institutional care, the desire to reduce State government expenditures, litigation on behalf of persons with mental illness, and public welfare programs that made it possible to house and provide income support and other services to clients with disabilities in the community (Mechanic, 1999). Managed care maintains the deinstitutionalization trend, continuing to reduce inpatient care. It is potentially an instrument to better allocate care; but, in managing costs, it also reduces expenditures for purchasers and allows profits for private companies and their stockholders, thus reducing the funding available for direct service provision. Public mental hospitals have been reduced or downsized from 560,000 resident patients in 1955 to fewer than 60,000 clients today, despite sizable population growth. Most acute inpatient care is now in general hospitals; and although case-mix and comorbidity are more complex, average length of stay has fallen steadily to less than 10 days, and continues to fall. In the period 1988 to 1994, some 12.5 million days were reduced in mental hospital care with only small compensation in days of care in the general hospital sector (Mechanic, McAlpine, & Olfson, 1998). The introduction of managed care in the private sector has reduced expenditures of some large corporate purchasers by as much as 3040 percent, with most of these reductions achieved by large reductions in average length of stay (Feldman, 1998; Mechanic & McAlpine, 1999). There is much debate on the consequences of such changes with allegations that care has significantly deteriorated, that patients are being discharged from hospitals "quicker and sicker," and that persons floridly ill are discharged to homelessness, neglect, victimization, and violent encounters (Isaac & Armat, 1990). Problems in care are common and are attributable to the deficiency of community services and the difficult task of providing the supervision and care available in hospitals, particularly to uncooperative clients, in dispersed settings in the community. Undesirable outcomes are inevitable when supervision is relaxed for high-risk patient populations. There are many deficiencies in access to and the comprehensiveness of community care, but allegations concerning the failures of deinstitutionalization ignore the large social and human costs of alternative policies (Mechanic, 1999). The traditional custodial mental hospital ruined many lives. But many communities, even now, have yet to develop the networks of community services essential to an effective system of deinstitutionalized care. Nevertheless, the evidence is overwhelming that most clients are immeasurably better off in the deinstitutionalized care system than they ever could be in mental hospitals. It remains less clear, however, whether reduced hospitalization has been too extensive and is now introducing unacceptable risks to persons with complex mental health needs. One significant criticism of the extent of deinstitutionalization is that it has contributed to "criminalization" of persons with mental illness. The extent of such criminalization is difficult to assess because of increased inclusion of deviant behavior within psychiatric categories and particularly the inclusion of substance abuse and antisocial behavior. Arrests commonly involve such behavior (Hiday, 1999). The jail and prison population has grown substantially and now includes many persons who have Diagnostic and Statistical Manual (DSM) disorders, but it is difficult to determine how large a change this is from prior periods when such disorders were not recognized or defined as such. Nevertheless, the freedom of community life, the fragmentation of service systems, easy availability and use of substances, and the unavailability of hospital beds for other than short-term acute care make it inevitable that many persons with serious mental illness in the community will, at some time, face arrest. A Justice Department study estimated that in midyear 1998, there were more than 280,000 persons with mental illness in jails and prisons, and more than a half million more on probation (Ditton, 1999). Although the methods used to assess and count mental illnesses were crude, the findings suggest the magnitude of the problem. Many of the violations committed for which people were incarcerated occurred under the influence of alcohol and drugs, and persons with substance abuse comorbidities are involved disproportionately in instances of violent behavior (Steadman et al., 1998). The substantially increased pattern of substance use and abuse associated with severe mental illness in the community poses serious treatment and management problems. Also, persons with mental illness in prisons have more difficulty with prison life and are more likely to get into fights and commit other rule violations (Ditton, 1999). Some persons with mental illness have committed serious and violent crimes and require secure detention. But many are in jails and prisons by virtue of community neglect and lack of appropriate treatment. Others have repeatedly committed nuisance offenses and are jailed only for short periods, sometimes as "compassionate arrests" to get them off the streets and out of dangerous situations. Nevertheless, the criminalization of their behavior reinforces stigmatization that is already a barrier to community support and care, and complicates relationships with family, caretakers, and the community. As we begin a new century, the decriminalization of mental illness and provision of a safe and appropriate environment for those who must remain in detention will have