(p. 179) Global Perspectives on Mental Health Care
In the previous chapter we cited the report of the World Health Organization on the elements that should be a part of a well-functioning health delivery system (Tandon et al., 2000). As noted, in its study of 191 countries, the WHO assessed the quality of the nations’ health care systems, including mental health, on the following dimensions: (1) overall general health of the population; (2) fairness in financing, which includes the distribution of the health system’s financial burden within the population; and (3) responsiveness of the system. This last dimension is measured by patient satisfaction and how well the system behaves in response to the needs of consumers in providing them dignity, confidentiality, autonomy to make decisions about their own health, and choice of provider. In addition, the WHO also studied access to care, health inequalities or disparities, and how well people of varying economic backgrounds felt they were being served by the health system.
The WHO correlated these variables with the level of sophistication in care and the degree of distribution of these important elements in the population to yield measures of equity of care and quality of care. As mentioned previously, the United States ranked 37th among all countries, with 17% of its GDP spent on health care, while the United Kingdom was 18th, with 6% of its GDP going to health care. Thirty-three other countries were ahead of the United States on 1,000 different parameters; France, Italy, and San Marino topped the list, and Sierra Leone came in last. Singapore was 6th, Norway was 11th, and the Middle Eastern country of Oman was 8th (WHO, 2005).
The WHO concluded that virtually all countries underutilize the resources available to them with resulting deaths and disabilities that are preventable. Fortunately, bringing about changes by reallocating resources is not unachievable and can produce results in a short period of time. As an example, Oman was not performing well on many parameters, including infant mortality, but major government investments produced significant improvements over a period of five years.
(p. 180) Another important factor in a well-functioning system is fairness in financing, which refers to the distribution of the cost of health care purchased: Are those with the least income paying the same as those with the highest income? In Colombia, South America, low-income people pay less for health care than do people with high incomes, $1 versus $7.60. This equity in cost earned it a high rank in the WHO study.
The WHO stressed the importance of two other factors: (1) workforce inputs and balance within the workforce, that is, the right number of nurses per doctor, and (2) extending insurance coverage to the entire population. The literature suggests that the prepayment for health care in the form of insurance, taxes, or social security reduces the cost of health care in the long run. Most industrialized countries have only 25% of health care being delivered via private entities, in comparison to 56% within the United States.
Although the WHO report does not break down the specific areas of health care into mental and physical, it seems logical to assume that the rankings for physical health reflect those for mental health. The WHO offers the following definition of mental health: “the state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (Herrman, Saxena, & Moodie, 2005, p. 2).
Based on this broad definition, many countries are addressing the issue of mental health in a comprehensive and holistic manner, acknowledging the importance of addressing all aspects of an individual’s functioning, including the strong interdependence of mental and physical health. (Nonetheless, it is important to note that the preponderance of resources in developing and Third World countries goes toward control of infection and acute illnesses, with mental health lagging far behind in priorities.) Progressive social policies in some industrialized nations such as Sweden, France, the United Kingdom, Norway, Denmark, and Germany, which have liberal paid maternity leave policies ranging from 18 to 32 weeks, clearly suggest recognition of the importance of good maternal physical and mental health for the well-being of an infant. Such social policies have a long-term impact on the well-being of the family.
It is noteworthy that the WHO decided to discontinue report cards on the status of health care in countries of the world after publishing its 2000 report (WHO, 2000), citing the enormous complexity and difficulty of the task. Nevertheless, this report gives nations of the world a strong platform from which to examine health delivery systems, including those focused on mental health.
In this chapter we review how various nations successfully approach the issue of ensuring positive mental health for their citizens. Wherever it appears appropriate we glean approaches and lessons that may be useful in improving the mental health system in the United States.
(p. 181) Wide Disparities Exist among Nations
Several conclusions emerge from a review of the limited literature on mental health services throughout the world. First, as might be expected, there is considerable variation in the scope and nature of mental health services. Some of these differences can be attributed to cultural perspectives that shape how a country defines and deals with mental health issues. While it is possible to identify prevalent national views and trends, there are often discrepant perspectives even within a particular country. For example, in the United States, most mental health professionals view the onset of mental illness as a complex interaction of predisposing and precipitating factors, and view the biopsychosocial approach as a useful conceptual model for understanding and treating these disorders (Pies, 1994). There is not a clear consensus on this issue, however. Many professionals view mental illness as primarily a biological phenomenon, while a segment of the population still considers all aberrant behavior to be a manifestation of immorality (Stier & Hinshaw, 2007).
