# 40 - 35 Public Psychiatry

# 01 - 35 Public Psychiatry

# 35 Public Psychiatry

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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.
Evidence of serious and pervasive barriers to accessing mental health care can be found in several social crises. Poor
children and adults increasingly are deferring physical and mental health care until illnesses become chronic and severe and
then often do not know or cannot gain entry into any setting for services except public hospital emergency departments.
Children with severe psychiatric or behavioral disorders are being held in emergency department facilities for days and
even weeks because the staff cannot locate any treatment facilities with an appropriate level of care that have an opening
or are willing to take the child as a patient (or accept the child or family’s insurance coverage or lack thereof). People who
cannot afford private services thus face daunting obstacles when seeking appropriate mental health care as a result of a
serious underfunding of practitioners and programs. The economic forces and public policy dilemmas driven by the everincreasing cost of health care bear directly on the field of public psychiatry, as well as the lives of tens or hundreds of
thousands of people who do not receive adequate care.
Psychiatry and Public Agencies
Psychiatry’s relationship to public sector agencies has, with some specific exceptions,
been one of detachment because of the dominance of the private practice models before
the advent of managed care and also largely because of the nature and structure of U.S.
social welfare programs. This is a divide that often begins during academic preparation,
in that many psychiatry training programs eschew meaningful rotations in public sector
settings. In contrast to most industrial nations in which comprehensive social welfare
reforms have been initiated, U.S. social welfare programs grew incrementally and
categorically, that is, one category of service at a time. Large-scale initiatives, such as
President Johnson’s War on Poverty, have been implemented in piecemeal fashion by
fragmented federal, state, and local government bureaucracies and have been vastly
reduced through subsequent initiatives, such as the recent changes in federal regulations
to “end welfare as we know it.” Various social service agencies have been created
through a process and set of alliances that has been called the iron triangle. Advocates
form an organization to champion a particular cause, such as blindness, developmental
disabilities, primary care, or mental health, among others. They find key legislative
sponsors who advance the cause through legislation and appropriation. This creates a
bureaucracy and bureaucrats that join the alliance. Through successive legislative
sessions, the alliance of advocates, lawmakers, and bureaucrats builds a stronger and
stronger categorical agency, for example, adults and families with dependent children
or people with biologically based, severe mental illness. From the 1930s through the end
of the twentieth century, U.S. social welfare agencies were created on this pattern: The
system has resulted in generous funding and hopeless fragmentation of services at local
service delivery levels in which each agency depends on separate funding silos that also
deliver conflicting rules and regulations.
It has been said that “mental health is not a place.” Psychiatrists have a role at the receiving end of every categorical silo
because the clients of each categorical agency experience mental illness or various addictions. Services for children with
severe emotional, mental, or behavioral disturbances are a dramatic case. Five categorical agencies—child welfare,

education, primary health, substance abuse, and juvenile justice—all have a responsibility to care for these children (and,
indirectly, for their caregivers, including parents and families). Especially for the children with the most severe
disabilities, the protective service worker taking a child into court, the special education teacher working day to day with
the child, the juvenile probation officer, the substance abuse counselor, and the child’s pediatrician all need the
consultation and support of a skilled psychiatrist. The situation is similar for adults with severe mental illness, for whom
case managers, vocational rehabilitation counselors, basic needs benefits specialists, social workers, psychotherapists,
substance abuse counselors, parole or probation officers, legal conservators, visiting nurses, peer specialists, and
physicians all may be mandated to deliver services.
Workforce Influences on Contemporary Practice
Shortages in the ranks of psychiatry have been well documented historically, and some
project this to continue. However, as the field of psychiatry connects with its science
and evidence base (e.g., neuroscience, genetics, pharmacology, outcomes science) while
retaining its strength in the meaningful connection with patients and their families,
some would argue that the reversal of the shortage trend has begun. The Decade of the
Brain in the 1990s and the Decade of the Mind begun in the 2000s sponsored by the
National Institutes of Health (NIH) contributed to this change. Medical students are
increasingly stimulated to enter the field by recognizing the importance of psychiatry to
health care in general, realizing that this is still a field in which the practitioner (and by
extension the interdisciplinary team) is an instrument of change through integration of
contemporary knowledge, skillful learned interactions with patients, and a willingness
to commit to providing value. The national aggregate numbers, however, cannot
adequately capture the extreme variations that exist geographically: Rural and frontier
sites are dramatically more likely to experience shortages than more urban
environments.
Because subsets of the public sector populations have special needs, responses to their
needs have to be correspondingly tailored:
 Children and family needs are expressed differently than those for adults and require
different responses.
 Mental illnesses have culturally driven ways of presenting, and interventions must be
culturally competent.
 Issues of language (including American Sign Language with hearing-impaired
individuals) can complicate diagnosis and treatment.
 The rapidly expanding elderly population will pose significant new challenges for
effective treatment.
Just these few examples suggest the sophistication with which education and training
must be engineered to meet the existing and changing demands of people in need of
services.
Contemporary Evidence Base for Effective Public and Community
Psychiatry

