Am
J Psychiatry
/35:1/,
November
/978
STEVEN
REFERENCES 1. Task
Force
Patterns
6: The Present and Future Importance of Psychiatric Practice in the Delivery of Men-
Report
of Private
tal Health Association,
Services. 1973
Washington,
2. Marmon I, Scheidemandel Their Patients: A National Washington,
3. Sharfstein
DC,
accountability: practice. Am
4. Alexander
Will BY
loint
SS, Taube response I Psychiatry
F, French
P.
CK:
Psychiatrists
Practice.
psychiatry
to the APA task force 132:43-47, 1975
report
Therapy.
Mental
on private
New
York,
bio-medicine.
Health
1975
8. Klerman G: Ethical issues in pharmacotherapy. sented at the Washington School of Psychiatry, DC, April 9, 1975 9. Engel GL: The need for a new medical model:
and
SHARFSTEIN
NY, Ronald Press, 1946 5. Sharfstein SS, Taube CA, Goldberg ID: Problems in analyzing the comparative costs of private versus public psychiatric care. Am I Psychiatry 134:29-32, 1977 6. Ginzberg E: The young physician-inevitable changes ahead. Pharos of Alpha Omega Alpha 38 (1): 18, 1975 7. Walls PD, Walls LH, Langsley DG: Psychiatric training and practice in the People’s Republic of China. Am I Psychiatry 132:121-128,
1975
ID: Private
T: Psychoanalytic
and
Office
Service,
Goldberg
S. SHARFSTEIN,
Psychiatric
of Private
Information
CA.
American
Kanno
Study
Community STEVEN
DC,
S.
Survive
Science
in the
196:129-136,
Lecture preWashington, a challenge
for
1977
1980s?
M.D.
There are nott’ 675funded community mental health centers (CMHCs), covering almost halfthe country. Many ofthese prograns ss’erefunded in the social optimism ofthe /960s and nowface a crisis of purpose andfunding. Additional requirements imposed by the /975 amendments to the CMHC act are not matched by additionalfiscal resources. Prograns are graduatingfrom thefederal grant tofind that other sources offunds, especially third-party insurance f unds, are not replacing the lostfederal dollars. There is evidence that CMHCs are changingfrom clinical/ medicalprograms to socialprograms: the numbers of persons seeking care who have diagnosable mental illness and ofpsychiatrists and nurses relative to other staffare decreasing. The issue is whether CMHCs as a national program are headedfor extinction or whether there si’ill be new vitality for this program into the /980s.
nity mental health center (CMHC) is in danger of cxtinction. This is the story of that program, conceived and nurtured in the optimism and abundant budgets of the 1960s but coping with a precarious adolescence in the 70s, increasingly burdened by fiscal constraints and multiple levels ofaccountability. The ending of the story is still in doubt. Whether the program will end with a whimper, collapsing under the weight of its own problems and changing times, or whether it will generate a new vitality, producing a second generation of service programs fitted for survival in the l980s, will become evident in the next two years.
SURVIVAL
FROM
1963
TO
1977
At the time of its inception in 1963 the community mental health center represented a bold new approach’ toward meeting the mental health needs of the community. The scope of its mission was delibenately writ large-a minimum of 5 essential services to be made readily accessible to all in need, regardless of ability to pay, a commitment to service to the community at large as well as to troubled individuals. At the same time it was assumed that after a 51-month period of declining federal financial support, the centers would generate alternative sources of funding and become self-sufficient. After the first 51 months, when significant nonfederal sources did not materialize, the period of federal support was extended to 8 years. The CMHC prognam continues to nest on the notion that after federal “seed money” initiates a program, it will be replaced over time with increasing amounts of non‘ ‘
‘
IN THE
ices,
GENUS
a species
Revised
version
the American 2-6,
of social programs called human servknown as the federally funded commuof a paper
Psychiatric
presented
Association,
at the
130th
Toronto,
annual
Ont.,
meeting
Canada,
of
May
1977.
Dr. Sharfstein is Director, Division of Mental grams, National Institute of Mental Health, Rockville, Md. 20857.
Health 5600
Service ProFishers Lane,
Views expressed herein are those of the author and do not necessarily reflect the opinions, official policies, or positions of the Alcohol, Drug Abuse, and Mental Health Administration or the National Institute
of
Mental
Health.