The mind–body schism is reflected in the decades of disparity between the approach to delivering care and the funding of coverage of mental and physical health issues. In Asian cultures, emotional stress presents in physical ways, such as stomachaches, headaches, pseudoseizures, or myalgias, and seeking help for physical symptoms is a culturally accepted way of seeking help for stresses that cannot be publicly acknowledged. Systems of care delivery within those countries value biological origins as explanations of these presentations, and intervention is often provided within the physical medicine venue rather than within traditional psychiatry. General practitioners provide the bulk of interventions in China, which has undergone radical changes in political structure during the past several decades; parallel shifts have occurred in conceptualizing mental health problems and treatment.(Hong, Yamakazi, Banaag, & Yasong, 2004). Although there has been some movement toward co-locating behavioral health services in primary health care settings in the United States, we would benefit from further integration of behavioral and physical care service provision.
In China during the first part of the 20th century, Western medicine began to supplement traditional Eastern approaches to health and illness. While development of mental health services was largely dormant between 1930 and 1949 because of the war with Japan, during the Cultural Revolution, from 1950 to 1980, there was a growth in mental health services, with primary reliance on use of medication in both inpatient and outpatient settings. In the past 30 years there has been considerable reform in approaches to mental health within China (Hong et al., 2004).
On the continent of Africa, formal systems of care are beginning to emerge, but informal approaches such as those provided by folk and indigenous healers still play (p. 182) a significant role in dealing with mental health problems (Robertson, Mandlhate, Seif El Din, & Seck, 2004).
A second conclusion that can be readily drawn from the literature on international mental health is that the prevalence and impact of mental health disorders is significant but has not yet been sufficiently acknowledged by government authorities. For example, the WHO calculates the “burden of disease” in terms of disability-adjusted life years (DALY). According to the WHO DALY calculations, neuropsychiatric conditions account for more than 25% of the total burden of disease worldwide (Remschmidt & Belfer, 2005). In its report, “Caring for Children and Adolescents and Mental Disorders” (WHO, 2003), the WHO states that, worldwide, nearly 20% of children and adolescents suffer from a mental health disorder that has a disabling impact. These data are consistent with epidemiological findings of prevalence rates for mental disorders for children and adolescents in the United States (National Research Council and Institute of Medicine, 2009). Developing countries are frequently mired in constructing policies to manage acute physical illnesses and infectious diseases and do not have the manpower, resources, or national policy to meet the challenges of mental disorders. In the United States, however, the health care burden comes from chronic illnesses like cancer, cardiovascular disease, accidents, and mental illness.
Finally, there appears to be a large disparity in the degree to which countries acknowledge the importance of mental health and support work in this area. Sadly, no single country has achieved a level of development that represents exemplary mental health care. One measure of commitment is the amount of money budgeted for mental health as a proportion of the total health budget. In a report on 101 countries, covering a population of more than 1 billion people, 20% of countries spend less than 1% of their total health care budget on mental health services. In Africa and Southeast Asia, more than half of countries spend less than 1% of their health budget on mental health. In contrast, more than 60% of countries in Europe spend more than 5% of their health budget on mental health care, with at least six countries in Europe and the Americas allocating 10% or more of their health budget to mental health. The United States spends 6% of its health budget on mental health care (WHO, 2005).
Significant variation also exists in how mental health care is financed for people with different income levels. Specifically, out-of-pocket payment is the most prevalent form of financing in low-income countries in areas such as northern Africa and Southeast Asia, while Europe relies almost exclusively on tax-based and social insurance. Analysis of financing methods by income reveals that low-income groups are expected to pay a significantly greater proportion of their incomes for mental health care through out-of-pocket payment. For this group, self-pay (uninsured and paying out of pocket) is the most common method of financing for 3% of the population and the second most common method of financing for 35%. In comparison, out-of-pocket (p. 183) payment (insured but choosing to bypass insurance) is seldom used by persons at higher middle- and high-income levels, as tax-based and social insurance provide funding for mental health care for 90% of the population.