Since the 1980s, several structured interventions have been developed to address the
gap between what historically has been taught in most psychiatry training programs—
typically, an office-, clinic-, or hospital-based approach focusing on diagnoses and
pharmacotherapy supplemented by psychotherapy—and the competencies required to
deliver or to support the delivery of the full array of psychiatric rehabilitation services.
Public and community approaches to psychiatric rehabilitation involve not only
pharmacotherapy but also an array of complementary services that must be coordinated
to assist people with severe mental illness or behavioral disorders and their families and
support systems to manage symptoms, to access and use resources effectively, and to
gain the greatest degree of autonomy in the least restrictive setting possible. The
competences required to effect these interventions go beyond the scope of psychiatry,
thus requiring that psychiatrists effectively collaborate with other rehabilitation and
mental health specialists. Although psychiatrists rarely implement the educational,
resource linkage, and psychotherapy interventions involved in these protocols, it is
essential that the psychiatrist become aware of and be able to reinforce these
interventions. Hence, familiarity with the manuals that describe how to implement these
interventions with fidelity is strongly advised—and increasingly incorporated into
psychiatry training.
Evidence-Based Manualized Interventions for Child Psychiatric
Rehabilitation.
 Children with severe emotional disturbance and adolescents with
severe behavioral disorders traditionally have been removed from their families and
placed in restrictive psychiatric or juvenile justice settings (e.g., psychiatric inpatient
wards, residential group homes, and juvenile detention centers). These placements
separate the child from the natural family, school, peer group, and community
environments, which may provide some benefit by reducing the child’s exposure to
addiction, conflict, violence, or deviant behavior. However, the placements also deprive
the child and family of the opportunity to build better relationships with one another
and with other children, families, teachers, and community groups. The second key
ingredient to effective public and community child psychiatry comprises interventions
that complement pharmacotherapy. Since the 1970s, several rehabilitative approaches
for children with severe disorders (and their families) have been developed, tested, and
disseminated in replicable manuals and training programs.
Implementation of evidence-based practices is not always easy and rarely occurs even
in clinics and practice groups that are well trained and motivated to use evidence-based
treatment models, given that most current systems of payment and service delivery
were not designed to accommodate or support the use of science-based interventions
such as those highlighted here. In addition, evidence-based dissemination and
implementation strategies must be deliberately designed to support the initial adoption
and sustained use of evidence-based mental health treatment models. For example, a
recent study of the implementation of one of the most widely disseminated evidencebased mental health interventions for children and families, multisystemic therapy
(MST), demonstrated that initial training yielded a very positive early rate of adoption