1363
COMMUNITY
MENTAL
HEALTH
IN
THE
l980S
Am
federal support. Much of this support has come from state and local funds and service receipts for older centens, with state, local, and third-party funding being a limited source of funding for centers in the initial years of existence. The initial expectations of the new program were very high. Its success, although variable, was on the whole evaluated as satisfactory (1 2) It managed to survive the dank ages of the Nixon-Ford years, which attempted to phase out the program on the basis that it was ‘a successful demonstration’ and should therefore be picked up entirely by state, local, and private resources without any federal ‘seed money. It was the Congress that provided the impetus for its continued survival through Public Law 94-63, which clearly stated in its preamble to Title II! that ,
‘
‘
‘
‘ ‘
the Congress finds that community mental health care is the most effective and humane form of care for a majority of mentally ill individuals: the federally funded cornmunity
mental
health
centers
have
had
a major
impact
on
the improvement of mental health care by (a) fostering coordination and cooperation between various agencies responsible for mental health care, which in turn has resulted in a decrease in overlapping services and more efficient utilization of available resources, (b) bringing cornprehensive community mental health care to all who need care within a specific geographic area regardless of ability to pay, and (c) developing a system ofcare which insures continuity of care for all patients and thus our national resource to which all Americans should enjoy access. Through P.L. 94-63, Congress provided for the survival of a ‘Great Society’ program while many others perished. However, in its enthusiasm for this species of social and medical programming Congress may have created a modern day dinosaur, a huge and cornplex organism that requires nutrients which, from a Darwinian perspective, fan exceed the capacity of the environment to sustain its existence. From 5 essential services the comprehensive concept was expanded to 12 essential services. In addition to the original 5 services, P.L. 94-63 now requires services for children and the elderly, for persons with alcohol and drug abuse problems, and for the ‘deinstitutionalized” populations through the triad of screening, follow-up, and transitional living arrangements. Congress also added a number of compliance or accountability features designed to promote the accessibility and acceptability of the services provided. Requirements regarding the governing body, quality assurance, meeting certain cultural sensitivities, using at least 2% of the budget for evaluation, complying with the provisions of the law in 1 year and converting to the 12 services in 2 years, and implementing multiple reporting systems required by the federal government impose a significant and continuing management burden on CMHCs. Additional pressures from state and local governments and from the private sector to provide data and to meet certain standards create a situation in which ‘
‘
‘
1364
the CMHC people but and in great
BUDGETARY
J Psychiatry
is not only expected to document that detail to a variety
/35:1/,
November
1978
to be all things to all happy status regularly of audiences.
SHORTFALLS
The idealism and competence of the program-oriented authorizing’ Congressional committees is not matched by the budget-oriented ‘appropriating’ cornmittees. Funds were appropriated at lower levels than authorized. For 5 of the 6 grant mechanisms under P.L. 94-63, funds made available by Congress were 60% below the authorized amounts; for a sixth grant ‘ ‘
‘
‘
mechanism, ing category
there was no appropriation. in 1976, the first year
‘
In each
fund-
of experience with the new law, there was a shortfall of funds leading to an impressive backlog of approved but not funded grants. The high number of projects recommended for approval but unfunded (123) amounted to $37.3 million in fiscal year 1976. At the end of FY 1977 the approved but unpaid account amounted to $37.8 million. If General Motors had to face the same backlog of orders for automobiles petitor,
it would a new mode
rapidly be replaced of transportation
by would
a corn-
be invented! Those centers that have gotten funds have neceived less than the amount necessary to sustain costly clinical care-a full range ofemergency, diagnostic, treatment, and follow-up services. As of June 1978 it is estimated that there are 675 funded CMHCs. Sixty ofthese are alumnae ofthe federal CMHC programs, i.e. programs that have graduated from all forms of federal support and have not received any additional support from P.L. 94-63. An additional 329 are still being funded through the old limited staffing program, with no P.L. 94-63 funds involved, but they were expected to comply by August 1978 with the requirement ofexpanding to 12 essential services and the other P.L. 94-63 requirements for accountability. Without additional funds they might become ‘dropouts’ from the federal program. Further, there remain oven 800 unfunded catchment areas in the country. Today it is no wonder that there is cynicism based on the gap between the grand expectations of the federally funded community mental health center and the reality in the community, with massive unmet needs and budget shortfalls. or
,
‘
SOCIAL
‘
OR
MEDICAL
One potential major vival is health insurance. based on an “illness” trend in CMHCs seems the clinical or medical model. Trend data show 1974. Almost 20% of carried a diagnosis of gory dropped to 13%
PROGRAMS?
