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The Substance Abuse and Mental Health Services Administration (SAMSHA) estimates that more than 18.6% of Americans aged 18 years and older have some form of mental illness—approximately 43.7 million persons. In the past year, 20.7 million people or 18.6%, had a substance use disorder. Of these, 8.4 million had co-occurring mental illness and substance use disorder, or dual diagnosis (2015). Furthermore, mental illness or serious emotional disturbances impair daily activities for an estimated 15 million adults and 4 million children and adolescents. For example, attention deficit hyperactivity disorder affects 3% to 5% of school-aged children. More than 10 million children younger than 7 years grow up in homes where at least one parent suffers from significant mental illness or substance abuse, a situation that hinders the readiness of these children to start school. The economic burden of mental illness in the United States, including both health-care costs and lost productivity, exceeds the economic burden caused by all kinds of cancer. Mental disorders are the leading cause of disability in the United States and Canada for persons 15 to 44 years of age. Yet only one in four adults and one in five children and adolescents requiring mental health services get the care they need.

Some believe that deinstitutionalization has had negative as well as positive effects. Although deinstitutionalization reduced the number of public hospital beds by 80%, the number of admissions to those beds correspondingly increased by 90%. Such findings have led to the term revolving door effect. Although people with severe and persistent mental illness have shorter hospital stays, they are admitted to hospitals more frequently. The continuous flow of clients being admitted and discharged quickly overwhelms general hospital psychiatric units. In some cities, emergency department (ED) visits for acutely disturbed persons have increased by 400% to 500%. Patients are often boarded or kept in the ED while waiting to see if the crisis de-escalates or till an inpatient bed can be located or becomes available.


Revolving door

Shorter, unplanned hospital stays further complicate frequent, repeated hospital admissions. People with severe and persistent mental illness may show signs of improvement in a few days but are not stabilized. Thus, they are discharged into the community without being able to cope with community living. However, planned/scheduled short hospital stays do not contribute to the revolving door phenomenon, and may show promise in dealing with this issue (see Chapter 4). The result frequently is decompensation and rehospitalization. In addition, many people have a dual problem of both severe mental illness and substance abuse. Use of alcohol and drugs exacerbates symptoms of mental illness, again making rehospitalization more likely. Substance abuse issues cannot be dealt with in the 3 to 5 days typical for admissions in the current managed care environment.

Homelessness is a major problem in the United States today with 610,000 people, including 140,000 children, being homeless on any given night. Approximately 257,300 of the homeless population (42%) have a severe mental illness of a chronic substance use disorder. The segment of


the homeless population considered to be chronically homeless numbers 110,000 and 30% of this group has a psychiatric illness and two thirds have a primary substance abuse disorder or other chronic health condition (Substance Abuse and Mental Health Services Administration, 2015). Those who are homeless and mentally ill are found in parks, airport and bus terminals, alleys and stairwells, jails, and other public places. Some use shelters, halfway houses, or board-and-care rooms; others rent cheap hotel rooms when they can afford it. Homelessness worsens psychiatric problems for many people with mental illness who end up on the streets, contributing to a vicious cycle.

Many of the problems of the homeless mentally ill, as well as of those who pass through the revolving door of psychiatric care, stem from the lack of adequate community resources. Money saved by states when state hospitals were closed has not been transferred to community programs and support. Inpatient psychiatric treatment still accounts for most of the spending for mental health in the United States, so community mental health has never been given the financial base it needs to be effective. In addition, mental health services provided in the community must be individualized, available, and culturally relevant to be effective