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 the theory with the mandate to use finite resources in the development of an optimal care system for a given population. 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.² 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.”³

“…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.”⁴

“…subspecialty area in which psychiatrists deliver mental health services to populations defined by a common workplace, activity, or geographical area of residence.”⁵

“…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.”⁶

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, multidisciplinary, 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 is a term borrowed from sanitation engineering (i.e., a cistern into which the sewage of a defined area is dumped) that refers to a CMH service area with a popula-tion of 75,000 to 200,000.⁷ Public psychiatry, a system of government-funded inpatient and outpatient services, was also initially conceived as meeting the needs of all, but in reality this system has narrowed its focus to the seriously and persistently 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. It has been argued that this should have been called dehospitalization⁸ (or transinstitutionalism²) because patients were maintained in nonhospital, but still institutional, settings. (Although the point is well taken, the former term has wide recognition, and will be used here in reference to this occurrence.) There is also evidence of this trend 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.⁹ Primary prevention is concerned with measures to decrease the new onset (incidence) of disease (e.g., causa-tive agent eradication, risk factor reduction, host resistance enhancement, and disease transmission disruption). Such measures, while highly effective in the realms of infectious disease, toxins, deficiency states, and habit-induced chronic illnesses (e.g., lung and heart diseases), are less obviously efficacious in the realm of psychiatry because the outcome without intervention 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 or 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 avoid or lessen 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 and complex system of (often disconnected) agencies, providers, and services, with the goal of care continuity and coordination through better interprovider communication.¹⁰ Obviously, patients with more, and more complex, needs will also require more intensive care management, and the greater the intensity of the management needs, the fewer cases a manager can adequately handle.¹¹ Care managers are the members of the treatment planning team who follow the patient through all care levels (e.g., inpatient, aftercare, and residential), types (e.g., mental health, substance abuse, and physical health), and agencies or services (e.g., housing, welfare, and 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 that this has negatively affected the therapeutic process, proponents believe that it has led to greater transparency, standardization, and evidence-based care (which may also have paved the way for the current explosion of pay-for-performance [PFP] initiatives¹²).

HMOs are a type of MCO that generally contract for the global provision of health care services for a specified population by paying an up-front amount to the provider, 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 and mental health services. That is, such plans “carve out” mental health and substance abuse benefit management from the management of other medical care and services. 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, that 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).¹³ 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 mental health 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 mental health to correctional system because the disenfranchised (e.g., the persistently mentally ill, the dually diagnosed, and substance abusers) may receive consistent care only when incarcerated.¹⁴

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 behavioral health portion of non–carve-out MCOs.¹⁵ NCQA standards address accessibility and availability of appropriate, culturally sensitive services, coordination between behavioral and physical health care services, communication between all care providers, and disease management/preventive health services. Both overutilization and underutilization 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 their requests for care or particu-lar services are initially denied by the MCO (or by the MBHO).

The Age of Enlightenment

The “first psychiatric revolution” occurred late in the eighteenth century when a French alienist (i.e., a psychiatrist), Philippe Pinel, advanced the concept that physical work and fresh air would return the mentally ill to a state of mental health and well-being.¹⁶ Moral treatment dawned as Pinel released the insane from their shackles.¹⁷ By the early nineteenth century, the movement had found its way to the United States, where Dorothea Dix promoted the development of village-style asylums for the mentally ill to retreat from the stresses of daily living.¹⁸

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31: Psychiatric Illness during Pregnancy and the Postpartum Period 11: Brief Psychotherapy: An Overview 87: Emergency Psychiatry 65: Aggression and Violence 91: Coping with the Rigors of Psychiatric Practice 63: Genetics and Psychiatry

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