source of funds for CMHC surHowever, health insurance is or “medical” model and the to indicate a shift away from approach toward a “social” a shift in diagnosis from 1970 to all additions to CMHCs in 1970 depressive disorders. This catein 1974. For schizophrenia the
Am
J Psychiatry
shift this
November
/978
1970 to 1974 5-year period
STEVEN
was from 19% to 1 1%. During diagnoses of social maladjustments” increased from 4.6% to 20%. Complementing this diagnostic shift is a shift away from medical practitioner staff. In 1970 there were 6.8 average
from same
135:1/,
full-time
equivalent
‘ ‘
psychiatrists
pen
S.
SHARFSTEIN
vide the necessary funds, and state mental thonities themselves are experiencing their getany shortfalls in attempting humane and sound programs for the chronic patient.
health auown budmedically
commu-
nity mental health center; in 1975, there were 4.3. The number of registered nurses decreased from 9.7 fulltime equivalents per CMHC in 1970 to 8.9 in 1975. During the same period the numbers of psychologists increased from 4.9 full-time equivalents pen CMHC to 8.5 and social workers from 9. 1 full-time equivalents to 12.2 (3). Even for diagnosed mental illness, there is great difficulty in obtaining third-party coverage. Extra restnictions are enforced on reimbursement for psychiatric services in the Medicare and Medicaid programs and in most private health insurance programs. There are four types of restrictions in Medicare and Medicaid. First, no CMHCs are certified as providers under Medicare, and many states exclude CMHCs from provider status under Medicaid. Second, there is great variation in the eligibility of patients even when CMHC services are covered under Medicaid. For cxample, many poor patients seen in a CMHC are inchgible for Medicaid because Medicaid eligibility is tied to certain welfare categories rather than income. Third, benefits are limited and are often discriminatory toward the mentally ill, e.g., the limitation on the amount Medicare will pay for outpatient psychiatric care. Fourth, reimbursement, even when available, often does not fully coven the cost of services to Mcdicane and Medicaid eligible patients. Therefore, CMHCs remain on the periphery of third-party financing. Although CMHCs improve their third-party status as they get into their sixth, seventh, and eighth years, this source still represents a relatively small source of support and cannot be expected to generate the funding necessary for comprehensive services that are closely coordinated with other social and medical agencies in the community. Health insurance does not pay for the time spent on the telephone, traveling between appointments, or consulting, i.e., meeting with school personnel, the police, social agencies, and dealing effectively with multi-problem families and highly disturbed individuals. It then is up to the state to pro-
CONCLUSIONS
If the evidence beans out the notion that the CMHC program is mutating from a clinical-medical program toward a social program, what does this portend for its survival? If national health insurance will pay for only a small portion of the total program, can we expect a companion social insurance program to fill in the missing pieces? Given the concern today for rapidly rising health costs-health cane approached almost 9 percent of the gross national product this year-can we expect the federal Treasury to bear the costs of the CMHC program over the next 10 to 20 years? These are difficult questions, posed so that we can help the CMHC program cope, adapt, and survive using federal dollars, health dollars, social service dolhans, and private funds. It is clean that the requirements and expectations of the CMHC program must be brought into line with fiscal realities. Never has so much been expected of so few with so little. Planning and priority-setting are critical, but planning is no substitute for adequate support and resources in the community. The CMHC program, as an organized care system, publicly financed and accountable to a catchment area, oriented toward quality clinical cane and prevention, is a system worth preserving. Ifit fails, the alternative is a return to the ‘economies of scale” of isolated large state hospitals and institutions for the many and the private mental hospital and office-based practitioner for the few. ‘
REFERENCES 1. Ozarin
LD: Community
evaluation
Mental
literature,
Health
Lexington,
in
Movement.
Mass,
Lexington
mental
health:
An
Assessment
Edited Books,
does
it work? of
by Barton
the
WE,
Review
of
Community
Saulson
Ci.
