System of Care and Usual Services for Youth in U.S. Psychiatric Outpatient Facilities, 1997 and 2007

Background and Purpose:  Since 1986, Systems of Care (SOC) have been implemented across the U.S. to ensure that youth with serious emotional disturbances receive a comprehensive array of services in the least restrictive settings possible.  However, SOC has not fully penetrated all statewide mental health programs due to financial and political realities. Using federal data on youth in specialty outpatient mental health programs in 1997 and in 2007, this paper sheds light on the processes of policy maturation over two decades.  Knowledge of differences over time in demographic characteristics, clinical profiles, and services received by youth in SOC versus usual services, could inform program planners and policymakers about opportunities for future intervention.

Specific questions are:  (1) How many youth received specialty outpatient care in 1997 and 2007 and what are their demographic and clinical characteristics?; (2) To what extent do the demographic characteristics, clinical profiles, and services received among youth involved in SOC and usual services differ in the two years?; (3) Have the correlates of SOC involvement changed?

Method: Data are from the 1997 and 2007 nationally representative Client/Patient Sample Survey (CPSS), conducted by the National Institutes for Health’s Center for Mental Health Services.  After randomly-selected specialty outpatient mental health programs were sampled, data on SOC involvement, demographic characteristics, clinical profiles, and services were extracted from case files of randomly-selected children and adolescents under 18 years of age. Bivariate relationships between SOC involvement, demographic characteristics, clinical factors, and services were assessed using chi-square tests.  Multivariate logistic regressions were used to identify the correlates of involvement in SOC versus usual services in each survey year. All analyses were weighted and adjusted for the complex sample design.

Results:  The number of child and adolescent youths doubled over the two study years from about half a million to over one-million outpatients on a given day, representing an increase from 744 to 1,392 per 100,000 youths.  The proportion of youth involved in SOC and usual services remained constant at about 50%. Compared to 1997, in 2007 youth in SOC and usual care were more likely to be covered by Medicaid diagnosed with internalizing disorders and dual diagnoses, and have significantly worse global assessment of functioning (GAF) scores. Receipt of psychotropic medication increased for both groups, and counseling decreased.  In 1997, correlates of  SOC involvement versus usual care included: (1) public versus private insurance coverage, (2) juvenile justice, social service or community referral system versus self, family or friend, (3) GAF scores of <50 versus >61. In 2007, no factors were associated with SOC involvement.  In both years, youth in SOCs received significantly more services than those in usual care. 

Conclusion: Increased numbers of Medicaid-insured youths with multiple mental health problems, coupled with rising rates of psychotropic medication use and decreasing rates of counseling, suggests that professionals and policy makers must work to ensure that the outpatient mental health workforce is adequately prepared to meet the increased demand, especially as SOC and usual service youth are presenting as increasingly similar.