Issue Paper

Caring for Patients With Mental Illness and Substance-Use Disorders: California’s Increasing Challenge
Issue Summary
March 2011

Mental illness (MI) and substance-use disorders (SUD) are common, affecting almost every family, every demographic background and almost every age group in California.

Yet many Californians with MI/SUD do not have access to the appropriate level of care to meet their needs. In fact, their care remains fragmented, disconnected and inadequate. State funding for MI/SUD services has been severely cut, resulting in closures and downsizing of traditional treatment settings. As a result, hospitals and emergency rooms (ERs) are forced to function as the only source for both emergency and non-emergency treatment in many communities. Often, hospitals provide these services without the specialty resources needed to properly serve this population and without the financial resources required to sustain this level of care.

The Issue

The Substance Abuse and Mental Health Services Administration recently released data indicating 20 percent of U.S. adults experienced mental illness in 2009. Overall, 4.8 percent suffered serious mental illness, including 8.4 million people with serious thoughts of suicide, 2.2 million with suicide plans and 1 million attempting suicide.

Nearly 20 percent of adults with mental illness in the past year also had a substance–use disorder. The rate was 25.7 percent for those with a serious mental illness, about four times higher than the rate of 6.5 percent among people without a serious mental illness.

Thirty of California’s 58 counties have no acute inpatient psychiatric hospital beds to care for patients with mental health care needs. Statewide, there are 6,000 inpatient psychiatric beds supporting a population of more than 36 million people. As a result, individuals with mental illness turn to hospitals for services that could have been avoided if primary care, mental health or substance-use disorder treatment was more readily available in the community.

Since ERs are the only health care resource that by law must screen anyone who walks through the door, they have become the only 24/7 provider of services available for individuals with mild, moderate, acute and chronic MI and SUD needs. This translates into patients being forced to inappropriately access the most expensive level of care, putting at risk hospitals’ ability to care for individuals with life-threatening medical emergencies.

Untreated mental illness is the leading cause of disability and suicide, and imposes high costs on state and local governments. Many people left untreated or with insufficient care see their illnesses worsen. Many become homeless and are subject to frequent hospitalizations or jail/prison incarcerations. Our communities are paying a high price for our failure to treat those with severe and persistent mental illness and substance use disorders, and those not receiving treatment are severely suffering.

Community hospital ERs are designed to provide episodic acute physical health care, and are not designed or equipped to assist patients with the array of chronic mental illness, substance–use disorder and social issues often experienced by those with these types of chronic illness. Additionally, ERs are not designed to safely care for patients who are a danger to themselves or others due to their mental status.

Effectively treating these disorders has obvious clinical benefits, but it also has profound economic and social benefits. Conversely, not treating these disorders means greater costs for patients, providers and the community at large. Untreated acute episodes may progress to become chronic conditions, leading to long-term disabilities and an increased dependence on state and local government programs.

Hospitals throughout California are increasingly developing programs that address social barriers to accessing appropriate care and are providing aggressive community case-management services. They are helping coordinate medical, mental and substance-use care for frequent users of their ERs. Hospitals are also performing outreach and engagement strategies, including providing transportation, offering links to permanent housing, coaching toward self-directed care and identifying outpatient mental health medical homes for these patients.

In addition, hospitals are also acting as catalysts, bringing together local government officials, community outpatient mental health providers, law enforcement/judicial system representatives, emergency transportation providers and all hospitals in their communities to develop a local framework for improving care for individuals with MI/SUD disorders.


New federal health reform and mental health parity laws are poised to transform today’s mental health and substance-use disorder delivery system. Mental health and physical health care providers, along with community stakeholders and policymakers, must work together to implement innovative and cost-effective solutions for treating the “whole person” in an integrated (mental and physical health) setting. We must develop a person-centered system of care that includes appropriate access to mental health and coordinated care plans.