Another indicator of disparity among nations is the number of psychiatric services and professionals available. Countries classified as low income have a median number of 2.4 psychiatric beds per 10,000 people as compared to higher middle- and high-income countries, which have approximately 7.5 beds per 10,000. The United States has 7.7 psychiatric beds per 10,000 people, which is slightly less than the average for Europe—8 beds per 10,000 people (WHO, 2005). The same relationship of having fewer resources in poorer countries exists for the availability of mental health professionals. The United States has 13.7 psychiatrists per 100,000 in comparison to the African region, which has .04 psychiatrists per 100,000, and Southeast Asia, which has .2 psychiatrists per every 100,000 people (WHO, 2005).
Work force issues have impacted the delivery of health care even in the United States, where the availability of child psychiatrists (7,000) has never kept pace with the projected need for child psychiatrists (30,000) (Thomas & Holzer, 2006). In the United States and some other countries, the mental health needs of an individual are not considered to be primary care needs. This has contributed to a lack of funding for training people in the field of mental health.
Approaches to Mental Health around the World
The way in which mental health disorders are manifested, the magnitude and nature of risk and protective factors, and the most appropriate ways to provide care vary from culture to culture. In Sub-Saharan, Africa, where 70% of all people with AIDS live, more than 13 million children under 15 years of age have lost mothers to HIV/AIDS since the epidemic began. As a result of the AIDS epidemic and multiple armed conflicts, 95% of all the worlds’ orphans now live in Africa (Robertson et al., 2004). The loss and trauma experienced by young people living in these countries certainly pose extraordinary risks for their mental health and overall development.
While there are excellent examples of specific programs that address mental health issues at a local or regional level, it is generally acknowledged that, including the United States, no country has a comprehensive system of care for individuals with mental disorders (Belfer, 2004). Overall, the strongest systems of care in mental health are located in the United States and Europe, with considerable variation among the states in the United States and countries within Europe. In assessing the level of development of mental health services, it is useful to distinguish between the following aspects of systems of care: (1) the clinical and programmatic philosophies and paradigms used (p. 184) to educate staff and families on how to understand and treat mental health disorders, and (2) the structure and organization of service provided to patients (Rydelius, 2004).
While the development of the system of care paradigm and efforts to develop comprehensive service approaches originated in the United States, in some ways, European countries have made greater progress. Two factors that have influenced the rate of progression are (1) the relation to and integration of mental health services with primary care and (2) strong government funding of mental health services. Countries such as Austria, Finland, Germany, and Sweden have a long tradition of close collaboration between child psychiatry and pediatrics (Rydelius, 2004). In addition to typical consultation-liaison work, good collaboration has resulted in the development of special programs for pregnant mothers, newborn children with obstetrical/neonatal complications, abused children, and children with serious physical health diseases. Child and adolescent psychiatrists routinely provide services within pediatric clinics, and in those instances where cooperation between psychiatry and pediatrics is not strong, “social pediatrics” and “behavioral pediatrics” programs have been developed within some pediatric settings.
Effective Mental Health Care Approaches Worldwide
While the term system of care is relatively new, some of the principles embodied in this model have been incorporated in the care of persons with mental disorders for a long time. Perhaps the most noteworthy historical example of an authentic community-based care system for persons with serious mental disorders is found in Geel, Belgium. Beginning in the mid-13th century, persons with mental illness were brought to this small municipality in the northeast Belgium province of Antwerp to receive help. Initially, the cure consisted of a religious ritual designed to rid them of the evil spirits that supposedly possessed them. Over time, treatment evolved from a church-sponsored intervention to a system of psychiatric care, managed by the Belgian state, beginning in the mid-19th century. Persons from all sections of the country were sent to Geel for treatment. What made the Geel experience unique was that although almost all of the people served were severely disabled and exhibited symptoms of psychosis, they were not placed in an institution. Instead, they lived with local host families while they received treatment. This system of placing persons with mental illness in the homes of local residents resembles today’s family foster care program (Roosens, 1979).
Although living conditions have improved considerably for the Geel patients since the 1850s, when they were often placed in irons or chained to walls, the basic (p. 185) concept of integrating persons with severe mental illness into the community has remained constant. Because patients consistently showed improvement, the number of patients sent to Geel continued to increase. At the turn of the 20th century there were approximately 2,000 patients participating in the Geel family care experience. The program peaked in 1938, when there were 3,700 participants. Today, Geel, with an overall population of 35,000 people, has approximately 500 patients with chronic mental illness living with families and participating in typical activities within the community.
Interestingly, research conducted on the Geel program found that these families did not see their participation as an act of charity. Rather, they viewed this work as a business, motivated primarily by the economic benefits it provides to the host families. Nonetheless, this unique family care program enables many individuals with severe disabilities to lead relatively normal lives within the mainstream community (Goldstein & Godemont, 2005; Roosens, 1979).