to be addressed more intensively. Avoiding criminalization will require aggressive and effective community care services and diversion programs that appropriately reroute patients into mental health systems of care. Improved mental health services in jails and prisons also are needed. Collaboration between the mental health and criminal justice systems always has been difficult and the complications of managed care contracting will not make it easier. Different cultures and priorities impose barriers to effective communication and collaboration. The fundamental challenge is to fulfill the promises of deinstitutionalization policies faithfully by developing well-organized and balanced systems of community care with a broad spectrum of services and clear focus of responsibility and accountability. Such services must include assertive case management; sophisticated medication management; attention to housing, work, and needed social supports; substance abuse education and treatment; and many more. After several decades, we are finally seeing more States and localities developing assertive community treatment teams for those with more serious and persistent conditions. Managed behavioral health care was believed to have the incentives to create more balanced systems of care within a deinstitutionalized system, but this potential is yet to be demonstrated (Mechanic, 1998b; Mechanic & McAlpine, 1999). Improving Treatment Technologies A second major change in the later decades of the past century was the introduction of new approaches to investigate the scientific bases of mental illness and the application of tools from molecular biology, genetics, behavioral science, epidemiology, and health services research (U.S. Department of Health and Human Services, 1999). New imaging technologies have made it possible to directly track changes in the brain and to potentially use such observations for specific targeting of drugs. Although the payoffs from this sophisticated scientific infrastructure development are yet to be realized, the scientific advances set the stage for substantially improved understanding and treatment in the new century. The scientific approach to mental illness has become more sophisticated and rigorous and the standards for evidence have been elevated. After many decades of psychoanalytic dominance and facile theorizing, research models and standards for evidence have tightened significantly. Psychiatry as a profession has moved closer to medicine, investigation has accelerated on the biological dimensions of psychiatric disorders, and research collaboration among disciplines in psychiatry and the behavioral sciences is more common. Randomized controlled trials have become the gold standard in evaluating interventions and there is a greater focus on evidence-based practice. There has also been growing realization that research results obtained under highly controlled conditions in research centers with carefully selected patients cannot necessarily be generalized to the unwieldy patterns of practice in the community. There now is increased attention to the gap between efficacy studies and effectiveness of practice. Moreover, health services research studies show significant failures to provide the treatments that are best supported by research evidence (Lehman & Steinwachs, 1998; Wells, Sturm, Sherbourne, & Meredith, 1996), and it is inevitable that overcoming barriers and developing strategies for dissemination and implementation will be high on our agenda in the coming decades. Although we have yet to have fundamental advances in drug therapy, the medications now available for treatment of schizophrenia, depression, and other major mental illnesses have improved. Newer drugs such as selective serotonin reuptake inhibitors (SSRIs) and atypical antipsychotics appear generally to be no more efficacious than earlier medications, but they have fewer side effects and are tolerated more easily, facilitating medication adherence and improved outcomes. The unwillingness of many persons with serious mental illness to continue on their medications constitutes one of the most serious obstacles to effective management and will continue to be a major focus of attention in treatment and research. The availability of a larger range of medications also facilitates treatment because patients have atypical and unpredictable responses to medications, and more options increases the probability of identifying compatible treatments. In schizophrenia, patients unresponsive to other drugs often respond remarkably well to clozapine, which has become an important backup treatment for patients who fail on the more commonly used medications. Although the thrust of pharmaceutical development and marketing has been on the specificity of drug action, there is ample evidence that many of the common medications affect a range of seemingly different disorders (Healy, 1997). Mental health services research also has demonstrated the advantages of a variety of psychosocial management approaches from assertive community treatment to family psycho-education (Lehman & Steinwachs, 1998). These social technologies have been more difficult to disseminate than new medications, and services studies show that most patients who can benefit still do not receive such treatment (Lehman & Steinwachs, 1998; Young, Sullivan, Burnam, & Brook, 1998). Nevertheless, there has been growing appreciation of the importance of these management approaches and slow but increasing adoption. Assertive community treatment is accepted widely as the best available approach for managing severe and