A more recent household survey in 1998 found that people with a probable mental disorder are more likely than those without a disorder to have lost their health insurance and to report lower access to care (Sturm and Wells, 2000). The consequences of the disparities in insurance coverage for mental illness have led to legislative proposals at the state and federal level for parity—coverage for mental illness equivalent to that for other health conditions (US DHHS, 1999). While there do not appear to be any studies directly examining cost as a barrier to treatment for suicidal people, most researchers believe that cost does play a role.

Mental Health System Barriers

The fragmented organization of mental health services has been repeatedly recognized as a serious barrier to obtaining treatment (US DHHS, 1999). The vision, beginning in 1975, of the community support reform movement—an integrated, seamless service system that brings mental health services directly to the community—has not fully materialized. Mental health services continue to be so fragmented that they have been termed the “de facto” service system (Regier et al., 1993). People with mental illness frequently report their frustrations and waiting times as they navigate through a maze of disorganized services (Sturm and Sherbourne, 2001; Sussman et al., 1987). The disorganization is a product of historical reform movements, separate funding streams, varying eligibility rules, and disparate administrative sources—all of which have created artificial boundaries between treatment settings and sectors (Ridgely et al., 1990). Among the hardest hit are people with co-occurring substance abuse and mental health problems, a group at higher risk of suicidality. Co-occurring disorders are the rule rather than the exception in mental health and substance abuse treatment (US DHHS, 1999).

Linkages between different settings are critical for detection and treatment of mental disorders and suicidality (Mechanic, 1997). They include linkages between primary care and specialty mental health care; emergency department care and mental health care; substance abuse and mental health care; and, for adolescents, school-based programs with mental health or substance abuse care. The transition from inpatient care to community-based care is an especially critical period for suicidality in light of studies finding that a large proportion of completed suicides come after recent inpatient discharge, often before the first outpatient appointment (Appleby et al., 1999; Morgan and Stanton, 1997). In addition to improved linkages between different settings, many new programs strive to integrate mental health and primary care, through a variety of service configurations (e.g., a psychiatric nurse practicing with the primary care setting who treats some patients and is a referral source for others). Several



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