In the 19th century, many countries established institutions for persons with aberrant behavior. These institutions, initially referred to as asylums for lunatics or insane persons, eventually evolved into state-operated psychiatric hospitals. As attitudes and treatment approaches for persons with mental illness changed in the middle of the 20th century these facilities became unpopular. While there is much to criticize about how these institutions segregated individuals with mental illness from the mainstream community as well as the abuses that occurred within many of these cloistered facilities, it is worth noting that asylums and state-operated psychiatric hospitals performed some of the same functions as modern systems of care, albeit in much more restrictive settings. For instance, state hospitals addressed all the needs of the individual, including physical, medical, social, and spiritual, under a single administrative and physical structure. Critics of deinstitutionalization often point to the lack of attention to a holistic approach in the early days of transition from state hospital to community setting (Lamb, 1984).
Many countries in Europe have been progressive in their approach to mental health care. One of the strengths of the European Union is its systematic effort to monitor the health status of its citizens. Through assessments, such as the Survey of Health, Aging and Retirement in Europe (SHARE), the Health Behavior in School-age Children (HBSC), and the EU Labor Force Survey (LFS), the EU tracks the status and changes of different age groups in member states on a variety of indicators related to mental health. Given the importance of epidemiological data in formulating policy and practice, this comprehensive and systematic approach to measuring and monitoring a mental health status is worth consideration by policy-makers in the United States.
Scotland has adopted a national program that brings together policy, strategy, programs, research and evaluation, capacity building, and indicator development (p. 186) in an integrated approach, to promote and improve mental health and well-being of the entire population, prevent mental health problems and suicide, and support the improvement of quality of life, social inclusion, and health of people with mental health issues (Robison, 2009).
The Labour Force Service Centres (LAFOS) have been established in Finland to provide employment and social and health services for disadvantaged adults in an integrated fashion, at a common site. This one-stop approach has proven to be very effective (McCollam, O’Sullivan, Mukkala, Stengard, & Rowe, 2008).
In Germany, a systematic evaluation of inpatient versus home treatment of children and adolescents with psychiatric disorders found favorable results for home treatment. Germans have also introduced a systematic method for conducting routine quality assurance and evaluation of therapy, using telephone interviews (Mattejat, Hirsch, & Remschmidt, 2003).
The United States could benefit from adopting some of the constructive strategies employed by European countries. At the macro-level we need to place more emphasis on collecting and using data on the behavioral health status of our citizens, including outcomes associated with significant policy and program changes. Germany’s use of systematic evaluation and quality assurance processes would be beneficial at local and program levels in the United States. In response to the desire to move care from restricted to community settings, there has been a proliferation of new community-based programs, such as group homes and in-home services. Unfortunately, efforts to ensure that these programs are appropriate and provide high-quality services have lagged behind the development of these new initiatives. If systematic monitoring efforts were in place, policy-makers and administrators would be able to identify problems in a timely manner and pursue corrective action strategies. If the United States adopted the routine, comprehensive data-gathering efforts employed in Europe we would be in a better position to improve services and hold providers accountable.
Perhaps the most significant difference between the European and American mental health service programs is the method of funding. In the United States, strong emphasis on managed care during the past two decades has taken a negative toll on support for mental health services. During the recent economic downturn, funding reductions have been made at state and local levels. At best, funding for mental health services in the United States is provided by a patchwork of government programs and private insurance companies that reimburse providers for specific services. It became evident during the discussions on health care reform that millions of individuals do not have any health insurance coverage. Given the lack of parity between physical and (p. 187) behavioral health insurance coverage, many individuals lack sufficient resources to pay for the care they need for their mental health issues. What is the effect of such policies, where a bulk of health care is privatized and a large population lives at or under the poverty line? With no insurance, the poor pay a disproportionately large portion of their income for health care needs and are often driven into debt, which impacts their overall well-being. The health care safety net is thus an important concept for policy-makers to grasp. Mental health delinked from physical health is often not on the radar of policy-makers and is further marginalized when resources are allocated.