of the program with good fidelity to the model, but only teams that were provided with
regular ongoing supervision and support (for supervisors as well as therapists) from
expert consultants were able to sustain the initial successes.
Roles of Psychiatrists in Public and Community Psychiatry
Multidisciplinary Teams
Psychiatrists in the public sector rarely work in isolation. Most often, psychiatrists work
within a team that includes professionals from several disciplines (e.g., psychology,
social work, nursing, occupational therapy, rehabilitation or addiction counseling, social
services, housing, and employment specialists) and nondegreed direct care workers
(e.g., bachelor’s degree–level counselors or case managers, high school graduate
indigenous outreach workers, peer-support specialists, and family advocates), each of
whom brings unique skills and experience to address the varied needs of people with
severe and persistent mental illnesses. The team, rather than any single provider,
assumes responsibility for the ongoing care of each patient across the many levels of
services and often for many years. Its success is based on effective communication.
Every communication should be explicitly focused on the client’s (i.e., patient and
family) stated goals, as well as on the team’s technical and logistical issues, to maximize
the client’s motivation to participate actively and productively in all services by
ensuring that the services truly are patient centered and collaborative.
Psychiatrists play three primary roles on multidisciplinary psychiatric rehabilitation
teams: Conducting psychiatric evaluations, providing pharmacotherapy, and serving as
the team’s medical director (and, at times, as the administrative supervisor or team
leader).
Psychiatric Evaluation and Diagnosis.
 In public and community settings and
populations no less than in any other practice setting or patient population, the sine
qua non is a thorough evaluation of all relevant history and systems and an accurate
diagnosis. The goal of evaluation and diagnosis is to develop the most clinically
effective individualized approach to treatment and rehabilitation for each patient.
Psychiatric evaluations in public and community settings must include a careful review
of the individual’s psychosocial strengths and resources. The focus on strengths and
resources often is lost or obscured when systemic factors (e.g., eligibility regulations for
governmentally funded services or benefits) emphasize disability or limit the individual’s
or family’s access to services or benefits (e.g., welfare-to-work regulations that place
time or other eligibility restrictions on types of temporary aid, such as food stamps or
vouchers for household supplies or housing).
Pharmacotherapy.
 The psychiatrist’s most visible role usually is providing
pharmacotherapy. The most difficult challenge in public sector mental health settings
often is not the technical formulation of an effective medication regimen but instead the
arranging of a plan of care so that the patient reliably follows the prescribed regimen

(i.e., adherence or compliance). A recent review of interventions designed to enhance
adherence to psychotropic medication regimens by patients with schizophrenia found
that education alone often was the only strategy used even though it was less effective
than approaches that focus on “concrete problem solving,” “motivational techniques,”
and “reminders, self-monitoring tools, cues, and reinforcements” or that provide “an
array of supportive and rehabilitative community-based services.” Thus, although the
psychiatrist must address technical medical issues accurately to formulate diagnoses and
to establish an effective psychotropic regimen, effective pharmacotherapy depends
heavily on providing—directly, in encounters with patients, or indirectly, by working
closely with nonpsychiatric mental health professionals and nondegreed care workers—
practical assistance to patients to enable them to anticipate and to manage the
psychosocial stressors or problems that can render even the most technically sound
medication regimen completely ineffective as a result of nonadherence by the patient.
Team Leadership.
 The psychiatrist also often plays a leadership role as the project
or program medical director—with the attendant responsibilities of monitoring the
medical safety and well-being of all patients and establishing or supporting
management and clinical procedures that support quality of care and a cohesive
treatment team. As the team leader or simply as a team member, the psychiatrist serves
as a role model for compassionate and professional behavior in relation not only to
patients but also to all other team members. Formal or informal leadership is especially
important when psychiatry residents and medical students work on a team as a training
experience. The team psychiatrist serves not only as a mentor and a role model for the
core aspects of psychiatric practice but also to demonstrate the values and skills
necessary to integrate psychiatry within the framework of multimodal community-based
longitudinal psychosocial interventions.
Psychiatrists who work with persons with severe mental illness and who wish to contribute as key members or leaders
of their teams must go beyond their prescription pads to acquire knowledge, attitudes, and skills congruent with
contemporary practice guidelines for psychiatric rehabilitation; give respect and support to multidisciplinary team
members and gain their respect and support in return; cope with large caseloads; collaborate with agencies and programs
to ensure continuity, consistency, and coordination of care; and value the roles and expertise of staff who provide case
management, supported employment, skills training, and family and housing supports. If psychiatrists can incorporate
these attitudes and skills, they can expect reciprocity and cohesion from other team members, and clients will benefit.
Surveys of psychiatrists in the public sector indicate that those who embrace the rehabilitation perspective by expanding
their roles to be consultants and teachers for patients, families, trainees, and colleagues from other mental health
disciplines are more satisfied professionally than those who focus on diagnosis and treatment alone.
New Paradigms.
 Virtually all health care should be integrated and coordinated to
deliver effective, rational, and cost-efficient care. The broader, contemporary definition
of care must include public health. In fact, linking public health models with acute care
management, which, in turn, is coupled with chronic illness care management,
rehabilitation, or recovery models, represents the continuum for an integrated system.