1977
2. Ochberg FM: Community mental health center legislation: flight of the phoenix. Am I Psychiatry 133:56-71, 1976 3. Provisional Data on Federally Funded Community Mental Health Centers 1974-1975. Rockville, Md, National Institute of Mental Health, Division of Biometry and Epidemiology, Survey and
Reports
Branch,
May
1976
1365
J Psychiatry
/35:1/,
November
/978
STEVEN
REFERENCES 1. Task
Force
Patterns
6: The Present and Future Importance of Psychiatric Practice in the Delivery of Men-
Report
of Private
tal Health Association,
Services. 1973
Washington,
2. Marmon I, Scheidemandel Their Patients: A National Washington,
3. Sharfstein
DC,
accountability: practice. Am
4. Alexander
Will BY
loint
SS, Taube response I Psychiatry
F, French
P.
CK:
Psychiatrists
Practice.
psychiatry
to the APA task force 132:43-47, 1975
report
Therapy.
Mental
on private
New
York,
bio-medicine.
Health
1975
8. Klerman G: Ethical issues in pharmacotherapy. sented at the Washington School of Psychiatry, DC, April 9, 1975 9. Engel GL: The need for a new medical model:
and
SHARFSTEIN
NY, Ronald Press, 1946 5. Sharfstein SS, Taube CA, Goldberg ID: Problems in analyzing the comparative costs of private versus public psychiatric care. Am I Psychiatry 134:29-32, 1977 6. Ginzberg E: The young physician-inevitable changes ahead. Pharos of Alpha Omega Alpha 38 (1): 18, 1975 7. Walls PD, Walls LH, Langsley DG: Psychiatric training and practice in the People’s Republic of China. Am I Psychiatry 132:121-128,
1975
ID: Private
T: Psychoanalytic
and
Office
Service,
Goldberg
S. SHARFSTEIN,
Psychiatric
of Private
Information
CA.
American
Kanno
Study
Community STEVEN
DC,
S.
Survive
Science
in the
196:129-136,
Lecture preWashington, a challenge
for
1977
1980s?
M.D.
There are nott’ 675funded community mental health centers (CMHCs), covering almost halfthe country. Many ofthese prograns ss’erefunded in the social optimism ofthe /960s and nowface a crisis of purpose andfunding. Additional requirements imposed by the /975 amendments to the CMHC act are not matched by additionalfiscal resources. Prograns are graduatingfrom thefederal grant tofind that other sources offunds, especially third-party insurance f unds, are not replacing the lostfederal dollars. There is evidence that CMHCs are changingfrom clinical/ medicalprograms to socialprograms: the numbers of persons seeking care who have diagnosable mental illness and ofpsychiatrists and nurses relative to other staffare decreasing. The issue is whether CMHCs as a national program are headedfor extinction or whether there si’ill be new vitality for this program into the /980s.
nity mental health center (CMHC) is in danger of cxtinction. This is the story of that program, conceived and nurtured in the optimism and abundant budgets of the 1960s but coping with a precarious adolescence in the 70s, increasingly burdened by fiscal constraints and multiple levels ofaccountability. The ending of the story is still in doubt. Whether the program will end with a whimper, collapsing under the weight of its own problems and changing times, or whether it will generate a new vitality, producing a second generation of service programs fitted for survival in the l980s, will become evident in the next two years.
SURVIVAL
FROM
1963
TO
1977
At the time of its inception in 1963 the community mental health center represented a bold new approach’ toward meeting the mental health needs of the community. The scope of its mission was delibenately writ large-a minimum of 5 essential services to be made readily accessible to all in need, regardless of ability to pay, a commitment to service to the community at large as well as to troubled individuals. At the same time it was assumed that after a 51-month period of declining federal financial support, the centers would generate alternative sources of funding and become self-sufficient. After the first 51 months, when significant nonfederal sources did not materialize, the period of federal support was extended to 8 years. The CMHC prognam continues to nest on the notion that after federal “seed money” initiates a program, it will be replaced over time with increasing amounts of non‘ ‘
‘
IN THE
ices,
GENUS
a species
Revised
version
the American 2-6,
of social programs called human servknown as the federally funded commuof a paper
Psychiatric
presented
Association,
at the
130th
Toronto,
annual
Ont.,
meeting
Canada,
of
May
1977.
Dr. Sharfstein is Director, Division of Mental grams, National Institute of Mental Health, Rockville, Md. 20857.
Health 5600
Service ProFishers Lane,
Views expressed herein are those of the author and do not necessarily reflect the opinions, official policies, or positions of the Alcohol, Drug Abuse, and Mental Health Administration or the National Institute
of
Mental
Health.
