About the Department of Mental Health

History

Massachusetts has been a leader in caring for people with mental illness since it built the first public asylum in America. The Worcester State Hospital opened in 1833, serving as a model that other states soon followed. Over the next century, Massachusetts established a network of public hospitals, responding to needs as they arose. A Board of Health, Lunacy and Charity, established in 1879, was responsible for overseeing and inspecting the public asylums and eventually evolved into the Department of Mental Health (DMH) in 1938.

A study commissioned by Congress in 1955 eventually led to a report, "Action for Mental Health," published in 1961, that called for creating community mental health centers and reducing the size of state mental hospitals to no more than 1,000 beds. This in turn led to enactment of the Community Mental Health Centers Act of 1963, signed by President John F. Kennedy. This legislation espoused treating people with mental illness locally, rather than in large isolated state hospitals, and led to the construction of federally funded community mental health centers across the country, including several in Massachusetts.

A community-based system of care has been evolving in Massachusetts since 1966, when the state legislature enacted the Comprehensive Mental Health and Retardation Services Act. The goal was to decentralize DMH and set up a network of services within each community so that people could receive help close to their homes. A federal consent decree in the Western Massachusetts Area, from 1978 to 1992, asserted the right of mentally disabled individuals to receive care in the least restrictive setting and increased and enhanced the availability and quality of community programs.

In 1984, Executive Order 244 prohibited children (under 19) from being treated on adult inpatient wards of state hospitals and led to the creation of new residential prototypes and the privatization of most care for children. This order was replaced by Executive Order 422 in June 2000, which continues the prohibition but permits placement of certain forensically involved 17 or 18 year olds on adult inpatient units in DMH facilities and permits individuals under 19 to be admitted to certain specialty units in DMH facilities.

Chapter 599 of the Acts of 1986 split DMH into separate departments of mental health and mental retardation and created a new mission for DMH to "provide for services to citizens with long term or serious mental illness and research into the causes of mental illness." The Department's enabling statute is M.G.L. Chapter 19 and its operating statute is M.G.L. Chapter 123. From 1998 to 2000, DMH revised its Regulations (104 CMR). These regulations outline the Department's authority, mission and organizational structure, citizen participation, licensing and operational standards for inpatient facilities (DMH-operated and other licensed inpatient facilities) and community programs, and standards for service planning, fiscal administration, research, investigation procedures, and designation and appointment of professionals to perform certain statutorily authorized activities.

Between 1991 and 1993, the Department closed four of its antiquated hospitals as well as the Gaebler Children's Center. This coincided with a massive effort to place clients who were discharge-ready in appropriate community settings with the necessary supports and an interim arrangement whereby DMH contracted with private and general hospitals for "acute replacement" beds. It also resulted in an array of new inpatient, intensive residential and other community options for children. DMH now provides extended stay and forensic inpatient services and MassHealth, the Commonwealth's Medicaid agency, provides most emergency and acute psychiatric care through its mental health and substance abuse vendor. This is carried out under the terms of an Interagency Service Agreement between the two agencies. In addition, DMH provides an array of community-based services for adults and children.

Structure

In Massachusetts, responsibility for providing public mental health services falls under the umbrella of the Executive Office of Health and Human Services (EOHHS). DMH is one of 15 EOHHS agencies. Others include the Department of Public Health, Department of Developmental Services, Department of Children and Families, Department of Youth Services (juvenile justice), Massachusetts Rehabilitation Commission (vocational services), and Division of Medical Assistance (Medicaid). 

DMH is organized into six geographic Areas, each of which is managed by an Area Director. Each Area is divided into Local Service Sites. Each Site provides case management and oversees an integrated system of state and vendor-operated adult and child/adolescent mental health services. Most planning, budget development, program monitoring, contracting, quality improvement and citizen monitoring emanate from Site and Area offices. Citizen advisory boards at every level of the organization participate in agency planning and oversight. DMH allocates funds from its state appropriation and federal block grant to the Areas for both state-operated and contracted services. This includes four state hospitals, five community mental health centers with inpatient units, adult inpatient units at two public health hospitals, contracted adult, adolescent and latency age inpatient units and latency and adolescent intensive residential treatment programs, and community-based services.

The central office of DMH, located in Boston, has three divisions in addition to the Commissioner's office - Program Operations, Clinical and Professional Services and Management and Budget. It coordinates planning, sets and monitors attainment of broad policy and standards, and performs certain generally applicable fiscal, personnel and legal functions. Some specialized programs, such as forensic mental health services, and the child and adolescent inpatient units and intensive residential treatment programs, are managed centrally.

Research

To support research concerning mental illness, the Boston Psychopathic Hospital was established in 1912 as the research arm of the existing Boston State Hospital. This renowned teaching and research center was renamed the Massachusetts Mental Health Center in 1956. To carry out its research mission today, DMH funds two Centers of Excellence, one in Clinical Neuroscience and Neuropharmacology (Harvard Medical School) and one in Behavioral and Forensic Sciences (University of Massachusetts Medical School). Both centers are conceptualized as Public/Academic Liaisons and are structured independently with DMH and an accredited academic institution. They are expected to meet mutually agreed upon standards and to augment DMH funds with outside research grants. DMH also supports a 12-bed clinical research unit at one of its mental health centers in Boston.

Demographics

Approximately six million people reside in the Commonwealth of Massachusetts. The federal Center for Mental Health Services recently developed and published methodologies for estimating the prevalence of serious mental illness among adults and serious mental illness or serious emotional disturbance among children and adolescents in each state. Using these formulas, it is estimated there are about 44,731 adults (.98% of the adult population) in Massachusetts with serious and persistent mental illness and severe dysfunction likely to need publicly funded mental health services. In addition, it is estimated there are about 18,476 children aged 0-8 (2.5% of the child population) and about 96,740 children aged 9-19 (11% of the child/adolescent population) with serious mental illness or serious emotional disturbance. These are children who are likely to need mental health services from DMH, from one of the state's other child-serving agencies, including local education authorities, or from the Division of Medical Assistance or private insurance.

The Department of Mental Health currently serves about 27,000 adults, adolescents and children through an array of inpatient and community-based services, such as residential and intensive residential services, case management and community rehab support. As noted above, acute care services are provided primarily through the Division of Medical Assistance. Other community care includes day treatment, in-home services, community and school therapy, flexible and family support, respite, outpatient, medication monitoring and dual diagnosis services, psychosocial rehabilitation programs (including clubhouses), supported employment, supported education and client empowerment activities. The Department also has an extensive array of services targeted to people with serious mental illness who are homeless. In addition, in fiscal year 2006, DMH forensic specialists performed 16,300 evaluations in the adult courts, and provided services in 3,684 cases for children and families involved in the juvenile justice system.