The next wave of change for psychology and mental health services in the health care revolution.

Recent national changes in the de facto system of health and mental health care are described. Although the percentage of people without health insurance (always or sometimes) has not decreased, the organization of insured care has changed dramatically. Of the insured population, 75% are under some form of managed care. For 88% of the managed care population, mental health care has not been integrated with health care: the so-called carve-out. The author argues that system integration (carve-ins), for a variety of reasons, will begin soon and will occur very rapidly. A tilt toward carve-ins will have substantial impact on psychologists' training, service delivery, and research.

U.S. mental health policy. Doomed to fail.

Changes in the de facto system of mental health care in the last decade reflect organizational and entrepreneurial responsiveness to changes in health policy, not mental health policy. Various other actions described here reduced statutory or institutional leadership roles in mental health and increased the pace at which mental health policy was becoming dependent on health policy. In turn, U.S. health policy in the 20th century has been inherently flawed. The short-term general hospital--the "doctors' workshop"--emphasizing acute care and surgery, has been the cornerstone of U.S. health policy throughout the 20th century. The mimicry of health services by mental health leads to demonstrably more expensive and less effective mental health care and dooms mental health policy to failure.

Changes in diagnostic case mix in psychiatric care in general hospitals, 1980-85.

The Hospital Discharge Survey of 1980 and 1985 was used to assess changes in diagnostic case mix of psychiatric inpatient care in short-term, nonfederal general hospitals. Information regarding presence of psychiatric and chemical dependency units was added to both surveys, and information regarding exemption from Medicare's PPS system was noted for 1985. The largest increase was in ICD-9 code 296 (affective disorder), which more than doubled in frequency, along with a similar decrease in Diagnosis-Related Group 426, depressive neurosis. One explanation for this sizable shift was "gaming the system." One cannot conclusively, however, distinguish between gaming the system and the effects of changing professional views of depression during this time period. Other variables potentially contributing to the effect are described as well.

The emergence of psychiatric departments as quasi-units in general hospitals.

The organization of inpatient psychiatric treatment in general hospitals was investigated using data from the Hospital Discharge Surveys for 1980 and 1985 and definitions of psychiatric services used by the American Hospital Association and the National Institute of Mental Health. The definitions differ in that psychiatric services meeting the AHA definition are formally organized and physically separate units, while those meeting the NIMH definition may have a less formal structure. The number of psychiatric inpatient episodes in psychiatric departments as defined by NIMH increased sixfold between 1980 and 1985, while those in formal psychiatric units as defined by AHA decreased by 16 percent. The increase was completely accounted for by episodes of mental disorders; episodes of alcohol and drug disorders decreased in both settings. The implications of the psychiatric department as an entrepreneurial newcomer in the competitive general hospital market are discussed.

Homelessness and public policy priorities.

Public policy issues related to homelessness and their priorities are reviewed. It is argued that the three most important policy issues are housing, income, and health. Cutting across these priority areas are the special problems of homeless children and youth, both in families and alone. Alcohol, drug abuse, and mental health services, although needed and effective, will neither stop nor slow the rate of increase in homelessness experienced in recent years. Psychologists, in emphasizing aspects of homelessness that they are expert in, are deflected from variables determining the prevalence and incidence of homelessness. The latter variables must be regarded as the priority policy issues in homelessness.

Changes in psychiatric inpatient treatment of children and youth in general hospitals: 1980-1985.

Changes in the prevalence of inpatient psychiatric treatment of children and youth in short-term general hospitals between 1980 and 1985 were investigated. During that period, the locus of treatment of mental illness among children and youth shifted dramatically away from specialized facilities to general hospitals without psychiatric units. Among general hospitals without psychiatric units, the number of inpatient psychiatric episodes treated increased dramatically, patients' average length of stay almost doubled, and the total days of care provided more than tripled. The increased care was paid for primarily by Medicaid and commercial insurance. Total days of care for drug and alcohol problems among children and youth in general hospitals decreased substantially. The results suggest that general hospitals may be relying on psychiatric treatment to supplement revenues that were limited by Medicare's prospective payment system, which became effective during the period under study.

The de facto national system of psychiatric inpatient care. Piecing together the national puzzle.

National data regarding psychiatric inpatient episodes can be viewed in 2 ways. The normative method surveys the "specialty mental health sector." A more inclusive method includes smaller sites (e.g., the military), all of general hospital treatment (rather than only the psychiatric unit), residential treatment centers, and other residential care. The difference between the 2 methods represents approximately 725,000 episodes, at a direct cost of more than $6 billion. The more inclusive analysis of the years 1980 and 1985 reveals a strong shift to the private sector and an increase in inpatient care of children and youth that might be obscured by limiting national treatment statistics to the specialty mental health sector.

Changes in general hospital psychiatric care, 1980-1985.

More than 60% of all inpatient psychiatric episodes occur in general hospitals. The need for psychologists' involvement in this important area is discussed. Changes in general hospital inpatient care from 1980 to 1985 are described. These include important and controversial changes in public policy, most notably Medicare's prospective payment system. Substantial changes in the de facto system occurred in patterns of diagnosis, sites of care, and the role of third-party payers. Implications for public policy and future investigations are drawn.

Prevalence of dual diagnoses of mental and substance abuse disorders in general hospitals.

