That local variations may be quite extensive is documented in an Given the extensiveness of such local variation, there may, indeed, be reason to question the validity of discussing community mental health centers as an aggregate. In fact, such grouping of seemingly different units becomes meaningful only when it is understood that there is a common denominator which binds together the various component centers. The common denominator derives from the raison d'être of the community mental health center movement and lends to CMHC's a uniqueness which causes them to stand apart from other mental health facilities. The uniqueness of the community mental health center results largely from what Tischler and associates refer to as "catchmenting," by which each center has "the responsibility for developing a comprehensive and coordinated system of care capable of meeting the diverse needs for mental health services of a geographically-defined target population." The community mental health center, in other words, in serving a defined catchment area is .... mandated to meet the diverse needs of community residents for to facilitate the efforts of individuals in need of care to obtain Another source of the uniqueness of CMHC's lies in the scope of services In addition to catchmenting and primary treatment, another component in the movement's uniqueness derives from its emphasis on continuity of care: different treatment modalities are provided within a single institutional setting. This effort to limit the "fragmentation and lack of coordination"7/ that frequently reduce the efficacy with which patients move from one service to another is indeed a factor that makes the community mental health center stand apart. 1 A review of recent literature concerning community mental health centers suggests that one of the functions of the CMHC is residual in rature. Irrespective of size, location, addition rates or other variables, individual centers tend to minister to population groups who are in a sense "left over." These are persons who are in need of mental health care and who might otherwise go unserved but for the existence of the center persons, in other words, who are either not reachable or not reached by alternate mental health facilities existing in the community. Although the specifics of the residual function will vary from center to center, depending on which particular population groups are locally unserved, it is clear that the community mental health center tends to recruit or invite patients in a manner not typical of other mental health facilities. 8/ Age, Color and Sex of Community Mental Health Center Additions Table A analyzes patient additions to CMHC's by age, color and sex. For all color-sex groups combined, the highest representation of patient additions (37 percent) occurred in the 25 to 44 year age group. This age group also contained the highest percentages of additions ranging from 34 to 40 percent -- in each of the individual color-sex groups. Males, white and black alike, had a higher percentage of additions in the 5 to 14 year age group than in either the 15 to 19 or 20 to 24 year groups. Females, by contrast, showed a steady increase in percent distribution of additions from the under 5 year group to the peak representation in the 25 to 44 year group. Irrespective of age, whites ranged from 76 to 83 percent of all additions to community mental health centers (Table A). White females had the highest number of patient additions and accounted for 42 percent of the total. In fact, white females led in additions for all age groups except the under 5 and 5 to 14 year groups, where they represented less than one-third of all additions and were exceeded, in both cases, by white males. In the age group 65 and over, white females accounted for 48 percent of all patient additions. The magnitude of the excess of white over black additions was not constant among the age groups. Although blacks accounted for 16 percent of the additions for all age groups combined, they tended to have somewhat higher representations among younger age groups. Thus, blacks accounted for about 20 percent of all additions under 15 years of age in contrast with 15 percent of additions in the age group 65 and over (Table A). Nonwhites other than blacks accounted for 5 percent of additions in all age groups combined. Because of their relatively small absolute number, the text discussion is limited to whites and blacks. Statistics for other nonwhites are, however, shown in Table A. Table B shows that black CMHC additions of both sexes had lower median ages than did white additions. At the same time, the median ages of males in both color groups were lower than those of females. The lowest median age (24.3 years) was found among black males and the highest (30.4 years) among white females. TABLE A. ADDITIONS TO FEDERALLY FUNDED COMMUNITY MENTAL HEALTH CENTERS BY AGE, COLOR 4 * Where percents do not add up to totals shown, discrepancies are due to rounding. TABLE B. MEDIAN AGE OF ADDITIONS TO FEDERALLY FUNDED COMMUNITY MENTAL The overall excess of female over male additions is noted once more in Table C, which presents sex ratios among patient additions for whites and blacks. For all ages combined, there were 90 male additions for every 100 females among whites and 91 male additions for every 100 females among blacks. For both color groups, males exceeded females among additions under 15 years of age, while females exceeded males in all age groups 15 years of age and older. The female excess was especially marked for whites aged 25 to 44, where there were only 77 male additions for every 100 females, for blacks aged 45 to 64 with a sex ratio of 74, and for whites and blacks aged 65 and over, with respective sex ratios of 73 and 67. TABLE C. SEX RATIOS (MALES PER 100 FEMALES) AMONG WHITE AND BLACK How does the population of community mental health center additions differ from the general resident population of the United States? This question is explored in the following discussion, but some words of caution should be interjected at the outset. In discussions of differential utilization of mental health facilities, statements are sometimes made that suggest "underutilization" by certain population subgroups -e.g., blacks, the poor, the aged, the less educated, etc. These population subgroups are said to be "underserved" by mental health facilities or "underrepresented" in mental health facility populations, when compared with their proportionate representations in the population of the United States. 5 In fact, relatively low or high utilization of community mental health center services by specific population subgroups does not by itself necessarily imply that these groups are either "underserved" or "overutilizing." Different population subgroups have differential needs for mental health care. Some subgroups -- for example, the aged have historically been relatively low users of mental health services, even though their need may be considerable. The "underutilization" by some persons must also be understood, at least in part, in terms of resistances to mental health care and not only in terms of accessibility of services. The converse should also be considered: that certain population subgroups are proportionately more highly represented among CMHC additions than in the United States population need not necessarily imply "overutilization" but rather a greater need for services and perhaps, in some cases, less resistance to mental health care. The present Note focuses on percentage distributions in comparing the population of CMHC additions with the resident United States population. Statistical Note 86 in this series, by contrast, analyzed, for 69 selected centers, relationships between additions and catchment area populations through a series of addition rates. It is meaningful to use rates when the denominator represents the at-risk population from which the numerator -- i.e., patient additions -- is drawn. In the present Note, however, the emphasis is not on the relationship between patient additions and the population at risk but rather on how certain population subgroups are differentially distributed among CMHC additions and within the United States as a whole. Tables D and E present comparative statistics for the population of community mental health center additions and the general resident population of the United States for selected demographic characteristics 97. Generally speaking, the population of center additions had lower representations of persons in "dependency" age groups (i.e., children and aged persons) but a higher representation of persons aged 25 to 44, and was more heavily weighted with females (except among children under 15 years of age) and with blacks in all age groups. More specifically, although children under 15 years of age accounted for over 28 percent of the United States population, they represented only 14 percent of the CMHC additions. Similarly, the population group 65 years and older accounted for ten percent of the United States population but only four percent of CMHC additions. By contrast, 37 percent of center additions were between the ages of 25 and 44, as compared with 24 percent of the United States population. These differentials in age distribution existed for both color groups (Table D). In terms of median age, the two white populations did not differ appreciably; both had median ages of about 29 years. But blacks among CMHC additions had a median age that was four years higher than that of blacks in the United States population -- 26.4 years for CMHC additions, as opposed to 22.4 years for the population of the United States (Table D). |