persistent illness in the community. We can anticipate more energy devoted to implementation and further study of the type and intensity of management that best fits varying client populations. As we begin a new century, our hopes and expectations are high, but our understanding of the major mental illnesses is still limited. Our tools and approaches for studying these problems are improved, but history teaches us that it is easy to make claims of being on the threshold (Grob, 1998). A certain modesty is needed, as well as a willingness to be open to new conceptualizations, theories, methods, and approaches. The DSM is an important example. Developed as a descriptive convenience to help standardize scientific work and practice and to improve communication, DSM has been reified by many practitioners and decisionmakers in ways that are not constructive. Inconsistent with its own conceptual view of mental illness, and probably greatly overinclusive (Regier et al., 1998; Wakefield 1997, 1996), DSM is no more than a convenient instrument and should not be used as a standard to limit research on alternative approaches. It introduces and reinforces conceptions of greater specificity of mental disorders than can be validated empirically (Healy, 1997). The profusion of diagnostic entities probably partly explains the degree of comorbidity reported in most studies. Views of mental illness and mental health policy have cycled widely over the years between biological and social conceptions, often exaggerated at both extremes. This cycling occasionally is useful as a strategy because it helps move a particular line of research forward. However, research on mental illness is served poorly by disciplinary parochialism. Most of the mental illnesses have to be understood in a multicausal context requiring consideration of biology, social structures, human development, and social processes. Science policy in the future should enable such cross-disciplinary fertilization and cooperation. Given the many uncertainties that continue to characterize treatment of mental disorders, there is concern with the present focus on biological aspects and the preference of managed care for medication treatments over psychotherapy, counseling, or other modalities. Such direct approaches as interpersonal psychotherapy and rehabilitation approaches remain important as alternative treatments or as adjuncts to medication. They often are fundamental to facilitating greater personal comfort, improved social function, and higher quality of life. Mental Illness and Mental Health Policy in a Societal Context The prevalence of mental illness varies substantially among nations and among various social and cultural groups within countries, regions, and communities (Dohrenwend et al., 1992; Weissman et al., 1996). The occurrence of some mental illnesses, such as schizophrenia, is more invariant than most, but even rates of schizophrenia will vary substantially among some subgroups (Bhugra et al., 1997; Harrison et al., 1997). Some of the environmental contributors to some mental illnesses may include nutrition, birth practices, infections, and epidemics; but the causal factors and how they interact with genetic and other biological risk factors remain unknown. Major depression and substance abuse, two of the most common mental disorders, are very much influenced by social and cultural factors, and factors in individuals' lives and relationships (Brown & Harris, 1978; Horwitz & Scheid, 1999). Socioeconomic status has one of the strongest associations with the prevalence of mental disorders (Dohrenwend et al., 1992; Eaton & Muntaner, 1999) as well as many physical conditions, but the causal pathways involved are complex, multidimensional, and incompletely understood (Amick, Levine, Tarlov, & Walsh, 1995; Dohrenwend et al., 1992; Link & Phelan, 1995; Wilkinson, 1996). Nevertheless, it is reasonably clear that social structures make their mark on the occurrence of psychiatric morbidity through class, culture, and gender. Although the relationship between social structure and mental illness has been observed for 100 years or more, there is now renewed interest in how social structures might be modified to reduce disability and improve health (Benzeval, Judge, & Whitehead, 1995). Although there is much research on contributory factors such as helplessness, fatalism, social support, coping, and the like (Horwitz & Scheid, 1999), it remains uncertain how such understanding can be translated usefully into efforts to improve mental health, especially in the case of the major mental illnesses. Yet, there are many good research leads that require further development (Mrazek & Haggerty, 1994). The Uninsured, Undertreatment, and Unmet Need More apparent is the continuing evidence that most persons with mental illness remain untreated (Kessler et al., 1994; McAlpine & Mechanic, 2000), that those who are treated often receive inappropriate and incorrect treatment (Wells et al., 1996; Lehman & Steinwachs, 1998), and that mental disorders remain highly stigmatized and neglected. Social policies have a major role in making treatment available. Persons with serious and persistent mental illness remain perhaps the most disadvantaged and neglected group in our society and suffer from the failures of American health care policy. The United States remains the only major nation in the world without universal health insurance. In the past decade, despite a growing and highly successful economy, the number of uninsured persons has grown (Kronick & Gilmer, 1999). Persons with serious mental illness are disproportionately