In contrast, in European countries such as Sweden and Germany, which have compulsory health insurance, funding challenges are less complex. Moreover, it is clear that cheaper and more universal coverage than is provided in the United States is a characteristic of the British National Health Service (NHS). However, as we have seen in recent years, general economic conditions have had a significant impact on the availability of resources even in countries with universal coverage or publicly funded health care (Schleimer, 2002). While it is unrealistic to expect that we can buffer the mental health service system from the effects of a severe economic downturn, if we were able to create more rational funding policies and better integrate behavioral health with physical health care systems, it would be possible to realize some cost savings and perhaps make these services less vulnerable to large funding reductions that are often driven as much by political expediency as by cost–benefit analysis.
Integrating Mental Health with Primary Care
A report by the WHO and the World Organization of Family Doctors (Wonca) provides a compelling rationale for integrating mental health services into primary health care as the most viable method for enhancing availability of treatment and ensuring that people get the mental health care they need (WHO and World Organization of Family Doctors [Wonca], 2008). The report describes numerous efforts to achieve integration of primary care and mental health. Interestingly, many of the examples come from low- and middle-income countries where strong formal mental health systems do not exist. There are several examples of best practice in relation to integrating mental health into primary care.
In the Patagonia region of Argentina, primary care physicians are responsible for the diagnosis, treatment, and rehabilitation of individuals who have serious mental disorders. Outpatient treatment is provided in these communities, and psychiatrists and other mental health specialists are available to review and advise in complex situations. Complementary clinical care is provided at a community-based rehabilitation center which also serves as a training site for general medicine residents and practicing primary care physicians. This program has increased access for those in need of mental (p. 188) health services and lowered costs, while at the same time allowing people with mental disorders to continue to live in their home communities.
In Belize, psychiatric nurse practitioners play a critical role in delivery of service and preparation of primary care personnel to work with individuals with mental health disorders. The nurse practitioners make home visits to patients and work with primary care staff to improve their knowledge base and skills. Through these efforts, admissions to psychiatric hospitals have been reduced. While administrators of this initiative acknowledge that these programs are less than optimal, they note that in countries where there are very few trained mental health specialists it may be necessary to enhance primary care practitioner’s skills over time rather than aspire to reach a fully integrated system of care prematurely.
In the Kerala State in India medical officers trained in mental health provide diagnostic and treatment services for persons who have mental disorders as a regular part of their general primary care functions. Their work is supplemented by a multidisciplinary district mental health team that offers outreach clinical services. The services may involve direct management of persons with complex situations and provide in-service training to support the trained medical officers and operate mental health clinics with only occasional support from formal mental health professionals. The availability of psychotropic medication in the clinics has allowed patients to remain in their home communities and reduces expenses as well as travel time to hospitals.
The Islamic Republic of Iran has achieved a nationwide integration of mental health into its primary care system. Similar to programs in Belize and India, general practitioners deliver mental health care within their primary health practices. District or provincial health centers, which have mental health specialists on staff, are available to serve patients with complex problems. Through outreach efforts, community health workers identify and refer people in their villages to primary care settings for assessment. The scope of the Iranian integration of mental health is particularly impressive, reaching urban and rural areas. A sizeable portion of the country’s citizens now have access to affordable and acceptable mental health care. As cited earlier in this chapter, better integration of behavioral health and primary care in the United States would likely lead to more responsive care, reduced fragmentation of services, and cost savings associated with earlier appropriate intervention and reductions in parallel administrative structures. Similar programs using primary care physicians, nurses, and community outreach workers have shown promising results in South Africa, Uganda, and Australia.
In addition to community- and nation-specific programs to improve mental health care, there have also been broader campaigns to address problems and disparities. The most prominent efforts have been led by the WHO. Recognizing the interdependence of physical and mental health and the importance of positive mental health for the (p. 189) individual, family, and society, the WHO recently developed a Mental Health Gap Action Program (MhGAP) (WHO, 2008). This initiative was established to advance work that produced the original global action program for mental health, endorsed in 2002. MhGAP focuses on reducing the treatment gap of more than 75% that exists between lower- and lower middle-income countries. The program has identified specific evidence-based approaches for mental, neurological, and substance abuse disorders that have been identified as priorities. MhGAP acknowledges the critical need to obtain political commitment at the highest levels of government and has established a structure and process for developing and implementing a comprehensive, coordinated campaign for acquiring funding and providing prevention and treatment services in resource-poor countries (WHO, 2008).