Data from a 1980 discharge survey of general hospitals were analyzed to determine the prevalence of cases with coexisting diagnoses of mental and substance abuse disorders. Twelve percent of total cases (or 208,000 episodes) had dual diagnoses, a proportion similar to that found in another analysis of 1985 data. Of these cases, 55.5 percent had a primary diagnosis of an alcohol or drug disorder, most commonly alcohol- or drug-induced organic brain syndrome. Thirty-four percent of cases with a primary diagnosis of mental disorder had depressive neurosis, 24 percent had psychosis, and 19 percent had personality disorder. An additional 18.9 percent of all cases had two or more mental or substance abuse disorders. Dual-diagnosis cases had a shorter mean hospital stay than cases with mental disorder only.

Characteristics of psychiatric discharges from nonfederal, short-term specialty hospitals and general hospitals with and without psychiatric and chemical dependency units: the Hospital Discharge Survey data.

Hospitalization for mental disorders (Major Diagnostic Categories 19 and 20) was examined using the 1980 Hospital Discharge Survey (HDS) data. We added to the HDS data by noting whether each hospital had a specialized psychiatric and/or chemical dependency unit, especially noting short-term specialty psychiatric and chemical dependency hospitals. Of the approximately 1.7 million episodes with MDC-19 and -20 diagnoses in the nation's nonfederal short-term hospitals in 1980, 13.5 percent were in specialty hospitals. Of the remaining general hospital episodes: 31 percent occurred in hospitals with only psychiatric units, 5 percent in hospitals with only chemical dependency units, 31 percent in hospitals with both types of specialized treatment units, and 33 percent in hospitals with neither type of unit. The last figure is much less than previously thought. The five hospital types may be arrayed on a continuum of resource utilization and severity of cases treated, with general hospitals with no special units at one end, specialty hospitals at the other, and general hospitals with psychiatric or chemical dependency units intermediate. Presence or absence of a chemical dependency unit influences a hospital's profile in this regard, particularly for MDC-20. Future studies should take into account the presence of a chemical dependency unit.

Predicting length of hospital stay for psychiatric inpatients.

Medicare's use of diagnosis-related groups and the frequent acceptance of length of stay as an indicator of resource utilization has caused a surge of interest in the predictability of length of hospital stay for psychiatric inpatients. By constructing a weighted least squares regression model using data from the 1980 Hospital Discharge Survey, the authors were able to account for an increased amount of variance in length of stay for the major diagnostic categories of mental disorder and substance abuse for Medicare and Blue Cross/Blue Shield patients. The enhanced ability to predict length of stay is attributed to a carefully constructed data base and an increased number of predictor variables, particularly comorbidity. Knowledge of the presence or absence of a chemical dependency unit in the hospitals from which patients were discharged substantially increased the proportion of variance accounted for in the analysis.

The psychiatric inpatient treatment of children and youth in general hospitals.

National attention has recently focused on the mental health needs and services of children and youth. The lack of outpatient services and their coordination has been noted, as well as the consequent press towards inpatient care. We describe the inpatient treatment of children and adolescents (ages 0-18) in short-term, non-Federal general hospitals in 1980. Nationally, 128,300 children were treated for mental disorders in general hospitals at an estimated cost of over $1.5 billion. Compared to adults, children were more likely to be treated in scatter beds (vs. specialty units); have a diagnosis of mental disorder (vs. alcohol/drug disorder); stay much longer; and pay with commercial insurance. Previous work focusing on psychiatric units of general hospitals identified less than 40% of the total episodes, a figure very similar to that for adults. The majority of psychiatric inpatient episodes for children and youth in the United States takes place in short-term general hospitals. Community psychologists need to be aware of national trends in inpatient care and be involved in the development and promulgation of alternative models of care.

Episodic rate of mental hospitalization: stable or increasing?

It is generally accepted that the national rate of mental hospitalization has been stable in recent years (at 1.8 million). That conclusion, based largely on data from the National Institute of Mental Health (NIMH), ignores all inpatient episodes for mental disorders in general hospitals without psychiatric units. Surveying the more extensive data base, the authors previously reported a much larger number of inpatient episodes (about 3 million). This article investigates changes in rates across years and finds a steady increase from 1965 to 1979. The difference is entirely attributable to inpatient episodes in general hospitals without psychiatric units, where the number of episodes has been rapidly increasing.

Proportion of inpatient days for mental disorders: 1969-1978.

Mental hospitalization is an important part of the national picture of hospitalization. Total inpatient days for mental disorders, and their proportion of total hospital days for all disorders, is a statistic of considerable national import, yet there has never been a complete description of total inpatient days for mental disorders. The authors present data from the National Center for Health Statistics for nine years (data for only two years had been published previously), and correct them, and national totals, for the previous exclusion of data from residential treatment centers and community mental health centers. From 1969 through 1978, inpatient days for mental disorders fell from 168 million to 95 million. This decrease was more than accounted for by decreased psychiatric inpatient days at two sites: state mental hospitals and Veterans Administration psychiatric hospitals. The number of psychiatric inpatient days at all other sites increased during this time period. The authors also note a decrease in total inpatient days for all disorders over the decade. However, 85 percent of the total national decrease was accounted for by the decrease in psychiatric inpatient days. The authors stress the implications for public policy and the need for a more adequate national data base.