The Department of Health and Human Services (2002)
estimates that 56 million Americans have a diagnosable
mental illness. Furthermore, mental illnesses or
serious emotional disturbances impair daily activities
for an estimated 10 million adults and 4 million children
and adolescents. For example, attention deficit/
hyperactivity disorder affects 3% to 5% of school-age
children. More than 10 million children younger than
7 years grow up in homes where at least one parent
suffers from significant mental illness or substance
abuse, which hinders the readiness of these children
to start school. The economic burden of mental
care costs and lost productivity, exceeds $170 billion
(Department of Health and Human Services [DHHS],
2002). Four of the ten leading causes of disability in the
United States and other developed countries are mental
disorders: major depression, bipolar disorder, schizophrenia,
and obsessive-compulsive disorder (NIMH,
2002). Yet only one in four adults and one in five children
and adolescents in need of mental health services
get the care they need.
Some believe that deinstitutionalization has had
negative as well as positive effects (Torrey, 1997).
Although deinstitutionalization reduced the number
of public hospital beds by 80%, the number of admissions
to those beds correspondingly increased by 90%
(Appleby & Desai, 1993). Such findings have led to
the term revolving door effect. While people with severe and persistent mental illnesses have shorter
hospital stays, they are admitted to hospitals more
frequently. The continuous flow of clients being admitted
and discharged quickly overwhelms general
hospital psychiatric units. In some cities, emergency
department visits for acutely disturbed persons have
increased by 400% to 500%.
Shorter hospital stays further complicate frequent,
repeated hospital admissions. People with
severe and persistent mental illness may show signs
of improvement in a few days but are not stabilized.
Thus they are discharged into the community without
being able to cope with community living. The result
frequently is decompensation and rehospitalization.
In addition, many people have a “dual” problem
of both severe mental illness and substance abuse.
Use of alcohol and drugs exacerbates symptoms of
mental illness, again making rehospitalization more
likely. Substance abuse issues cannot be dealt with
in the 3 to 5 days typical for admissions in the current
managed care environment.
Many providers believe today’s clients to be more
aggressive than those in the past. Four to eight percent
of clients seen in psychiatric emergency rooms
are armed (Ries, 1997), and people with severe and
persistent mental illness who are not receiving adequate
care commit about 1,000 homicides per year
(Torrey, 1997). Ten to fifteen percent of those in state
prisons have severe and persistent mental illness
(Lamb & Weinberger, 1998).
Homelessness is a major problem in the United
States today. The Department of Health and Human
Services (2002) estimates that 750,000 people live
and sleep in the streets. Estimates of the prevalence of mental illness among the homeless population are
that one-third of adult homeless persons have a serious
mental illness and more than one-half also have
substance abuse problems (DHHS, 2002). Those who
are homeless and mentally ill are found in parks, airport
and bus terminals, alleys and stairwells, jails,
and other public places. Some use shelters, halfway
houses, or board-and-care rooms; others rent cheap
hotel rooms when they can afford it (Haugland et al.,
1997). Homelessness worsens psychiatric problems
for many people with mental illness who end up on
the streets, which contributes to a vicious cycle.
Many problems of the homeless mentally ill, as
well as those who pass through the revolving door of
psychiatric care, stem from the lack of adequate community
resources. Money saved by states when state
hospitals were closed has not been transferred to
community programs and support. Inpatient psychiatric
treatment still accounts for most of the spending
for mental health in the United States, so community
mental health has never been given the
financial base it needs to be effective. In addition,
mental health services provided in the community
must be individualized, available, and culturally relevant
to be effective (Lamb & Bachrach, 2001). Only 15% of people with mental illness appear to be getting
minimally adequate treatment, which is a prescription
for medication and four or more visits with
a psychiatrist or eight visits with any kind of mental
health specialist (Wang, 2002).
In 1993, the federal government created and
funded Access to Community Care and Effective Services
and Support (ACCESS) to begin to address
the needs of people with mental illness who were
homeless either all or part of the time. The goals of
ACCESS were to improve access to comprehensive
services across a continuum of care, reduce duplication
and cost of services, and improve the efficiency
of services (Randolph et al., 1997). Programs such as
these provide services to people who otherwise would
not receive them.
