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There is substantial evidence indicating that, when properly developed and implemented, school-based mental health programs can produce positive effects on children’s behavioral and emotional functioning (Durlak & Wells, 1997; Greenberg, Domitrovich, & Bumbarger, 2001; Wilson, Lipsey, & Derzon, 2003). As psychosocial factors play a significant role in influencing academic learning (Wang, Haertel, & Walberg, 1997), many programs targeting socioemotional functioning also note benefits for children’s academic functioning as well (Durlak & Wells, 1997; Ialongo et al., 1999; Tremblay, Pagani-Kurtz, Masse, Vitaro, & Pihl, 1995). Thus, there is growing recognition that enhancing children’s social and emotional competencies also facilitates their ability to learn and achieve academically (Adelman & Taylor, 2000; Greenberg et al., 2003; Zins, Weissberg, Wang, & Walberg, 2004). At the same time, increased confidence in the basic efficacy of school-based mental health programs has led to more wide-spread program implementation (Clayton, Ballif-Spanvill, & Hunsaker, 2001; Elliot, 1998). One consequence of this movement toward the dissemination or scaling up of evidence-based programs is that more attention is being directed to understanding the complexities of program implementation under “real-world” conditions (Domitrovich & Greenberg, 2000; Elias, Zins, Graczyk, & Weissberg, 2003; Pentz, 2004).

The fates of mentally ill persons have always been intertwined with the shifting boundaries between the criminal justice and mental health systems. Just as public mental hospitals once served as the institutions of last resort for the care and confinement of mentally ill persons, jails have become the last secure environment in most communities for the control of mentally ill persons when they are unmanageable and noncompliant. The U.S. Justice Department has reported that nearly 284,000 people with mental illnesses were in jail or prison on any given day–about 16 percent of the incarcerated population and more than four times the resident census in state mental hospitals (Ditton 1999). The presence of mentally ill persons in jails is not a new problem–it has been around for the 200 years since the beginnings of organized efforts to improve the care of mentally disordered persons in the United States (Grob 1994).

Overlying the jail and public mental health systems is managed care, which has spread rapidly during the past decade throughout the behavioral health care system. Managed care carve-outs may lead to cost-shifting, defined as one agency reducing its own expenditures by inducing another agency to pay for similar services (Norton, Lindrooth, and Dickey 1997, 1999). Cost-shifting may happen when two different agencies offer treatments that are substitutes and the treatment is paid for out of different budgets. For example, in a mental health carve-out, the managed care organization may be able to direct patients to receive care in mental hospitals paid for by the state, thereby reducing its own expenditures while increasing expenditures for care not covered through the mental health carve-out. This meaning is distinct from hospitals raising private reimbursement rates in response to lower public reimbursement rates, the traditional definition of cost-shifting in the health care literature (e.g., Sloan, 1983; Sloan, Morrisey, and Valvona 1988; Dranove 1988).

States have in recent years taken a more prominent role in social policy, including health care and welfare programs that were previously administered at the federal level (the so called “new federalism”). In the arena of health care policy, new federalism often takes the form of health insurance mandates. While some applaud the increased activism of states in health policy, others criticize state legislation as creating an impenetrable jungle of regulations that increases health care costs, possibly causing employers (usually of small firms) to drop insurance benefits and therefore increasing the uninsurance rate. Therefore the overall question of policy interest is whether state legislation can make a substantial difference at the population level and serve as a substitute for federal legislation. This study focuses on one area that has been prominent in the past decade: mental health benefits.

Traditionally, insurance benefits for mental health care have been more restrictive than benefits for medical and surgical services. The 1996 federal Mental Health Parity Act (MHPA; see, e.g., http://www.cms.hhs.gov/hipaa/ hipaa1, for a summary of the legislation and the statutory text) was an attempt to address this discrepancy and prohibited differential dollar limits for mental health and medical care in employer-sponsored insurance plans, but allowed differential limits in terms of hospital days and outpatient visits as well as differential cost-sharing features such as copayments, coinsurance, or deductibles. Thus, this legislation resulted in virtually no substantial changes in consumers’ health benefits, their access to mental health care, or health care costs related to the parity bill (General Accounting Office 2000). However, the federal legislation may have had an important symbolic value and encouraged many states to follow up with stronger mandates. By 2001, 31 states passed some form of parity legislation (National Advisory Mental Health Council 2001; Gitterman et al. 2001). In this article, we study the question to what extent recent state parity legislation changed perceived health insurance benefits, perceived access to care, and use of mental health specialty care, using survey data from 1998 and 2001.