1363
COMMUNITY
MENTAL
HEALTH
IN
THE
l980S
Am
federal support. Much of this support has come from state and local funds and service receipts for older centens, with state, local, and third-party funding being a limited source of funding for centers in the initial years of existence. The initial expectations of the new program were very high. Its success, although variable, was on the whole evaluated as satisfactory (1 2) It managed to survive the dank ages of the Nixon-Ford years, which attempted to phase out the program on the basis that it was ‘a successful demonstration’ and should therefore be picked up entirely by state, local, and private resources without any federal ‘seed money. It was the Congress that provided the impetus for its continued survival through Public Law 94-63, which clearly stated in its preamble to Title II! that ,
‘
‘
‘
‘ ‘
the Congress finds that community mental health care is the most effective and humane form of care for a majority of mentally ill individuals: the federally funded cornmunity
mental
health
centers
have
had
a major
impact
on
the improvement of mental health care by (a) fostering coordination and cooperation between various agencies responsible for mental health care, which in turn has resulted in a decrease in overlapping services and more efficient utilization of available resources, (b) bringing cornprehensive community mental health care to all who need care within a specific geographic area regardless of ability to pay, and (c) developing a system ofcare which insures continuity of care for all patients and thus our national resource to which all Americans should enjoy access. Through P.L. 94-63, Congress provided for the survival of a ‘Great Society’ program while many others perished. However, in its enthusiasm for this species of social and medical programming Congress may have created a modern day dinosaur, a huge and cornplex organism that requires nutrients which, from a Darwinian perspective, fan exceed the capacity of the environment to sustain its existence. From 5 essential services the comprehensive concept was expanded to 12 essential services. In addition to the original 5 services, P.L. 94-63 now requires services for children and the elderly, for persons with alcohol and drug abuse problems, and for the ‘deinstitutionalized” populations through the triad of screening, follow-up, and transitional living arrangements. Congress also added a number of compliance or accountability features designed to promote the accessibility and acceptability of the services provided. Requirements regarding the governing body, quality assurance, meeting certain cultural sensitivities, using at least 2% of the budget for evaluation, complying with the provisions of the law in 1 year and converting to the 12 services in 2 years, and implementing multiple reporting systems required by the federal government impose a significant and continuing management burden on CMHCs. Additional pressures from state and local governments and from the private sector to provide data and to meet certain standards create a situation in which ‘
‘
‘
1364
the CMHC people but and in great
BUDGETARY
J Psychiatry
is not only expected to document that detail to a variety
/35:1/,
November
1978
to be all things to all happy status regularly of audiences.
SHORTFALLS
The idealism and competence of the program-oriented authorizing’ Congressional committees is not matched by the budget-oriented ‘appropriating’ cornmittees. Funds were appropriated at lower levels than authorized. For 5 of the 6 grant mechanisms under P.L. 94-63, funds made available by Congress were 60% below the authorized amounts; for a sixth grant ‘ ‘
‘
‘
mechanism, ing category
there was no appropriation. in 1976, the first year
‘
In each
fund-
of experience with the new law, there was a shortfall of funds leading to an impressive backlog of approved but not funded grants. The high number of projects recommended for approval but unfunded (123) amounted to $37.3 million in fiscal year 1976. At the end of FY 1977 the approved but unpaid account amounted to $37.8 million. If General Motors had to face the same backlog of orders for automobiles petitor,
it would a new mode
rapidly be replaced of transportation
by would
a corn-
be invented! Those centers that have gotten funds have neceived less than the amount necessary to sustain costly clinical care-a full range ofemergency, diagnostic, treatment, and follow-up services. As of June 1978 it is estimated that there are 675 funded CMHCs. Sixty ofthese are alumnae ofthe federal CMHC programs, i.e. programs that have graduated from all forms of federal support and have not received any additional support from P.L. 94-63. An additional 329 are still being funded through the old limited staffing program, with no P.L. 94-63 funds involved, but they were expected to comply by August 1978 with the requirement ofexpanding to 12 essential services and the other P.L. 94-63 requirements for accountability. Without additional funds they might become ‘dropouts’ from the federal program. Further, there remain oven 800 unfunded catchment areas in the country. Today it is no wonder that there is cynicism based on the gap between the grand expectations of the federally funded community mental health center and the reality in the community, with massive unmet needs and budget shortfalls. or
,
‘
SOCIAL
‘
OR
MEDICAL
One potential major vival is health insurance. based on an “illness” trend in CMHCs seems the clinical or medical model. Trend data show 1974. Almost 20% of carried a diagnosis of gory dropped to 13%
PROGRAMS?
