1. The Care of Special Populations and Special Disorders Chapter 18 Dr. Tracey Lynn Koehlmoos HSCI 678 Intro to US Healthcare System

2. Introduction • Defining special populations • Systems that exist • Types of providers • Policy issues

3. American Psychiatric Assoc. • A mental disorder is a clinically significant behavior or psychologic syndrome or pattern that occurs in an individual and that is typically associated with either a painful symptom (distress) or impairment in one or more important areas of functioning (disability). (APA 1980)

4. Conceptualization • Mind/Body Schism—historical • Emotional/Mental distress = Morbidity • Immune functions • Cancer • Heart Disease Biologically perceived health is a strong predictor of mortality

5. Defining Mental Illness • Multiple disorders - More than 15% (30% annually) - 1% unable to care for themselves • Common diagnoses • Schizophrenia, Schizoaffective, Bipolar • Notable Exclusions • Developmental disabilities • Substance abuse: lack of data/excessive care

6. Providers • Psychiatrists, psychologists, counselors, therapists, social workers, ARNP, etc. • Numerous facilities • State, VA • Private (health plan participants)

7. Public/Governmental Role • Chronic Mental illness: some can be treated/some limited recovery options • Government institutions (48 states) • Mental health care unresponsive to financial incentives; outside continuum of care • State mental hospitals—long tradition • 80% had chronic mental illness in the 1930’s • Population peaked at ~1/2 million in 1955

8. Movement toward Community Care • Shift of psychiatrists out of mental hospitals/replaced by FMGs—problematic • Psychoanalytical transition—little proof • Social welfare increases RESULTS: Smaller in-patient population Allowed for treatment/ not warehousing Only care for severely mentally ill

9. Deinstitutionalization • 33-40% homeless, chronic illness • Elderly residents—to nursing homes (Medicaid/ Medicare) • Payment shift from State to Federal govt. • Federal programs: • SSDI • SSI MEDICAID big payer for mental health services

10. Un-met Need • About 150,000 chronic residential patients • Where is everyone else? • No access to care • 15% uninsured—hard to get to Medicaid • Private insurance—inadequate provisions • Managed care—discourage enrollment • Social stigma

11. Policy Issues • Physical/Mental health schism • Institution/Community schism • Unmet treatment needs • Substance abuse • Young, disturbed and alcoholic • Stigma, stigma, stigma • Managed Care-advent of mental healthcare

12. Conclusion • Diverse population--disparities • Difficult to reach • Difficult to treat • Difficult to project prognosis • Lack of advocacy • Lack of parity