uninsured (McAlpine & Mechanic, 2000). Many others with health insurance have only very limited coverage for mental health and substance abuse services, which typically are not available on the same basis as other types of care and limited by more deductibles, coinsurance, and caps (Buck, Teich, Umland, & Stein, 1999; Mechanic & McAlpine, 1999). The Parity Issue In recent years there has been growing interest in parity of mental health with other medical services. Legislative efforts have been made at both State and Federal levels, but the concept of parity varies from one context to another and the level of legislative intervention varies a great deal as well. The underlying idea of parity is that the same range and comprehensiveness of insurance benefits available for other illnesses should apply as well to persons with mental illness and substance abuse problems. There is a growing political constituency for parity among influential consumer groups and some politicians, and we are likely to see continuing efforts in the future. A major concern to policy-makers has been the cost of parity, since research indicates that some mental health services (particularly psychotherapy) are more responsive to insurance coverage than other types of medical services (Frank & McGuire, 1986; McGuire, 1981). Parity in a managed care context is more palatable because cost can be held readily in check through managed care strategies and the additional premium costs required for more complete mental health coverage appear to be modest (Goldman, McCulloch, & Sturm, 1998; Sturm, 1997). Moreover, some influential consumer groups like the National Alliance for the Mentally Ill (NAMI) would restrict the application of parity to the major mental illnesses, conditions they refer to as diseases of the brain. Nevertheless, there are serious issues with the application of the parity concept, particularly as it affects persons with serious and persistent mental illness, and numerous issues remain unresolved. First, managed care purports to provide "all necessary services" (Mechanic, 1998a), but many of the services required by persons with serious mental illness are excluded from "medical necessity" definitions. Indeed, more than half the expenditures required for persons in the community with severe mental illness are usually not covered by conventional health insurance (Hollingsworth & Sweeney, 1997). Thus, benefit designs cannot depend on vague definitions of medical necessity and need to be clearly specified. This may involve services not typically problematic in the treatment of persons with physical illness, such as assistance in becoming adequately housed. It should be noted, however, that many of these sociomedical services become more commonly needed with population aging and the management of chronic disease and disability. Second, because standards of mental health care are less clear than for surgical and medical treatment, such care seems to be managed in a more rigorous way with much larger reductions of treatment requested by physicians (Mechanic & McAlpine, 1999; Wickizer & Lessler, 1998). Moreover, there is evidence that while the management process seems to provide a nominal mental health service to more people than typically found in fee-for-service practice, those with the greatest need and disadvantage receive less intense services. Decision processes seem not sufficiently sensitive to the seriousness and complexity of illness, and patients with the most severe illnesses appear to do less well under present management arrangements as compared to fee-for-service practice (Mechanic, 1998b, 1999). Inclusion of parity for mental health services within a "medical necessity" definition has no real meaning if services are not reasonably accessible, appropriate, and of high quality (Mechanic & McAlpine, 1999). There is still a great deal to learn about these management processes and their relationship to quality of care. Good evidence on the effects of managed care on the severely and persistently ill population is difficult to obtain because varied outcomes have to be assessed over reasonably long periods and few studies do this. The Difficulty of Establishing Boundaries for Mental Health Coverage Many policymakers, while sympathetic to the idea that persons with mental illness should have access to treatment comparable to those with other types of disorders, worry about opening the flood-gates to increased utilization and costs. The appeal of managed care and the idea of using a "medical necessity" definition is that tight controls are in place to manage potential overutilization. We now have a large number of clinicians from many disciplines and professions prepared to offer reimbursed services for persons with mental illness. It is well established that a major determinant of utilization and costs is the supply of reimbursable services available and, thus, without some form of gatekeeping, utilization could expand in irrational and costly ways. There are a number of alternative solutions. One form of control is to have different levels of cost-sharing depending on the service and the extent of moral hazard. Thus, services like diagnostic assessment, medication management, and inpatient care may have lower cost-sharing than psychotherapy, a service that often is attractive to persons with lesser disorders, for existential and self-realization reasons. This approach is unpopular with such professions as psychology and social work, which provide much of the psychotherapy. A common approach, based on the notion that persons with more severe conditions