Mental Health Services: Where are We and Where do We Need to Go?

by Ann Acheson, Ph.D, Research Associate
Margaret Chase Smith Center for Public Policy, University of Maine

Background

Services for the mentally ill in Maine are influenced by a variety of factors. Public awareness and reaction tend to be driven by “newsworthy” events, such as the death of patients while in state-run facilities, jail suicides, or the few well-publicized instances when a mentally ill person harms someone else or themselves. Increased general publicity about special populations can also raise public and legislative awareness, with subsequent investigations, hearings, and sometimes-resultant policy and fiscal changes. For example, a class action suit led to the AMHI consent decree, a judicially enforced plan for developing community-based services for class members (defined as persons who were AMHI patients on or after January 1, 1988). Similar class action suits filed in 1975 and 1994 played an important role in the eventual closure of the Pineland Centered in Pownal; Maine is only the fourth state to do away with placement of persons with developmental disabilities in large institutions such as Pineland.

More recently (2000), Maine’s chapter of the National Alliance for the Mentally Ill (NAMI) prepared a detailed report (http://me.nami.org/jailreport.html) and later follow-up report (2002) on the condition of the mentally ill in Maine’s jail and prison system (http://me.nami.org/jailrpt2002.htm). A recent critical series in the Portland Press Herald (August 18, 19, 20, 2002, http://www.pressherald.com/news/children/) dealing with children’s behavioral and mental health has produced some controversy and an outpouring of responses (for example, a follow-up essay by Maine’s commissioners of the departments of education, human services, public safety, corrections, and behavioral and developmental services, September 22, 2002) (http://www.pressherald.com/viewpoints/mvoice/020922castaway.shtml). Some publicity has also been turned toward problems of homelessness among those with mental illness and/or substance abuse problems, and toward several other populations, such as those with co-occurring disorders (mental illness and mental retardation, mental illness and substance abuse), and to trauma survivors. Some would argue that publicity and class action suits can sometimes drive policy and funding decisions in ways that are detrimental to providing comprehensive, well-planned care to the state’s population at large, potentially leading to an increasing problem of “haves” and “have-nots.”

Certainly funding and provider availability issues are important factors impacting mental health services. Providing insurance “parity” for serious mental health problems can be an important step (http://www.nami.org/Parity.htm), but does not address the broader issue of coverage for the large population of uninsured and underinsured in the state. On the service provision side, Maine is a rural state, and as such suffers disproportionately from a shortage of mental health professionals (Bird, Dempsey and Hartley, 2001, http://muskie.usm.maine.edu/Publications/rural/wp23.pdf). Provision of mental health services often falls to general medical practitioners, with schools also playing an increasing role as more children are diagnosed with (and medicated for) disorders such as ADD/ADHD.

On the state and national level, there are increasing efforts to infuse research results and quality improvement processes into mental health services policy, planning, and resource allocation decisions. Performance-based contracting for state-funded services, and efforts to allocate resources to “evidence-based” service practices are among the current efforts underway in Maine, which will need further attention from policy-makers. For example, under the current administration, the Department of Behavioral and Developmental Services has established a research office, which has served as a catalyst for bringing together a variety of internal and external stakeholders, including university researchers, medical and psychiatric personnel, service providers and service recipients, and members of the Department. One of the primary aims is to support studies that promote use of evidence-based services and outcomes in the planning process.

Issues in mental health services are complex, difficult, and sometimes contentious. At a time of lowered resource availability, the needs of vulnerable populations are difficult to meet in the face of multiple, sometimes conflicting demands. Some of the important areas of concern for mental health services in Maine in the next few years are outlined below, divided into a series of topics, with highlights under each. Space forbids more extensive discussion here, but the references and links provided hopefully will be useful for those who wish to pursue individual topics in greater depth. 

