Care of Underserved People with Mental Illness

  • Francisco A. Moreno
  • Sarah Heron


Before delving into a discussion about care of the uninsured and underserved mentally ill population, it is important to reflect on the historical under-representation of the field of mental health as a whole from a medical, political, social, and economic standpoint. The approach to the care of the mentally ill has been an area of debate for centuries, and the evolution of the field of mental health and substance use disorder has often lagged behind other areas of health care and social services. Following an extensive period of institutional care of the mentally ill using therapeutic asylum, a revolutionary movement came to light in the 1960s with the promise of delivering comprehensive community-based mental health services to support the de-institutionalization of the mentally ill. The Community Mental Health Movement was ethically strong and philosophically progressive, yet it was very poorly funded, and services were intermittently dispersed and fragmented. The challenge to implementation grew more daunting as a result of a drastic concurrent increase in our country’s population, an epidemic rise in drug and alcohol use disorders, and the worsening medical and social infrastructures. Communities in the United States continue to experience the unfavorable consequences of this movement, while poorly equipped criminal justice systems, and overwhelmed emergency medical and homeless services are left to deal with the results of this tragic legacy.

In an era where a general healthcare care crisis has received little attention, the severe limitation of services for the mentally ill and those affected with substance use disorders is not an exception to the rule. Rather, it has become a sad symbol of the neglect for the needs of this special community which has traditionally received a disproportionately small amount of funding (federal and otherwise), attention to reform and policy, and medical services. This is especially concerning, given the social and moral burden that mental illnesses engender. According to the World Health Organization, “mental disorders collectively account for more than 15% of the overall burden of disease from all causes and are among the most disabling.” To put this into more tangible terms, five of the top ten causes of disability worldwide are mental health conditions (Depression #1, Alcohol use #4, Bipolar Disorder #6, Schizophrenia #9, and Obsessive Compulsive Disorder #10) (Murray and Lopez 1996).


Mental Health Mental Illness Mental Health Service Mental Health Care Obsessive Compulsive Disorder 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. (2004) Diagnostic and statistical manual of mental disorders, 4th ed: DSM-IV. American Psychiatric Association, Washington, DCGoogle Scholar
  2. Daniel AE (2007) Care of the mentally ill in prisons: challenges and solutions. J Am Acad Psychiatry Law 35(4):406–410PubMedGoogle Scholar
  3. Duhoux A, Fournier L, Nguyen CT, Roberge P, Beveridge R (2009) Guideline concordance of treatment for depressive disorders in Canada. Soc Psychiatry Psychiatr Epidemiol 44(5):385–392CrossRefPubMedGoogle Scholar
  4. Fuller J, Edwards J, Martinez L, Edwards B, Reid K (2004) Collaboration and local networks for rural and remote primary mental healthcare in South Australia. Health Soc Care Community 12(1):75–84CrossRefPubMedGoogle Scholar
  5. Gallo JJ, Zubritsky C et al (2004) Primary care clinicians evaluated integrated and referral models of behavioral health care for older adults: results from a multi-site effectiveness trial. Annals of Family Medicine 2(4):305–309CrossRefPubMedGoogle Scholar
  6. James DJ, Glaze LE (2006) Mental health problems of prison and jail inmates. Department of Justice, Bureau of Justice Statistics Special Report, Washington, DCGoogle Scholar
  7. Jeste DV, Unutzer J (2001) Improving the delivery of care to the seriously mentally ill. Med Care 39(9):907–909CrossRefPubMedGoogle Scholar
  8. Katon WJ, Schoenbaum M, Fan MY et al (2005) Cost-effectiveness of improving primary care treatment of late-life depression. Arch Gen Psychiatry 62(12):1313–1320CrossRefPubMedGoogle Scholar
  9. McCabe S, Macnee CL (2002) Weaving a new safety net of mental health care in rural America: a model of integrated practice. Issues Ment Health Nurs 23(3):263–278CrossRefPubMedGoogle Scholar
  10. Murray CJL, Lopez AD (eds) (1996) A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. The Global Burden of Disease. Published by The Harvard School of Public Health on Behalf of the World Health Organization and The World BankGoogle Scholar
  11. National Rural Health Association (2008) What’s different about rural health? Accessed 29 Mar 2008
  12. Price-Hanson DR (2007) The medical treatment of patients with psychiatric illness, Chapter 28. In: King TE, Wheeler MB (eds) Medical management of vulnerable and underserved patients. McGraw Hill, New York, pp 285–295Google Scholar
  13. Smith JL, Rost KM, Nutting PA, Elliott CE (2001) Resolving disparities in antidepressant treatment and quality of life outcomes between uninsured and insured primary care patients with depression. Med Care 39(9):910–922CrossRefPubMedGoogle Scholar
  14. Unützer J, Katon W, Callahan CM, Williams JW, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noël PH, Lin EH, Areán PA, Hegel MT, Tang L, Belin TR, Oishi S, Langston C (2002) IMPACT investigators. Improving mood-promoting access to collaborative treatment. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 288(22):2836–2845CrossRefPubMedGoogle Scholar
  15. Vega WA, Kolody B, Aguilar-Gaxiola S, Alderete E, Catalano R, Caraveo-Anduaga J (1998) Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Arch Gen Psychiatry 55:771–778CrossRefPubMedGoogle Scholar
  16. Wells KB, Sherbourne CD, Sturm R, Young AS, Burnam MA (2002) Alcohol, drug abuse, and mental health care for uninsured and insured adults. Health Serv Res 37(4):1055–1066CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Francisco A. Moreno
    • 1
  • Sarah Heron
    • 1
  1. 1.Psychiatry, University of Arizona, College of MedicineTucsonUSA

Personalised recommendations