Implications for Mental Health Policy and Practice in the United States
As in other areas of endeavor, it is apparent that the United States has been a leader in advancing the field of mental health care. Many of the conceptual and empirical discoveries and innovations have occurred here, including the development of diagnostic tools and psychotherapeutic and pharmacological interventions. In addition to being the source of these specific advances, the United States has also contributed significantly at the macro-level. Major paradigm shifts such as the community support and systems of care models cited earlier occurred in this country.
However, in spite of the abundance of its intellectual and financial resources, the United States still has significant deficits in the way in which it deals with mental health issues and could benefit from the progressive approaches used by other nations. Ironically, some of these lessons come from countries with far fewer resources. For instance, many of the best examples of sites that have effectively integrated mental health with primary health care settings happen to be poor areas with few fiscal or technical resources, such as those programs cited earlier. These nations’ willingness to cross traditional disciplinary boundaries may be due, in large part, to not having the ability to create separate mental health structures because of scarce resources.
Likewise, some of the exemplary efforts to provide creative, innovative services seem to be spurred by an attitude of providing the best care possible within the constraints of limited resources. Within the United States there is often an expectation that new programs require additional resources. While it is reasonable to assume that additional funding is helpful for improving services, categorically linking innovation to new funding severely limits reform efforts, particularly during periods of economic distress. The willingness of people in other cultures to collaborate across disciplines (p. 190) and sectors to produce improved care within existing resource limitations is a practice Americans should consider emulating.
However, some managed care organizations in the United States, such as the Kaiser Permanente system, use true integration of care, and have been proposed as models to further improve the British system (Feachem, Sekhri, & White, 2002). The Kaiser organization embraces the integration of services through the continuum of care, to ensure that patients are treated at the most appropriate level of care and that their journey through the system is as rapid and efficient as possible. This system integrates all specialties, including primary care, as equal members of a multispecialty team; this team also jointly controls financial resources. Because the financial integration is complete, all parties in the system (primary care doctors, consultants, and hospitals) are jointly responsible for a single bottom line. This ensures that available resources are spent most effectively to achieve good health care outcomes.
Kaiser also emphasizes integration of leadership and management to ensure partnership between clinical governance and administration in achieving shared goals. This integration of culture and vision within a single organizational structure is helpful in moving a vertically integrated system in one clinical direction while providing high-quality, cost-effective care. This model of care, which is reminiscent of the systems of care model referenced in Chapter 8, holds the promise of creating a uniform health delivery system. Unfortunately, such systems are often strongly resisted in a market economy, which thrives on competition among various vendors or agencies. Disparate systems cause poor sharing of information and duplication of services that cannot justify the cost to the consumer based on poor outcomes. We have created a complex model for health care with stakeholders who have disparate missions, significant interdependencies, and the inability to work together to produce an optimal outcome. Simplification of the payor system from the administrative end and pay for performance on the provider end may hold some promise for the consumer of health care.
In addition to poor integration of services, there are two other contextual impediments to adopting a government-supported or single-payor coverage for health care financing in the United States. First, the sociopolitical culture of the United States is complex and well established. Historically, there have been significant tensions in this area, with a high priority placed on privatization of health and other human services while government continues to play a strong role in funding mental health care through Medicaid, Medicare, and other state and federal programs. There is little likelihood that this often inharmonious balance will shift significantly in the foreseeable future.
The second caveat regarding the benefits of other funding models relates to changes in the economy. Countries such as Sweden and Norway, which have provided (p. 191) state-supported health services, have recently experienced problems in delivering high-quality services because of the financial burdens placed on them during the global economic downturn. Perhaps the lesson to be taken from this is that any model of service provision and funding is only as good as the ability and willingness of the political system to provide sufficient support.
Variations in the political, economic, social, and cultural conditions of the countries we have described in this chapter preclude recommending that the United States adopt another nation’s system of mental health care. The fact that none of these other systems can claim anything resembling perfection also bolsters the argument against a replication strategy. Still, there are some specific lessons and recommendations that can be culled from the experiences of other countries and applied to our approach to providing mental health care in the United States. Concepts and strategies employed by other nations that are worthy of consideration include the following:
• Making Mental Health a Priority. One of the critical requisites of establishing behavioral health as a high priority is to integrate mental health into that nation’s mainstream policy agenda. The primary strategies for accomplishing this appear to be public education directed at heightening the awareness of citizens and public officials about the importance and benefits of good mental health, and integrating mental health into the physical health system. In the United States, the responsibility for educating the public about important health and social issues usually resides with advocacy and professional groups associated with the issue.