However, this continuum is insufficient without four other components: (1) the
application of new research to improve care and the application of bench-to-bedside
models to translational research, (2) meaningful involvement of patients and families in
a shared decision-making paradigm, (3) integration with primary and specialty care
systems, and (4) the development of the clinical system as a system of advocacy.
Training preprofessionals in such a model is one approach to introduce meaningful and
sustained change to health care and its delivery and is already operational in some
systems.
New Models for Service Delivery and Treatment
Organized Systems of Care.
 The focus of reform has moved increasingly to
coherent, efficient, and accountable delivery systems. The basic idea of the system of
care for children with serious emotional disturbances can be described in two ways—in
terms of interagency structures and in terms of clinical processes. Five categorical
agencies in a given community form a strong consortium that targets a specific
population of children (and their families) to whose needs none of the agencies can
adequately respond on their own. The consortium agencies commit themselves to treat
the child and family with a common plan of care and to find ways to pool their resources
to do so appropriately. This often requires that in the central bureaucracies at the state
level, a parallel interagency commitment be in place that supports the local system of
care initiative, resolves any regulatory conflicts that may arise, and gives permission to
innovative aspects of the delivery system. The collaborative interagency structure
provides the resources and the flexibility for effective clinical work.
From the viewpoint of clinical processes, the system of care provides a full enactment of the traditional clinical practice
that meets the requirements of medical quality assurance. What is different is that it is carried out in home and
community settings, and it involves participants from different disciplines—child welfare, special education, and juvenile
justice—in one standardized treatment methodology. The center of the system of care is the child and family team that is
made up the child and family, clinicians and agency representatives involved in the case, and significant supportive
individuals identified by the child and family. Current issues are reviewed—strengths, problems, and needs—diagnostic
issues are considered, clinical goals are articulated, and appropriate treatment strategies are identified. The expected
outcome of each intervention is specified, and progress toward it is systematically charted. The system of care requires a
full array of flexible services. The essential starters include clinical diagnostic services, care coordination or case
management, crisis intervention services, and a flexible essential supportive service—child care specialists who can be
assigned to support the child and family in any situation. Systems of care that have been particularly effective have relied
on substantial community organization and collaboration or innovative funding models, or both, that blend or braid
funding streams to focus on clear assignment of responsibility for a particular child and family, as well as adequate
resources.
The basic model for community support for adults was called assertive community
treatment (ACT). ACT was implemented with multidisciplinary teams with psychiatrists,
nurses, psychologists, social workers, psychiatric aides, and paraprofessionals. The ACT