should receive priority, is to restrict the definition of conditions covered by the parity concept to several of the major mental disorders such as schizophrenia, major depression, and bipolar disorders. These are typically referred to by proponents as "diseases of the brain" and distinguished from other disorders which presumably are not. This distinction, while practical, may be both too inclusive and too exclusive. It is unclear that all of the more serious disorders usually suggested for coverage are "disease of the brain" except in the trivial sense that all behavior is mediated by the brain. Nor is it evident that some seemingly less serious conditions are not. Many conditions that would be excluded under these suggested definitions are painful and seriously interfere with function. Many may, indeed, offer opportunities for improved outcomes that are comparable or better than outcomes achieved in the case of the most serious mental illnesses (Mrazek & Haggerty, 1994). As we look toward a fairer system of health insurance, we require the application of tools that allow us to assess the cost-effectiveness of alternative interventions, while remaining sensitive to other community values as well (Ubel, 2000). The Legal Context of Mental Health Services In the 1970's, legal activists in mental health almost "made a revolution" (Appelbaum, 1994) around a range of issues including right to treatment, right to refuse treatment, involuntary commitment, and least restrictive alternatives, among others. After a flurry of turmoil, disputes abated and these contentious matters reached a certain equilibrium. A variety of new legal issues of large import are now emerging and are likely to have an important impact on future mental health services. One new potential instrument is the Americans with Disabilities Act (ADA) and the U.S. Supreme Court decision in Olmstead vs. L. C. which required the State of Georgia to provide community care to persons with mental illnesses and mental retardation who could function in such less restrictive settings without placing an undue burden on the State or requiring that the State establish a particular type of program. The decision was sufficiently qualified to be uncertain about its ultimate reach, but the ADA adds an additional instrument through which persons with mental illness and their advocates can challenge arrangements and programs that limit their opportunity for fuller community participation. Lawyers representing persons with mental illness also are using ADA to challenge discrimination in health insurance (Moss, Ullman, Starrett, Burris, & Johnsen, 1999). The litigation of earlier decades was focused on increasing the rights of persons with mental illness and reducing coercive controls. Current legal approaches, in contrast, are more focused on developing mechanisms that support deinstitutionalization by imposing more controls on living in the community. Outpatient commitment or other conditions for remaining in the community are more common today, despite difficult legal dilemmas, as a way of inducing patients who are at risk to maintain contact with treatment programs and to take their medications (Torrey & Kaplan, 1995). Here, the threat of hospitalization may be a significant deterrent to noncooperation, although the legal basis for imposing limits on freedom in the community is more debatable and contested. A recent study of outpatient commitment in New York found that outpatient commitment had some success in reducing subsequent hospital readmissions, but the effects were explained by the intensity of service provision (Swartz et al., 1999). The effects, thus, came not from the legal intervention itself but from the fact that the intervention was linked to providing more services to clients. The underlying issue is the quality and intensity of the services available to clients in the community. The Challenges of Managed Behavioral Health Care About three-quarters of Americans with health insurance are now under some form of managed behavioral health program. Although there are complaints about managed behavioral health care, particularly with respect to access to specialty services, and intensity of care, the industry has demonstrated its capacity to reduce private sector costs considerably without much evidence of impairing care (Mechanic, 1999). One of the advantages of behavioral health care carve-out arrangements is that they tend to give more people access to at least some specialty mental health services than occurs under the fee-for-service system. Intensity of care is much reduced, however, particularly regarding inpatient services and extensive psychotherapy (Mechanic, 1998b; Mechanic & McAlpine, 1999). A significant limitation of carve-outs is the lack of coordination between mental health and substance abuse services, and other medical services. Even mental health and substance abuse may be separately carved out with prescriptions involving still another carve-out. The fragmentation of care and boundary problems that occur can be substantial; but, thus far, there is little evidence that integrated care is a high priority. The ideal of integrated care is widely endorsed, but, with current pressures on clinicians, the realities of high-quality integrated care are challenging. Despite several decades of effort in attempting to make primary care clinicians more receptive to and skilled at providing mental health services, their performance in recognizing and treating psychiatric illness remains limited (Mechanic, 1997; Wells et al., 1996). Carve-outs, whatever their limitations, organize providers