By William K. Alcorn
Clinical treatment of Ohioans with mental illnesses has done a virtual about-face over the past half- century.
Previously, long-term stays in state-run institutions, such as the long-closed Woodside Receiving Hospital in Youngstown, was the treatment of choice for people with severe mental illness.
Today, community-based networks of services, created by state and federally funded county mental health and recovery boards and aimed at achieving the least restrictive treatments, are preferred and required.
The number of people with mental illness in the Mahoning Valley cannot be definitively determined. That’s because mental health boards get information only on people who received mental-health treatment from provider organizations that are certified by the Ohio Department of Mental Health and Addiction Services, said Kathleen Chaffee, executive director of the Columbiana County Mental Health and Recovery Board.
According to the March 2015 report from the Congressional Research Service titled “Prevalence of Mental Illness in the US: Date Sources and Estimates,” the prevalence rate for adults in the nation with a diagnosable mental illness which is mild and transitory is 20 to 25 percent.
About 5 percent of the population experiences serious mental illnesses, defined as lasting at least six months with symptoms that are persistent and debilitating and that moderately to seriously impair functioning.
About 14,000 people, or some 5.6 percent of Mahoning County’s population, received mental health care through the Mahoning County Mental Health and Recovery Board’s network of contract agencies in fiscal year 2015; and about 5,532 Columbiana County residents received mental health treatment services through Columbiana County Mental Health and Recovery Board provider organizations that are certified by the Ohio Department of Mental Health and Addiction Services. That’s about 5.3 percent of that county’s population.
In Trumbull County, more than 11,600 people received mental health care through its network of contract agencies fiscal year 2015 (July 1, 2014-June 30, 2015) representing almost 6 percent of the county’s population, said April J. Caraway, Trumbull County Mental Health and Recovery Board executive director.
In the 1950s, the nation’s state psychiatric hospitals reached their peak with about 560,000 residents before the shift toward de-institutionalization began.
As the number of patients declined at Woodside and other state hospitals, the state made the decision to close the facilities because of the high cost of operations and focus on state-funded, community-based care, Caraway said.
The change also occurred because of humanitarian concerns and the rights of patients; new medications that were more effective in controlling the symptoms of some disorders; and public policies that made “cost-shifting” among federal, state and local funders possible, she said.
With the funding going to county mental health boards, innovative community treatment options were established and fewer patients were hospitalized for long periods, Caraway said.
The legislation that made mental health boards responsible for the care of people with mental illness also served to increase the involvement of consumers and their families, enhanced training for mental health professionals, strengthened requirements to assure quality, and made case management a piece of the community-support system, said Duane Piccirilli, executive director of the Mahoning County Mental Health and Recovery Board.
With the closing of Woodside, Mahoning County residents with mental illnesses and those in recovery were placed in the least restrictive environment possible, Piccirilli said.
He noted that hospitalizing a person with mental illness costs three to five times more per year than treating them in the community.
Also, Piccirilli said, recent Medicaid expansion has greatly enhanced access to community-based services for those previously uninsured.
The intent of the Mental Health Act of 1988, the impetus for closure of state-operated mental health hospitals in Ohio, is to ensure people get hospital-based treatment when necessary and community-based treatment at all other times, Piccirilli said.
The question is: How is the community-based network of care working, especially with state funding reduced significantly in recent years?
Community-based network of treatment is working for the vast majority of people with behavioral health issues in Trumbull County, said Caraway. Most with severe mental illnesses are living successfully in the community with appropriate clinical and supportive services.
But, she noted, a small number of people with the most severe disorders may not recognize their own illnesses, may not be compliant with treatment, may abuse substances, and may cycle repeatedly through local and state hospitals and jails as they experience psychiatric crises.
“It has been said that the successes of the community mental health movement are everywhere but hard to recognize, while the movement’s failures are few in number but plainly visible for all to see,” Caraway said.
In addition to behavioral health treatment, supportive services such as housing, medical care, food, clothing, socialization, work experiences, transportation, and crisis intervention are needed.
“We have sound, evidence–based models for community systems of care that are effective for most people with severe mental illnesses,” Caraway said.
Financing these community systems of care has undergone dramatic changes in recent years.
Medicaid is now the major source of funding for Ohio’s public behavioral health systems. But, as Medicaid eligibility was expanded, state funding to community Alcohol, Drug Addiction and Mental Health Services has been sharply reduced, she said.
But, Medicaid is not a perfect payer source for community care.
It does not cover many services that are essential for recovery and successful living in the community, such as housing, food and clothing. Nor does Medicaid cover clinical services for indigent people, or people incarcerated in prisons and jails. Financial responsibility for many of these supports still rests with local ADAMHS boards, Caraway said.
The Mental Health Act of 1988 created financial incentives for community systems to “do the right thing,” she said.
But the cost to local systems of doing the “right thing” continues to grow; and significantly, after decades of decline, use of state psychiatric hospitals increased in fiscal year 2014.
“This suggests that incentives to reduce our reliance on the most restrictive level of care have become less effective as our population continues to experience greater needs,” said Caraway.
In order to fulfill their statutory responsibility, mental health and recovery services boards must work closely with other partners, such as schools, child protective services, the juvenile justice system, and child-focused community organizations.
“I cannot emphasize enough how important this is, ” said Chaffee. “For people with severe and persistent mental illness, we do not get very far unless we partner effectively with other entities whose mission and interests overlap with our responsibilities.”
In Mahoning County, thanks to the support of its voters, levy dollars have enhanced local programming and services, Piccirilli said.