Rituals and routines involved in family meal times contribute to the mental health of children, says a new study of 75 families.

They also establish a sense of family identity and provide a positive environment for problem-solving by both parents and children. Syracuse professor Dr. Barbara Fiese distinguishes between routines and rituals; routines are directly observable behaviors, like the habit of scheduling meals at a specific time each day; rituals are acts more closely linked to emotional or symbolic aspects of family life, such as using nicknames or enjoying a traditional family recipe. Both help families connect and function on a daily basis, and bond by developing strong memories. Fiese offers these tips: set a goal of having a family meal four times a week; make one meal a week “children’s choice” night (have dessert first, eat all blue foods, etc.); keep marital spats away from the dinner table; have everyone identify one good thing and one not so good thing that happened to them during the day; and keep track of “inside jokes,” nicknames, special foods, etc., those things that make your family different from other families you know.

The high rate at which mental and substance-use disorders occur together has been well documented in epidemiological and clinical studies (Regier and Farmer 1990; Kessler, Nelson et al. 1996). For example, in the National Comorbidity Study, 51 percent of those who met criteria for a substance disorder at some time in their life also met criteria for a mental disorder at some point, and in the large majority of cases individuals reported that the mental disorder preceded the substance disorder (Kessler et al. 1996). Researchers and clinicians have advanced a number of theories to explain the high rates of co-occurrence. One prominent explanation for the high rates of co-occurrence is that individuals use psychoactive substances to “self-medicate” painful or disturbing psychiatric symptoms (Khantzian 1997; Chilcoat and Breslau 1998; Strakowski and DelBello 2000). Other theories suggest that substance-use disorders cause mental health problems or that substance use and mental health problems have common underlying genetic and environmental causes (Chilcoat and Breslau 1998).

Understanding the underlying causes of co-occurrence is important for improving the treatment and prevention of mental health and substance-use problems. If self-medication is common, then timely screening and treatment of mental health problems may prove the key in preventing the onset of substance-use disorders among the population with mental disorders. Although predictions about the substitutability of psychoactive substances and mental health care are implicit in the self-medication hypothesis, they have gone unexplored in the health services literature.

More of the financial burden of mental health treatment shifted to public programs during the decade ending 2001, according to new research published March 29 on the Health Affairs web site. Public programs, such as Medicare and Medicaid, grew at an annual rate of 6.8 percent, while spending by private payers grew at an annual rate of 3.7 percent.

Researchers also found that while the share of spending for inpatient mental health services declined 12 percentage points to 28 percent by 2001, the share of spending for mental health drugs grew percentage points, to 7 percent, in 2001.

To read the article, go to www.healthaffairs.org, click on “Web Exclusives” and then “2005,” and scroll down to “U.S. Spending for Mental Health and Substance Abuse Treatment, 1991-2001.”

Considerable evidence exists that children’s mental health problems are undertreated, with fewer than half and as few as 11 percent of children who screen positive for some disorder actually receiving treatment (Zahner et al. 1992; Cohen and Hesselbart 1993; Leaf et al. 1996; Costello et al. 1997; Verhulst and van der Ende 1997; Farmer et al. 1999; Haines et al. 2002). Undertreatment for mental health problems is especially tragic, given that depression, attention-deficit, hyperactivity, and other mental health problems have been shown to interfere not only with children’s current well-being, but also with educational attainment and future job performance, and therefore with future psychosocial and economic well-being (Mannuzza et al. 1997; Velting and Whitehurst 1997, Caspi et al. 1998; Fergusson and Horwood 1998). The importance of these problems is heightened by the fact that over the last 50 years, the trend has been for ever earlier onset of mental health problems, now reaching well into childhood (Burvill 1995).

Starting this year, tax money from California’s wealthiest citizens will be pumped into a fund designated to expand care for the state’s mentally ill,

Proposition 63, also known as the Mental Health Services Act, was passed last November by 53 percent of voters. The novel plan adds an additional 1 percent tax on California millionaires, affecting the pocketbooks of an estimated 30,000 people. The new legislation will provide up to $1 billion in revenue for mental health services within the next few years.