of care who are interested in behavioral health problems and experienced in managing them. One significant advantage of managed behavioral health care is the opportunity to introduce practice standards and guidelines in a systematic way. Studies of quality care repeatedly indicate poor performance as measured by the scientific evidence about appropriate treatment of even such major conditions as schizophrenia and major depression. Managed behavioral health care has the potential to bring practice more in line with the evidence base. If managed behavioral health care was working successfully, we would expect a close relationship between intensity of care and severity of illness and disability, and evidence of substitution of care when more intensive treatments are reduced. Unfortunately, there is little evidence in support of these expectations (Mechanic & McAlpine, 1999). The role of managed behavioral health care for populations of those more severely and persistently ill is problematic and uncertain in the future. The idea of managing care is hardly new for this population it typically has been served by public programs with scarce resources and the need to make allocations carefully. Over several decades, mental health professionals and administrators in the public sector in many States developed a broad community support structure that fit the wide range of needs of persons with serious mental illnesses in the community. To the extent that States shift this responsibility to private managed care companies, which have little experience managing the needs of such highly disadvantaged populations, the outcomes become more uncertain. States have had varying experiences with managed care for persons with serious mental illness; but it is not clear that the private sector has an appropriate infrastructure in place for such care and, if it does, whether it can profit from providing such management. There are some indications that managed behavioral health care companies are backing off public contracts for the psychiatrically disabled population, and States, too, are being cautious. Managed care is a work in progress, and patterns of management change fairly quickly. Thus, it is difficult to know how this sector will evolve, what adaptations it will make as it gains experience, or whether it will survive in its present forms. Managed care in the general medical sphere has been highly adaptive in response to public criticism, and has increased access to specialty care and made other changes consistent with consumer concerns. It has sought to reduce tensions resulting from utilization management by shifting risk to provider groups so that utilization review could be relaxed. There has been little such transfer of risk in behavioral health and little confidence that provider groups would know how to manage such risk. Thus, almost all reductions of cost have come from reduced inpatient care and negotiated reductions in rates. With increased competition, capitation payments have been driven to levels that make one skeptical that an appropriate pattern of care can be maintained, particularly after administrative costs and profits are extracted from the system of care. The Growth of Consumer Involvement One of the remarkable changes in mental health services has been the increasing involvement of consumer groups that play an important advocacy and political role, and that have developed a wide range of self-help and informal care services (Kaufmann, 1999). Many of the consumer services are consumer-run or administered by professionals committed to an empowerment philosophy that regards consumers as members rather than clients. These various groups may have different philosophies and ideologies, view mental health differently, have different treatment preferences, and often compete in their advocacy. Both the Federal and State governments have worked with these advocacy and consumer groups and have supported their development. The informal and self-help sectors are a very significant component of the system of mental health services (Kessler et al., 1999). The National Mental Health Association (NMHA) dates back to Clifford Beers and the mental hygiene movement early in the century. NAMI an organization less than 25 years old has also become a highly influential mental health advocacy group. NAMI's membership of about 210, 000 includes persons with mental illness and their family members. The organization has built a powerful State and Federal constituency that lobbies extensively; partners with professionals, researchers, and advocates; carries out extensive communications and educational programs; and sponsors its own research program. While NAMI's membership is diverse, the organization strongly endorses a focus on the most serious mental disorders. NAMI's political agenda is to support biomedical and health services research funding, parity in health care coverage, and improved care for persons with mental illness. NAMI has formed strategic alliances with members of Congress and the Executive branch and with many key policymakers in the States. As a federation of local organizations, NAMI provides support to its local AMIs who in many States are quite effective in promoting legislative initiatives. NAMI is sometimes at odds with other mental health organizations and groups that favor different priorities. Although NAMI, at times, has been highly critical of mental health professionals, it opposes groups who reject the idea of mental illnesses as diseases and who reject medication. NAMI supports the use of civil commitment and more forceful