Recovery and rehabilitation of persons with severe mental illness: a vision

American Rehabilitation,  Winter, 1994  by Bernard Arons,  Carole Schauer

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Although some progress has been made to counteract the myths, misperceptions, and stereotypes surrounding mental illness, stigma still prevents many people from seeking treatment and causes countless others to keep their conditions secret for fear of losing their jobs, health insurance, or homes. This article describes the mission of the Center for Mental Health Services and its current initiatives in the area of vocational rehabilitation. A model mental health service system is described with particular emphasis on the involvement of mental health consumers in designing and implementing the services. The article concludes with discussion of the emerging vision of the future of psychiatric rehabilitation services.

Statistics regarding the number of children with emotional disturbance and adults with mental illness and the subsequent impact on productivity are overwhelming.

* Approximately 9-13 million children and adolescents (14-20 percent) from birth through age 21 have a diagnosable emotional disturbance and require mental health services (Brandenburg et al., 1990). Yet, less than one out of five receive appropriate care (Office of Technology Assistance, 1986).

* During any given year, more than 40 million adult Americans are affected by one or more mental disorders; 5.5 million Americans are disabled by severe mental illness, such as schizophrenia, manic-depressive illness, and severe depressive disorders (Bourdon et al., 1992).

* Even by conservative estimates, up to 600,000 people are homeless throughout the country on any given night (Burt & Cohen, 1989). One-third are estimated to be adults with serious mental illness (Manderscheid & Rosenstein, 1992; Tessler & Dennis, 1989).

* For people with mental illness, the unemployment rate is estimated to be 85 percent (Orrick, 1992, President's Committee on Employment of People with Disabilities).

* Morbidity costs--the value of goods and services not produced because of mental disorders--was estimated at $63.1 billion for all mental disorders in 1990; schizophrenia alone accounted for $10.7 billion (Rice Miller, 1993).

* At least two-thirds of elderly nursing home residents have a diagnosis of at least one mental disorder (National Institute of Mental Health, 1992,1990).

* Between 6 and 14 percent of the correctional population are estimated to have major psychiatric disorders (Government Accounting Office, 1991b); 61,000 inmates of state adult correctional facilities received psychiatric care or lived in separately designated housing units (National Institute of Mental Health, 1992).

The Center for Mental Health Services

The 1992 Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act (Public Law 102-321) established the Center for Mental Health Services (CMHS) to provide national leadership for the treatment and prevention of mental illness. The act mandates vigorous federal leadership in mental health service delivery and policy development. CMHS is a component of the Substance Abuse and Mental Health Services Administration, one of eight Public Health Service agencies within the U.S. Department of Health and Human Services.

The center pursues its mission by helping states improve and increase the quality and range of treatment, rehabilitative, and supportive services for people with mental illness and their families and communities. Congress further provided support for a wide range of programs to respond to the increasing number of mental, emotional, and behavioral problems among America's youth and for programs of outreach and case management to serve hundreds of thousands of Americans who are homeless and severely mentally ill. In addition, the center supports efforts to create and enhance the effectiveness of consumer run and self-help alternatives (CMHS, 1993).

Definition of Serious Mental Illness

Clearly, the development of quality programs and supports for adults with serious mental illness and children with serious emotional disturbance is a CMHS priority. As part of the CMHS mandate, Congress required the development of a common definition of serious mental illness. This permits uniform estimates of the number of adults with serious mental illness and children with serious emotional disturbance and encourages comprehensive planning for mental health services to address multiple needs.

The new definition encompasses two parameters:

* the disorder itself, and

* the impact of the disorder on functional status.

The definitions for children and adults are identical, except for age and type of functional impairment.

Children with serious emotional disturbance are defined as persons "from birth up to age 18 who currently or at any time during the past year have had a diagnosable mental, behavior, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DSM-III-R that resulted in functional impairment which substantially interferes with or limits the child's role or function in family, school, or community activities." Functional impairment for children is defined as "difficulties that substantially interfere with or limit a child or adolescent from achieving or maintaining one or more developmentally appropriate social, behavioral, cognitive, communicative, or adaptive skills."