So far, there are no definite plans for how to spend the money. The state government is prohibited from slashing existing mental health funding in response to the new influx of cash. The money will be doled out to counties to expand services and develop innovative programs for mentally ill children, adults and seniors, focusing on prevention and early intervention. One new proposal aims to tackle chronic homelessness among the mentally ill in San Francisco.

The legislation follows on the heels of California’s pioneering Stem Cell Initiative, another publicly funded program that allocates $3 billion for stem cell research.

INTRODUCTION

One of the major challenges facing the field of substance abuse treatment is the coordination of community-based services for clients with cooccurring mental or physical health disorders (1). Given their multiple health needs, these clients often are required to participate in two or more specialized programs that involve providers in areas such as mental health and primary care. As a result of this specialization, many policymakers and researchers have raised the concern that the substance abuse treatment system may be too fragmented to deliver effective care (2, 3).

The fragmentation of community-based substance abuse treatment became an issue in the 1980s when the plight of persons disabled with serious cooccurring disorders was recognized as a burgeoning social problem (4). The issue has intensified in recent years as managed care has assumed a stronger presence in behavioral health care and as an increasing numbers of persons with substance abuse, mental illness, and chronic health problems such as HIV/AIDS have begun to be treated in outpatient settings (1). Treatment of these multineed persons constitutes a major frustration among outpatient substance abuse treatment providers because many of these persons are revolving door clients who enter treatment, often discontinue early, relapse, and recycle anew (1). Some researchers have suggested that in order to reduce recidivism among these substance abuse clients, multiple types of treatment must be provided concurrently through better linkage of care between outpatient substance abuse treatment agencies (OSATs) and other service providers (1, 5-9).

Indeed, empirical evidence supports the effectiveness of concurrent treatment. Joe and colleagues (10) showed that methadone clients had less relapse to opiate use when they received ancillary services, particularly mental health care. McLellan and associates (11) found similar results in a study of 649 opiate, alcohol, and cocaine patients. An evaluation of a combined substance abuse and mental health case management program also found a 31% reduction in the number of days homeless for dually diagnosed persons as compared to 6% in a typical service control group (12). More recently, Jerrell, Wilson, and Hiller (13) showed in a demonstration project that clients receiving services through a well-implemented dual disorder treatment program functioned better in the community than clients not receiving services from such a program.

FINDING lately that you are too blue to get out of bed, let alone get dressed and go to work?

How about food? Eating more or less? What about sleep–too much or too little? Does the slightest provocation trigger tsunami-like mood swings? And do the unflinching demands of daily life, such as showering, cooking and cleaning, seem like insurmountable tasks? Have any of these symptoms persisted for weeks on end?

But despite the huge toll mental disorders exact on the lives of its sufferers, only a small percentage of Black women who suffer from depression and other ailments receive any treatment.

Shame, embarrassment, fear of being labeled “crazy,” the disparity in health care, and lack of insurance coverage are just a few of the reasons many African-American women do not seek professional help for mental health issues. But failure to seek treatment for any form of mental illness can result in a recurrence of the disease–yes, it is a disease–and a litany of other troubles, including hospitalization, substance abuse, economic woes, isolation, and ultimately suicide.

“True, there was a time–happily, a time past–when mental illness was used as an excuse to shackle those of us who listened to a different drummer,” writes Marilyn Martin, M.D., M.P.H., in Saving Our Last Nerves: The Black Woman’s Path to Mental Health. “The result was that many Black women are afraid of the mental health care industry, and buckling under pressures we could have handled if we’d had a little help …”

If you’ve answered yes to any combination of the above questions, you may be experiencing some form of depression and should seek professional help, mental health experts say.

You are not alone, especially if you are an African-American woman. Clinical depression is a serious medical illness that has a 15 percent chance of affecting a person during his or her lifetime. That figure is perhaps as high as 25 percent for women, according to the Diagnostic Statistical Manual of Mental Disorders, the reference guide for mental health professionals.

Higher rates of clinical depression among women may be linked to stress from work, family responsibilities, the roles and expectations of women and increased rates of sexual abuse and poverty, researchers say. Other factors such as diet, hormones, genetics and other biological differences (premenstrual syndrome, childbirth, infertility and menopause) also are thought to play a role in depressive illnesses.