interventions in opposition to liberty advocates. NAMI also sometimes comes into conflict with NMHA on the range of conditions to be included in mental health legislation and on the priority the NMHA gives to preventive efforts and public education. In the inevitable conflicts between persons with mental illnesses and their families, NAMI generally advocates for families and for means of reducing their burden in caring for a relative with mental illness. The empowerment philosophy advocated by clubhouses such as Foundation House and by consumer- administered self-help programs and drop-in centers also sometimes comes into conflict with NAMI philosophy. There is no single viewpoint that pervades these programs, and clubhouses modeled after Fountain House may be quite different from one another or consumer-run services. But in some instances members adopt an antipsychiatry and antimedication view. They also commonly side with members in conflict with families. We know little definitively about the value of mental health consumer-run services, but both theory and research suggest that empowerment can be a powerful influence on how clients view themselves and their quality of life (Rosenfield, 1992). The best known of all self-help efforts is Alcoholics Anonymous (AA) and its 12-step program. Twelve-step programs are now widely used in formal treatment settings as well as by community groups. With the increasing use of alcohol and drugs, "double trouble" groups appear to be growing. They offer persons with mental illness a more supportive environment for maintaining their medications than traditional AA groups. One significant problem in behavioral health advocacy is the conflict among groups advocating for attention for different disorders such as mental illness, alcoholism, substance use disorder, and developmental disabilities. The lack of more united advocacy limits mental health efforts relative to other important disease advocacy organizations. A New Century Much is uncertain about the future of mental health services. A few observations are quite firm, however. First, although there is much wishful thinking and rhetoric about advances, there remains a great deal we do not know. Many mental disorders remain intractable, and treatment is still often on a hit-or-miss basis. How soon advances in neuroscience and molecular genetics will bring new and more effective treatments remains uncertain. Second, there is considerable evidence that the treatments we do have are not well distributed because of insurance limitations, public stigma, lack of patient choice, and professional ignorance. The failure to use our existing science base and research evidence must be high on the agenda as we begin this new century. The evidence is that we do much better at disseminating new drug treatments than behavioral programs, but even in the drug area, current practice is seriously deficient. Again, it is important to understand that the future of mental health treatment is as likely to depend on policy decisions outside the mental health sector as within it. Perhaps most important is whether our Nation can move to a system of universal access to care and whether the benefit design covers those services that we know are invaluable for persons with serious mental disorders. Such community care will also depend on the strength of public social supports such as those dealing with income maintenance, housing, work rehabilitation, and the like. It will also depend on community attitudes, feelings of safety, and levels of tolerance. In the past several decades, American society has changed dramatically in its view of persons with disabilities. These individuals now participate in all aspects of community life. The passage and implementation of the ADA reinforce these changes and break new ground for further advances for full participation. Prominent individuals who have struggled with mental illnesses, including authors, politicians, celebrities, sports figures, and others, are now more likely to publicly acknowledge and discuss what were previously deeply held secrets. Many more people are now willing to seek treatment, and mental health care is more respectable among general physicians. Nevertheless, mental illness remains stigmatized and discrediting, and public perceptions still remain punitive relative to other disabling conditions. This is particularly true of persons with psychoses and those with substance abuse disorders. In the latter case, provision of treatment is particularly inadequate, with long waiting lists for access to treatment and punitive official policies. Persons with substance disorders are commonly seen as the "undeserving sick" in the public eye (Mechanic, 1999). Study of history tells us that social policy does not progress in a linear fashion and often moves in cycles of advance and retrogression. Thus, it is impossible to foresee how the tensions relating to the identification and treatment of persons with mental illness may play out in the future. Few observers anticipated that 40 years after implementing an ideological victory to replace custodial mental health care with a community public health approach, we would have to address the problem of hundreds of thousands of persons with mental illness in jails, in prisons, or on probation and the large numbers of homeless persons with mental illness seen on the streets of all our large cities. Yet, the vast majority of persons with mental illnesses today lead better lives, get more effective treatment, and are less stigmatized than in the past. 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