Public Psychiatry

The subject area of public psychiatry embodies a fundamental core of experience and tradition. In the context of the reexamination of American health care initiated by the effect of managed care and the health care reform, the experience of public psychiatry is poised to serve as the foundation for a transformation of behavioral health care.

The term public can refer to psychiatric programs, treatment, or institutions paid for by public funds or as objects of public policy, whether paid for or not. The traditional concept of public psychiatry has been expanded to include medical and psychosocial initiatives directed for the public good, whether funded by public or private funds, and directed in particular to those who are economically disadvantaged.

The care and treatment offered under public psychiatry are delivered in a variegated mosaic of inpatient and community-based services that are more or less integrated into a coherent network sponsored by public agencies. Funding for public psychiatric services tends to be provided by federally legislated appropriations that are passed through state, county, and municipal government agencies (such as departments of mental health; substance use treatment services; children, youth, and family services; and public health, social services, education, adult corrections, and juvenile justice agencies). Ultimately, most public psychiatry and community services are provided by not-for-profit community mental health, substance use treatment, child guidance, or health care organizations that either are funded by or subcontracted to government agencies. Thus, the very existence of public and community psychiatric services and the policies and resources determining how they are delivered are extremely dependent on legislative mandates and fiscal appropriations from all levels of public government.

CONTEMPORARY PUBLIC AND COMMUNITY PSYCHIATRY

There are five themes around which the discussion of contemporary public and community psychiatry is structured: public health, public agencies, evidence-based psychiatry, roles for psychiatrists, and delivery systems.

Public Health

Public health is not simply publicly funded health care but is rather a specific discipline and tradition. It is a complicated field that historically has been defined negatively by the dominance of personal health, that is, the health care delivery systems that take care of individual patients. Until the advent of managed care in the 1990s, U.S. health care was an industry organized largely in terms of individual doctor-entrepreneurs. Each jurisdiction uniquely defined and organized its public health programs, and the particular pattern of personal health practices had substantial influence—hence the wide variation in public health programs. Nonetheless, as a discipline and tradition, public health’s mission is to assure the conditions in which people can be healthy. Public health consists of organized community efforts aimed at the prevention of disease and the promotion of health. It involves many disciplines but rests on the scientific core of epidemiology. It provides an essential template for contemporary public and community psychiatry.

The Surgeon General’s report on mental health underscored the necessity of a public health approach to care and rehabilitation for people experiencing mental illness that is “broader in focus than medical models that concentrate on diagnosis and treatment.” Although diagnosis and treatment are core areas of expertise for all psychiatrists, the Surgeon General recommended that even when psychiatric diagnosis or treatment is the primary focus for practitioners, researchers, or educators, they should ground their professional activities in a vision and knowledge base that is “population-based…encompass[ing] a focus on epidemiologic surveillance, health promotion, disease prevention, and access to services.” These fundamental public health functions define the public health perspective in public and community psychiatry. In the discussion that follows, these four public health components are framed in current terms of health care reform to define a coherent “public health” strategy for public and community psychiatry.

Health Promotion

Psychiatric professionals can contribute substantially to the promotion of public health by working with primary health care professionals and educators to identify and provide front-line treatment and referrals to adults and children who have undetected psychiatric symptoms, subthreshold syndromes, and psychiatric disorders. Collaborative care models bring psychiatric professionals into primary care and school settings as consultants for medical, nursing, and education professionals who work in those settings, as well as for educators and direct treatment providers to at-risk or psychiatrically impaired individuals.

Furthermore, people with identified mental illness or addictive disorders can benefit from enhanced physical and mental health care, as well as from the alleviation or management of psychiatric symptoms. Achieving or regaining physical or mental health (i.e., recovery) depends not only on genetic and biological factors but also on a person’s or family’s access to social and psychological resources and integration into supportive social networks. Illness management (also known as disease management or chronic illness care management) is a framework that has been adapted from medicine to guide mental health professionals in delivering services that go beyond traditional diagnostic treatment to promote the health and recovery of people with mental illness or addiction. Illness management has been defined as “professional-based interventions designed to help people collaborate with professionals in the treatment of their mental illness, reduce their susceptibility to relapses, and cope more effectively with their symptoms…[to] improve self-efficacy and self-esteem and to foster skills that help people pursue their personal goals.” A number of approaches to illness management have been scientifically and clinically evaluated and have been found to enhance standard psychiatric treatment.

Prevention. Psychiatric disorders most often follow a course over time that begins with an often lengthy period in which prodromal or subthreshold symptoms or functional problems precede the full onset of a disorder with marked impairment. Intervention with adults, adolescents, or children who are not clinically impaired but who are at high risk (e.g., owing to a family history of psychiatric or addictive disorders or exposure to extreme stressors, such as violence, neglect, or the modeling of antisocial behavior) or who are manifesting preclinical symptoms or functional problems (e.g., periodic or pervasive dysphoria, problems with separation from caregivers, or involvement with deviant peers) is an approach to prevention that has been found to be cost effective because it targets a relatively small group of individuals in a timely manner.

