This is the first in a series of articles on mental health. I should begin by reviewing the ways in which mental health care is provided. My field is psychiatry. However, there are many other mental health professions.

Psychologists have graduated from four-year colleges and gone on to receive advanced degrees, such as a master’s degree (M.A.) or doctorate (Ph.D., Ed.D., or Sci.D.). Psychologists who have earned a doctorate are addressed as “doctor”, but are not physicians. Some psychologists take even more training in fellowship programs called “post-docs”. Psychologists may provide psychotherapy, and they may administer various tests, such as intelligence (I.Q.) tests, personality tests, and tests of brain functioning.

Licensed clinical social workers (LCSWs) have graduated from four-year colleges and gone on receive a master’s degree. In addition, they have provided at least 2,000 hours of supervised psychotherapy and passed a comprehensive exam. LCSWs provide individual and group psychotherapy and substance abuse treatment.

Nurse practitioners (NPs) have graduated from four-year nursing colleges, gone on to receive a master’s degree, and passed a specialty exam. In Maine, NPs may practice without supervision from a doctor. Physician assistants (PAs) have graduated from a physician assistant program. They have passed a specialty exam, as well. PAs must work under the supervision of a doctor. NPs and PAs may provide psychotherapy and may prescribe most mental health (psychotropic) medicines.

Psychiatrists are physicians (MD or DO). We have graduated from four-year colleges and gone on to four-year medical schools. We have completed another year of general medical training in a teaching hospital (internship) and another three years of specialty training in psychiatry (residency). Some psychiatrists then take sub-specialty training (fellowship) in child, geriatric, forensic, addiction, or psychoanalytic psychiatry. We do diagnostic assessments, provide psychotherapy and substance abuse treatment, and prescribe medicine. We are aware of the ways in which physical diseases, and medicines prescribed for physical ailments, may affect our patients’ mental functioning. Psychiatrists may be involved in the administration (management) of hospitals and clinics.

Mental health care is available in several settings. Sometimes, hospital care is best. Maine has four psychiatric hospitals. In addition, many community hospitals have mental health units. Since space is limited, and the average cost of hospital care is $1,000 per day, this level of care is reserved for people who are so disorganized or impaired that they are likely to harm themselves, or some one else. Detoxification from alcohol or drugs may also be provided in hospitals. Hospital stays are usually brief. Some hospitals are now providing “observation” or “72-hour” care for patients who come to the emergency department in need of more careful assessment and treatment, but who are not clearly ill enough to be admitted. In psychiatric hospitals, or mental health units, a great deal of the most important care is provided by psychiatric nurse specialists, in addition to all of the professionals listed above.

Day treatment, day hospital, or intensive outpatient programs provide several hours of treatment per day, several days each week. These programs are usually located in or near hospitals. Day treatment is a good option for some people after they have been stabilized in a psychiatric hospital. It may be a good choice for people who are becoming more ill, but can manage at home with some extra help until they feel better.

ECT, or electroconvulsive therapy, is provided in the ambulatory surgery unit (ASU or day surgery) of some hospitals. People come in to the ASU for their treatments and go home after one or two hours.

In some areas of Maine, assertive community treatment (ACT) teams provide care to people who are seriously mentally ill but can live on their own with frequent assessments and help with taking medicines. An ACT team usually consists of a psychiatrist, psychiatric nurse specialist (RN-C), licensed clinical social worker (LCSW) and psychologist. ACT teams may see clients as often as five days per week.

Outpatient clinics, or mental health centers, provide psychotherapy, prescription medicines, and substance abuse treatment. Mental health centers have psychiatrists, and all of the other professionals described above. In addition, mental health centers have psychiatric nurse specialists (RN-Cs) and licensed alcohol and drug counselors (LADCs). Because mental health centers often have waiting lists, primary care doctors also prescribe medicine for their patients with mental health problems.

Local crisis services provide emergency assessment of mental health problems in hospital emergency departments, at the crisis service office, or “on the street”. Crisis services attempt to insure safety, then refer people to the best level of care. In some areas of the state, there are crisis residences which provide short-term help for people who need 24-hour care, but don’t need to be hospitalized.

These services are not available in every part of Maine. East of Ellsworth or north of Lewiston, mental health care quickly becomes more difficult to find. In large areas of Maine, there a few psychiatrists, and even fewer with training in child or geriatric psychiatry. There are many reasons for this, and I am not going to expound on them here. As with every systemic difficulty, there are no easy answers.

In future columns, I’ll discuss the more common forms of mental illness, and the ways in which treatment works.