Adult Mental Health

• Affordable housing/homelessness. In many parts of Maine, affordable housing (rentals or home ownership) are beyond the means of average workers. Many mentally ill persons have very limited incomes (often SSI/SSDI), and are at great risk of homelessness. The problem is particularly well publicized in the Portland area, but affects people in all parts of Maine.
• Community supports. While the state has made great progress, and increasing portions of the mental health budget have been shifted from institutional to community services, there is still a long way to go. There are perceived disparities between regions of the state, and between those who are and are not AMHI consent decree class members.
• Acute care. There has been a rise in demand for acute inpatient care, which is putting increasing pressure on BMHI and AMHI, at a time when they have both had a substantial reduction in beds, as well as on the state’s private psychiatric facilities.
• Employment. There is a very high rate of unemployment among the mentally ill, with heavy reliance on disability payments and other forms of public support. Increased opportunities for supported employment, and increased coordination with other branches of state government (e.g., Voc. Rehab.) could help.

Children’s Mental Health

• System coordination. While the creation of the Governor’s “children’s cabinet” and regional children’s cabinets is a step in the right direction, provision of services to children with emotional and behavioral problems suffers from an ongoing problem of system fragmentation and overlap. The Department of Human Services, schools, the Department of Correction, local law enforcement, medical personnel, and mental health and substance abuse service providers are all involved. The system can be confusing and difficult for families to negotiate, at best, and at worst there is the ongoing risk of children and adolescents “falling through the cracks.”
• Community-based and in-home services. As in adult mental health services and in mental retardation services, children’s services are trying to move as rapidly as possible to a system where residential care (in or out of state) is minimized. Financing and organizing such services are ongoing concerns.
• Infant mental health. There is growing awareness of the importance of the earliest stages of development, and the need for appropriate intervention and services for vulnerable individuals and families. (See also: Prevention and Early Intervention, below)

Co-occurring Conditions

• Substance abuse. Large numbers of adults diagnosed with mental illness also have problems with substance abuse, as do increasing numbers of young people.
• Physical health status. Many children and adults with mental illness diagnoses also have diagnosed, or sometimes undiagnosed, physical health problems. Resolving physical health problems can sometimes lead to major improvements in mental health status, in some cases eliminating the need for mental health services.
• Mental retardation. Some persons with mental illness are also diagnosed with mental retardation or developmental disabilities.
• Challenges: Providing the appropriate mix of services to these complex populations is an ongoing problem that needs to be addressed by the mental health, substance abuse, mental retardation, and medical systems.

Mentally Ill Persons in Jails and Prisons

• Jail diversion programs. Persons whose primary problem is mental illness need to receive more adequate community services, so they do not end up in understaffed penal facilities that are not designed for mental health treatment. Some have suggested that deinstitutionalization (reducing the availability of longer term inpatient or residential placements), combined with scarce community resources, has to a “revolving door” situation for the mentally ill in jails and prisons nationally and in Maine.
• Expanded services. More and better mental health services are needed for those who are incarcerated, along with better training for law enforcement and correctional staff regarding the mentally ill.
• Barriers to system change include: budget deficits, philosophical and training differences between systems (corrections and mental health systems), stigma, and the fact that problems cross jurisdictions, in terms of state departments, levels of state government, and legislative committees.
• Improved conditions in penal facilities. Overcrowding, other physical facility problems, and less than humane jail and correctional procedures can exacerbate mental health problems of inmates. Funding, education of staff, and changes in policy and procedures all need to be addressed.

Workforce

• Recruitment, retention, and education. There is a need for increased numbers of mental health professionals, especially in rural areas.
• Ongoing education, support, and cross training. Medical personnel (including physicians, physician extenders, nurses) and other non-mental health staff (e.g. school and homeless shelter personnel) often find themselves in the “front line” of mental health service provision, both for children and adults. Expanding support and education for these staff and practitioners is one way that mental health services can be improved and expanded, even if the number of mental health professionals cannot be substantially increased in particular geographic areas.