source of funds for CMHC surHowever, health insurance is or “medical” model and the to indicate a shift away from approach toward a “social” a shift in diagnosis from 1970 to all additions to CMHCs in 1970 depressive disorders. This catein 1974. For schizophrenia the
Am
J Psychiatry
shift this
November
/978
1970 to 1974 5-year period
STEVEN
was from 19% to 1 1%. During diagnoses of social maladjustments” increased from 4.6% to 20%. Complementing this diagnostic shift is a shift away from medical practitioner staff. In 1970 there were 6.8 average
from same
135:1/,
full-time
equivalent
‘ ‘
psychiatrists
pen
S.
SHARFSTEIN
vide the necessary funds, and state mental thonities themselves are experiencing their getany shortfalls in attempting humane and sound programs for the chronic patient.
health auown budmedically
commu-
nity mental health center; in 1975, there were 4.3. The number of registered nurses decreased from 9.7 fulltime equivalents per CMHC in 1970 to 8.9 in 1975. During the same period the numbers of psychologists increased from 4.9 full-time equivalents pen CMHC to 8.5 and social workers from 9. 1 full-time equivalents to 12.2 (3). Even for diagnosed mental illness, there is great difficulty in obtaining third-party coverage. Extra restnictions are enforced on reimbursement for psychiatric services in the Medicare and Medicaid programs and in most private health insurance programs. There are four types of restrictions in Medicare and Medicaid. First, no CMHCs are certified as providers under Medicare, and many states exclude CMHCs from provider status under Medicaid. Second, there is great variation in the eligibility of patients even when CMHC services are covered under Medicaid. For cxample, many poor patients seen in a CMHC are inchgible for Medicaid because Medicaid eligibility is tied to certain welfare categories rather than income. Third, benefits are limited and are often discriminatory toward the mentally ill, e.g., the limitation on the amount Medicare will pay for outpatient psychiatric care. Fourth, reimbursement, even when available, often does not fully coven the cost of services to Mcdicane and Medicaid eligible patients. Therefore, CMHCs remain on the periphery of third-party financing. Although CMHCs improve their third-party status as they get into their sixth, seventh, and eighth years, this source still represents a relatively small source of support and cannot be expected to generate the funding necessary for comprehensive services that are closely coordinated with other social and medical agencies in the community. Health insurance does not pay for the time spent on the telephone, traveling between appointments, or consulting, i.e., meeting with school personnel, the police, social agencies, and dealing effectively with multi-problem families and highly disturbed individuals. It then is up to the state to pro-
CONCLUSIONS
If the evidence beans out the notion that the CMHC program is mutating from a clinical-medical program toward a social program, what does this portend for its survival? If national health insurance will pay for only a small portion of the total program, can we expect a companion social insurance program to fill in the missing pieces? Given the concern today for rapidly rising health costs-health cane approached almost 9 percent of the gross national product this year-can we expect the federal Treasury to bear the costs of the CMHC program over the next 10 to 20 years? These are difficult questions, posed so that we can help the CMHC program cope, adapt, and survive using federal dollars, health dollars, social service dolhans, and private funds. It is clean that the requirements and expectations of the CMHC program must be brought into line with fiscal realities. Never has so much been expected of so few with so little. Planning and priority-setting are critical, but planning is no substitute for adequate support and resources in the community. The CMHC program, as an organized care system, publicly financed and accountable to a catchment area, oriented toward quality clinical cane and prevention, is a system worth preserving. Ifit fails, the alternative is a return to the ‘economies of scale” of isolated large state hospitals and institutions for the many and the private mental hospital and office-based practitioner for the few. ‘
REFERENCES 1. Ozarin
LD: Community
evaluation
Mental
literature,
Health
Lexington,
in
Movement.
Mass,
Lexington
mental
health:
An
Assessment
Edited Books,
does
it work? of
by Barton
the
WE,
Review
of
Community
Saulson
Ci.
1977
2. Ochberg FM: Community mental health center legislation: flight of the phoenix. Am I Psychiatry 133:56-71, 1976 3. Provisional Data on Federally Funded Community Mental Health Centers 1974-1975. Rockville, Md, National Institute of Mental Health, Division of Biometry and Epidemiology, Survey and
Reports
Branch,
May
1976
1365