• For mental health, consumer-directed groups, such as the National Alliance for the Mentally Ill and Mental Health America, and professional groups, including the American Psychiatric Association, American Psychological Association, and National Association for Social Work, are well positioned to provide this education. Their efforts would be significantly enhanced by government or foundation support that stipulated collaboration among these organizations as a requisite for receiving funding.
• The importance of integrating mental health and primary care has previously been discussed. Although bringing these typically separate provider systems together represents a significant challenge, progress would be facilitated by offering incentives for co-location, such as favorable reimbursement rates, targeted funding devoted to assisting organizations with developing integrated infrastructure, policy and regulations fostering coordination and co-location, and research funds dedicated to examining the health outcomes and economic impact of integrating mental and physical health.
(p. 192) • Money Matters. Changes in public attitude and policy are essential requisites for enhancing mental health care. However, these efforts will not yield significant improvement without sufficient and appropriate financial support. As noted earlier, several European countries with strong mental health systems allocated 10% of their health care budgets to mental health care, in contrast to the United States, which spends only 6% on mental health. Another correlate of successful systems is the involvement of government in funding and operating health care. Compared to health care provision in many industrialized countries, in the United States the private sector provides more than twice as much of the total health care. Likewise, countries that require mandatory health insurance have been more successful in improving health outcomes.
Given the prevailing anti-government sentiment in this country, it is not likely that any group will be able to rally support in the near future for greater government involvement in the mental health system. Even with the attention given to mental health in light of the recent mass shootings in Tucson, Aurora, and Newtown, there is little indication of stronger government support for mental health, other than perhaps attention to gun purchase screening. Other countries have demonstrated, however, that the amount of resources available is not the only critical factor in responding to mental health needs. The way in which those resources are used is also important.
For example, in the United States there are significant disparities between the level of care available to persons in lower-income groups and that available to those with greater fiscal resources. We might use the principles employed by the Mental Health Gap Action Program of WHO, which systematically identified relevant evidence-based approaches, established priorities, and mobilized the political commitment necessary to obtain funding and develop programs to reduce the gap in care between low- and low-middle-income countries. We would also benefit from the experience of countries directing funding to integrated, one-stop centers where individuals can have multiple health and mental health needs addressed in a single location. Aligning financial incentives to support policy and program goals can be a powerful tool for achieving desired outcomes as long as planners realize that effective care requires attention to other factors, such as a well-prepared workforce and a responsive administrative infrastructure.
Unlike some of the countries cited in this chapter, the United States has not established mental health as a national priority. Without a clear vision and strong plan for mental health care, policy-makers tend to make decisions that may do more harm than good. For example, in the current economic downturn, elected officials are inclined to reduce funding for services as a knee-jerk response to budget imbalances. If these officials had a better understanding of and commitment to mental (p. 193) health care, they might also consider measures that would enhance efficiency and improve services while at the same time being responsive to the broader fiscal crisis. Examples of this approach to budget problems include offering incentives for better integration and less duplication of services, and incorporation of evidence-based programs that produce better outcomes.
• Data Drive Policy. The European Union and members such as Scotland have demonstrated how establishing and tracking key health status and outcome indicators can focus attention on critical policy concerns and directions. Systematic monitoring efforts have been effectively used to promote nationwide initiatives to prevent and treat mental health disorders, as well as to address labor force issues. While we collect large amounts of data in the United States, some of which is used to justify politically driven decisions, we have not done as well in developing and utilizing highly visible, sustainable data-tracking mechanisms that allow the policy-makers, as well as citizens, to assess progress on important mental health issues and outcomes.
Even today, the Belgian city of Geel’s centuries-old effort to reintegrate individuals with severe mental disabilities into their community is seen as the most comprehensive and impressive model of community recovery. Although it would be difficult to replicate this approach anywhere in the United States, one feature of the Geel model bears consideration as we strive to improve our current system of care. The common perception is that the citizens of Geel must have been very compassionate and kind to take these disabled individuals into their homes and community. While there probably was some charitable intent, historians have noted that the primary motivating force behind this movement was economic, as the host families benefited financially from having these individuals in their homes (Goldstein & Godemont, 2005).
In our current political and economic climate, policies based on compassion may be praised but are seldom implemented. Therefore, making a persuasive argument for improving care for persons with mental health challenges will require providing empirical evidence that these reforms will not only produce benefits for behavioral health service recipients but also yield tangible economic benefits for all citizens and communities.