Prevention and Early Intervention

• Increase prevention efforts. Mental health services are far behind in terms of prevention activities compared to what is happening in the substance abuse arena. Some general community prevention activities around substance abuse prevention for young people (especially those focused on risk and protective factors) can also impact on mental health, and should be coordinated and expanded. Unfortunately, with the tremendous demand for treatment services, and the difficulty in measuring effectiveness and outcomes, prevention efforts are a “hard sell” to hard-pressed administrators and legislators.
• Early intervention. Programs aimed at high risk populations (e.g., young unwed mothers with small children, children with a mentally ill or substance abusing parent) need to be evaluated and expanded where there is evidence for successful outcomes. Such programs include home visiting, Head Start, parent education, school-based programs for children with particular behavioral problems, etc.
• Trauma. Maine was the first state in the country to create a trauma services unit within a state mental health department, highlighting the impact of trauma on many of the clients served by the Bureau of Behavioral and Developmental Services. Recent efforts, some in cooperation with law enforcement, are bringing early intervention services to children who are witnesses to or involved in violent or traumatic events. Many believe that expansion of these kinds of specific early intervention services will reap long-term benefits in improved mental health later in life.

Informational and Reference Links

General Information

State of Maine Department of Behavioral and Developmental Services (http://www.state.me.us/bds/)

National Alliance for the Mentally Ill, NAMI-Maine (http://me.nami.org/)

National Association of State Mental Health Directors (http://www.nasmhpd.org/)

National Association of State Mental Health Directors Research Institute (http://nri.rdmc.org/)

National Institute of Mental Health (http://www.nimh.nih.gov/)

Substance Abuse and Mental Health Services Administration (SAMHSA), National Mental Health Information Center (http://www.mentalhealth.org/default.asp)

Adult Mental Health

Mental Health: A Report of the Surgeon General. (http://www.surgeongeneral.gov/library/mentalhealth/home.html)

Children’s Mental Health

Maine Children’s Cabinet (http://www.state.me.us/cabinet/)

Maine Children’s Alliance (http://www.mekids.org/)

Report of the Surgeon General's Conference on Children's Mental Health: A National Action Agenda (http://www.surgeongeneral.gov/topics/cmh/childreport.htm)

Portland Press Herald series of articles on problems in Maine children’s mental health services, “CASTAWAY CHILDREN: Maine's Most Vulnerable Kids.” (August 18, 19, 20, 2002, with later follow-ups) (http://www.pressherald.com/news/children/)

Reply to “Castaway Children” series, “Maine agencies working hard for kids with mental illness” (September 22, 2002) http://www.pressherald.com/viewpoints/mvoice/020922castaway.shtml

Mental Retardation

Center for Community Inclusion, University of Maine (http://www.ume.maine.edu/cci/)

Maine Developmental Disabilities Council (http://www.state.me.us/bds/ddcouncil/Maine_council_disability.htm)

Closing the Gap: A National Blueprint to Improve the Health of Persons with Mental Retardation. Report of the Surgeon General's Conference on Health Disparities and Mental Retardation (http://www.nichd.nih.gov/publications/pubs/closingthegap/index.htm)

Mental Health Workforce Issues

“Addressing mental health workforce needs in underserved rural areas: Accomplishments and challenges.” (Working Paper #23) Bird, D. C., Dempsey, P., & Hartley, D. (2001). Portland, ME: University of Southern Maine, Edmund S. Muskie School of Public Service, Institute for Health Policy, Maine Rural Health Research Center. (http://muskie.usm.maine.edu/Publications/rural/wp23.pdf)

Insurance Parity

“NAMI Maine’s report on the status of mental health insurance parity in Maine.” November, 2000 (http://nami.org/Parity.htm)

Mentally Ill in Jails and Prisons in Maine

“Report on the Current Status of Services for Persons with Mental Illness in Maine’s Jails and Prisons.” (Prepared by NAMI Maine, Fall 2000) (http://me.nami.org/jailreport.html)

“Report on the Current Status of Services for Persons with Mental Illness in Maine’s Jails and Prisons: 2002.” (Prepared by the Citizen’s Committee on Mental Illness, substance Abuse and Criminal Justice and NAMI Maine, September, 2002) (http://me.nami.org/jailrpt2002.htm)

Substance Abuse

State of Maine Office of Substance Abuse (http://www.state.me.us/bds/osa/)

Maine Guide to Using the Internet for Substance Abuse Prevention http://www.state.me.us/bds/osa/pubs/prev/1999/webguide/webguide.htm

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