team would assume the care of a designated number of adult patients with serious and
persistent mental illness and would be available around the clock, 7 days a week. The
team would help find housing, manage money, organize household routines, find social
contacts, find work, and support the individual’s adjustment to workplace settings.
Concurrently, medications would be managed and help provided to facilitate an
individual adjusting to community living. At the heart of the program was the basic
clinical process that developed and maintained an individualized treatment plan, which
was constantly adjusted to the changing needs of each client. The ACT model has been
modified in various ways as it has been implemented in different states. Innovative
funding models have been developed in several states by using bundled rates and case
rates, which make it easier to implement and to sustain than traditional fee-for-service
payment systems.
In contemporary managed care terms, ACT teams are disease and disability
management models that assign accountability to provider systems that may not assume
risk in managing community support of persons with disabling conditions. The National
Alliance on Mental Illness (NAMI) has developed program models and protocols for the
Program for Assertive Community Treatment (PACT) to encourage public agencies to
contract for ACT services.
Effective Treatment Models.
 The previous discussions have outlined the various
treatment models that have been introduced since the 1980s in the effort to establish an
evidence base for the effectiveness of specific interventions and approaches to care. The
attention to evidence-based treatment models has been a response to the call for quality
and accountability for service outcomes demanded from health care services in general
by purchasers and policy makers and part of an effort to cope with the difficulties of
evaluating service delivery models or systems of care.
The movement to evidence-based services is necessary to break down components of
the service delivery system to determine the relative effectiveness of specific service
interventions using the evaluative tools and methods that are available. Eventually, the
case will be made to address the larger policy questions concerning the value of
coherent and rationally organized service delivery in mitigating the effects of mental
disability on the development of the child and enabling the recovery process for adults
with serious and persistent mental illness.
Chronic Illness Care Model: Psychiatry in the Context of Primary Care.
Finally, the care of persons with long-term mental health problems is included in
innovative developments in the provision of primary health care for persons with
chronic illnesses (http://www.improvingchroniccare.org). The Health Resources Services
Administration (HRSA), the federal agency responsible for the community health centers
or Federally Qualified Health Centers (FQHCs), has adopted the chronic illness care
model in its training and technical assistance efforts for community health centers. The
model grows out of the current concern for quality of care and accountability for health
care delivery systems for effective outcomes. Depression management is one of the four

chronic health conditions that the HRSA has selected for its training collaboratives.
The model begins with the assumption that the health care delivery system is part of a community context and must be
responsive in its interactions with the community. Four areas of focus are essential in implementing the model in the
health care delivery system: self-management support, delivery system design, decision support, and clinical tracking
system. Self-management support gives patients a central role in determining their care, fostering a sense of responsibility
for their health. Patients collaborate with the primary care team to establish goals, create treatment plans, and solve
problems along the way. Delivery system design requires a reorganization of the way in which the health system operates,
so that up-to-date information about a given patient is centralized, follow-up responsibility is assigned as a standard
procedure, and so on. Decision support requires that treatment decisions are based on explicit, proven practice guidelines
supported by at least one defining study. Guidelines are discussed with patients and providers, and treatment team
members are constantly trained in the latest proven methods. Finally, clinical tracking systems track individual patients and
populations of patients with similar problems. These systems must be practical and operational—able to check an
individual’s treatment at any point to confirm that the treatment conforms to recommended guidelines. The real
integration of psychiatric care into primary care is an important innovation to consider that would improve physical
health care for individuals with psychiatric disorders and eliminate the separation imposed by placing individuals with
psychiatric problems into community mental health centers.
THE ROLE OF PUBLIC AND COMMUNITY PSYCHIATRY IN TWENTYFIRST CENTURY HEALTH CARE
Public psychiatry emerged historically as an attempt to provide humane care for people
with severe mental disabilities who did not have the resources to be protected from the
stigma and approbation that shielded so-called “eccentrics” and “black sheep” fortunate
enough to have been born into the wealthier social strata. Community psychiatry
evolved as an answer to concerns that public psychiatric treatment was a de facto form
of marginalization and oppression, if not inhumane exile and imprisonment, of
economically disadvantaged persons with mental illness. The great ideas of public
psychiatry (e.g., providing compassionate respite and meaningful social and vocational
rehabilitation) and community psychiatry (e.g., preserving social ties while providing
evidence-based treatment) often are lost in the competition for scarce economic and
political resources that faces every mental health, medical, and human service
profession and organization in the early twenty-first century. The spirit and skills of
advocacy that sparked the development and continue to characterize the best practices
of public and community psychiatry, as well as the dedication to bring demonstrably
effective services to the people who are most in need but are least served, have never
been more needed by the entire mental health field.
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