Application of the traditional public health concepts of primary, secondary, and tertiary psychiatry has been confusing in psychiatry. Primary prevention involves addressing the root causes of illness with healthy individuals, with a goal of preventing illness before it occurs. Secondary prevention involves the early identification and early treatment of individuals with acute or subclinical disorders or high-risk persons to reduce morbidity. Tertiary prevention attempts to reduce the effects of a disorder on an individual through rehabilitation and chronic illness care management. The Institute of Medicine, in an effort to clarify different aspects of prevention, developed a classification system with three different categories. Universal interventions are those intended for the general public, such as immunizations or media campaigns providing information about illnesses, early warning signs, and resources for health promotion and timely treatment. Selective interventions focus on individuals at higher-than-average risk (e.g., persons with prodromal symptoms or a family history of psychiatric disorders) to reduce morbidity by enhancing resilience and preventing the onset of illness. Indicated interventions target individuals who are experiencing impairment as a result of illness as early as possible in the course of the illness, to reduce the burden of the illness on the individual, family, community, and treatment system. Psychiatric services most often take the form of indicated interventions, but the smaller number of psychiatric practitioners and researchers who conduct and evaluate selective or universal interventions in public and community settings is making a substantial contribution to the larger health of society.

Prevention interventions have been found to be effective with adults with a variety of risk factors or preclinical problems. For example, women who have been raped are less likely to develop posttraumatic stress disorder (PTSD) if they receive a five-session cognitive-behavioral treatment than if their recovery is left to chance. Men and women identified with subthreshold symptoms of depression by primary care medical providers are more likely to remain free from the full syndrome of depression or to be able to recover rapidly with treatment if they do become clinically depressed if their standard medical treatment is enhanced by education about depression and learning skills for coping actively with depressive symptoms or stressors. Prevention with adults must be judiciously designed to address the specific factors that place a person at risk for illness or that enhance the person’s ability to cope effectively. For example, brief supportive meetings with people who have experienced a traumatic stressor (e.g., a mass disaster or life-threatening accident) tend to have little benefit and may inadvertently intensify posttraumatic stress, whereas a focused cognitive-behavioral approach to teaching skills for coping with traumatic memories and stress symptoms has been shown to be effective in preventing posttraumatic stress and depressive disorders with adult and child disaster or accident survivors.

A number of prevention programs have been developed and evaluated to address physical and mental health risks in childhood and adolescence, incorporating several elements that influence intervention effectiveness. Their broad and systematic implementation, however, has been halting. A number of states have made an effort to implement school-based interventions involving teachers and the peer group. These tend to be more effective than programs exclusively relying on intervening with parents or children alone. Such interventions in middle childhood have been successful in influencing peer group norms regarding alcohol and substance use, violence and bullying, and depression, thus achieving the dual outcome of reducing immediate initiation of alcohol and substance use and increasing the long-term support within the peer group for sustained abstinence into adolescence. Thus, systems-based multimodal interventions simultaneously targeting and developing enhanced relationships among the child, peer group, school personnel, parents, and the wider community tend to be most effective as universal or selected approaches to early prevention of what otherwise may become lifelong behavioral, legal, academic, and addictive problems.

Access to Effective Mental Health Care. Access is a serious problem for most people with severe mental illness or addictions. In the United States, the National Comorbidity Study (NCS) and the National Comorbidity Study-Replication (NCS-R) found that fewer than 40 percent of people with severe psychiatric disorders had received any mental health treatment in the previous year, and fewer than one in six (15 percent) had received minimally adequate mental health services. Young adults, African Americans, people residing in certain geographical areas, people with psychotic disorders, and patients treated by medical but not mental health providers were at highest risk for inadequate psychiatric treatment. Although income was not a predictor of inadequate treatment, it is likely that many of the people who did not receive adequate mental health services were uninsured or had insufficient insurance coverage for mental health conditions and had no viable source of mental health care other than through a medical provider or clinic or in the public mental health system.

Even when mental illness is identified, people with socioeconomic adversities often do not, or cannot, get adequate mental health services in their communities. For example, although it is estimated that more than 200,000 incarcerated adults in the United States have psychiatric disorders, few were detected or received treatment until they reached jail or prison. Federal and state correctional systems have instituted mental health screening and treatment programs to address psychiatric disorders as a health problem for incarcerated adults and to manage the problematic behavior that can occur in controlled settings as a result of mental illness. On returning to the community, the vast majority of prisoners with psychiatric disorders cease to receive more than minimal mental health services: A recent study found that fewer than one in six (16 percent—strikingly similar to the NCS finding) received steady mental health services, and only one in 20 with addictions received steady substance abuse recovery services. Thus, access to mental health and addiction treatment services is far better in prison than in the community! This has caused great concern because of the possibility that correctional facilities may be a de facto system of care for low-income people (often of minority backgrounds) with serious mental illness.

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