This study used national VHA data to compare the proportions and characteristics of the 82% of veterans treated exclusively in mental health outpatient clinics to the 18% of veterans treated in four different types of specialized intensive community-based programs. Veterans treated in all four types of community programs were distinguished most strikingly, by being diagnosed with 2–3 times more numerous substance use disorders, were more likely to have HIV and hepatic disease, to be from urban areas, of black race and also had 3–13 times more mental health outpatient visits, most of which were in community-based programs themselves. Veterans served in the specialized programs for SMI veterans (only 2% of the total) were much more likely than clinic patients to be diagnosed with psychotic disorders, to manifest psychiatric multimorbidity and personality disorders and had 13 times more total visits, receiving over three times as many prescriptions for psychotropic medications.
In the decades after the closure of public psychiatric hospitals in the 1950s-70 s, public mental health systems faced the question of how to address the broad needs of: 1) SMI patients who formerly would have been institutionalized, as well as the needs of emerging populations of 2) homeless and 3) criminal justice involved adults with mental health disorders and 4) those seeking rehabilitation/employment along with 5) the growing numbers of people newly seeking effective care for less severe problems. While there has been extensive documentation of the reduction in long term State and VHA psychiatric hospital beds [47, 48, 5], and many studies of the growth of outpatient mental health treatment generally [49–51]; we know of no system-wide studies of the place of intensive community-based services in any public mental health system nor of characteristics of people who use these services. The main reason for this lack of studies is that, with the VHA as an exception, there are few integrated public mental health systems responsible for entire poplations that have comprehensive electronic health records to support such an analysis.
On the one hand, available studies have shown that “the system” still faces challenges with respect to the treatment engagement of people with mentally illness [52]. On the other, the National Comorbidity Survey (NCS) and NCS Replication show that between 1990 and 2003, while the overall rates of mental illness did not significantly change, basic treatment rates for people with mental illness increased significantly [49] although many still did not receive adequate treatment [53]. Additionally, among people with SMI, rates of any mental health treatment increased from 24.3–40.5% [49]. Further data from the Healthcare for Communities Survey showed an increase in mental health specialty treatment for people with SMI from 39% in 1997 to 51% in 2001 with an even larger increase (from 47–76%) for the subgroup who perceived a need for treatment [51]. Most research on utilization of mental health services, however, has focused on people with mild to moderate mental illness. For example, studies based on the National Ambulatory Medical Care Survey that found that treatment for depression tripled between 1987 and 1997 [50], and that most antidepressants are prescribed by primary care providers [54, 55].
Local studies based on Medicaid data show that community programs continued to provide ACT and ACT-like services to the most seriously mentally ill and functionally impaired adults [56], though a recent survey suggested that less than 20% of non-VA community mental health facilities offer ACT [57] and even fewer offer other community services such as peer support, employment, and housing services [58]. While most research has focused on either people who use less intensive services (i.e. from standard mental health outpatient clinics) or specific community-based treatments like ACT or supported housing, no study to our knowledge has addressed the broad array of clinic and intensive community-based services offered in a national system or even in one comunity. The present study, based on VHA data showed intensive community-based service are provided to 18% of those receiving any specialty mental health services especially to those with multiple substance use disorders, severe mental illness, criminal justice involvement, and/or homelessness. A previous study of VHA care suggested that considering all patients with psychiatric diagnoses, one-third receive no specialty mental health treatment at all and recieive care for mental disorders exclusively in primary or specialty care clinic setiings [59]. These VHA studies, taken together, thus appear to be unique in mapping the major components of a complete contemporary mental health system in which most patients receive care in standard outpatient clinics but significant subgroups receive intensive community-focused care largely shaped by social determinants and SUD-related multimorbidity.
In view of this mapping, it is notable that several recent reviews have emphasized the unique role of mental health services in addressing social determinants of health as well as individual biomedical conditions [60, 26, 27]. The portrait of community-based care in VHA presented here illustrates the way mental health systems have been shaped by such social determinants. Sheilds-Zeeman described two types of intervention which she referred to as “social risk–informed” care and “social risk-targeted care.” Social risk–informed care tailors clinical plans to reduce the effect of social or economic adversity, most often in a conventional clinic setting, without necessarily targeting the social condition itself. Social risk-targeted care, in contrast, more directly helps patients to reduce social or economic adversity, and is more focused on community intervention. The community-based programs described here fall into both categories in that they seek to provide in vivo services at the individual level focusing on real world adaptation to challenging circumstances and directly addressing patient-level problems such as housing, criminal justice involvement, impaired activites of daily living, limited employment opportunities, social isolation and a stigmatizing environment. The developing conceptualization of mental health care within a social determinants of health framework, thus provides an overarching context for understanding the unique role of community-focused programs.
Several methodological limitations of this study require comment. First, our ability to identify services delivered through community-based programs is limited to those identified by specific clinic codes in VHA administrative records. There are, no doubt other programs in VHA that would conform to our concept of community-based care that were implemented through local initiatives, which we could not identify. However, those examined here were developed through national initiatives, often supported by special funding and are probably the largest and best definied. Perhaps the issue most neglected by this study is poverty, addressed by VA disability compensation and pension programs for many veterans. These programs were less commonly used by veterans served by outreach programs to criminal justice involved and homeless veterans although their access to these benefits likely increases after a period of program participation [61]. Crucial data are also not available on social security and local welfare programs.
Second, the definition of intensive community-based programs is not precise and while most programs addressed here involve frequent contact with veterans outside of health care facilities there is variability from program to program and facility to facility in the extent of vivo as contrasted with office-based service delivery in these programs. Nevertheless, all of the programs are intended to address exceptionally serious clinical conditions and specific socially determined challenges to community adaptation.
Third, administrative diagnoses are not based on formal diagnostic instruments or criteria, but have the advantage of representing real-world clinical judgements.
Fourth, this study focuses on data from the VHA which offers the advantage of providing comprehensive national data from electronic health records. However VHA is federally funded and operated and serves only veterans, who are overwhelmingly male, and thus its generalizability to other populations and health systems is unknown. This study offers a sketch of one system which, it is hoped, will stimulate similar studies of others.